Hospital Acute Care Surge Capacity (HACSC), Hospital Acute Care Surge Threshold (HACST), and Total Hospital Capacity (THC) are scales that were developed to quantify surge capacity in the event of a multiple-casualty incident (MCI). These scales take into consideration the need for adequate care for both critical (T1) and moderate (T2) trauma patients. The objective of this study was to verify the validity of these scales in nine hospitals of the Milano (Italy) metropolitan area that prepared for a possible MCI during EXPO 2015.

Both HACSC and HACST were computed for individual hospitals. These were compared to surge capacities declared by individual hospitals during EXPO 2015, and also to surge capacity evaluated during a simulation organized on August 23, 2016.

Both HACSC and HACST were smaller compared to capacities measured and reported by the hospitals, as well as those found during the simulation. This resulted in significant differences in THC when this was computed from the different methods of calculation.

Surge capacity is dependent on the method of measurement. Each method has its inherent deficiencies. Until more reliable methodologies are developed, there is a benefit to analyze surge capacity using several methods rather than just one. Emergency committee members should be aware of the importance of critical resources when looking to the hospital capacity to respond to an MCI, and to the possibility to effectively increase it with a good preparedness plan. Since hospital capacity during real events is not static but dynamic, largely depending on occupation of the available resources, it is important that the regional command center and the hospitals receiving casualties constantly communicate on specific agreed upon critical resources, in order for the regional command center to timely evaluate the overall regional capacity and guarantee the appropriate distribution of the patients.

FaccincaniR, Della CorteF, SesanaG, StucchiR, WeinsteinE, AshkenaziI, IngrassiaP. Hospital Surge Capacity during Expo 2015 in Milano, Italy. Prehosp Disaster Med. 2018;33(5):459–465.

The aim of this study was to assist organizations seeking to develop or improve their medical disaster relief effort by identifying fundamental elements and processes that permeate high-quality, international, medical disaster relief organizations and the teams they deploy.

A qualitative descriptive design was used. Data were gathered from interviews with key personnel at five international medical response organizations, as well as during field observations conducted at multiple sites in Jordan and Greece, including three refugee camps. Data were then reviewed by the research team and coded to identify patterns, categories, and themes.

The results from this qualitative, descriptive design identified three themes which were key characteristics of success found in effective, well-established, international medical disaster relief organizations. These characteristics were first, ensuring an official invitation had been extended and the need for assistance had been identified. Second, the response to that need was done in an effective and sustainable manner. Third, effective organizations strived to obtain high-quality volunteers.

By following the three key characteristics outlined in this research, organizations are more likely to improve the efficiency and quality of their work. In addition, they will be less likely to impede the overall recovery process.

BrobyN, LassetterJH, WilliamsM, WintersBA. Effective International Medical Disaster Relief: A Qualitative Descriptive Study. Prehosp Disaster Med. 2018;33(2):119–126.

Hemorrhage remains the major cause of preventable death after trauma. Recent data suggest that earlier blood product administration may improve outcomes. The purpose of this study was to determine whether opportunities exist for blood product transfusion by ground Emergency Medical Services (EMS).

This was a single EMS agency retrospective study of ground and helicopter responses from January 1, 2011 through December 31, 2015 for adult trauma patients transported from the scene of injury who met predetermined hemodynamic (HD) parameters for potential transfusion (heart rate [HR]≥120 and/or systolic blood pressure [SBP]≤90).

A total of 7,900 scene trauma ground transports occurred during the study period. Of 420 patients meeting HD criteria for transfusion, 53 (12.6%) had a significant mechanism of injury (MOI). Outcome data were available for 51 patients; 17 received blood products during their emergency department (ED) resuscitation. The percentage of patients receiving blood products based upon HD criteria ranged from 1.0% (HR) to 5.9% (SBP) to 38.1% (HR+SBP). In all, 74 Helicopter EMS (HEMS) transports met HD criteria for blood transfusion, of which, 28 patients received prehospital blood transfusion. Statistically significant total patient care time differences were noted for both the HR and the SBP cohorts, with HEMS having longer time intervals; no statistically significant difference in mean total patient care time was noted in the HR+SBP cohort.

In this study population, HD parameters alone did not predict need for ED blood product administration. Despite longer transport times, only one-third of HEMS patients meeting HD criteria for blood administration received prehospital transfusion. While one-third of ground Advanced Life Support (ALS) transport patients manifesting HD compromise received blood products in the ED, this represented 0.2% of total trauma transports over the study period. Given complex logistical issues involved in prehospital blood product administration, opportunities for ground administration appear limited within the described system.

MixFM, ZielinskiMD, MyersLA, BernsKS, LukeA, StubbsJR, ZietlowSP, JenkinsDH, SztajnkrycerMD. Prehospital Blood Product Administration Opportunities in Ground Transport ALS EMS – A Descriptive Study. Prehosp Disaster Med. 2018;33(3):230–236.

The efficacy of oral cholera vaccines (OCVs) in laboratory conditions has been established, and the World Health Organization (WHO; Geneva, Switzerland) has recommended their preventative use in high-risk settings. The WHO recommendation has not been fully operationalized, nor has it been extended to apply to the reactive use of OCVs in real field epidemic conditions due to concerns about potential resource diversion, feasibility, cost, and acceptability. The purpose of this study is to assess and synthesize existing evidence of OCV effectiveness when used reactively in real field conditions.

A systematic review and meta-analysis was conducted involving studies that investigated vaccine effectiveness when used as a reactive measure; that is, cases had reached epidemic threshold and a cholera epidemic was declared in real field epidemic conditions. OVID Medline (US National Library of Medicine, National Institutes of Health; Bethesda, Maryland USA), CINAHL (EBSCO Information Services; Ipswich, Massachusetts USA), and EMBASE (Elsevier; Amsterdam, Netherlands), along with grey literature, were systematically searched using pre-determined criteria. Two independent reviewers identified studies that met the selection criteria and data were extracted using validated tools. Pooled estimates were obtained using fixed effect models.

Of the 347 articles that met the inclusion criteria, four studies were retrieved for meta-analysis (three were case-control studies and one was a case-cohort study) involving a total of 1,509 participants and comprising 175 cases and 1,334 case controls. The effectiveness of one or two doses of either Shanchol (Shantha Biotechnics; India) or ORC-Vax (Vabiotech; Vietnam) OCVs showed a combined vaccine effectiveness of 75% (95% CI, 61-84).

A positive association was demonstrated between the reactive use of OCVs and protection against cholera. This supported the WHO recommendation to utilize OCVs reactively as an additional measure to the standard cholera epidemic response package.

SchwerdtleP, OnekonCK, RecocheK. A Quantitative Systematic Review and Meta-Analysis of the Effectiveness of Oral Cholera Vaccine as a Reactive Measure in Cholera Outbreaks. Prehosp Disaster Med. 2018;33(1):2–6.

For more than 60 years, Colombia experienced an armed conflict involving government forces, guerrillas, and other illegal armed groups. Violence, including torture and massacres, has caused displacement of entire rural communities to urban areas. Lack of information on the problems displaced communities face and on their perceptions on potential solutions to these problems may prevent programs from delivering appropriate services to these communities. This study explores the problems of Afro-Colombian survivors from two major cities in Colombia; the activities they do to take care of themselves, their families, and their community; and possible solutions to these problems.

This was a qualitative, interview-based study conducted in Quibdó and Buenaventura (Colombia). Free-list interviews and focus groups explored the problems of survivors and the activities they do to take care of themselves, their families, and their community. Key-informant interviews explored details of the identified mental health problems and possible solutions.

In Buenaventura, 24 free-list interviews, one focus group, and 17 key-informant interviews were completed. In Quibdó, 29 free-list interviews, one focus group, and 15 key-informant interviews were completed. Mental health problems identified included: (1) problems related to exposure to torture/violent events; (2) problems with adaptation to the new social context; and (3) problems related to current poverty, lack of employment, and ongoing violence. These problems were similar to trauma symptoms and features of depression and anxiety, as described in other populations. Solutions included psychological help, talking to friends/family, relying on God’s help, and getting trained in different task or jobs.

Afro-Colombian survivors of torture and violence described mental health problems similar to those of other trauma-affected populations. These results suggest that existing interventions that address trauma-related symptoms and current ongoing stressors may be appropriate for improving the mental health of survivors in this population.

Santaella-TenorioJ, Bonilla-EscobarFJ, Nieto-GilL, Fandiño-LosadaA, Gutiérrez-MartínezMI, BassJ, BoltonP. Mental Health and Psychosocial Problems and Needs of Violence Survivors in the Colombian Pacific Coast: A Qualitative Study in Buenaventura and Quibdó. Prehosp Disaster Med. 2018;33(6):567–574.

Terrorism and natural catastrophes have made disaster preparedness a critical issue. Despite the documented vulnerabilities of children during and following disasters, gaps remain in health care systems regarding pediatric disaster preparedness. This research study examined changes in knowledge acquisition of pediatric disaster preparedness among medical and non-medical personnel at a children’s hospital who completed an online training course of five modules: planning, triage, age-specific care, disaster management, and hospital emergency code response.

A multi-disciplinary team within the Pediatric Disaster Resource and Training Center at Children’s Hospital Los Angeles (Los Angeles, California USA) developed an online training course. Available archival course data from July 2009 to August 2012 were analyzed through linear growth curve multi-level modeling, with module total score as the outcome (0 to 100 points), attempt as the Level 1 variable (any module could be repeated), role in the hospital (medical or non-medical) as the Level 2 variable, and attempt by role as the cross-level effect.

A total of 44,115 module attempts by 5,773 course participants (3,686 medical personnel and 2,087 non-medical personnel) were analyzed. The average module total score upon first attempt across all participants ranged from 60.28 to 80.11 points, and participants significantly varied in how they initially scored. On average in the planning, triage, and age-specific care modules: total scores significantly increased per attempt across all participants (average rate of change ranged from 0.59 to 1.84 points) and medical personnel had higher total scores initially and through additional attempts (average difference ranged from 13.25 to 16.24 points). Cross-level effects were significant in the disaster management and hospital emergency code response modules: on average, total scores were initially lower among non-medical personnel compared to medical personnel, but non-medical personnel increased their total scores per attempt by 3.77 points in the disaster management module and 6.40 points in the hospital emergency code response module, while medical personnel did not improve their total scores through additional attempts.

Medical and non-medical hospital personnel alike can acquire knowledge of pediatric disaster preparedness. Key content can be reinforced or improved through successive training in an online course.

PhamPK, BeharSM, BergBM, UppermanJS, NagerAL. Pediatric Online Disaster Preparedness Training for Medical and Non-Medical Personnel: A Multi-Level Modeling AnalysisPrehosp Disaster Med.2018;33(4):349–354.

Great demands have been placed on disaster medicine educators. There is a need to develop innovative methods to educate Emergency Physicians in the ever-expanding body of disaster medicine knowledge. The authors sought to demonstrate that video-based learning (VBL) could be a promising alternative to traditional learning methods for teaching disaster medicine core competencies.

The objective was to compare VBL to traditional lecture (TL) for instructing Emergency Medicine residents in the American College of Emergency Physicians (ACEP; Irving, Texas USA) disaster medicine core competencies of patient triage and decontamination.

A randomized, controlled pilot study compared two methods of instruction for mass triage, decontamination, and personal protective equipment (PPE). Emergency Medicine resident learning was measured with a knowledge quiz, a Likert scale measuring comfort, and a practical exercise. An independent samples t-test compared the scoring of the VBL with the TL group.

Twenty-six residents were randomized to VBL (n=13) or TL (n=13). Knowledge score improvement following video (14.9%) versus lecture (14.1%) did not differ significantly between the groups (P=.74). Comfort score improvement also did not differ (P=.64) between video (18.3%) and lecture groups (15.8%). In the practical skills assessment, the VBL group outperformed the TL group overall (70.4% vs 55.5%; P<.0001), with significantly better performance in donning PPE and decontamination. Although not part of the original study design, a three-month post-hoc analysis was performed. When comparing the pre-intervention and three-month post-hoc performances, there were no significant differences in knowledge increases between VBL versus TL (P=.41) or in comfort (P=.39).

Video modules can be as effective as TL when utilized to train Emergency Medicine residents in the ACEP disaster medicine core competencies of patient triage and decontamination.

Curtis HA , Trang K , Chason KW , Biddinger PD . Video-Based Learning vs Traditional Lecture for Instructing Emergency Medicine Residents in Disaster Medicine Principles of Mass Triage, Decontamination, and Personal Protective Equipment. Prehosp Disaster Med. 2018;33(1):7–12.

Major-incident triage ensures effective emergency care and utilization of resources. Prehospital emergency care providers are often the first medical professionals to arrive at any major incident and should be competent in primary triage. However, various factors (including level of training) influence their triage performance.

The aim of this study was to determine the difference in major-incident triage performance between different training levels of prehospital emergency care providers in South Africa utilizing the Triage Sieve algorithm.

This was a cross-sectional study involving differently trained prehospital providers: Advanced Life Support (ALS); Intermediate Life Support (ILS); and Basic Life Support (BLS). Participants wrote a validated 20-question pre-test before completing major-incident training. Two post-tests were also completed: a 20-question written test and a three-question face-to-face evaluation. Outcomes measured were triage accuracy and duration of triage. The effect of level of training, gender, age, previous major-incident training, and duration of service were determined.

A total of 129 prehospital providers participated. The mean age was 33.4 years and 65 (50.4%) were male. Most (n=87; 67.4%) were BLS providers. The overall correct triage score pre-training was 53.9% (95% CI, 51.98 to 55.83), over-triage 31.4% (95% CI, 29.66 to 33.2), and under-triage 13.8% (95% CI, 12.55 to 12.22). Post-training, the overall correct triage score increased to 63.6% (95% CI, 61.72 to 65.44), over-triage decreased to 17.9% (95% CI, 16.47 to 19.43), and under-triage increased to 17.8% (95% CI, 16.40 to 19.36). The ALS providers had both the highest likelihood of a correct triage score post-training (odds ratio 1.21; 95% CI, 0.96-1.53) and the shortest duration of triage (median three seconds, interquartile range two to seven seconds; P=.034). Participants with prior major-incident training performed better (P=.001).

Accuracy of major-incident triage across all levels of prehospital providers in South Africa is less than optimal with non-significant differences post-major-incident training. Prior major-incident training played a significant role in triage accuracy indicating that training should be an ongoing process. Although ALS providers were the quickest to complete triage, this difference was not clinically significant. The BLS and ILS providers with major-incident training can thus be utilized for primary major-incident triage allowing ALS providers to focus on more clinical roles.

AlenyoAN, SmithWP, McCaulM, Van HovingDJ. A Comparison Between Differently Skilled Prehospital Emergency Care Providers in Major-Incident Triage in South Africa. Prehosp Disaster Med. 2018;33(6):575–580.

The Australian prehospital profession has not yet facilitated a comprehensive discussion regarding paramedic role and responsibility during disasters. Whether paramedics have a duty to treat under extreme conditions and what acceptable limitations may be placed on such a duty require urgent consideration. The purpose of this research is to encourage discussion within the paramedic profession and broader community on this important ethical and legal issue.

The authors employed qualitative methods to gather paramedic and community member perspectives in Victoria, Australia.

These findings suggested that both paramedic and community member participants agree that acceptable limitations on paramedic duty to treat during disaster are required. These limitations should be based on consideration of the following factors: personal health circumstances (eg, pregnancy for female paramedics); pre-existing mental health conditions (eg, posttraumatic stress disorder/PTSD); competing personal obligations (eg, paramedics who are single parents); and unacceptable levels of personal risk (eg, risk of exposure and infection during a pandemic).

It is only with the engagement of a more broadly representative segment of the prehospital profession and greater Australian community that appropriate guidance on limiting standards of care under extreme conditions can be developed and integrated within prehospital care in Australia.

SmithE, BurkleFM Jr., GebbieK, FordD, BensimonC. Acceptable Limitations on Paramedic Duty to Treat During Disaster: A Qualitative Exploration. Prehosp Disaster Med. 2018;33(5):466–470.

Needle thoracostomy (NT) is a common prehospital intervention for patients in extremis or cardiac arrest due to trauma. The purpose of this study is to compare outcomes, efficacy, and complications after a change in policy related to NT in a four-county Emergency Medical Services (EMS) system with a catchment area of greater than 1.6 million people.

This is a before and after observational study of all patients who had NT performed in the Central California (USA) EMS system. The before, anterior midclavicular line (MCL) group consisted of all patients who underwent NT from May 7, 2007 through February 28, 2013. The after, midaxillary line (MAL) axillary group consisted of all patients who underwent NT from March 1, 2013 through January 30, 2016, after policy revisions changed the timing, needle size, and placement location for NT. All prehospital and hospital records where NT was performed were queried for demographics, mechanism of injury, initial status and post-NT clinical change, reported complications, and final outcome. The trauma registry was accessed to obtain Injury Severity Scores (ISS). Information was manually abstracted by study investigators and examined utilizing univariate and multivariate analyses.

Three-hundred and five trauma patients treated with NT were included in this study, of which, 169 patients (the MCL group) were treated with a 14-guage intravenous (IV) catheter at least 5.0-cm long at the second intercostal space (ICS), MCL after being placed in the ambulance; and 136 patients (the MAL group) were treated with a 10-guage IV catheter at least 9.5-cm long at the fifth ICS, MAL on scene. The mean ISS was lower in the MAL cohort (64.5 versus 69.2; P=.007). The mortality rate was 79% in both groups. The multivariate model with regard to survival supported that a lower ISS (P<.001) and reported clinical change after NT (P=.003) were significant indicators of survival. No complications from NT were reported.

Changing the timing, length of needle, and location of placement did not change mortality in patients requiring NT. Needle thoracostomy was used more frequently after the change in policy, and the MAL cohort was less injured. No increase in reported complications was noted.

WeichenthalLA, OwenS, StrohG, RamosJ. Needle Thoracostomy: Does Changing Needle Length and Location Change Patient Outcome?Prehosp Disaster Med. 2018;33(3):237–244.

The “Stop the Bleed” campaign advocates for non-medical personnel to be trained in basic hemorrhage control. However, it is not clear what type of education or the duration of instruction needed to meet that requirement. The objective of this study was to determine the impact of a brief hemorrhage control educational curriculum on the willingness of laypersons to respond during a traumatic emergency.

This “Stop the Bleed” education initiative was conducted by the University of Texas Health San Antonio Office of the Medical Director (San Antonio, Texas USA) between September 2016 and March 2017. Individuals with formal medical certification were excluded from this analysis. Trainers used a pre-event questionnaire to assess participants knowledge and attitudes about tourniquets and responding to traumatic emergencies. Each training course included an individual evaluation of tourniquet placement, 20 minutes of didactic instruction on hemorrhage control techniques, and hands-on instruction with tourniquet application on both adult and child mannequins. The primary outcome in this study was the willingness to use a tourniquet in response to a traumatic medical emergency.

Of 236 participants, 218 met the eligibility criteria. When initially asked if they would use a tourniquet in real life, 64.2% (140/218) responded “Yes.” Following training, 95.6% (194/203) of participants responded that they would use a tourniquet in real life. When participants were asked about their comfort level with using a tourniquet in real life, there was a statistically significant improvement between their initial response and their response post training (2.5 versus 4.0, based on 5-point Likert scale; P<.001).

In this hemorrhage control education study, it was found that a short educational intervention can improve laypersons’ self-efficacy and reported willingness to use a tourniquet in an emergency. Identified barriers to act should be addressed when designing future hemorrhage control public health education campaigns. Community education should continue to be a priority of the “Stop the Bleed” campaign.

RossEM, RedmanTT, MappJG, BrownDJ, TanakaK, CooleyCW, KharodCU, WamplerDA. Stop the Bleed: The Effect of Hemorrhage Control Education on Laypersons’ Willingness to Respond During a Traumatic Medical Emergency. Prehosp Disaster Med. 2018;33(2):127–132.

The most commonly used methods for triage in mass-casualty incidents (MCIs) rely upon providers to take exact counts of vital signs or other patient parameters. The acuity and volume of patients which can be present during an MCI makes this a time-consuming and potentially costly process.

This study evaluates and compares the speed of the commonly used Simple Triage and Rapid Treatment (START) triage method with that of an “intuitive triage” method which relies instead upon the abilities of an experienced first responder to determine the triage category of each victim based upon their overall first-impression assessment. The research team hypothesized that intuitive triage would be faster, without loss of accuracy in assigning triage categories.

Local adult volunteers were recruited for a staged MCI simulation (active-shooter scenario) utilizing local police, Emergency Medical Services (EMS), public services, and government leadership. Using these same volunteers, a cluster randomized simulation was completed comparing START and intuitive triage. Outcomes consisted of the time and accuracy between the two methods.

The overall mean speed of the triage process was found to be significantly faster with intuitive triage (72.18 seconds) when compared to START (106.57 seconds). This effect was especially dramatic for Red (94.40 vs 138.83 seconds) and Yellow (55.99 vs 91.43 seconds) patients. There were 17 episodes of disagreement between intuitive triage and START, with no statistical difference in the incidence of over- and under-triage between the two groups in a head-to-head comparison.

Significant time may be saved using the intuitive triage method. Comparing START and intuitive triage groups, there was a very high degree of agreement between triage categories. More prospective research is needed to validate these results.

HartA, NammourE, MangoldsV, BroachJ. Intuitive versus Algorithmic TriagePrehosp Disaster Med.2018;33(4):355–361.

Located in the Sunda Megathrust zone, Mentawai Island is known as the epicenter of an active earthquake that has the potential to cause a tsunami. Students would be one of the most vulnerable groups during the disaster.

The low-level of School-Based Disaster Preparedness/Sekolah Siaga Bencana (SSB) of students’ preparedness in disaster risk reduction (DRR) can lead to increased vulnerability of students in facing disaster threats, especially a tsunami.

The study employed observational, correlative analytics with a cross-sectional approach. The sample includes 109 students from fifth and sixth grade in three elementary schools in Sipora, Mentawai Island district.

There was a significant influence between knowledge and attitude towards the preparedness of SSB students in DRR in Sipora, Mentawai Islands district.

Knowledge and attitudes are key factors that must be taken into account in efforts to increase student preparedness to reduce the risk of a tsunami disaster.

Sujarwo, Noorhamdani, Fathoni M. Disaster Risk Reduction in Schools: The Relationship of Knowledge and Attitudes Towards Preparedness from Elementary School Students in School-Based Disaster Preparedness in the Mentawai Islands, Indonesia. Prehosp Disaster Med. 2018;33(6):581–586.

Mass gatherings are common in Australia. The interplay of variables, including crowd density and behavior, weather, and the consumption of alcohol and other drugs, can pose a unique set of challenges to attendees’ well-being. On-site health services are available at most mass gatherings and reduce the strain on community health facilities. In order to efficiently plan and manage these services, it is important to be able to predict the number and type of presenting problems at mass gatherings.

There is a lack of reliable tools to predict patient presentations at mass gatherings. While a number of factors have been identified as having an influence on attendees’ health, the exact contribution of these variables to patient load is poorly understood. Furthermore, predicting patient load at mass gatherings is an inherently nonlinear problem, due to the nonlinear relationships previously observed between patient presentations and many event characteristics.

Data were collected at 216 Australian mass gatherings and included event type, crowd demographics, and weather. Nonlinear models were constructed using regression trees. The full data set was used to construct each model and the model was then used to predict the response variable for each event. Nine-fold cross validation was used to estimate the error that may be expected when applying the model in practice.

The mean training errors for total patient presentations were very high; however, the distribution of errors per event was highly skewed, with small errors for the majority of events and a few large errors for a small number of events with a high number of presentations. The error was five or less for 40% of events and 15 or less for 85% of events. The median error was 6.9 presentations per event.

This study built on previous research by undertaking nonlinear modeling, which provides a more realistic representation of the interactions between event variables. The developed models were less useful for predicting patient presentation numbers for very large events; however, they were generally useful for more typical, smaller scale community events. Further research is required to confirm this conclusion and develop models suitable for very large international events.

Arbon P, Bottema M, Zeitz K, Lund A, Turris S, Anikeeva O, Steenkamp M. Nonlinear modelling for predicting patient presentation rates for mass gatherings. Prehosp Disaster Med. 2018;33(4):362–367