Recent events have brought disaster medicine into the public focus. Both the government and communities expect hospitals to be prepared to cope with all types of emergencies. Disaster simulations are the traditional method of testing hospital disaster plans, but a recent, comprehensive, literature review failed to find any substantial scientific data proving the benefit of these resource and time-consuming exercises.

The objective of this study was to test the hypothesis that an audiovisual presentation of the hospital disaster plans followed by a simulated disaster exercise and debriefing improved staff knowledge, confidence, and hospital preparedness for disasters.

A survey of 50 members of the medical, nursing, and administrative staff were chosen from a pool of approximately 170 people likely to be in a position of responsibility in the event of a disaster.The pre-intervention survey tested factual knowledge as well as perceptions about individual and departmental preparedness. Post-intervention, the same 50 staff members were asked to repeat the survey, which included additional questions establishing their involvement in the exercise.

There were 50 pre-intervention tests and 42 post-intervention tests. The intervention resulted in a significant improvement in test pass rate: preintervention pass rate 9/50 (18%, 95% confidence interval ((CI) = 16.1–19.9%) versus post-intervention pass rate 21/42 (50%, 95% CI = 42.4–57.6%; X2 test, p = 0.002). Emergency department (ED) staff had a stronger baseline knowledge than non-ED staff: ED pre-test mean value for scores = 12.1 versus nonED scores of 6.2 (difference 5.9, 95% CI = 3.3–8.4); t-test, p <0.001. Those that attended >1 component had a greater increase in mean scores: increase in mean attendees was 5.6, versus the scores of non-attendees of 2.7 (difference 2.9, 95% CI = 1.0–4.9); t-test, p = 0.004. There was no significant increase in the general perception of preparedness. However, the majority of those surveyed described the exercise of benefit to themselves (53.7%,95% CI = 45.5–61.8%) and their department (63.2%, 95% CI = 53.5–72.8%).

The disaster exercise and educational process had the greatest benefit for individuals and departments involved directly. The intervention also prompted enterprise-wide review, and an upgrade of disaster plans at departmental levels. Pre-intervention knowledge scores were poor. Post-intervention knowledge base remained suboptimal, despite a statistically significant improvement. This study supports the widely held belief that disaster simulation is a worthwhile exercise, but more must be done. More time and resources must be dedicated to the increasingly important field of hospital disaster preparedness.

There is a growing interest in cases in which emergency medical services (EMS) providers evaluate a patient, but do not transport the patient to a hospital. A subset of these cases, the patient-initiated refusal (PIR) in which the patient refused care and transport, was studied and evaluated. The objectives of the study were to examine the adequacy of ambulance call report documentation in PIR, to examine the clinical outcome of these patients in one hospital-based, suburban EMS system, and to assess the potential impact of on-line medical command (OLMC) on cases of PIR.

The system studied is a hospital-based, transport-capable, advanced life support service in a suburban EMS system, with an annual call volume of 4,200 runs. During the 6-month study period, all ambulance call reports completed by the paramedics and medical command control forms completed by medical command physicians were examined, and cases of PIR collected. Each ambulance call report was examined for adequacy of documentation. Patient outcome was determined from emergency department records and telephone follow-up.

Eighty-five PIRs were documented during the study period. Four cases were excluded because of a missing ambulance call reports and/or medical command control forms, leaving 81 PIRs for analysis. Despite policy requiring OLMC in cases of PIR, OLMC was established in only 23 PIRs (28%). Of these, two (9%) had inadequate ambulance call report documentation. Of the 58 PIR in which OLMC was not established, 25 (43%) had inadequate ambulance call report documentation (p <0.001, Fisher's exact test). Follow-up was obtained for 54 (67%) PIR. Of these, 37 (68%) did not subsequently see a physician, and all needed no further medical care. Seven (13%) saw their own physicians within a few days of the initial refusal of prehospital care, and had no further problems. Ten patients were seen in an emergency department within a few days. Three (6%) were discharged, and did well. Seven (13%) were admitted to the hospital, with four (7%) admitted to monitored beds, and three (6%) to unmonitored beds. There were no deaths.

Ambulance call report documentation is better with OLMC than without. Patients who initially refuse care may be ill, and some ultimately will be hospitalized. Further research may elucidate a role for OLMC in preventing refusals by incompetent patients, convincing patients who are competent but appear ill to accept transport, and assisting paramedics with other difficult or unusual circumstances.

Public health agencies have been participating in emergency preparedness exercises for many years. A poorly designed or executed exercise, or an unevaluated or inadequately evaluated plan, may do more harm than good if it leads to a false sense of security, and results in poor performance during an actual emergency. At the time this project began, there were no specific standards for the public health aspects of exercises and drills, and no defined criteria for the evaluation of agency performance in public health.

The objective of this study was to develop defined criteria for the evaluation of agency performance.

A Delphi panel of 26 experts in the field participated in developing criteria to assist in the evaluation of emergency exercise performance, and facilitate measuring improvement over time. Candidate criteria were based on the usual parts of an emergency plan and three other frameworks used elsewhere in public health or emergency response.

The response rate from the expert panel for Delphi Round I was 74%, and for Delphi Round II was 55%. This final menu included 46 public health-agency level criteria grouped into nine categories for use in evaluating an emergency drill or exercise at the local public health level.

Use of the public health-specific criteria developed through this process will allow for specific assessment and planning for measurable improvement in a health agency over time.

The History, Electrocardiogram (ECG), Age, Risk Factors, and Troponin (HEART) score is a decision aid designed to risk stratify emergency department (ED) patients with acute chest pain. It has been validated for ED use, but it has yet to be evaluated in a prehospital setting.

A prehospital modified HEART score can predict major adverse cardiac events (MACE) among undifferentiated chest pain patients transported to the ED.

A retrospective cohort study of patients with chest pain transported by two county-based Emergency Medical Service (EMS) agencies to a tertiary care center was conducted. Adults without ST-elevation myocardial infarction (STEMI) were included. Inter-facility transfers and those without a prehospital 12-lead ECG or an ED troponin measurement were excluded. Modified HEART scores were calculated by study investigators using a standardized data collection tool for each patient. All MACE (death, myocardial infarction [MI], or coronary revascularization) were determined by record review at 30 days. The sensitivity and negative predictive values (NPVs) for MACE at 30 days were calculated.

Over the study period, 794 patients met inclusion criteria. A MACE at 30 days was present in 10.7% (85/794) of patients with 12 deaths (1.5%), 66 MIs (8.3%), and 12 coronary revascularizations without MI (1.5%). The modified HEART score identified 33.2% (264/794) of patients as low risk. Among low-risk patients, 1.9% (5/264) had MACE (two MIs and three revascularizations without MI). The sensitivity and NPV for 30-day MACE was 94.1% (95% CI, 86.8-98.1) and 98.1% (95% CI, 95.6-99.4), respectively.

Prehospital modified HEART scores have a high NPV for MACE at 30 days. A study in which prehospital providers prospectively apply this decision aid is warranted.

StopyraJP, HarperWS, HigginsTJ, ProkesovaJV, WinslowJE, NelsonRD, AlsonRL, DavisCA, RussellGB, MillerCD, MahlerSA. Prehospital Modified HEART Score Predictive of 30-Day Adverse Cardiac Events. Prehosp Disaster Med. 2018;33(1):58–62.

The [US] Nunn-Lugar-Domenici Defense Against Weapons of Mass Destruction (WMD) Act (the WMD Act of 1996) heralded a new wave of spending by the federal government on counter-terrorism efforts. Between 1996 and 2000, the United States of America (US) federal government allocated large sums of funding to the States for bioterrorism preparedness. Distribution of these funds between institutions involved in first-responder care (e.g., fire and safety departments) and hospitals was uneven. It is unknown whether these additional funds had an impact on the level of hospital preparedness for managing mass casualties involving hazardous materials at the local level, including potential terrorist attacks with chemical agents.

(1) To compare 1996 and 2000 measures of preparedness among hospitals of a major US metropolitan area for dealing with hazardous material casualties, including terrorism that involved the use of weapons of mass destruction; and (2) To provide guidance for the improvement of emergency preparedness and response in US hospitals.

In July 1996 and again in July 2000, 21 hospitals in one major US city were surveyed by questionnaire. A survey was used to assess the amounts of antidote stocks held available for treatment of casualties caused by toxic chemical agents and institutional response capabilities including the number of showers for decontaminating patients, the level of worker protection, and the number of staff trained to decontaminate patients.

Hospital preparedness for treating and decontaminating patients exposed to toxic chemical agents was inadequate in 1996 and in 2000. From 1996 to 2000, there was no statistically significant change in the lack of hospital preparedness for stocking of nerve agent and cyanide antidotes. Capacity for decontamination of patients, which included appropriate hazardous material infrastructure and trained staff, generally was unimproved from 1996 to 2000 with the exception of an increase of nearly 30% in hospitals with at least one decontamination shower facility.

Hospitals surveyed in this study were poorly prepared to manage chemical emergency incidents, including terrorism. This lack of hospital preparedness did not change significantly between 1996 and 2000 despite increased funds allocated to bioterrorism preparedness at the local level.

To analyze the characteristics of fatal ambulance crashes to assist emergency medical services (EMS) directors in objectively developing their EMS system's policy governing ambulance operations.

No difference exists between the characteristics of fatal ambulance crashes during emergency and nonemergency use.

Retrospective, cross-sectional, comparative analysis of ambulance crashes resulting in fatalities reported to the Fatal Accident Reporting System (FARS) from 1987 to 1990.

Twenty variables, representing characteristics of fatal ambulance crashes, were selected from the National Highway Traffic Administration FARS Codebook and were evaluated using tests of significance for categorical data grouped by emergency use and nonemergency use. Crash variable categories examined included demographics, accident configuration, accident severity, vehicle description, and ambulance operator action.

During the four-year study period, 109 fatal ambulance crashes occurred producing 126 deaths. Four states, New York, Michigan, California, and North Carolina, accounted for 37.5% of all fatal crashes. Seventy-five fatal crashes (69%) occurred during emergency use (EU) and 34 fatal crashes (31%) occurred during nonemergency use (NEU). The total number of fatal crashes varied in a downward trend (1987:32; 1988:24; 1989:28; 1990:25). The number of fatal EU crashes also varied in a downward trend (1987:28; 1988:16; 1989:19; 1990:12), while the number of fatal NEU crashes increased each year [1987:4; 1988:8; 1989:9; 1990:13](p = .016). Most EU fatal crashes occurred between 1200 h and 1800 h (p = .009). Most NEU fatal crashes occurred during times when light conditions were poor (p = .003). When a violation was charged to the ambulance driver (17 cited), the vehicle was more likely to be in EU (p = .056). No statistically significant differences between EU and NEU were identified by: 1) day of week; 2) season; 3) atmospheric conditions; 4) roadway surface type; 5) roadway surface condition; 6) speed limit; 7) roadway alignment; 8) relationship to junction; 9) manner of collision; 10) year manufactured; 11) vehicle role; 12) vehicle maneuver; 13) manner leaving scene; 14) extent of deformation; 15) violations charged; or 16) number of persons killed in accident.

Few characteristics differentiate between fatal ambulance crashes during EU and NEU. The difference between EU and NEU were statistically significant in only three out of the 20 variables examined: 1) year occurred; 2) time of day; and 3) light condition. These data provide few objective measures that may be used to develop ambulance operation policies to decrease fatal ambulance crashes.

Disaster and humanitarian responders are at-risk of experiencing a wide range of physical and psychological health conditions, from minor injuries to chronic mental health problems and fatalities. This article reviews the current literature on the major health outcomes of responders to various disasters and conflicts in order to better inform individuals of the risks and to inform deploying agencies of the health care needs of responders.

In March 2014, an EMBASE search was conducted using pre-defined search criteria. Two reviewers screened the resultant 2,849 abstracts and the 66 full-length manuscripts which are included in the review.

The majority of research on health outcomes of responders focused on mental health (57 of 66 articles). Posttraumatic stress disorder (PTSD) and depression were the most studied diagnoses with prevalence of PTSD ranging from 0%-34% and depression from 21%-53%. Physical health outcomes were much less well-studied and included a wide range of environmental, infectious, and traumatic conditions such as heat stroke, insect bites, dermatologic, gastrointestinal, and respiratory diseases, as well as burns, fractures, falls, and other traumatic injuries.

The prevalence of mental health disorders in responders may vary more and be higher than previously suggested. Overall health outcomes of responders are likely poorly monitored and under-reported. Improved surveillance systems and risk mitigation strategies should be employed in all disaster and conflict responses to better protect individual responders.

GarbernSC , EbbelingLG , BartelsSA . A Systematic Review of Health Outcomes Among Disaster and Humanitarian Responders. Prehosp Disaster Med. 2016;31(6):635–642.

In recent years, controversy has surrounded the issue of whether infectious disease should be considered a serious potential consequence of natural disasters. This article contributes to this debate with evidence of a significant outbreak of malaria in Costa Rica's Atlantic region after the 1991 earthquake and subsequent floods.

This study is an epidemiologic investigation of the incidence of malaria for the periods of 22 months before the April 1991 Limon earthquake and for 13 months afterward. Data were obtained from the Costa Rican Ministry of Health's malaria control program.

Some of the cantons in the region experienced increases in the incidence of malaria as high as 1,600% and 4,700% above the average monthly rate for the pre-earthquake period (p ≤0.01). Causal mechanisms are postulated as relating to changes in human behavior (increased exposure to mosquitoes while sleeping outside, and a temporary pause in malaria control activities), changes in the habitat that were beneficial to mosquito breeding (landslide deforestation, river damming, and rerouting), and the floods of August 1991.

It is recommended that there be enhanced awareness of the potential consequences of disaster-wrought environmental changes.

Date of Event: 22 April 1991; Type: Earthquake, 7.4 Richter scale; Location: Costa Rica; Number of deaths and casualties: 54 deaths and 505 moderate to severe injuries.

Current research of moral distress is mainly derived from challenges within high-resource health care settings, and there is lack of clarity among the different definitions. Disaster responders are prone to a range of moral challenges during the work, which may give rise to moral distress. Further, organizations have considered increased drop-out rates and sick leaves among disaster responders as consequences of moral distress. Therefore, initiatives have been taken to address and understand the impacts of moral distress and its consequences for responders. Since there is unclarity among the different definitions, a first step is to understand the concept of moral distress and its interlinkages within the literature related to disaster responders.

To examine how disaster responders are affected by moral challenges, systematic knowledge is needed about the concepts related to moral distress. This paper aims to elucidate how the concept of moral distress in disaster response is defined and explained in the literature.

The paper opted to systematically map the existing literature through the methods of a scoping review. The searches derived documents which were screened regarding specific inclusion criteria. The included 16 documents were analyzed and collated according to their definitions of moral distress or according to their descriptions of moral distress.

The paper provides clarity among the different concepts and definitions of moral distress within disaster response. Several concepts exist that describe the outcomes of morally challenging situations, centering on situations when individuals are prevented from acting in accordance with their moral values. Their specific differences suggest that to achieve greater clarity in future work, moral stress and moral distress should be distinguished.

Based on the findings, a conceptual model of the development of moral distress was developed, which displays a manifestation of moral distress with the interplay between the responder and the context. The overview of the different concepts in this model can facilitate future research and be used to illuminate how the concepts are interrelated.

To design and test a model to predict surge capacity bottlenecks at a large academic medical center in response to a mass-casualty incident (MCI) involving multiple burn victims.

Using the simulation software ProModel, a model of patient flow and anticipated resource use, according to principles of disaster management, was developed based upon historical data from the University Hospital of the University of Michigan Health System. Model inputs included: (a) age and weight distribution for casualties, and distribution of size and depth of burns; (b) rate of arrival of casualties to the hospital, and triage to ward or critical care settings; (c) eligibility for early discharge of non-MCI inpatients at time of MCI; (d) baseline occupancy of intensive care unit (ICU), surgical step-down, and ward; (e) staff availability—number of physicians, nurses, and respiratory therapists, and the expected ratio of each group to patients; (f) floor and operating room resources—anticipating the need for mechanical ventilators, burn care and surgical resources, blood products, and intravenous fluids; (g) average hospital length of stay and mortality rate for patients with inhalation injury and different size burns; and (h) average number of times that different size burns undergo surgery. Key model outputs include time to bottleneck for each limiting resource and average waiting time to hospital bed availability.

Given base-case model assumptions (including 100 mass casualties with an inter-arrival rate to the hospital of one patient every three minutes), hospital utilization is constrained within the first 120 minutes to 21 casualties, due to the limited number of beds. The first bottleneck is attributable to exhausting critical care beds, followed by floor beds. Given this limitation in number of patients, the temporal order of the ensuing bottlenecks is as follows: Lactated Ringer's solution (4 h), silver sulfadiazine/Silvadene (6 h), albumin (48 h), thrombin topical (72 h), type AB packed red blood cells (76 h), silver dressing/Acticoat (100 h), bismuth tribromophenate/Xeroform (102 h), and gauze bandage rolls/Kerlix (168 h). The following items do not precipitate a bottleneck: ventilators, topical epinephrine, staplers, foams, antimicrobial non-adherent dressing/Telfa types A, B, or O blood. Nurse, respiratory therapist, and physician staffing does not induce bottlenecks.

This model, and similar models for non-burn-related MCIs, can serve as a real-time estimation and management tool for hospital capacity in the setting of MCIs, and can inform supply decision support for disaster management.

AbirM, DavisMM, SankarP, WongAC, WangSC. Design of a Model to Predict Surge Capacity Bottlenecks for Burn Mass Casualties at a Large Academic Medical Center. Prehosp Disaster Med. 2013;28(1):1-10.

As prehospital care became emphasized in emergency medical services in Japan, qualification as a “paramedic” was established in 1991 as a requirement for national qualification as a emergency medical technician (EMT).With recent increases in emergency transportation, the responsibilities of paramedics have become more complex and demand a higher level of competency; however, no method of evaluating occupational stress among Japanese EMTs currently exists.

A questionnaire survey of the working conditions and health of 2,017 EMTs in Hyogo Prefecture was conducted. To analyze stress levels among these EMTs, the survey was divided into two categories: (1) physical stress; and (2) mental stress.

The number of responses was 1,551 (76.9%) and the average age of the respondents was 35.4 years. The lower back, neck, and shoulders were most frequently subjected to physical stress, which was related to the daily operations as an EMT. Mental stress was reported more frequently by those who were older or qualified paramedics.

The high frequency of lower back pain suggests the need for improvement in the work environment and periodic education.

Although job satisfaction among paramedics was high, they were exposed to greater mental stress. Therefore, systematic management of stress must be developed and established.