Establishing Welfare Evacuation Shelters for Children With Medical Complexity: A Prefecture-Wide Policy Shift Driven by Simulation in Tottori, Japan

Children with medical complexity (CMC) are highly vulnerable during disasters, yet few Japanese welfare evacuation shelters accept them, leading to hospital-dependent planning. We aimed to assess the key issues hindering the establishment of welfare evacuation shelters for CMC.

In Tottori Prefecture (2020-2024), the government, municipalities, a university hospital, and device partners used facility assessments, staff education, and tabletop/field simulations (weekday earthquake with power outage and ventilator-dependent 5-year-old model) to identify gaps and iteratively revise manuals.

Key issues included space underestimation, difficult mobility, power insecurity, unreliable verbal information, unclear deterioration pathways, and undefined public health nurse (PHN) roles. Revisions established PHN-led reception/triage, standardized information collection, specified power sourcing, and set escalation/transport flows. A section on "Persons Requiring Medical Care" was added to prefectural policies, and the disaster medical guidance was updated, shifting preparedness from hospital-centered to shelter-based welfare.

This simulation-driven intersectoral model appears scalable; however, it was performed in a single prefecture with limited follow-up, impairing generalizability.