Introduction: With the increasing availability of longer-range missiles and explosive-carrying unmanned aerial vehicles, the risk to civilian targets, including hospitals, has increased worldwide. Recent events place Israeli cities and hospitals at high risk of such attacks. Following four months of preparations, a large-scale missile attack drill was conducted at Beilinson Tertiary Medical Center. Drill components included missile strikes on hospital buildings, followed by a multi-casualty chemical incident caused by a missile strike on a HAZMAT container. Methods: Descriptive analysis of the drill design, preparatory actions, and after-action reports. Results: Preparations included: re-training hospital staff on the actions during an imminent missile strike, training of ED and ED staff reinforcements on logistical and medical preparedness for mass casualty chemical incidents. The drill scenario included structural damage to four hospital wards. Injured patients and staff members were evacuated to the ED, and a rapid safety assessment was performed, leading to the decision to evacuate them. In the following stage, over 50 simulated chemical injury patients from a nearby explosion were transported by EMS to the hospital. Insights gained from the second stage highlight the need to improve staff preparedness for mass chemical incidents, communication, and command and control challenges by fully training personnel in decontamination areas. There was a personnel shortage in the decontamination areas operating in the ED ambulance bay, and frequent staff rotations were needed due to fatigue. Staff training on actions during a pre-strike alarm, post missile strike safety assessment, and ward evacuation proved effective. Conclusion: A hospital missile strike scenario is extremely challenging. It requires enhancing hospital preparedness, focusing on rapid actions during a pre-strike alarm and post-strike care and evacuation of the injured. It also requires immediate assessment of post-attack structural safety and the need for complete evacuation of structurally unsafe hospital areas. Difficulties included assuring patient flow and command and control during decontamination.
Schwartz et al. (Sun,) studied this question.