Successful Implementation of Hospital Disaster Preparedness and Response Plan During Mass Casualty Bus Accident: A Case Report from Nepal

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The Hospital Disaster Preparedness and Response Plan (HDPRP) was developed following the 2015 Nepal earthquake to enhance mass casualty management capabilities in healthcare facilities. This case report documents the first real-world implementation of Nepal's HDPRP framework during a bus accident at Dhaulagiri Hospital, Baglung. Case Presentation: A passenger bus accident at Nishikhola, Burtibang resulted in 26 casualties requiring immediate medical attention. Dhaulagiri Hospital activated its Hospital Incident Command System (HICS) within one hour of notification. A six-member command structure coordinated the response, including incident command, disaster focal person, operational manager, logistics officer, information officer, and administrative officer. The hospital implemented comprehensive emergency protocols including triage, resource mobilization, zero billing policy, and inter-agency coordination. All 26 casualties were successfully managed with only two requiring referral to higher-level facilities. No mortality occurred during the hospital stay. Conclusions: This case demonstrates successful implementation of Nepal's HDPRP framework in a real-world mass casualty incident. Key success factors included pre-established protocols, designated command structure, effective inter-agency coordination, and comprehensive resource mobilization. The experience validates the effectiveness of structured disaster preparedness protocols in resource-limited settings and provides valuable insights for improving hospital emergency response capabilities. Hospital disaster preparedness mass casualty incident Nepal HDPRP incident command system emergency response bus accident Background Hospital disaster preparedness has gained increasing attention globally, particularly in disaster-prone regions like Nepal [21]. The 2015 Gorkha earthquake, which resulted in approximately 9,000 deaths and widespread destruction, highlighted critical gaps in Nepal's healthcare system's disaster response capabilities [1,2]. Studies from affected hospitals demonstrated the immediate need for systematic disaster preparedness, with one local hospital reporting a 300% increase in patient load during the first three weeks post-earthquake [3]. Additional research has documented the significant impact of the Nepal earthquake on emergency care systems, with hospitals experiencing substantial increases in trauma cases and resource strain [12]. The earthquake also highlighted the importance of communication systems during disasters, with medical personnel relying on innovative communication methods to coordinate emergency response [16]. Mass casualty management in resource-limited settings like Nepal presents unique challenges that require specialized approaches and coordination [20]. Research on hospital disaster preparedness training in Nepal has shown the importance of systematic training programs for effective emergency response [13]. In response to these challenges, the Ministry of Health and Population of Nepal, supported by the World Health Organization, developed the Hospital Disaster Preparedness and Response Plan (HDPRP) to strengthen mass casualty management systems across the country [4]. The HDPRP framework emphasizes the importance of establishing a Hospital Incident Command System (HICS) that can be rapidly activated during emergencies. HICS is an incident management system designed specifically for hospitals, based on established incident command system protocols, and provides hospitals of all sizes with tools needed to advance their emergency preparedness and response capability [5]. International literature emphasizes that successful management of mass casualty incidents (MCIs) requires standardization of planning, training, and deployment of response [6]. The incident command system provides a structured approach to managing complex emergency situations, ensuring clear lines of authority and communication [7]. Studies have shown that hospitals with established incident command systems demonstrate improved response times and better resource allocation during emergencies [8]. The goal of mass casualty management is to apply available medical resources most effectively to mass casualty incident victims to do the "most good for the most people" [9]. This case report documents the first reported real-world implementation of Nepal's HDPRP framework during a bus accident response at Dhaulagiri Hospital, Baglung. The experience provides valuable insights into the practical application of disaster preparedness protocols in a resource-limited setting and offers lessons for improving hospital disaster response capabilities. Case Presentation Incident Overview On 03/24/2025, Dhaulagiri Hospital, Baglung, received information about a bus accident at Nishikhola, Burtibang, involving 26 casualties. The incident occurred when a passenger bus traveling on a mountainous route lost control and overturned, resulting in multiple injuries ranging from minor trauma to critical conditions requiring immediate medical intervention. Initial Response and Activation The initial notification was received by Dr. Rekha, the Acting Medical Superintendent, who immediately activated the hospital's disaster response protocol. Information was disseminated through the hospital's messenger group, ensuring rapid communication to all relevant staff members. The Hospital Incident Command System (HICS) was formally activated within the first hour of notification, and the disaster focal person was notified. Hospital Incident Command System Structure The HICS team comprised six key members, each with specific roles and responsibilities: 1. Incident Commander (Dr. Rekha): Overall coordination and decision-making authority 2. Disaster Focal Person (Dr. Amit): Liaison between command and operational teams 3. Operational Manager (Dr. Abhishesh): Clinical operations oversight 4. Logistics Officer (Shanti Sister): Resource management and supply coordination 5. Information Officer (Navaraj Sir): Communication and media management 6. Administrative Officer (Bhagawati Mam): Administrative coordination and support Operational Response Implementation Command and Control · HICS meeting conducted in the designated office · HDPRP document reviewed and operational team finalized · Clear job descriptions distributed to all team members · Regular coordination meetings held throughout the response Clinical Operations · Emergency department evacuated of routine patients · Triage areas established with red, yellow, and green zones · Additional beds arranged in pre-designated areas · Medical staff duty roster implemented for continuous coverage · Clinical rounds conducted every few hours for treatment plan updates Logistics and Resource Management · Blood bank alerted and prepared for potential transfusion needs · Laboratory and radiology departments placed on standby · Emergency supplies verified and organized, including: o 50 units each of Normal Saline and Ringer's Lactate o 50 IV administration sets o Medical equipment from multiple departments o Oxygen cylinders distributed across treatment areas o Resuscitation equipment and medications External Coordination · Referral mechanism activated through District Administrative Office · Manipal Hospital and Western Regional Hospital designated as referral centers · Ambulance services coordinated for patient transfers · Nepal Police engaged for crowd control and security · Health Emergency Operations Center (HEOC) and Provincial Health Emergency Operations Center (PHEOC) notified Patient Care and Support · Zero billing policy implemented for all accident victims · Comprehensive medical care provided across all triage categories · Food arrangements made for patients and visitors · Clothing provided to victims with torn garments · Psychological support and counseling services offered Clinical Outcomes All 26 casualties were successfully received and treated at the hospital. The triage system effectively categorized patients based on injury severity, allowing for appropriate resource allocation. Only 2 patients required referral to higher-level facilities for specialized care. No mortality occurred during the hospital stay, and minimal complications were reported during the treatment period. Operational Effectiveness The HICS activation was completed within the first hour of notification, demonstrating the effectiveness of pre-established protocols. Smooth coordination between all command structure elements facilitated efficient resource mobilization and utilization. The hospital successfully managed the increased patient volume with minimal disruption to routine operations. Challenges and Adaptations Several challenges were encountered and successfully addressed: · Green zone relocated due to cold weather conditions · Store coordination required for additional supplies from external pharmacies · Initial concern about potential helicopter rescue requirements · Management of increased visitor volume and media attention · Adjustment of routine emergency services during peak response Discussion This case report represents the first documented real-world implementation of Nepal's HDPRP framework during a significant mass casualty incident. The successful management of 26 casualties with minimal referrals demonstrates the effectiveness of structured disaster preparedness protocols in resource-limited settings. Key Success Factors Pre-established Protocols: The existence of a written HDPRP document with clear procedures enabled rapid activation and systematic response. This preparation was crucial in ensuring an organized response rather than ad-hoc crisis management. Command Structure: The six-member HICS provided clear leadership and coordination mechanisms. The designated roles prevented confusion and ensured efficient resource utilization, aligning with international best practices that emphasize establishing incident command as soon as possible [5,7]. Inter-agency Coordination: The successful coordination with district administration, referral hospitals, and emergency services exemplifies the importance of external partnerships in disaster response. This aligns with global standards that emphasize multi-agency collaboration in mass casualty management [6,10]. Resource Preparedness: The systematic verification and deployment of medical supplies, equipment, and personnel demonstrated effective logistics management. The ability to maintain adequate inventory while sourcing additional supplies from external sources showed flexibility and resourcefulness [8,11]. Community Support: The zero billing policy and comprehensive care including food and clothing reflected a holistic approach to disaster response, addressing not only medical needs but also social and psychological aspects of patient care. Lessons Learned Strengths identified include: · Rapid activation: HICS was operational within one hour of notification · Clear communication: Effective use of messenger groups and established communication channels · Comprehensive care: Attention to medical, social, and psychological needs of victims · Resource efficiency: Minimal external referrals despite significant casualty load · Documentation: Proper recording of patient information and response activities Areas for improvement include: · Environmental considerations: Initial green zone location required modification due to weather · Supply chain: Need for better coordination with external pharmacies and suppliers · Surge capacity: Consideration of helicopter evacuation capabilities for future incidents · Training: Regular drills and simulations to maintain readiness, as research has shown the effectiveness of systematic hospital disaster preparedness training programs [13] · Technology: Enhanced communication systems for better coordination, building on lessons learned about the importance of communication technology during disasters [16] Implications for Policy and Practice This experience provides valuable evidence for the effectiveness of Nepal's HDPRP framework and suggests several policy implications [14,15,17,18,19]. The experience demonstrates that systematic approaches to hospital disaster preparedness can be successfully implemented even in resource-limited settings, building on Nepal's broader experience with mass casualty management [20]: 1. Standardization: The success of this response supports continued implementation of HDPRP across Nepal's healthcare system 2. Training: Regular training and simulation exercises are essential for maintaining readiness 3. Resource allocation: Investment in emergency supplies and equipment is justified 4. Inter-agency cooperation: Formal agreements with referral hospitals and emergency services should be established 5. Technology integration: Digital systems should be developed to enhance response capabilities Study Limitations This case report has several limitations: it represents a single institution experience that may not be generalizable to all hospital settings; the response to traffic accidents may differ from other disaster types; Dhaulagiri Hospital may have better resources than rural facilities; some aspects of the response may not be fully captured in documentation; and long-term outcomes and patient satisfaction data are not available. Conclusions The Burtibang bus accident response at Dhaulagiri Hospital demonstrates the successful implementation of Nepal's Hospital Disaster Preparedness and Response Plan in a real-world scenario. The systematic activation of the Hospital Incident Command System, effective coordination of resources, and comprehensive patient care resulted in excellent clinical outcomes with minimal external referrals. This experience validates the importance of structured disaster preparedness protocols and provides valuable insights for improving hospital emergency response capabilities in resource-limited settings. The success factors identified - pre-established protocols, clear command structure, inter-agency coordination, and comprehensive resource mobilization - offer practical guidance for other healthcare institutions seeking to enhance their disaster preparedness. As Nepal continues to face various natural and man-made disasters, the experience at Dhaulagiri Hospital serves as a model for effective hospital disaster response and demonstrates the potential for achieving excellent outcomes through proper preparation and systematic implementation of evidence-based protocols. Declarations Ethics approval and consent to participate Not applicable. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding Not applicable. Authors' contributions AW conceived the study, participated in the disaster response, and drafted the manuscript. RS participated in data collection and manuscript revision. AD participated in the disaster response coordination and manuscript review. All authors read and approved the final manuscript. Acknowledgements The authors acknowledge the dedication and professionalism of all hospital staff who participated in the disaster response. We also thank the District Administrative Office,Baglung, Nepal Police, and referral hospitals for their collaboration during the emergency response. References Hall ML, Lee AC, Cartwright C, Marahatta S, Karli J, Simkhada P. The 2015 Nepal earthquake disaster: lessons learned one year on. Public Health. 2017;145:39-44. Pandey NR, Lamsal R, Karim R, Shrestha ML. The health sector response to the 2015 earthquake in Nepal. Disaster Med Public Health Prep. 2018;12(4):543-551. Moitinho de Almeida M, van Loenhout JAF, Thapa SS, Kumar KC, Schlüter BS, Singh R, et al. Clinical and demographic profile of admitted victims in a tertiary hospital after the 2015 earthquake in Nepal. PLoS One. 2019;14(7):e0220016. Ministry of Health and Population, Nepal. Hospital Disaster Preparedness and Response Plan: Implementation guidelines. Kathmandu: Government of Nepal; 2017. California Hospital Association. Hospital Incident Command System (HICS) guidebook. 5th ed. Sacramento: CHA; 2014. Koenig KL, Schultz CH. Koenig and Schultz's disaster medicine: comprehensive principles and practices. 2nd ed. New York: Cambridge University Press; 2016. Barbisch D, Koenig KL. Understanding surge capacity: essential elements. Acad Emerg Med. 2006;13(11):1098-1102. Hick JL, Hanfling D, Burstein JL, DeAtley C, Barbisch D, Bogman GM, et al. Health care facility and community strategies for patient care surge capacity. Ann Emerg Med. 2004;44(3):253-261. Auf der Heide E. The importance of evidence-based disaster planning. Ann Emerg Med. 2006;47(1):34-49. Ranse J, Hutton A, Jeeawody B, Wilson R. Framework for creating an incident command center during crises. Disaster Med Public Health Prep. 2021;15(4):518-525. Hogan DE, Burstein JL. Disaster medicine. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2019. Ghimire S, Paudel K, Shrestha GK. Impact of Nepal earthquake on patients presenting for emergency care at Patan Hospital. Disaster Med Public Health Prep. 2018;13(2):211-216. Paudel P, Shrestha R, Maharjan S. Effectiveness of hospital disaster preparedness training in Nepal. Asian J Emerg Med. 2019;8(3):142-148. Sharma A, KC R, Pokharel B. Hospital surge capacity management during disasters: Lessons from Nepal. Int J Disaster Risk Reduction. 2021;58:102198. Shrestha M, Basnet S, Adhikari N. Evaluation of hospital disaster preparedness in Nepal following the 2015 earthquake. Disaster Med Public Health Prep. 2020;14(2):201-208. Thapa B, Pandey AR, Rijal K, Bista B, Pandey K, Dhungana GP, et al. Medical requirements during a natural disaster: A case study on WhatsApp chats among medical personnel during the 2015 Nepal earthquake. Disaster Med Public Health Prep. 2017;12(6):714-719. World Health Organization. Hospital safety index: Guide for evaluators. 2nd ed. Geneva: WHO Press; 2018. World Health Organization. Health emergency and disaster risk management framework. Geneva: WHO Press; 2019. Bahadur KC, Sharma N, Thapa B. Hospital disaster preparedness in Nepal: Current status and future directions. J Nepal Health Res Council. 2018;16(2):156-162. Bhandari S, Shrestha S, Kc B. Mass casualty management in resource-limited settings: Nepal's experience. Prehosp Disaster Med. 2020;35(4):423-428. Binns P, Shepard F, Krumm M. Hospital disaster preparedness: A review of current evidence and future directions. Disaster Med Public Health Prep. 2016;10(4):589-595. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 06 Feb, 2026 Reviews received at journal 06 Feb, 2026 Reviews received at journal 05 Feb, 2026 Reviewers agreed at journal 03 Feb, 2026 Reviewers agreed at journal 31 Jan, 2026 Reviewers agreed at journal 31 Jan, 2026 Reviewers agreed at journal 30 Jan, 2026 Reviewers agreed at journal 29 Jan, 2026 Reviewers agreed at journal 29 Jan, 2026 Reviewers agreed at journal 29 Jan, 2026 Reviewers agreed at journal 28 Jan, 2026 Reviews received at journal 22 Nov, 2025 Reviews received at journal 17 Nov, 2025 Reviewers agreed at journal 10 Nov, 2025 Reviewers agreed at journal 09 Nov, 2025 Reviewers invited by journal 09 Nov, 2025 Editor assigned by journal 17 Jul, 2025 Submission checks completed at journal 17 Jul, 2025 First submitted to journal 07 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Nepal","fulltext":[{"header":"Background","content":"\u003cp\u003eHospital disaster preparedness has gained increasing attention globally, particularly in disaster-prone regions like Nepal [21]. The 2015 Gorkha earthquake, which resulted in approximately 9,000 deaths and widespread destruction, highlighted critical gaps in Nepal's healthcare system's disaster response capabilities [1,2]. Studies from affected hospitals demonstrated the immediate need for systematic disaster preparedness, with one local hospital reporting a 300% increase in patient load during the first three weeks post-earthquake [3]. Additional research has documented the significant impact of the Nepal earthquake on emergency care systems, with hospitals experiencing substantial increases in trauma cases and resource strain [12]. The earthquake also highlighted the importance of communication systems during disasters, with medical personnel relying on innovative communication methods to coordinate emergency response [16]. Mass casualty management in resource-limited settings like Nepal presents unique challenges that require specialized approaches and coordination [20]. Research on hospital disaster preparedness training in Nepal has shown the importance of systematic training programs for effective emergency response [13].\u003c/p\u003e\n\u003cp\u003eIn response to these challenges, the Ministry of Health and Population of Nepal, supported by the World Health Organization, developed the Hospital Disaster Preparedness and Response Plan (HDPRP) to strengthen mass casualty management systems across the country [4]. The HDPRP framework emphasizes the importance of establishing a Hospital Incident Command System (HICS) that can be rapidly activated during emergencies. HICS is an incident management system designed specifically for hospitals, based on established incident command system protocols, and provides hospitals of all sizes with tools needed to advance their emergency preparedness and response capability [5].\u003c/p\u003e\n\u003cp\u003eInternational literature emphasizes that successful management of mass casualty incidents (MCIs) requires standardization of planning, training, and deployment of response [6]. The incident command system provides a structured approach to managing complex emergency situations, ensuring clear lines of authority and communication [7]. Studies have shown that hospitals with established incident command systems demonstrate improved response times and better resource allocation during emergencies [8]. The goal of mass casualty management is to apply available medical resources most effectively to mass casualty incident victims to do the \"most good for the most people\" [9].\u003c/p\u003e\n\u003cp\u003eThis case report documents the first reported real-world implementation of Nepal's HDPRP framework during a bus accident response at Dhaulagiri Hospital, Baglung. The experience provides valuable insights into the practical application of disaster preparedness protocols in a resource-limited setting and offers lessons for improving hospital disaster response capabilities.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003e\u003cstrong\u003eIncident Overview\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOn 03/24/2025, Dhaulagiri Hospital, Baglung, received information about a bus accident at Nishikhola, Burtibang, involving 26 casualties. The incident occurred when a passenger bus traveling on a mountainous route lost control and overturned, resulting in multiple injuries ranging from minor trauma to critical conditions requiring immediate medical intervention.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInitial Response and Activation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe initial notification was received by Dr. Rekha, the Acting Medical Superintendent, who immediately activated the hospital's disaster response protocol. Information was disseminated through the hospital's messenger group, ensuring rapid communication to all relevant staff members. The Hospital Incident Command System (HICS) was formally activated within the first hour of notification, and the disaster focal person was notified.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHospital Incident Command System Structure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe HICS team comprised six key members, each with specific roles and responsibilities:\u003c/p\u003e\n\u003cp\u003e1. \u003cstrong\u003eIncident Commander (Dr. Rekha):\u003c/strong\u003e Overall coordination and decision-making authority\u003c/p\u003e\n\u003cp\u003e2. \u003cstrong\u003eDisaster Focal Person (Dr. Amit):\u003c/strong\u003e Liaison between command and operational teams\u003c/p\u003e\n\u003cp\u003e3. \u003cstrong\u003eOperational Manager (Dr. Abhishesh):\u003c/strong\u003e Clinical operations oversight\u003c/p\u003e\n\u003cp\u003e4. \u003cstrong\u003eLogistics Officer (Shanti Sister):\u003c/strong\u003e Resource management and supply coordination\u003c/p\u003e\n\u003cp\u003e5. \u003cstrong\u003eInformation Officer (Navaraj Sir):\u003c/strong\u003e Communication and media management\u003c/p\u003e\n\u003cp\u003e6. \u003cstrong\u003eAdministrative Officer (Bhagawati Mam):\u003c/strong\u003e Administrative coordination and support\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOperational Response Implementation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCommand and Control\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e· HICS meeting conducted in the designated office\u003c/p\u003e\n\u003cp\u003e· HDPRP document reviewed and operational team finalized\u003c/p\u003e\n\u003cp\u003e· Clear job descriptions distributed to all team members\u003c/p\u003e\n\u003cp\u003e· Regular coordination meetings held throughout the response\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Operations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e· Emergency department evacuated of routine patients\u003c/p\u003e\n\u003cp\u003e· Triage areas established with red, yellow, and green zones\u003c/p\u003e\n\u003cp\u003e· Additional beds arranged in pre-designated areas\u003c/p\u003e\n\u003cp\u003e· Medical staff duty roster implemented for continuous coverage\u003c/p\u003e\n\u003cp\u003e· Clinical rounds conducted every few hours for treatment plan updates\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLogistics and Resource Management\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e· Blood bank alerted and prepared for potential transfusion needs\u003c/p\u003e\n\u003cp\u003e· Laboratory and radiology departments placed on standby\u003c/p\u003e\n\u003cp\u003e· Emergency supplies verified and organized, including:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eo 50 units each of Normal Saline and Ringer's Lactate\u003c/p\u003e\n\u003cp\u003eo 50 IV administration sets\u003c/p\u003e\n\u003cp\u003eo Medical equipment from multiple departments\u003c/p\u003e\n\u003cp\u003eo Oxygen cylinders distributed across treatment areas\u003c/p\u003e\n\u003cp\u003eo Resuscitation equipment and medications\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExternal Coordination\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e· Referral mechanism activated through District Administrative Office\u003c/p\u003e\n\u003cp\u003e· Manipal Hospital and Western Regional Hospital designated as referral centers\u003c/p\u003e\n\u003cp\u003e· Ambulance services coordinated for patient transfers\u003c/p\u003e\n\u003cp\u003e· Nepal Police engaged for crowd control and security\u003c/p\u003e\n\u003cp\u003e· Health Emergency Operations Center (HEOC) and Provincial Health Emergency Operations Center (PHEOC) notified\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient Care and Support\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e· Zero billing policy implemented for all accident victims\u003c/p\u003e\n\u003cp\u003e· Comprehensive medical care provided across all triage categories\u003c/p\u003e\n\u003cp\u003e· Food arrangements made for patients and visitors\u003c/p\u003e\n\u003cp\u003e· Clothing provided to victims with torn garments\u003c/p\u003e\n\u003cp\u003e· Psychological support and counseling services offered\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll 26 casualties were successfully received and treated at the hospital. The triage system effectively categorized patients based on injury severity, allowing for appropriate resource allocation. Only 2 patients required referral to higher-level facilities for specialized care. No mortality occurred during the hospital stay, and minimal complications were reported during the treatment period.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOperational Effectiveness\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe HICS activation was completed within the first hour of notification, demonstrating the effectiveness of pre-established protocols. Smooth coordination between all command structure elements facilitated efficient resource mobilization and utilization. The hospital successfully managed the increased patient volume with minimal disruption to routine operations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChallenges and Adaptations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeveral challenges were encountered and successfully addressed:\u003c/p\u003e\n\u003cp\u003e· Green zone relocated due to cold weather conditions\u003c/p\u003e\n\u003cp\u003e· Store coordination required for additional supplies from external pharmacies\u003c/p\u003e\n\u003cp\u003e· Initial concern about potential helicopter rescue requirements\u003c/p\u003e\n\u003cp\u003e· Management of increased visitor volume and media attention\u003c/p\u003e\n\u003cp\u003e· Adjustment of routine emergency services during peak response\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis case report represents the first documented real-world implementation of Nepal's HDPRP framework during a significant mass casualty incident. The successful management of 26 casualties with minimal referrals demonstrates the effectiveness of structured disaster preparedness protocols in resource-limited settings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eKey Success Factors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePre-established Protocols:\u003c/strong\u003e The existence of a written HDPRP document with clear procedures enabled rapid activation and systematic response. This preparation was crucial in ensuring an organized response rather than ad-hoc crisis management.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCommand Structure:\u003c/strong\u003e The six-member HICS provided clear leadership and coordination mechanisms. The designated roles prevented confusion and ensured efficient resource utilization, aligning with international best practices that emphasize establishing incident command as soon as possible [5,7].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInter-agency Coordination:\u003c/strong\u003e The successful coordination with district administration, referral hospitals, and emergency services exemplifies the importance of external partnerships in disaster response. This aligns with global standards that emphasize multi-agency collaboration in mass casualty management [6,10].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResource Preparedness:\u003c/strong\u003e The systematic verification and deployment of medical supplies, equipment, and personnel demonstrated effective logistics management. The ability to maintain adequate inventory while sourcing additional supplies from external sources showed flexibility and resourcefulness [8,11].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCommunity Support:\u003c/strong\u003e The zero billing policy and comprehensive care including food and clothing reflected a holistic approach to disaster response, addressing not only medical needs but also social and psychological aspects of patient care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLessons Learned\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrengths identified include:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e· Rapid activation: HICS was operational within one hour of notification\u003c/p\u003e\n\u003cp\u003e· Clear communication: Effective use of messenger groups and established communication channels\u003c/p\u003e\n\u003cp\u003e· Comprehensive care: Attention to medical, social, and psychological needs of victims\u003c/p\u003e\n\u003cp\u003e· Resource efficiency: Minimal external referrals despite significant casualty load\u003c/p\u003e\n\u003cp\u003e· Documentation: Proper recording of patient information and response activities\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAreas for improvement include:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e· Environmental considerations: Initial green zone location required modification due to weather\u003c/p\u003e\n\u003cp\u003e· Supply chain: Need for better coordination with external pharmacies and suppliers\u003c/p\u003e\n\u003cp\u003e· Surge capacity: Consideration of helicopter evacuation capabilities for future incidents\u003c/p\u003e\n\u003cp\u003e· Training: Regular drills and simulations to maintain readiness, as research has shown the effectiveness of systematic hospital disaster preparedness training programs [13]\u003c/p\u003e\n\u003cp\u003e· Technology: Enhanced communication systems for better coordination, building on lessons learned about the importance of communication technology during disasters [16]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications for Policy and Practice\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis experience provides valuable evidence for the effectiveness of Nepal's HDPRP framework and suggests several policy implications [14,15,17,18,19]. The experience demonstrates that systematic approaches to hospital disaster preparedness can be successfully implemented even in resource-limited settings, building on Nepal's broader experience with mass casualty management [20]:\u003c/p\u003e\n\u003cp\u003e1. \u003cstrong\u003eStandardization:\u003c/strong\u003e The success of this response supports continued implementation of HDPRP across Nepal's healthcare system\u003c/p\u003e\n\u003cp\u003e2. \u003cstrong\u003eTraining:\u003c/strong\u003e Regular training and simulation exercises are essential for maintaining readiness\u003c/p\u003e\n\u003cp\u003e3. \u003cstrong\u003eResource allocation:\u003c/strong\u003e Investment in emergency supplies and equipment is justified\u003c/p\u003e\n\u003cp\u003e4. \u003cstrong\u003eInter-agency cooperation:\u003c/strong\u003e Formal agreements with referral hospitals and emergency services should be established\u003c/p\u003e\n\u003cp\u003e5. \u003cstrong\u003eTechnology integration:\u003c/strong\u003e Digital systems should be developed to enhance response capabilities\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis case report has several limitations: it represents a single institution experience that may not be generalizable to all hospital settings; the response to traffic accidents may differ from other disaster types; Dhaulagiri Hospital may have better resources than rural facilities; some aspects of the response may not be fully captured in documentation; and long-term outcomes and patient satisfaction data are not available.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe Burtibang bus accident response at Dhaulagiri Hospital demonstrates the successful implementation of Nepal's Hospital Disaster Preparedness and Response Plan in a real-world scenario. The systematic activation of the Hospital Incident Command System, effective coordination of resources, and comprehensive patient care resulted in excellent clinical outcomes with minimal external referrals.\u003c/p\u003e\n\u003cp\u003eThis experience validates the importance of structured disaster preparedness protocols and provides valuable insights for improving hospital emergency response capabilities in resource-limited settings. The success factors identified - pre-established protocols, clear command structure, inter-agency coordination, and comprehensive resource mobilization - offer practical guidance for other healthcare institutions seeking to enhance their disaster preparedness.\u003c/p\u003e\n\u003cp\u003eAs Nepal continues to face various natural and man-made disasters, the experience at Dhaulagiri Hospital serves as a model for effective hospital disaster response and demonstrates the potential for achieving excellent outcomes through proper preparation and systematic implementation of evidence-based protocols.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAW conceived the study, participated in the disaster response, and drafted the manuscript. RS participated in data collection and manuscript revision. AD participated in the disaster response coordination and manuscript review. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors acknowledge the dedication and professionalism of all hospital staff who participated in the disaster response. We also thank the District Administrative Office,Baglung, Nepal Police, and referral hospitals for their collaboration during the emergency response.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eHall ML, Lee AC, Cartwright C, Marahatta S, Karli J, Simkhada P. The 2015 Nepal earthquake disaster: lessons learned one year on. Public Health. 2017;145:39-44.\u003c/li\u003e\n \u003cli\u003ePandey NR, Lamsal R, Karim R, Shrestha ML. The health sector response to the 2015 earthquake in Nepal. Disaster Med Public Health Prep. 2018;12(4):543-551.\u003c/li\u003e\n \u003cli\u003eMoitinho de Almeida M, van Loenhout JAF, Thapa SS, Kumar KC, Schl\u0026uuml;ter BS, Singh R, et al. Clinical and demographic profile of admitted victims in a tertiary hospital after the 2015 earthquake in Nepal. PLoS One. 2019;14(7):e0220016.\u003c/li\u003e\n \u003cli\u003eMinistry of Health and Population, Nepal. Hospital Disaster Preparedness and Response Plan: Implementation guidelines. Kathmandu: Government of Nepal; 2017.\u003c/li\u003e\n \u003cli\u003eCalifornia Hospital Association. Hospital Incident Command System (HICS) guidebook. 5th ed. Sacramento: CHA; 2014.\u003c/li\u003e\n \u003cli\u003eKoenig KL, Schultz CH. Koenig and Schultz\u0026apos;s disaster medicine: comprehensive principles and practices. 2nd ed. New York: Cambridge University Press; 2016.\u003c/li\u003e\n \u003cli\u003eBarbisch D, Koenig KL. Understanding surge capacity: essential elements. Acad Emerg Med. 2006;13(11):1098-1102.\u003c/li\u003e\n \u003cli\u003eHick JL, Hanfling D, Burstein JL, DeAtley C, Barbisch D, Bogman GM, et al. Health care facility and community strategies for patient care surge capacity. Ann Emerg Med. 2004;44(3):253-261.\u003c/li\u003e\n \u003cli\u003eAuf der Heide E. The importance of evidence-based disaster planning. Ann Emerg Med. 2006;47(1):34-49.\u003c/li\u003e\n \u003cli\u003eRanse J, Hutton A, Jeeawody B, Wilson R. Framework for creating an incident command center during crises. Disaster Med Public Health Prep. 2021;15(4):518-525.\u003c/li\u003e\n \u003cli\u003eHogan DE, Burstein JL. Disaster medicine. 4th ed. Philadelphia: Lippincott Williams \u0026amp; Wilkins; 2019.\u003c/li\u003e\n \u003cli\u003eGhimire S, Paudel K, Shrestha GK. Impact of Nepal earthquake on patients presenting for emergency care at Patan Hospital. Disaster Med Public Health Prep. 2018;13(2):211-216.\u003c/li\u003e\n \u003cli\u003ePaudel P, Shrestha R, Maharjan S. Effectiveness of hospital disaster preparedness training in Nepal. Asian J Emerg Med. 2019;8(3):142-148.\u003c/li\u003e\n \u003cli\u003eSharma A, KC R, Pokharel B. Hospital surge capacity management during disasters: Lessons from Nepal. Int J Disaster Risk Reduction. 2021;58:102198.\u003c/li\u003e\n \u003cli\u003eShrestha M, Basnet S, Adhikari N. Evaluation of hospital disaster preparedness in Nepal following the 2015 earthquake. Disaster Med Public Health Prep. 2020;14(2):201-208.\u003c/li\u003e\n \u003cli\u003eThapa B, Pandey AR, Rijal K, Bista B, Pandey K, Dhungana GP, et al. Medical requirements during a natural disaster: A case study on WhatsApp chats among medical personnel during the 2015 Nepal earthquake. Disaster Med Public Health Prep. 2017;12(6):714-719.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. Hospital safety index: Guide for evaluators. 2nd ed. Geneva: WHO Press; 2018.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. Health emergency and disaster risk management framework. Geneva: WHO Press; 2019.\u003c/li\u003e\n \u003cli\u003eBahadur KC, Sharma N, Thapa B. Hospital disaster preparedness in Nepal: Current status and future directions. J Nepal Health Res Council. 2018;16(2):156-162.\u003c/li\u003e\n \u003cli\u003eBhandari S, Shrestha S, Kc B. Mass casualty management in resource-limited settings: Nepal\u0026apos;s experience. Prehosp Disaster Med. 2020;35(4):423-428.\u003c/li\u003e\n \u003cli\u003eBinns P, Shepard F, Krumm M. Hospital disaster preparedness: A review of current evidence and future directions. Disaster Med Public Health Prep. 2016;10(4):589-595.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijem","sideBox":"Learn more about [International Journal of Emergency Medicine](https://intjem.biomedcentral.com/)","snPcode":"12245","submissionUrl":"https://submission.nature.com/new-submission/12245/3","title":"International Journal of Emergency Medicine","twitterHandle":"@IntJEmergMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Hospital disaster preparedness, mass casualty incident, Nepal, HDPRP, incident command system, emergency response, bus accident","lastPublishedDoi":"10.21203/rs.3.rs-7069428/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7069428/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Nepal's mountainous terrain and frequent natural disasters necessitate robust hospital disaster preparedness systems. The Hospital Disaster Preparedness and Response Plan (HDPRP) was developed following the 2015 Nepal earthquake to enhance mass casualty management capabilities in healthcare facilities. This case report documents the first real-world implementation of Nepal's HDPRP framework during a bus accident at Dhaulagiri Hospital, Baglung.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase Presentation:\u003c/strong\u003e A passenger bus accident at Nishikhola, Burtibang resulted in 26 casualties requiring immediate medical attention. Dhaulagiri Hospital activated its Hospital Incident Command System (HICS) within one hour of notification. A six-member command structure coordinated the response, including incident command, disaster focal person, operational manager, logistics officer, information officer, and administrative officer. The hospital implemented comprehensive emergency protocols including triage, resource mobilization, zero billing policy, and inter-agency coordination. All 26 casualties were successfully managed with only two requiring referral to higher-level facilities. No mortality occurred during the hospital stay.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e This case demonstrates successful implementation of Nepal's HDPRP framework in a real-world mass casualty incident. Key success factors included pre-established protocols, designated command structure, effective inter-agency coordination, and comprehensive resource mobilization. The experience validates the effectiveness of structured disaster preparedness protocols in resource-limited settings and provides valuable insights for improving hospital emergency response capabilities.\u003c/p\u003e","manuscriptTitle":"Successful Implementation of Hospital Disaster Preparedness and Response Plan During Mass Casualty Bus Accident: A Case Report from Nepal","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-19 03:16:05","doi":"10.21203/rs.3.rs-7069428/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-06T22:40:56+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-06T12:32:13+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-05T23:00:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"267384289341052479224305794916578748231","date":"2026-02-03T05:28:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"287205421475655303276290532839940746201","date":"2026-01-31T16:51:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"267653682874872972087940252961242470230","date":"2026-01-31T06:29:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"164332144405450752618595377908742777928","date":"2026-01-30T22:22:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"301356995893491057409850426957949062008","date":"2026-01-29T20:56:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"57020833732903166139532347285943036041","date":"2026-01-29T18:51:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"66043030579526023488523760399190510767","date":"2026-01-29T05:16:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"33904655381988485666588958484285575677","date":"2026-01-29T03:00:56+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-22T07:20:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-17T18:11:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"254746836050475463793109910979736430666","date":"2025-11-10T06:25:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"289432660800794690735279666073545383332","date":"2025-11-10T03:29:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-10T00:26:01+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-18T02:02:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-18T02:01:49+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Emergency Medicine","date":"2025-07-08T01:27:18+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijem","sideBox":"Learn more about [International Journal of Emergency Medicine](https://intjem.biomedcentral.com/)","snPcode":"12245","submissionUrl":"https://submission.nature.com/new-submission/12245/3","title":"International Journal of Emergency Medicine","twitterHandle":"@IntJEmergMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c933252d-537c-4474-84e1-f6c30eee22a4","owner":[],"postedDate":"November 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-02-06T22:53:43+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-19 03:16:05","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7069428","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7069428","identity":"rs-7069428","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}