Axel R. Heller, Amelie Oberst, Dennis M. Ritter
The increasing complexity of modern threats, from pandemics and cyberattacks to hybrid and conventional forms of warfare, requires a paradigm shift in disaster preparedness at medical facilities. Building on experiences from the war in Ukraine, business continuity management and a consistent all-hazards approach, a multilevel, practical resilience model for hospitals is presented. In the context of alliance and national defense, civilian hospitals assume the role of military level 4 facilities. They must be able to cold start and receive and stabilize wounded patients while maintaining regular care and transfer them onward in a scalable manner. To this end, military medical evacuation and distribution systems must be integrated in an interoperable manner.The approach integrates a legally robust procedural framework (disaster declaration, general administrative orders, medical management, hospital coordination) with operational capacity (resource-independent triage at entry, damage control resuscitation/surgery, chemical, biological, radiological, nuclear (CBRN) minimum protection standard) as well as hybrid documentation and communication (paper-based mode, digital coordination instruments, bed occupancy, wave plan/tickets, defined fallbacks). Resources are allocated without discrimination according to urgency and clinical prospects of success, supported by re-evaluation and the multiple assessor principle.In clinical operations, interdisciplinary anesthesiological and intensive care cross-sectional services make an essential contribution to maintaining overall system functionality. This includes, in particular, the management of intensive care capacity. These functions act in a complementary and cooperative manner alongside core surgical services, embedded within a multiprofessional and multidisciplinary framework.A staged resilience roadmap prioritizes upgrades to existing facilities (emergency power/water, protected operating room/ICU cores), network and cooperation structures and staff training; large-scale new construction is a lower priority. In addition, supplementary curricular qualifications (e.g. nursing assistant and emergency medical services modules for students) and binding funding commitments for training, infrastructure, supplies and cyber/IT resilience are required. The resulting synthesis of operational, ethical, legal and infrastructural elements anchors a highly resilient, interoperable care architecture that reliably preserves clinical functionality, decision-making ability and moral integrity even under extremely challenging conditions.