Advances in technology can drastically improve the ability of providers to care for survivors of a disaster. Research into new applications of technology in the Disaster Medicine space, and dissemination of new technological achievements are vital to saving lives. This presentation discusses several recently proven technologies in the field of disaster medicine which deserve further dissemination, as well as promising technologies currently being studied.

An overview of the current uses and upcoming research on several technologies will be definitive in future disaster responses.

Unmanned Aerial Vehicles (UAVs) and Telemedicine have been well studied and are proven game changers in field disaster response. Artificial intelligence continues to be studied and aid real-time, strategic and tactical decision making in the field. Virtual reality simulation has now advanced to be a feasible, cost effective and effective method of training disaster responders as well as for training the lay public in disaster risk reduction. Artificial Intelligence is also being studied for uses in the hospital and in all forms of Emergency Management, and is likely to be intricately tied to the future of the field.

As new technologies are developed, it is important for Disaster medicine practitioners to consider how they can be applied to the field. Advocating for applying new technologies to disaster medicine, and for dissemination of proven technologies is a vital part of advancing the field of disaster preparedness and response.

Cyberattacks against healthcare have been growing at an alarming rate globally targeting the theft of clinical research intellectual property, personally identifiable information, and personal health information. Recent studies have also shown a concerning correlation between cyberattacks and patient morbidity and mortality rates. Many top security experts consider cyberattacks a top national security concern.This paper is a descriptive analysis of healthcare-related breaches in the United States in the past decade and an analysis of cybersecurity threats that are currently facing the industry.

Breach reports of unsecured protected health information affecting 500 or more individuals in the US are publicly accessible through the U.S. Department of Health and Human Services Office for Civil Rights portal. The database was downloaded and searched for all reported breaches occurring between January 1, 2011 - December 31, 2021. Breaches were subdivided by states, dates, location, entity type, and individuals affected.

Of the 3,822 PHI breaches recorded, 1,593 (41.7%) were hacking/IT related, 1,055 (27.6%) were listed as unknown, 819 (21.4%) were theft related, 194 (5.1%) were loss related, 97 (2.5%) were related to improper disposal and 64 (1.7%) were listed as “others.”

Breaches occurred within the main categories as follows: network server (957 [25%]), email (877 [23%]), paper/films (665 [17%]), other (454 [12%]), laptop (341 [9%]), desktop (309 [8%]), and electronic medical records (220 [6%]).

A total of 3,822 breaches affecting 283,335,803 people in the United States were recorded from January 1, 2011 to December 31, 2021.

The most reported breaches were from healthcare providers with 2,827 (75.1%) events, followed by health plans (500 [13.1%]), business associates (480 [12.6%]) and healthcare clearinghouses (10 [0.3%]). 4 (0.1%) breaches were from unknown sources.

This report may help healthcare providers understand the extent of the issue and mitigate some of the associated risks.

RCHIS is an Electronic Medical Record (EMR) and Health Information System (HIS) that has been purpose-built for use by Red Cross Red Crescent (RCRC) Emergency Response Units (ERUs), which are the equivalent of Type 1 (fixed and mobile) and Type 2 facilities in the Emergency Medical Teams (EMT) classification.

A three day in-person super user training was held with 13 participants: 9 first aid volunteers, 2 nurses and 2 medical doctors. Seven of the delegates had experience using an EMR. These super users served as trainers for staff at the pilot.

The pilot occurred with the Portuguese Red Cross (PRC) for the Peregrinação de Fátima, where 200,000 people were in attendance. The PRC was part of a wider coordination cell with the civil defense authority, who required live reporting from the three Type 1 fixed clinics PRC had set up.

In total there were 77 user accounts, of which, 243 patients were consulted with and either discharged or referred throughout the four day pilot.

The delegates shared feedback directly and through a survey. 88% stated that RCHIS was ‘very easy’ to use with the majority of delegates requiring less than 20 minutes of training to be using the application and inputting patient data related to their user role. Additionally, after their training 95% of delegates stated they had sufficient training to use RCHIS to its full extent. Informal feedback from delegates was hugely positive, indicating that it was improving patient care and also continuity of care when a patient returned the next day.

The civil defense authorities were able to utilize the real-time reporting to assist in their operational response. The application was well received by the wider civil defense authority.

The first RCHIS pilot was very successful from both a technical and organizational perspective.

The critical role that nurses and midwives undertake during disasters has received significant attention in recent years. Nurses globally have faced multiple disasters, often occurring within months of each other and even overlapping. Within the past decade, on a global scale, nurses and midwives have experienced two Public Health Emergencies of International Concern (PHEIC) (SARS-CoV-2 and Monkeypox), the devastating and ongoing conflict in Ukraine and an unprecedented number of international natural hazards that have impacted them personally and professionally.

A discussion with frontline nurses and midwives provided insight into the challenges of delivering health care during disasters.

The results revealed that while there is some information available about disaster care and the role nurses play, there is minimal information about how nurses and midwives are personally affected by disasters impacting their own communities. Disaster nursing is a relatively new area of health care practice and is rarely taught at an undergraduate or workplace level.

Three opportunities for improving/acknowledging the critical role of nurses and midwives during disasters include:

1. 1) Acknowledging that the involvement of nurses and midwives is critical to any disaster response

2. 2) Promoting the importance of a nursing voice within the emergency management sector

3. 3) Structural reforms be urgently adopted to address workforce sustainability including addressing gender inequality

4. 4) These three approaches form only a part of the reform required to address the key roles that nurses and midwives perform during disasters.

The ongoing pandemic has placed severe stress on an already overstretched nursing workforce, now is the right time to empower and support our nurses. In all aspects of emergency and disaster management nurses and midwives are at the frontline. Greater acknowledgement of the value nurses bring and the sacrifices they make in serving their communities will strengthen nurses’ commitment and resolve in tackling future crises.

Pre-deployment training for nurses ensures readiness.

A quantitative descriptive research methodology was used to conduct an anonymous survey distributed to all registered nurses deployed in 2017 to Hurricane Maria with a hospital-supported team and a federal team. The project sought to improve the pre-deployment preparation experience of nurses to positively impact nurses' willingness to redeploy. The survey was administered for ten days in January 2021.

This quantitative descriptive study sought to understand nurses’ perceptions of their readiness for deployment during a disaster response. Thirty-nine surveys were distributed with a 46% response rate (n = 18).

Gender was not related to agreement with the role variable (p = 0.070). Marital status was significantly related to role (p = 0.015), as was age (p = 0.022). Single individuals and individuals >50 yo were more likely to agree that they understood their role during the disaster.

Gender was not related to agreement with the preparedness variable (p = 0.465), nor was marital status (p = 0.067). Age was significantly related to perceptions of preparedness (p = 0.004). Individuals >50 yo were more likely to respond that they were prepared for their deployment.

Gender was not related to perceptions of knowledge of providing clinical care during a disaster (p = 0.235), nor was marital status (p = 0.627) or age (p = 0.674).

The results suggest that single nurses > 50 yo with more years of nursing experience who have previously deployed may understand the role better and feel more prepared to deploy.

However, their responses do not indicate that they feel more knowledgeable about the type of nursing care they are expected to provide in a disaster response.

During the COVID-19 outbreak in May 2021, Taipei City has transformed many vacant hotels to augmented quarantine hotels, recruiting retired medical staff to provide medical care, in order to preserve hospitals’ medical capabilities. In an augmented quarantine hotel at Caesar Park Hotel Taipei, the complexity of COVID quarantine, quarantine status of the residents, and hotel staff working with medical staff has made the original emergency response plan inappropriate. Henceforth, a series of modifications were made to ensure the emergency response readiness of Caesar Park Hotel Taipei.

The enhancements of emergency response capability of the augmented quarantine hotel at the Caesar Park Hotel Taipei, were made in accordance with the following list: 1. Revise evacuation plan, 2. Setup emergency equipment cart, 3. Modify emergency response procedure, 4. Update staff training and resident notice, 5. Routine stock count of medical supplies and emergency equipment.

The enhanced emergency response plan has ensured the safety of all personnel, plans were made in accordance with the COVID-19 quarantine status, and the staff has a clear perception of their duty with a picture of the overall emergency response plan.

The enhanced emergency response plan was completed and under implementation in June 2021, and at the end of that month there was a fire that took four lives with 22 injured at a quarantine hotel in Changhua County. A review of the enhanced emergency response plan was made by the staff and corresponding hospital; many problems that happened at the Chunghua County quarantine hotel fire had already been considered or prevented in the enhanced emergency response plan. Such a method for building an enhanced emergency response plan has the potential to be implemented in more locations, and possibly in different scenarios.

As the largest body of health professionals, nurses are looked upon during a disaster for leadership, clinical assistance, and support during these events. Nurses are at the forefront of managing disasters in their communities, yet their complex role as advanced nurse practitioners, clinicians, managers, and leaders is not always fully understood and/or recognized. The aim of this paper is to explore the level of Advanced Nursing Practice (ANP) in Australia that takes place in a disaster

This scoping review was guided by Arksey and O’Malley’s framework. The review searched five relevant databases. A scoping review design was chosen as the authors expected that evidence in the field would be produced using a wide variety of methodologies.

Nurses work long hours during a disaster with hospitals and nurses becoming the center of events and the "go to" place during a disaster. During disasters nurses often have little sleep, have limited time to meet their individual/personal needs, and frequently put others needs before themselves. Nurses mentioned in these studies were reported to have worked while they were worried for themselves and their families. These nurses reported feeling capable and reported that all their experience and skills came to the fore during these challenging situations.

During disasters, most nurses are found to be flexible and adaptable, with many taking on a variety of roles. Nurses are quick to find solutions with problem-solving keys and their ability to respond to disasters "just what you do." The nurses in these studies demonstrated fundamental expertise and had the agility to pivot when the occasion demanded. As a result of this study, it is evident, and not surprising, that these Australian nurses work beyond conventional limits during a disaster.

Policymakers, practitioners and the public all have a role in health emergency and disaster risk management (Health EDRM). They need to access, understand and use evidence from research to take actions to reduce health risks and harm. They need the best available evidence to maximize their ability to save lives and reduce suffering. Evidence Aid seeks to meet this need through collections of specially prepared plain-language summaries of systematic reviews, freely available online in multiple languages (www.EvidenceAid.org). The summaries and webpages can be linked to reference management software and embedded in other websites.

Evidence Aid has added a substantial number of summaries to its collections since 2020, for example, adding a collection for reviews of relevance to the COVID-19 pandemic and its associated measures. From 2021, Evidence Aid built on its partnership with the Pan American Health Organization (PAHO/WHO) to identify and summarize reviews relevant to building resilience into health systems. This included enhancements enriching the content of each summary with the authors’ implications for practice and research, equity considerations and funding sources.

In November 2022, the Resilient Health Systems collection contained more than 200 summaries relevant to ensuring that health systems are resilient to emergencies, disasters and related challenges. There were also 600 summaries relevant to the COVID-19 pandemic, 150 on the health of refugees and asylum seekers, more than 100 on physical and mental health impacts of disasters and 110 on preventing and treating acute malnutrition.

Evidence Aid’s 1000+ summaries of systematic reviews relevant to Health EDRM provide a unique gateway into this evidence base for policymakers, practitioners and the public wishing to ensure that disaster preparedness, response, recovery and rehabilitation are effective and efficient. It should be a key component in helping people and organizations to care, cope and overcome in an increasingly challenging world.

Health and medical disciplines have traditionally preferred experimental and quasi-experimental methods to evaluate interventions. More recently, mathematical modeling was used to test intervention efficacy in the SARS-CoV-2 pandemic. The challenge for disaster researchers is neither approach suits examining phenomena about emergency health responses in disasters. This study applied an alternative methodology to examine questions of how and why emergency health and medical responses reduced mortality during six different natural hazard disaster events.

The case study methodology is orientated by the researcher’s perspective and ‘not assigned a fixed ontological, epistemological or methodological position’. This flexibility allows alignment of the researcher’s worldview with the methodology best fitting the research problem and its context, such as post-positivism. Qualitative case study design carefully links five key design elements and sequences, including research questions, propositions, a unit of analysis, data collection, and data analysis.

Six holistic single case studies described how and why the emergency health response reduced mortality risk of people affected by different disasters. An evidenced-based theoretical emergency health program logic model compared and contrasted inputs, activities, outputs, and outcomes between theoretical and actual responses. Rival explanations were tested before data collection for each single case and applied to challenge the logic model. Each case applied four strategies to increase the validity and reliability of the holistic single case study findings.

Qualitative case study methodology provides a robust and flexible framework to examine complex questions about emergency health and medical responses, including questions about events, processes, activities, performance, and outcomes. The methodology is equally suited to real-time or retrospective studies. The strength of the approach is the high compatibility for examining phenomena within the context they occur, and linking program logic, data collection, and data analysis methods to the specific question being investigated.

Cyberattacks on healthcare systems are increasing in frequency and severity. Hospitals need to integrate cybersecurity preparedness into their emergency operations planning and response in order to mitigate adverse outcomes during increasingly likely cyber events. No data currently exists regarding the level of preparedness of US hospital systems for cybersecurity attacks. We surveyed hospital emergency managers to assess cybersecurity preparedness for these events.

Fifty-seven emergency managers representing hospitals across the US participated in an online Qualtrics survey regarding current preparedness and response procedures for cybersecurity hazards.

Survey responses between April 2019 and May 2021 demonstrated that a majority of hospital systems surveyed included cybersecurity disasters in their HVA (82.4%, 47/57), and most ranked it as one of their top five priorities (57.4%, 27/47). However, over half denied specifically mentioning cybersecurity in their EOPs (52.6%, 30/57). Fourteen of the 57 hospital systems (24.5%) endorsed previously activating an Emergency Response for a cybersecurity incident unrelated to Information Technology (IT) failure.

The survey results suggest that American hospitals are currently underprepared for cybersecurity disasters. We emphasize the importance of prioritizing cybersecurity in HVAs and implementing specific EOP annexes for cybersecurity emergencies.

Japan is one of the most disaster-prone countries in the world. The government has traditionally taken the lead during disaster responses, but now NGOs have begun to play an active role in disaster response. Peace Winds Japan (PWJ), is the first Japanese NGOs to utilize medical teams, search-and-rescue dogs, and disaster response in conjunction with one another. The presentation will be focused on operations and lessons learned.

Initially, the NGO only supported disaster-affected areas, both domestic and abroad, by providing relief supplies. However, in 2010 they began training rescue dogs to perform life-saving search-and-rescue operations immediately after sudden onset disasters. In 2014 NGO dispatched rescue dogs and a disaster response team for the first time at the Hiroshima landslide disaster. A medical team was added in 2018, and since then has sent out teams to ten other disaster sites, including West Japan Flood in 2018 and Ukraine Crisis as an international EMT in 2022.

One of the strengths of the organization is the ability to respond quickly by using aviation and maritime transport. They operate two helicopters and one vessel and can promptly and effectively transport patients and resources. Eight critical patients were transported from the hospital by helicopter during the West Japan Flood.

Furthermore, joint rescue drills were conducted with both public and private organizations, and continue to seek ways for collaboration and cooperation in disaster settings.

Jakarta and Semarang are predicted to be engulfed by seawater by 2050, based on evidence by the Copernicus Sentinel-6 satellite. The current sinking rate is reaching almost 20 cm annually in both coastal cities, as reported at the World Economic Conference in May 2022, due to climate change, rising sea levels and excess groundwater extraction leading to land subsidence. Therefore, the objective of this study is to analyze the sinking of both coastal cities of Jakarta and Semarang, using indicators of vulnerability, exposure, and impact by 2050.

The YEW Disaster Severity Index (DSI) was used to analyze the impact, vulnerability, and exposure attributed to sinking. Data were obtained from real-time Google, Copernicus Sentinel-6 satellite, and triangulated with United Nations Office for Disaster Risk Reduction, World bank Data, Government of Indonesia Central Bureau of Statistics, as well as reputable journals.

The impact analysis on the sinking of Jakarta and Semarang, calculated in April 2022, using the YEW DSI, scored a High DSI impact of 6.03 and a Moderate DSI impact of 5.76, for each town respectively. Jakarta and Semarang also scored more than 100% baseline ability to cope on the YEW DSI indicators, which accounted for five vulnerability indicators and one exposure indicator of a total 13 million population affected. By 2050, both cities will be 5.6 meters below sea-level, with a constant current sinking of 20 cm per year.

At present, vulnerability and exposure of the affected population account for a total of 13 million in both coastal cities. The analysis showed the inability to cope within local capacity, indicating a response is needed. The future of Jakarta and Semarang is in the hands of local, national, and global decisions and policymakers, in mitigating its impact through forest land conservation, adaptation, and relocation of the affected population.

The complexity of disaster management is rising because of rapidly advancing technological changes and the challenges associated with coordinating responses among multi-organizational contexts. One of the common problems with multi-organizational disaster management is the need for an interoperability language. Therefore, by maintaining effective communication, risk can be reduced, and lives can be saved in times of crisis. The United States SCIPs represent one of the solutions used to achieve a culture of better interoperability. In 2019, The National Council of Statewide Interoperability Coordinators (NCSWIC) and CISA collaborated to create a tool that identified 25 Interoperability Markers. This tool is integrated with SCIPs to increase interoperability and serves as a national framework to describe interoperability maturity at the state levels.

This is a descriptive study documenting each state's 25 interoperability markers and analyzing common gaps and successes. Two methods were used for collecting data. First, an online search for each state's SCIP. Then, an email was sent to all state's Statewide Interoperability Coordinators (SWIC) to request the most recent update of that state’s SCIP. Data were collected from October 1-31, 2022 and exported into an Excel spreadsheet (Microsoft Corp; Redmond, Washington, USA) for descriptive statistics and analysis.

The level of interoperability maturity across the United States is 66%. The governance level in the interoperability continuum scored the highest across states with 76.4%. While the other levels of the interoperability continuum like technology, training and exercise, and interstate emergency communication scored 63.5%, 64%, and 60% respectively.

This study identifies a high level of interoperability maturity across the United States at the governance level. It is essential to continue to improve interstate interoperability through compatible technological solutions and multi-agency training. Finally, further research on interoperability markers is needed to enhance multi-agency emergency response.

The ISTARI unit is designed to be assembled in buildings or field hospitals to provide negative-pressure rooms in low-resource areas and decrease PPE use in the setting of highly-infectious diseases. Each unit is designed to perform ~20 air exchanges/hour with HEPA filters with multiple access points for providers to perform patient care without entering the unit while decreasing overall PPE usage. The goals of the design include patient safety, ease of use for, decreased infectious spread, and unit affordability.

A survey was obtained following a medical simulation within the ISTARI unit with Emergency Medicine resident physicians. The case involved an Ebola patient with Ventricular Tachycardia which progressed to cardiac arrest. Teams were given written and video instructions for the ISTARI unit and Ebola-level PPE. They were limited to one set of high-level PPE for the case. The survey scoring was a 0-5 scale, five being the highest.

Medical history-taking provider safety (PS)- 2.87, infection control (IC)-3.09, physical examination PS-3.52, IC-3.78, ultrasound usage PS-3.35, IC-3.43, intubation PS-2.35, IC-2.57, CPR PS-3.43, IC-3.65, cardioversion PS-3.35, IC-3.78, and overall average PS-3.145, IC-3.383.

Limitations were noted compared with traditional care, but 100% of teams met critical actions for patient management, including intubation, cardioversion, and CPR. GloGerm showed no contamination to those providing care outside the unit, but a small amount of contamination after doffing for those who entered the unit.

The ISTARI unit is a cost-effective isolation unit maximizing provider safety in management of patients with highly-infectious diseases, particularly in low-resource settings. It allows for easy mobilization of units and decreased medical supplies waste. The preliminary study shows satisfactory data about provider safety and infection control when using ISTARI for a highly-infectious patient, especially in providers unfamiliar with typical high-level PPE. Providers were able to provide all necessary critical actions for highly-infectious, critically-ill patients.

In a disaster, the number of victims and severity of injuries may overwhelm the treatment capacity of the local hospital. Surge capacity is the hospital’s ability to receive and treat an increased number of patients. This study aimed to explore if a past disaster or mass casualty incident (MCI) affects local hospital surge capacity preparedness.

The current hospital preparedness plans (HPPs) of University and central hospitals receiving surgical emergency patients in Finland were collected (n=28). The HPPs were read and analyzed using the World Health Organization (WHO) hospital emergency checklist tool with eight key components and 67 action items. The scores of key components were compared by percentage of the maximum score. The surge capacity score was compared between the hospitals that had been exposed to a disaster or MCI with those who had not. The effective level was considered as 70% of total points.

The overall median score of all key components was 76% (range 24%). The highest score was in command and control (median 93%, range 29%) and the lowest in post-disaster preparedness (median 50%, range 90%). The median surge capacity score was 65% (range 39%). There has been 12 disasters or MCIs during the past 25 years in Finland, all anthropogenic. There was no statistical difference between the surge capacity score of the hospitals with a history of a disaster or MCI compared to those without (65% for both, p=0.735).

In Finland, the overall hospital preparedness level is effective with command and control being the best covered area. Surge capacity preparedness was below the effective level and it was not affected by a past disaster or MCI. Present-day challenges with the lack of resources in the health care system, more attention should be drawn to the surge capacity aspect in hospital preparedness plans.

Major Incidents and Disasters are often associated with early, extensive and prolonged media reporting. It is important to understand the interaction between first responders/rescue services and the media to create better conditions for providing and making available correct and objective information to as many people as possible.

A systematic literature review and content analysis was made on all Swedish KAMEDO reports (emergency medicine observations published by the National Board of Health and Welfare) from the last twenty years, in total 39 reports. KAMEDO’s primary task is to feedback experience data (lessons learned) from disasters worldwide, through expert observers at the site of an emergency event. The aim of this study was to evaluate and analyze the experiences made regarding the interaction between media and healthcare in connection with major incidents and disasters, both on site and in hospitals.

The analysis resulted in the following main themes:

(1) Communication problems and other challenges in Major Incidents and Disasters

• No protection and restrictions

• Information craving and news hunt

• Interviews as intervention

(2) Recommendations for efficient interaction between healthcare and the media:

• Strategies from alert to action

• Satisfying information needs

• Clarity measures on site

• Key actors of importance

• Proactive media alertness

Some conclusions regarding lessons learned about interaction between healthcare and the media, as well as about communication with the afflicted and citizens, in brief: The hospital management should take control of the communication through efficient communication strategies. An accommodating approach to the media's presence can facilitate the dissemination of the necessary early, correct and balanced information. Joint authority press conferences are a model tested and positively evaluated. Healthcare communicators are key actors in hospital crisis communication and media management. Healthcare and media both benefit from developing routines and reciprocal respect for proactive and efficient interaction in emergencies.

Despite advancements in health behavior theories, understanding the human motivation to engage in disaster preparedness remains elusive. Most attempts at engaging the public in protective behavior rely on risk communication that assumes an information deficit among the people; ergo, risk communicators operate under the assumption that by increasing awareness of risks, sufficient motivation can be generated for preparedness behavior. Yet, this is far from being true.

A growing body of literature indicates the prevalence of fear-directed preparedness behavior, which is suboptimal in motivating behavioral change. This should come as no surprise, as using fear appeal tactics in risk communication designed to promote health behaviors have been proven to be primarily a failure.

Arguably, the phenomenon of failed risk communication campaigns could be linked to unconscious concerns about death, as proposed in the context of the Terror-Management Theory (TMT). According to TMT, since the experience of death-related thoughts triggers the potential for anxiety, the human psyche responds with motivated avoidance. In other words, the mind utilizes mechanisms that prevent death from becoming salient and remove death-related thoughts from focal attention when they arise. In turn, these defense mechanisms may yield procrastination in adopting protective behavior generated by denial as an adaptive coping mechanism.

Preliminary data suggest that procrastination in preparedness behavior until the threat becomes actual and imminent might be explained by TMT; however, explicit evidence for this association is yet to be provided. Should this understanding of the phenomenon be substantiated, it could significantly contribute to expanding our knowledge of the theoretical model behind public preparedness behavior.

The presentation will discuss the state-of-the-art research currently being done by the author to support the above claims. It will provide preliminary findings and will call the community to reconsider the current paradigm of disaster risk reduction and risk communication.

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The current Incident Command System (ICS) was developed to manage wildland fires, then was adopted by general firefighting. It has since been adapted to multiple other sectors and widely used. The Hospital Emergency Incident Command (HICS) was introduced in 1991. An ICS currently is required to be used for hospital incident management in the US.

The overarching structure of traditional HICS consists of Command Staff (Incident Commander, Public Information Officer, Safety Officer, Liaison Officer and Medical/Technical Specialist) and General Staff. The General Staff has Sections consisting of Operations, Planning, Logistics and Finance/Administration. Multiple and flexible subgroups carry out the processes in these areas.

This HICS structure does not adapt easily to hospital daily functions and alternatives have been proposed. This includes structuring around essential functions and mixed models. Over time hospital systems have become larger, and incidents more complex and sustained. New more expansive and flexible ICS structures are needed for complex responses.

We reviewed both the published and grey literature for examples of different incident management structures and evidence of their effectiveness.

There is very little scientific literature on this topic. Several different descriptive reports exist. Multiple examples of hospital incident command organization structures from the hospital level progressing to hospital (and healthcare) system level and then multistate regional models will be reviewed. This includes the standard HICS model, emergency support function models and modifications following advanced ICS principles such as area command.

Different ICS models exist that may offer individual healthcare systems improved ways to manage disasters.

Since the beginning of the COVID 19 pandemic, the EU-funded project, NO FEAR collected lessons observed from the response. One of the issues raised in the retrospective “lessons observed” exercise, was the need to better integrate health care into “crisis management structures” (e.g. Civil Protection).

Lessons observed from the COVID-19 response were collected and analyzed by the NO FEAR project, through a questionnaire, discussion with consortium partners, and a large conference in Madrid, with a high-level briefing for policymakers.

During the Madrid conference, different speakers pointed out the lack of training for healthcare professionals in crisis management (processes and procedures)–except those with military training or EMS officers who are part of Fire and Rescue Services. In a same manner, crisis managers have very little (if any) training in health. This was identified as a gap in future preparedness.

Looking into the future, healthcare professionals who will be called to take part in crisis management systems have to be trained in this task, as well as basic awareness of crisis managers to health issues in emergencies.

In October 2021, Hillel Yaffe, MC, suffered a ransomware attack which shutdown most hospital computer systems, including patient EMR, pharmacy, communications, administration and backup systems. Staff were left in a state of “cyber-shock” without access to essential information for maintaining safety, quality and continuity of care. The aim of this presentation is to share the hospitals' experience and insights of this cyber-attack, outlining preparedness and response strategies.

This attack required a multifaceted emergency response strategy, including:

• Immediate response activated according to specific pre-prepared emergency scenario action lists

• Leadership decision making in real time under conditions of uncertainty

• Identifying the extent of systems affected

• Establishing alternative communication across the organization

• Distributing real-time status updates and proactive guidelines, based on pre-existing emergency preparedness protocols

• Finding alternative access to patient health histories

• Adaptation and distribution of alternative hardcopy versions of patient evaluation and documentation normally done by EMR

• Distribution of instruction materials for staff via alternative communication, ensuring quick and correct adoption of alternative protocols

• Special emphasis on patient safety, risk management, quality and continuity of care

Recognition, support and resilience-building for staff facing uncertainty and unprecedented conditions

Required preparations include pre-prepared standing orders and procedures, exercises and simulations. Advanced preparation of alternative documentation and care protocols will enable uninterrupted, safe, high-quality patient care. Familiarity with pen-and-paper documentation may minimize shock and disorientation from “digital withdrawal”, especially among younger workers lacking manual documentation experience. Staff members should also be instructed in maintaining “digital hygiene”, such as using strong passwords and awareness about cyber-security threats.

Hospitals must prepare for potential cyber-attacks and EMR/digital system shutdowns. Cyber-attack should be treated by organizations as an emergency event, and they should prepare incident response and contingency plans, to assure business continuity and quick disaster recovery.