© 2021 International Journal of Preventive Medicine | Published by Wolters Kluwer – Medknow 1
Introduction
Hospitals as one of the most important
healthcare institutions have a vital role
in providing services under both normal
circumstances and emergencies.[1‑3]
Although hospitals are known as a safe
place to treat patients, they are prone to
internal and external disasters.[4] A damage
to the hospital structure or the occurrence
of a disaster may jeopardize the provision
of care services and the health of hospital
residents and ultimately lead to the
complete evacuation of the hospital.[1] The
incidence of a disaster in a hospital may
be associated with many physical injuries
because of the long evacuation time of
hospitals. Hospital evacuation is a process
with special complexities as they have
generally tall and colossal buildings.[5,6]
From 2000 to 2017, more than 150 hospitals
were emergency evacuated in the United
States. Studies showed that 16% of these
evacuations were related to man‑made
Address for correspondence:
Dr. Katayoun Jahangiri,
Velenjak, Shahid Shahryari
Squair, Daneshjoo Blvd.,
Tehran, Iran.
E‑mail: [email protected]
Abstract
Background: Although the hospital is known as a safe place for treating patients, due to various
reasons, it is prone to several internal hazards, including fre. This study aimed to identify the
factors affecting hospital emergency evacuation during fre. Methods: This was a systematic review
conducted according to the PRISMA guideline. Thematic Content analysis was utilized to analyze
and extract results. We found the studies investigating the factors affecting hospital emergency
evacuation during fre through a comprehensive search in various data resources (MEDLINE, Web
of Science, Google Scholar, Embase, ProQuest, Scopus, IRANMEDEX, SID, ISC, and Magiran) and
other sources from the beginning of January 2000 to the end of December 2019. Thematic Content
analysis was also employed to analyze. Results: At frst and based on the initial search, 4484 studies
were identifed, and 48 articles were fnally included in the study. Based on the results; fve main
themes along with 10 sub‑themes were identifed. The themes included the incident’s characteristics,
response measures, hospital preparedness, hospital residents, and hospital building, and the
sub‑themes were emergency evacuation features, fre characteristics, command, operation, patients’
and staff’s characteristics, planning, logistics, and structure and design hospital. Conclusions: Based
on the results of the present study, hospital preparedness as one of the most important factors can
reduce the hospital evacuation time. Therefore, hospitals can ensure a timely and more effective
response in emergency evacuation during fre by improving their preparedness.
Keywords: Disasters, emergencies, emergency evacuation, fre, hospitals
Factors Influencing Hospital Emergency Evacuation during
Fire: A Systematic Literature Review
Review Article
Ali Sahebi1,
Katayoun
Jahangiri1,2,
Ahmad Alibabaei3,
Davoud
Khorasani‑Zavareh4
1Department of Health in
Emergencies and Disasters,
School of Public Health
and Safety, Shahid Beheshti
University of Medical Sciences,
2Safety Promotion and Injury
Prevention Research Center,
Shahid Beheshti University of
Medical Sciences, 3Department
of E-Learning, Virtual School
of Medical Education and
Management, Shahid Beheshti
University of Medical Sciences,
4Workplace Health Promotion
Research Center, Department
of Health in Emergencies and
Disasters, Shahid Beheshti
University of Medical Sciences,
Tehran, Iran
How to cite this article: Sahebi A, Jahangiri K,
Alibabaei A, Khorasani‑Zavareh D. Factors influencing
hospital emergency evacuation during fire:
A systematic literature review. Int J Prev Med
2021;12:147.
This is an open access journal, and artcles are
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allows others to remix, tweak, and build upon the work
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the new creatons are licensed under the identcal terms.
For reprints contact: [email protected]
threats, and 13% were due to internal
factors from which fres accounted for about
40% of intrahospital threats.[7] Hospitals
because of using electrical equipment,
medical gases, and flammable liquids
are susceptible to fre.[8] Hospital fre,
due to limitations in relocating patients,
is a special event that usually associated
with high casualties. So, in managing the
hospital fre, many challenges including the
complex process of transferring of patients
are encountered.[9‑11]
Hospital evacuation while keeping the
safety of its residents is a complex
process.[12] Many hospital residents are those
with impaired mobility the transferring of
whom to a safe place can be very difcult
for staff.[13] One of the most important
differences between evacuating a hospital
and other buildings is that hospitalized
patients are often disabled and need the
help of other people to relocate.[14] Despite
all these issues, evacuating a hospital
should be fast and safe to prevent harm to
the residents, a large number of whom must

Sahebi, et al.: Systematic review hospital emergency evacuation during fre
2 International Journal of Preventive Medicine 2021, 12: 147
be evacuated within the shortest time.[15,16] However, a safe
hospital evacuation during fre is time‑consuming due to
patients’ limited mobility.[17]
The hospital emergency evacuation is a difcult process
due to the insecure translocation of critically ill patients
who should be evacuated without any disruption in their
treatment.[18] So, identifying the factors affecting hospital
emergency evacuation can boost the managers’ and staff’s
knowledge and skills and help to design and implement a
secure and rapid hospital evacuation program during fre.
Therefore, the aim of the present systematic review aimed
to characterize these factors.
Methods
The present study was conducted via the two methods
of systematic review and thematic content analysis. At
frst, a systematic review was performed based on the
Preferred Reporting Items for Systematic Reviews and
Meta‑Analyzes (PRISMA) guidelines[19] to acquire the
articles related to the research purpose. The protocol
of this review was registered in the International
Prospective Register of Systematic Review (PROSPERO)
under the code of CRD42020164943. According to the
PRISMA protocol, a search strategy was designed and
performed screening, study selection, quality evaluation,
and data extraction, respectively. The phases of study
selection and qualifcation and data extraction were
independently conducted by two researchers. In the
case of any disagreement between these researchers, a
fnal decision was made through group discussion. For
thematic content analysis, the six‑phase content analysis
framework of Braun & Clarke (2006) was used.[20] The
six steps of content analysis included familiarity with the
data, generation of initial codes, searching for themes,
reviewing themes,defning themes, and fnally writing the
draft” replacement with “The six steps of content analysis
included data familiarization, generating raw codes,
searching for topics (themes), reviewing and defningtopics,
and fnally writing the draft.[20]
Data resources and search strategy
To comprehensive search in this study, data resources
including MEDLINE in (PubMed, Web of Science, Google
Scholar, Embase, ProQuest, Scopus, IRANMEDEX, SID,
ISC, and Magiran, conference and congress papers, key
journals (Prehospital and Disaster Medicine, Disaster
Medicine and Public Health Preparedness) and reference
list of selected articles and systematic reviews were
employed. The MeSH terms, consulting with scientifc
experts, and terms in related articles were used to extract
valid keywords. The English keywords and their Persian
equivalents used in this study included “Emergency
Evacuation”, “Urgent Evacuation”, Evacuation, “Evacuation
Time”, “patient Evacuation”, “Medical Facility”, “Health
Center”, “Healthcare Center”, “Tertiary Referral Center”,
“Tertiary Care Center”, Hospital, “Health Facility”, Fire,
Event, Incident, Disaster, and Emergency. At frst, the
initial search syntax for PubMed by using the operators,
keywords and search felds, and then, designed the syntax
for other databases based on this structure was written. The
number needed to read (NNR) index was used for search
syntax evaluation. NNR index is defned as the ratio of the
number of retrieved articles to related articles.[21] The period
of the search was from the beginning of January 2000 to
the end of December 2019. Published articles gathered in
English and Persian. Examples of the used search strategy
have been mentioned in Appendix 1.
Eligibility criteria
All Persian and English studies about the hospital
emergency evacuation during a fre, published from the
beginning of January 2000 to the end of December 2019
were included. The studies dealing with the assessment of
fre safety in hospitals, emergency evacuation regardless of
the type of the incident and disasters, emergency evacuation
of buildings other than hospitals, hospital emergency
evacuation for reasons other than fre, decision‑making
during an emergency evacuation, emergency evacuation in
hospital external fres, and a general evaluation of hospital
emergency evacuation in various incidents and disasters
were excluded.
Study selection
In order to manage search results, all articles were inserted
into EndNote X7 software, and after removing duplicates,
their titles and abstracts were screened based on the
eligibility criteria to identify potentially relevant articles.
In the next step, two researchers (AS, KJ) independently
studied the full texts of the possibly related articles with
details and fnally selected qualifed articles.
Quality assessment
At this step, two researchers (AS, KJ) independently
evaluated the quality of the selected studies using
different tools including the Strengthening the Reporting
of Observational Studies in Epidemiology (STROBE)
for observational studies.[22] This tool has 22 items,
and each item is scored from 0 to 2 (the minimum
and maximum scores are 0 and 44, respectively).
Accordingly, the quality of studies was divided into
three categories including low (0–15 points), moderate
(16–30 points), and high (44–points). The Center for
Evidence‑Based Management (CEMBa)) was used for
case studies.[23] This tool has 10 items, and each item
is scored from 0 to 1 (the minimum and maximum
scores are between 0 and 10, respectively). The scores
of 0‑2, 3‑6, and 7‑10 indicated poor, moderate, and
high qualities, respectively. Consolidated Standards
of Reporting Trials (CONSORT) was used for trials
studies.[24] This tool contains 25 items, and each item is
scored from 0 to 2 (the minimum and maximum score
Sahebi, et al.: Systematic review hospital emergency evacuation during fre
International Journal of Preventive Medicine 2021, 12: 147 3
is 0 and 50, respectively). The scores of 0‑16, 17‑33,
and 34‑50 indicated poor, moderate, and good qualities,
respectively. The Modifed STROBE was used for the
studies that were not assessable by the mentioned standard
quality assessment tools [Appendix 2]. This tool contains
9 questions, and each question is scored from 0 and 1 (the
minimum and maximum scores are 0 and 9, respectively).
The scores of 0–2, 3–6, and 7–9 indicated poor, moderate,
and high qualities, respectively.
Data extraction and analysis
Two researchers (AS and KJ) extracted the fnal studies data
independently, in the pre‑prepared checklist. The checklist
included the frst authors’ name, the record type, year, place,
and design, as well as the fndings. Thematic content analysis
was used to analyze the data. Initially, the frst author (AS)
studied the results of 48 qualifed articles. In thematic content
analysis method, in addition to the headings obtained from
the studies, the text of the results was also studied and coded
accordingly. For coding, all the codes and basic concepts
related to the factors affecting hospital emergency evacuation
during fre, were extracted. Then they were, carefully
studied line by line, several times to identify initial codes.
Afterwards, the frst and second authors (AS, KJ) examined
all the identifed codes in terms of similarities and differences,
and then similar codes were classifed under one category to
form a sub‑theme. In the next step, the sub‑themes that had a
similar concept were placed together to form a theme. Finally,
a draft of the summarized designed fndings was discussed by
all the authors, and necessary amendments were applied until
reaching an agreement on the draft.
Results and Discussion
Search results
Initially, a total of 4484 studies were obtained in the
primary search, and after removing duplicates, the titles
and abstracts of 2976 studies were screened. After omitting
irrelevant articles, the full texts of 147 possibly related
studies were reviewed, and fnally, 48 articles entered the
fnal phase of the study [Figure 1].
Descriptive statistics
Among the fnal studies, 29 were journals, 13 conference
papers, four book sections, and two theses. Eight studies
had been conducted in the United Kingdom, eight in
the United States, eight in China, four in Italy, one in
the Netherlands, two in Sweden, two in Iran, fve in India,
two in Japan, and one in each of Spain, Germany, Canada,
Belgium, Russia, Turkey, Portugal, and Taiwan. In terms of
study design, most of the studies had been conducted with
the simulation method. Regarding the quality assessment
results, 23 and 25 studies had medium and good qualities,
respectively. The selected studies’ characteristics have been
shown in Table 1.
Thematic content analysis
Based on the systematic literature review and thematic
content analysis, the factors affecting emergency
evacuation during hospital fre were divided into fve
main themes and 10 sub‑themes. The themes included
the incident’s characteristics, response measures, hospital
preparedness, hospital residents, and hospital building, and
the sub‑themes were emergency evacuation features, fre
characteristics, command, operation, patients’ and staff’s
Included Eligibility Screening Identification
Records identified through data
Resources searching (n = 4445)
Additional records identified
through other sources (n = 39)
Records after duplicates removed
(n = 2976)
Records screened (n = 2976) Records excluded (n = 2829)
Full-text articles assessed for
eligibility (n = 147)
Studies included in this study
(n = 48)
Full-text articles excluded,
with reasons (n = 99)
1- Abstracts
2- Not Specifically Hospital
evacuation
3- Not specifically fire incident
4- Other languages except for
Persian and English
5- Hospital external fire
Figure 1: PRISMA Flowchart of systematic literature review of identifying the factors influencing on emergency evacuation in hospital fre
Sahebi, et al.: Systematic review hospital emergency evacuation during fre
4 International Journal of Preventive Medicine 2021, 12: 147

Contd…
Sahebi, et al.: Systematic review hospital emergency evacuation during fre
International Journal of Preventive Medicine 2021, 12: 147 5

Contd…
Sahebi, et al.: Systematic review hospital emergency evacuation during fre
6 International Journal of Preventive Medicine 2021, 12: 147
characteristics, planning, logistics, and structure and design
hospital [Table 2].
Based on our research, various factors such as
fre characteristics, command, operation, patients’
characteristics, planning, and logistics can have signifcant
roles in emergency hospital evacuation during fre.
The present systematic review showed that fre
characteristics such as its location, the extent of the smoke,
temperature, and visibility affect hospital emergency
evacuation. The results of a study in China showed that
items such as fre location, heat, ventilation system, and
type of burning materials affect emergency evacuation
during fre in metro.[69] Following a fre in a hospital,
the smoke and, heat rapidly disseminate throughout the
building. Inhaling smoke is usually the primary cause of
death in this situation.[70] On the other hand, smoke reduces
visibility so that people cannot track the evacuation routes
during the evacuation, and as a result, they encounter
obstacles delaying the evacuation.[71] In conclusion, fre
characteristics (heat, smoke, etc.,) affect the emergency
evacuation process, and hospitals should appropriately
adjust their responses corresponding to such characteristics.
So, it seems necessary that hospitals developing their
emergency evacuation plans based on possible fre features
according to the type of available inflammable materials.
According to the results of this study, the command has
an important role in hospital emergency evacuation during
fre by coordinating intra‑organizational communications.
The results of a study in the USA showed that the
emergency evacuation of a hospital is a complex process
requiring inter and intra organizational coordination
and communications.[43] So, using an incident command
system (ICS) is important to coordinate activities, optimally
use resources, and accomplish a successful emergency
evacuation,[72,73] even in pre‑hospital phase.[74,75] Also, we
observed that notifcation as one of the components of
command plays an important role in hospital emergency
evacuation. Rapidly informing personnel inside the
hospital, supportive organizations, and patients’ families
of the incident are essential. The results of a review in
2015 showed that communication and relationships with
society are important factors affecting hospitals’ emergency
evacuation. Following disasters, emergency evacuation
can cause anxiety in all the people involved. Either
misinformation or the lack of information exaggerates
anxiety and on the other hand delays evacuation.[76] In line
with our fndings, the results of previous studies emphasize
on the role of command in the emergency evacuation of
the hospital.[77] Since evacuating a hospital is a complex
process which requires the attendance of other organizations
including police, frefghting, and pre‑hospital emergency,
the presence of a command system through inter and
intra organizational coordination and communications can
facilitate the evacuation process.
In this study, we demonstrated that operation was one of
the most important and necessary measures in hospitals’
responses to emergency evacuation. A study in the United
States showed that many patients need constant medical care
during relocation,[78] and in other hand, people who lose their
family members or patients amid emergency evacuation will
require psychological consulting.[55] Another study showed
that one of the most essential elements of response measures
is to prioritize patients for translocation. The results of a
study in Japan showed that an inappropriate prioritization
can lead to overcrowding in the evacuation route, which

Sahebi, et al.: Systematic review hospital emergency evacuation during fre
International Journal of Preventive Medicine 2021, 12: 147 7
slows patient translocation speed and extends the evacuation
time.[52] So, it can be said that although the primary goal of
hospital emergency evacuation is to relocate as many people
as possible within the shortest time, adequate attention
should be paid to the healthcare and treatment of the patients
who may need such measures during evacuation.
Among other factors influencing hospital emergency
evacuation during fre were patients’ characteristics which
determine the number of required personnel and the
equipment necessary for translocation. We here found that
patients’ familiarization with emergency exit routes affected
evacuation time. Another study in China noted patients’
insufcient awareness of emergency exit routes delayed
evacuation and reduced their speed.[50] On the other hand,
adequate patients’ awareness of the emergency evacuation
facilitates personnel’s performance during the process.[28]

Sahebi, et al.: Systematic review hospital emergency evacuation during fre
8 International Journal of Preventive Medicine 2021, 12: 147
Also, the results of other studies have shown that guiding
patients by personnel can reduce evacuation time.[79] In
overall, in line with other studies, human characteristics,
risky behaviors, should take into account.[80] Overall, these
results indicate that the familiarity of patients with hospital
emergency evacuation facilitates the process. So, it is
recommended that hospitals provide patient education along
with staff training programs, which both are important
factors in emergency evacuation planning.
The present review proved hospitals need to develop
an evacuation plan with the incorporation of important
components such as exercise and training, for emergency
evacuation during fre. A case study about a fre in an
operation room in India found that holding fre drills
could improve hospitals’ response to fre, minimize the
incidence of potentially fatal problems, and create a more
secure environment for patients and personnel.[81] Other
studies have also emphasized on educating personnel
about fre safety plans, frefghting, evacuation of patients
based on triage, and identifcation of vulnerable patients
to boost. The knowledge and performance of hospital
personnel in managing fre and ensure patients’ and staff’s
safety.[62,82] Most of the studies reviewed here emphasized
on the need for having an emergency hospital evacuation
plan during fre. The results of other studies have
shown that a successful emergency evacuation depends
on previous planning. Therefore, healthcare centers,
especially hospitals, should develop operational emergency
evacuation plans and make sure that these plans are
readily available and regularly exercised and updated.[83,84]
Therefore, employing evacuation plans and strategies by
health centers can lead to a safe transfer of patients to
other medical organizations.[85] In line with the results of
other studies, our fndings highlighted the role of planning
in hospital emergency evacuation, and therefore, it seems
necessary for hospitals to developing required emergency
evacuation plans. As these plans are developed based on
available standards, it is possible to achieve appropriate
planning by continuous monitoring and implementing
these standards.
This study showed the necessity of the logistics, both
medical and non‑medical equipment, during the emergency
evacuation of the hospital after a fre. Other studies have
shown that most patients faces many challenges, especially
patients in critical care units are unable to move and
vertical evacuating.[4] On the other hand, there may be a
shortage of transportation equipment for patients with
critical conditions as they need special devices to move.[86]
Similar to the results of previous studies, we highlighted
the role of equipment, especially transportation equipment,
in the emergency evacuation of hospitals. This is because
most patients are not able to evacuate alone and require
devices such as wheelchairs and trolleys. As hospital
buildings have a complicated design and structure, it is
necessary for hospitals to adequately provide a variety of
patient transportation equipment with different applications
based on the number of patients and the type of their
diseases.
Strengths and limitations
This study systematically evaluated all factors affecting
hospital emergency evacuation during fre, and this was
a strength and unique feature in our research. From the
limitations of this review was different methodologies of
the selected studies, which due to their importance and
relevance to the topic, it was not possible to exclude
them. Another limitation was the unavailability of
the full texts of three articles that were excluded from
the study.
Conclusion
The results of the present review study showed that a
variety of factors including the incident characteristics,
response measures, hospital preparedness, hospital
residents’ features, and the hospital building were effective
on hospital emergency evacuation during fre. Data
synthesis revealed that hospital preparedness was one of
the main factors in hospital emergency evacuation during
fre, addressed by the most reviewed studies. As a vital
parameter, it is critical to improve the level of hospital
preparedness to shorten emergency evacuation time. In
conclusion, hospitals can use the results of this review
study to be prepared and perform a prompt and effective
emergency evacuation in case of fre.
Acknowledgments
This article is part of a PhD thesis with the Ethical
approval and study permission with ID of IR.SBMU.PHNS.
REC.1398.170 approved by Shahid Beheshti University of
Medical Sciences.
Financial support and sponsorship
The study was fnancially supported by Shahid Beheshti
University of Medical Sciences, Tehran.
Conflicts of interest
The authors declare that they have no conflict of interest.
Received: 24 Oct 20 Accepted: 08 Jan 21
Published: 26 Oct 21
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