Review www.thelancet.com Vol 379 June 2, 2012 2109 Lancet 2012; 379: 2109–15 Published Online April 16, 2012 DOI:10.1016/S0140- 6736(12)60313-4 University of Otago, Christchurch, New Zealand (Prof M W Ardagh PhD, S K Richardson PG Dip Heal Sci); Christchurch Hospital, Christchurch, New Zealand (V Robinson R Comp N, M Than MBBS, P Gee MBChB, S Henderson MBChB, L Khodaverdi MBChB, J McKie MBChB, G Robertson MBChB); Rolleston Medical Centre, Rolleston, New Zealand (P P Schroeder MBChB); and Canterbury District Health Board, Christchurch, New Zealand (J M Deely PhD) Correspondence to: Prof Michael Ardagh, University of Otago (Christchurch), Emergency Department, Christchurch Hospital, Private Bag 4710, Christchurch, New Zealand michael.ardagh@cdhb.govt.nz The initial health-system response to the earthquake in Christchurch, New Zealand, in February, 2011 Michael W Ardagh, Sandra K Richardson, Viki Robinson, Martin Than, Paul Gee, Seton Henderson, Laura Khodaverdi, John McKie, Gregory Robertson, Philip P Schroeder, Joanne M Deely At 1251 h on Feb 22, 2011, an earthquake struck Christchurch, New Zealand, causing widespread destruction. The only regional acute hospital was compromised but was able to continue to provide care, supported by other hospitals and primary care facilities in the city. 6659 people were injured and 182 died in the initial 24 h. The massive peak ground accelerations, the time of the day, and the collapse of major buildings contributed to injuries, but the proximity of the hospital to the central business district, which was the most affected, and the provision of good medical care based on careful preparation helped reduce mortality and the burden of injury. Lessons learned from the health response to this earthquake include the need for emergency departments to prepare for: patients arriving by unusual means without prehospital care, manual registration and tracking of patients, patient reluctance to come into hospital buildings, complete loss of electrical power, management of the many willing helpers, alternative communication methods, control of the media, and teamwork with clear leadership. Additionally, atypical providers of acute injury care need to be integrated into response plans. Introduction Christchurch City (figure) has an urban population of about 400 000. On Tuesday Feb 22, 2011, at 1251 h local time, a 6·3 magnitude earthquake struck Christchurch. Its epicentre was 5 km deep, and 10 km southeast of the city centre (figure). 1 Peak ground accelerations were among the highest recorded from this type of earthquake. 1–3 Destruction and liquefaction were widespread. 1 The central business district was extensively damaged, with two multistorey buildings collapsing, many others partly collapsing, and large amounts of rubble falling into the streets. A combination of high peak ground accelerations, the time of day, and the collapse of buildings resulted in injury and loss of life (table 1). This report is presented in three major sections. The first section describes Christchurch Hospital’s preparedness for a mass casualty event. The second section describes the challenges faced, health-care response, and injury burden within the first 24 h after the earthquake. The final discussion section reviews the response and injury burden in the context of responses to international earthquakes of similar magnitude in urban areas of high-income coun- tries and outlines the lessons learned. Preparedness Health system New Zealand has a publically funded health system with injury care funded by the Accident Compensation Corporation. Access to hospital care is free, and access to primary care is subsidised. A private health system operates in parallel. Panel 1 provides details of how the Accident Compensation Corporation scheme operates and how we collected injury data. Christchurch has seven hospitals (figure). The Christ- church Hospital campus is on the western edge of the central business district (figure). Christchurch Hospital is the only acute hospital in Christchurch, with an emergency department, an intensive-care unit (ICU), and a full range of tertiary hospital surgical and medical services. 15 It has a maximum capacity of 600–50 beds. The emergency department has full accreditation from the Australasian College for Emergency Medicine for emergency physician training and, at the time of the earthquake, was seeing an average of 220 new patients daily with an inpatient admission rate of about 48%. Mass casualty incident plan During a mass casualty incident response, the inter- national disaster colour triage differentiation is applied in the emergency department (panel 2). A senior doctor and nurse assume the roles of medical and nursing controllers, and doctors and nurses are assigned leadership roles for each of the colour-coded areas. Under their direction medical staff are assembled into teams and directed to patients. Medical controllers responsible for surgery, anaesthesia, and ICU attend the emergency department. Each department has its own sub-plan and a hospital control room is established. 18 Patients are tracked with papers prelabelled with preallocated unique identifier numbers, kept in packs with prelabelled assessment, radiology, and laboratory request forms. A pack is pinned to each patient’s clothing on arrival. 500 packs were available for immediate use in February, 2011. The plan is rehearsed annually and has been implemented in response to major multivehicle road accidents, chemical leaks, fires, and a passenger train crash. On Sept 4, 2010, the plan was activated in response to an earthquake 40 km west of Christchurch, which resulted in 97 earthquake- related presentations to Christchurch Hospital, including three serious injuries, but no deaths. 0–24 h after the earthquake Challenges During the earthquake the hospital was subjected to severe shaking. Staff could not stand unaided, trolleys