Development of documentation for a medical institution under Resolution No. 1158 during an air raid alert

During an air raid alert, a medical institution must simultaneously protect its employees and patients and avoid interrupting care where doing so would be dangerous. We develop internal documents for medical institutions under Resolution of the Cabinet of Ministers of Ukraine No. 1158, taking into account the services they provide, as well as the premises, shelter, movement routes and staff responsibilities.

The result is a set of rules that clearly explains what administrators, doctors and nurses should do at yellow and red threat levels, who is responsible for patients who cannot move independently, and where care should continue if transportation is impossible.

Why a ready-made template is not enough for a clinic

It is easy to write “everyone goes to the shelter” in a template. However, at that moment, a procedure under anaesthesia may still be taking place in your operating theatre. The phrase “medical staff continue working” is also not appropriate for everyone: a scheduled appointment can be stopped, while employees can be moved to a safer location. The boundary between these situations must be defined for the specific services provided by the institution.

Likewise, a template will not show whether a stretcher can pass through corridors and stairways to the designated shelter, how many people are needed to move a patient, or which room should be used if the patient’s condition or available time does not allow them to reach the shelter. Under the Procedure, the decision on whether medical care can be interrupted or a patient can be moved is made by the attending physician or, in their absence, the doctor on duty, in accordance with the algorithm approved by the head of the institution. Therefore, the algorithm should describe the actual options available in your clinic.

It is also important to define the procedure after the air raid alert ends: how to resume patient appointments, what to do with the queue, which procedures in the inpatient department should be prioritised, and which can be cancelled or rescheduled.

What we review before preparing the documents

• Medical processes. We determine which procedures can be stopped immediately, which require time for safe completion, and which types of care cannot be interrupted: for example, anaesthetic support, intensive care or emergency care, if such services are provided by the institution.
• Schemes and routes. We determine who can be moved to the shelter, who requires assistance from staff, and who should remain in place; we review the route description and the room with the lowest risk of harm.
• Staff operations. We allocate actions by department and threat level, determine responsible persons and replacements during their absence. We align decisions with current occupational safety rules and the institution’s employment documents.
• Information. We consider how staff, patients and visitors will be informed about the alert, the location of the shelter and the procedure for further actions, as well as what information should be recorded in the documents.

List of documents

Based on the analysis, we prepare a package for your institution. It includes the documents listed below; their content and appendices depend on the type of care, layout of the premises and availability of a shelter.

• Order “On organising work during an air raid alert”. Records the head’s decision, brings the algorithms into force and identifies the responsible persons.
• Regulation on organising work during an air raid alert. Describes the institution’s actions according to threat levels, the procedure for stopping or continuing care and moving people.
• Scheme or description of the route to the shelter. Shows the route for employees and visitors and separately takes into account the movement of patients who require assistance.
• Guidance for patients and visitors on actions in the event of an “Air Raid Alert” signal. Provides clear information about notification, shelter and actions during the alert.
• Voluntary patient consent to the provision and/or continuation of medical care during an air raid alert. Prepared as a separate form for appropriate situations; its use is aligned with the institution’s medical processes. It does not replace consent to medical intervention required by law and does not release the clinic from its safety obligations.
• Confirmation that the patient has been informed about the procedure to follow in the event of an air raid alert. Helps record what information the patient received before care began or continued.
• Minutes of the general meeting of the workforce and the registration sheet attached to them. We prepare these for cases where approval of work in the absence of a shelter is required in accordance with Resolution of the Cabinet of Ministers of Ukraine No. 1092.

The list is not limited to these documents. Depending on the institution, we add to the order or regulation algorithms for departments, a list of processes that cannot be stopped within a reasonable period, the procedure for completing them, a list of safer premises, persons responsible for moving patients and their replacements. If existing occupational safety instructions conflict with the new procedure, we determine what needs to be updated.

Work with such documents can form part of legal support for medical institutions or be a separate project for a clinic, medical centre or another healthcare provider.

How the work is carried out

First, we review the institution’s services, schedules and staff roles, existing orders and instructions, the floor plan, shelter and possible routes. We then agree with the head and medical team on solutions for situations where evacuation and continuity of care intersect. Based on this, we prepare the documents and provide them for approval and implementation.

An order on paper does not in itself ensure compliance with the rules. After approval, employees must be informed of their actions, appropriate briefings must be conducted, and the designation of responsible persons and routes must be kept up to date.

Why this is important for the head of the institution

Resolution of the Cabinet of Ministers of Ukraine No. 1158 does not cancel the requirements of labour legislation and occupational safety. Article 153 of the Labour Code of Ukraine places an obligation on the employer to create safe working conditions. If an employee is injured during an attack, not only the wording of the order will matter, but also the actual conditions, the justification for the decision to leave the employee at the workplace, the briefings and compliance with the algorithm. Where the grounds provided by law exist, including a proven causal link between a violation of occupational safety requirements and harm, the issue of liability under Article 271 of the Criminal Code of Ukraine may arise.

Preparation of internal algorithms is also advisable during a review of the Licensing Conditions for medical practice and when updating the institution’s internal documentation.

Do you need documents for your institution? Submit a request, and we will determine the composition of the package taking into account your services, premises and organisation of work.