The United Nations (UN) recognizes Small Island Developing States (SIDS) as a heterogenous group with common geographic and socio-economic challenges. Their vulnerability to disasters was exacerbated during COVID-19 because of emerging nationalism and protectionism towards supply chains and resources. This study aimed to determine if multilateralism engagement improved COVID-19 outcomes and if Foreign Affairs investment improved short term COVID-19 outcomes.

Metrics were developed to reflect country parameters, clinical impact of COVID-19, engagement in multilateralism, health systems strength and integration in the International Political Economy. Open-source information was used to quantify proxy measures with the calculated percent spent on foreign affairs being the major proxy of multilateralism and disaster impact as lag time to vaccination, case burden and deaths in the first six months of 2020. Data was collected for each of the 38 SIDS. SPSS was used to assess possible correlations with short- and long-term clinical outcomes of the COVID-19 pandemic.

SIDS were noted to have an average lag of 4.1 months to begin vaccination rollout compared with developed nations and prolonged below global average vaccination rates. Expenditure on Foreign Affairs reduced the vaccination lag (p=0.03), decreased short-term cases (p<0.001) and deaths (p<0.001), Human Development Index improved vaccination rates (p<0.001) and lowered total cases (p=0.03). Foreign Direct Investment (FDI) inflow also decreased vaccination lag (0.02). Dependence on Foreign Aid decreased vaccination rates (p=0.01).

These relationships suggest that there were multiple factors that determined short- and long-term health outcomes in SIDS. Mitigating the impact of a disaster therefore requires a multiple level investment solution that recognizes the importance of other actors in the global system. The COVID-19 experience suggests that engagement in multilateralism is important in countries that have a high vulnerability to disasters such as SIDS. This is valuable for future disasters in vulnerable states.

The COVID-19 pandemic poses challenges in maintaining global medical education partnerships, with travel restrictions and infection control concerns forcing program adaptation. The Pediatric Emergency Medicine Specialty Training and Accelerated Review (PEM-STAR) program is one such international collaboration which addresses education and training gaps in emergency care for children within Thailand. As an assessment of PEM-STAR’s ability to deliver consistent outcomes despite COVID-19 constraints, we compared program results for Cohort #1 (2018-2019, pre-pandemic) and Cohort #2 (2019-2021, spanning pandemic).

Oregon Health & Science University and Bangkok Dusit Medical Services implemented the PEM-STAR tandem physician-nurse curriculum in 2018. The cornerstone of the year-long course is a set of 22 PEM-specific topic modules, incorporating remote-accessible voiceover slide lectures, quizzes, and scholarly references to teach pediatric emergency medicine essentials. Content is reviewed via monthly teleconferences. Baseline and final assessments include written knowledge tests and high-fidelity simulation cases led by physician-nurse teams. Cohort #1 simulations were performed with evaluators in-situ using critical action checklists and validated teamwork assessment tools. Due to COVID-19 restrictions, Cohort #2 final assessments were hybrid; students completed Thailand-based simulations while Oregon leaders assessed and debriefed teams via videoconference.

Written exam scores for pre-pandemic Cohort#1 improved from 48.6% (95%CI 40.30-56.9) to 92.0% (95%CI 88.1-95.9) (p< 0.001). Cohort #2, during the pandemic, had scores improve similarly from 48.5% (95%CI 40.1-56.9) to 96.4% (95%CI 94.8-98.0) (p< 0.001). One-hundred percent of physician-nurse teams from both Cohort #1 and Cohort #2 achieved the program’s established passing score on final simulation testing: performing >85% of critical action items and scoring > 85% on the teamwork tool.

The PEM-STAR design, with its emphasis on videoconferencing, web-based content, and asynchronous learning, required minimal modifications to maintain satisfactory knowledge and skill acquisition during the pandemic. Educational partnerships emphasizing these features have distinct sustainability advantages in times of global disorder.

In 2022, the Harvard/Beth Israel Deaconess Disaster Medicine Fellowship conducted a full-scale exercise (FSX) with the dual mission of 1) training Disaster Medicine Fellows (DMFs) in exercise design, planning, and execution, and 2) expanding local first responder experience with pediatric casualties in a mixed-method terrorist attack.

Project PUNCH (Preparedness for Uncertain and Novel Chemical Hazards) was planned in two stages. A tabletop exercise in the form of a facilitated discussion was conducted in March 2022 with stakeholders from Fire, Emergency Medical Services (EMS), and the Massachusetts HazMat Team. A FSX simulating a combined blast and chemical attack on a family gathering was held in June 2022 at Anna Maria College in Paxton, MA.

Fire, EMS, HazMat, LifeFlight, local Police, MA State Police, a local Medical Reserve Corps, and over 40 volunteer victims including 16 pediatric volunteers participated in the FSX. The FSX was a two-hour exercise with a simulated explosion and a secondary drone-deployed dummy-opioid aerosol release. This was the first FSX for the Paxton Region since the coronavirus pandemic began. Planning was conducted by the DMFs between January and June 2022 with the aid of Fellowship faculty and local stakeholders following Homeland Security Exercise and Evaluation Program guidelines. Local and Fellowship leadership with Pediatric expertise were engaged to plan pediatric specific considerations, precautions and safety measures. COVID precaution guidelines were followed. These efforts are detailed in the forthcoming field report. Educational guides for toxidromes and triage and resuscitation of pediatric victims were distributed to first responders.

The end outcome was a FSX that trained DMFs in exercise design, planning, and execution, and increased experience of local first responders with the concepts of asymmetric terrorist attacks and comfort with pediatric disaster victims. Multi-agency disaster drills remain an important training tool for preparedness and response to mass casualty events.

Children are frequently victims of disasters. However, significant gaps remain in pediatric disaster preparedness planning. This includes a lack of planning for pediatric residents in long-term care facilities. The New York City (NYC) Pediatric Disaster Coalition (PDC) is funded by the New York City (NYC) Department of Health and Mental Hygiene (DOHMH) to improve NYC’s pediatric disaster preparedness and response. The NYC PDC partnered with experts in pediatric disaster management and the care of pediatric residents in long-term care facilities to create the Pediatric Long-Term Care Planning Committee (PLTCPC).

The PLTCPC included physicians, nurses, administrators, and emergency planning experts. The PLTCPC’s goal was to create guidelines and templates for use in disaster planning for pediatric residents at long-term care facilities. The committee met bi-weekly over three months and shared facility resources to create tools that meet the specific challenges presented by this population.

Utilizing an iterative process that included a literature review, participant presentations, review and improvement of the working documents, the final guidelines and templates for surge and evacuation of pediatric residents in long-term care facilities were created. Due to the onset of the COVID-19 pandemic, the NYC PDC reconvened the PLTCPC to focus on surge planning for pandemics at pediatric long-term care facilities. Two pediatric infectious disease clinicians were added to the committee. Utilizing the same process delineated above, a detailed pandemic specific annex was created based on clinical pediatric experience gained throughout the pandemic.

To the authors' knowledge, these are the first pediatric-specific resources for long-term care disaster planning. They address the importance of matching resources to the unique needs of PLTC facilities, in regard to space, equipment, staffing, and training. Pediatric long-term care facilities present special needs during pandemics and this approach can be utilized as a model for other facilities.

Improved understanding of pediatric emergency preparedness can ensure the safety of children during disaster events, a population that is often overlooked.1 2 One method to minimize disparities is to increase the pediatric preparedness workforce by providing education to trainees about the foundations of this field.

A pediatric emergency preparedness curriculum was created as part of an elective prehospital track within a pediatric emergency medicine fellowship program at a quaternary pediatric hospital.

The curriculum focuses on three domains: education, research, and administration. The trainee is required to participate in local and regional educational opportunities. Locally, trainees create and facilitate at least one tabletop exercise about a preparedness topic of their choice. They also attend regional and state-wide preparedness drills to foster better understanding of integrated system processes. Additional educational opportunities involve the creation of asynchronous learning modules for their division and development of just-in-time resources for disaster events. For research, they have the opportunity to pursue an original project in the field and participate in other research activities with the track director. The administration domain prepares the trainee to be a leader in the field. Trainees are active participants within the emergency department’s preparedness committee and during hospital-wide preparedness meetings. These meetings develop protocols and policies as well as educational initiatives. Fellows are also encouraged to join national collaborative preparedness efforts through the American Academy of Pediatrics and the EMSC innovation and Improvement Center (EIIC).

This curriculum provides an introduction to and continued education about disaster preparedness to pediatric emergency fellows early in their career. Completion of the sub-track fosters future leaders in the disaster medicine field. In the future, this curriculum can be adopted by other medical training programs to expand understanding of pediatric preparedness concepts.

Region V for kids (originally known as Eastern Great Lakes Consortium for Disaster Response ) is one of the US-ASPR (Administration for Strategic Preparedness and Response) funded Pediatric Center of Disaster Excellence (PCOE), serving nearly 12 million children and families in a six state region of the United States.

The original goals set forth were: to develop a coordinated pediatric disaster care capability, strengthen pediatric disaster preparedness plans and coordination, enhance state and regional medical pediatric surge capacity, increase healthcare professional educational competency and enhance situational awareness of pediatric disaster care across the spectrum.

The COVID-19 pandemic occurred shortly after original funding and caused a pivot from preparation to response for the partners, enhancing the collaboration and coordination for the region. The many lessons from the COVID response have been important to creating more partnerships with federal agencies around situational awareness and considering social and physical determinants of health that effect children and families. The partnerships with state agencies and other key stakeholders have been valuable to close the gaps in the pediatric/family disaster cycle. There has been a multitude of tools and products that have been created and disseminated from this PCOE, including educational tools, behavioral health training and tools, virtual exercises and quality improvement projects. The best practices and ongoing projects highlight how to improve coordinated care for children and families within a region and is an example for the United States and beyond. There are also challenges to coordinated preparedness due to jurisdictional barriers and these are as important to highlight and create mitigation strategies.

This US supported PCOE is an example of a regional disaster coordination to mitigate and prepare for response concentrating on the needs of children and families in the larger disaster cycle.

Pediatric disaster science is critical to provide data and discovery to guide evidence-based preparedness, response, mitigation and recovery to best serve children, families and society. With the increasing frequency, severity and global scope of disasters, there is now an unprecedented imperative and opportunity to build a sustained pediatric disaster science workforce and infrastructure. The expertise, perspective and collaboration of the international, multidisciplinary community, including WADEM members, is integral to supporting effective, efficient, ethical, high quality pediatric disaster science and its implementation.

A landmark Pediatric Disaster Science Symposium was convened in-person/virtually by the US National Academies of Science Engineering and Medicine in August 2022. Forty-eight pediatric disaster focused invited speakers, collectively representing government, non-governmental organizations, academia and community attended, and online. Attendees were polled during the two-day meeting to assign priority ratings to the topics discussed.

Symposium topics included the importance, history and scope of pediatric disaster science, and research across the disaster management cycle. Research considerations specific to children included medical and psychosocial vulnerabilities and manifestations; ethics and protections; protocol development and deployment; research tools; and data collection/integration. Scientific methodology topics addressed pediatric considerations for basic science, surveillance, clinical trials, applied sciences, community-engaged research, dissemination and implementation. Infrastructure needs described leveraging disaster centers, research networks, disaster response teams, government agencies and professional societies integratively across disciplines. Building a sustainable workforce, including training and engaging pediatric scientists with disaster-focused/disaster-relevant research, funding streams, regulation and advocacy were also discussed. Research priority ratings yielded preliminary data to inform pediatric disaster science priorities.

The meeting provided insights that can further guide discussions among global disaster experts and scientists, including WADEM members, to prioritize, build and scale sustainable pediatric disaster science that yields evidence-based strategies, plans, resources, and actions that improve disaster preparedness, response, mitigation, and recovery for children, families and societies worldwide.

Terrorism remains a major threat and concern in many countries around the world. Children represent approximately 30% of the world population and in the event of a terrorist attack can either be primary targets, to include the possibility of abduction, or unintended victims. Children are unique in their vulnerabilities and therefore, require special consideration.

This study is a semi-quantitative epidemiological analysis of all terrorism-related pediatric fatalities and injuries sustained between 1970-2019. Data collection was performed using a retrospective database search through the Global Terrorism Database (GTD). Summaries of events including search terms associated with children were individually reviewed and those describing the deaths, injuries, or abduction of children were tallied.

Of the over 200,000 terror events, 2,302 events met inclusion criteria. This represented 1.14% of total events which involved death, injury, or abduction of children. Of 2,032 events a total of 2,275 pediatric fatal injuries (FI) were recorded, as well as 2,280 pediatric non-fatal injuries (NFI). The most common weapons used in all attacks involving the pediatric population were explosives (1539[66.8%]), firearms (543 [23.5%]), other (169 [7.3%]) and melee (83 [3.6%]). 275 of the 2,032 were related to abductions, with 71 cases involving the abduction of ten children or more.

Pediatric casualties in terrorist events represent a small proportion of overall victims, however, they have unique vulnerabilities, and when directly impacted by terrorism, can have long term physical and psychosocial sequelae, as well as a devastating emotional impact on the community.

Children are frequently victims of disasters. However, gaps remain in pediatric disaster preparedness. The New York City Pediatric Disaster Coalition (NYCPDC) is funded by the NYC Department of Health and Mental Hygiene (DOHMH) to prepare NYC for mass casualty events that involve large numbers of children. The NYC PDC conducted a functional exercise testing surge, communications, and secondary transport. Participants included 28 NYC hospitals, the NYC Fire Department-Emergency Medical Services (FDNY-EMS), NYC Emergency Management (NYCEM), NYC DOHMH and the NYC Medical Reserve Corps (MRC).

The hospitals and agencies participated in group and individual planning meetings. Scenario-driven, operations-based activities challenged participants to employ their facility's existing pediatric surge and secondary transport plans during an event. The exercise assessed: Communications, Emergency Operation Plans, Surge, Patient Tracking, Patient Transfer, Supplies, and Staffing. Internal and external evaluators assessed the exercise performance.

An After-Action Report was written based on information from evaluation data, site-specific and group hot-washes, and an after-action conference. Strengths included meaningful improvement of plans before/after the exercise and doubling pediatric critical care capacity through the implementation of the exercise objectives. Challenges included: gaps in communication/patient tracking, lack of sufficient sub-specialty support, the need for "babysitters” and inadequate supplies of blood products and ventilators.

Conducting a multi-hospital and agency pediatric specific exercise demonstrated current planning and produced lessons learned to address planning and training gaps that can improve citywide planning and capabilities during future full-scale exercise and real-time events.

Children are frequently victims of disasters; however important gaps remain in pediatric disaster planning. This includes a lack of resources for pediatric preparedness planning for patients in outpatient/urgent-care facilities. The New York City Pediatric Disaster Coalition (NYCPDC) is funded by the NYC Department of Health and Mental Hygiene (DOHMH) to improve NYC’s pediatric disaster preparedness and response.

After creating planning resources in Pediatric Long-Term Care Facilities, Hospital Pediatric Departments, Pediatric and Neonatal Intensive Care Units, and Obstetric/Newborn Services within NYC hospitals, the NYCPDC partnered with leaders and experts from outpatient/urgent-care facilities caring for pediatric patients and created the Pediatric Outpatient Disaster Planning Committee (PODPC). PODPC’s goal was to create guidelines and templates for use in disaster planning for pediatric patients at outpatient/urgent-care facilities.

The PODPC includes physicians, nurses, administrators and emergency planning experts who have experience working with outpatient facilities. There were 21 committee members from eight organizations (the NYCPDC, DOHMH, Community Healthcare Association of NY State, NY State DOH, NYC Health and Hospitals, Maimonides Medical Center and Presbyterian/Columbia University Medical Center). The committee met six times over a four-month period and shared information to create disaster planning tools that meet the specific pediatric challenges in the outpatient setting.

Utilizing an iterative process including literature review, participant presentations, discussions review and improvement of working documents, the final guidelines and templates for surge and evacuation of pediatric patients in outpatient/urgent care facilities were created in 2018. Subsequently model plans were completed and implemented at five NYC Outpatient/Urgent-care facilities.

An expert committee utilizing an iterative process successfully created disaster guidelines and templates for pediatric outpatient/urgent care facilities. They addressed the importance of matching the special needs of children to available space, staff and equipment needs and created model plans for site-specific use.

During public health emergencies, like COVID-19 or natural disasters, care for the pediatric population can become fragmented. Communication between systems may be challenged due to lack of relationships or infrastructure barriers such as incompatible electronic health record (EHR) systems. This can create critical, life-threatening situations for pregnant patients, infants, and children with exposures to threats. A systems-level approach was developed to guide planning efforts to improve and enhance communication and data sharing along the spectrum of care for children during public health emergencies.

The American Academy of Pediatrics (AAP) and the Centers for Disease Control and Prevention (CDC) gathered subject matter experts to discuss how healthcare systems and community partners could strengthen the communication within the pediatric system of care. Three primary challenges emerged: Communication, Screening and Data, and Preparedness and Planning. Action steps were identified to address these challenge areas and meet the goals of reaching diverse populations, addressing health disparities, improving collaboration between health systems and public health, implementing effective screening practices that are guided by data, and strengthening infrastructure.

As a result of the in-depth discussions a graphic was developed to help guide those working to improve the system of care in their communities by implementing the activities described above. Selected multidisciplinary state teams will test strategies to address these goals.

Improving communication and data sharing in the pediatric system of care will improve care and better inform the response during public health emergencies. Building successful partnerships, such as those between health care and public health, will be critical to success. The example of the Surveillance for Emerging Threats to Mothers and Babies Network (SET-NET) program, which collects and analyzes data related to public health threats, demonstrates the strength of this approach.

With the publication of the Health Emergency and Disaster Risk Management (H-EDRM) Framework in 2019, the World Health Organization (WHO) emphasized the need for disaster preparedness in all sectors of the health system, including primary health care (PHC). PHC disaster preparedness plays a crucial role in guaranteeing continuity of care and responding to the health needs of vulnerable populations during disasters. While this is universally acknowledged as an important component of disaster management (DM), there is still a severe paucity of scholarship addressing how to practically ensure that a PHC system is prepared for disasters. The objective of this study is to propose a new framework that describes key characteristics for PHC disaster preparedness and lays the groundwork to deliver operational recommendations to assess and improve PHC disaster preparedness.

A systematic literature review including the following online scientific databases was performed: Cochrane Library, Embase, Medline, National Library of Medicine, PubMed, Scopus, and Web of Science. Gray literature was also found by searching in: Trove, Mednar, and OpenGray. A total of 145 records were analyzed.

Twenty-five characteristics that contribute to a well-prepared PHC system were identified and categorized according to the WHO Health System Building Blocks to form a new PHC disaster preparedness framework.

The findings will contribute to the elaboration of a set of guidelines for PHC systems to follow in order to assess and boost their disaster preparedness. This will hopefully help to raise awareness among international policymakers and health practitioners on the importance to design interventions that integrate PHC into overall DM strategies, as well as to assess the preparedness of PHC systems in different political, developmental, and cultural contexts. The proposed framework is currently being used by our research group as groundwork for the creation of an assessment tool for evaluating all-hazards preparedness at the PHC level.

Primary healthcare providers (PHCPs) are uniquely positioned to evaluate and increase vulnerable patients' disaster preparedness, in that they have detailed information about their medical needs, resources, and limitations. Nevertheless, it is still unclear what their roles and services are in this field. This study aimed to review the literature on PHCPs services to prepare the vulnerable population for disasters.

MEDLINE, Scopus, and PubMed databases were searched. Inclusion criteria include peer-reviewed articles published in English with no restriction on publication date. In order to obtain a broad perspective on the subject, the study type was not limited. The retrieved articles were imported into EndNote Reference Manager to manage duplications. Then, the reference lists of retrieved articles were checked for the relevance of the title and abstract. Lastly, fulltext articles identified were inspected against the inclusion criteria. Thematic analysis was performed to consolidate the commonalities in PHCPs roles and services for disater preparedness.

From the database search, 2193 articles were retrieved and 844 duplications were eliminated. Afterwards, 1349 articles were screened based on title and abstract, 49 full-text articles were assessed for eligibility, and 22 full-text articles were included. The six themes associated with services provided by PHCPs were emerged as follows: identifying vulnerable groups and assisting them in disaster planning, providing written materials and/or recommendations; protecting vulnerable population’ records; educating staff, vulnerable clients, and their caregivers; coordinating disaster planning and response across agencies; routine assessment of disaster preparedness, and planning for evacuation.

This scoping review reveals that the literature on PHCPs services to improve vulnerable populations’ disaster preparedness is limited. Consequently, there is a need for scientific research to increase the existing capabilities of PHCPs for vulnerable population disaster preparedness and identify barriers and facilitators affecting their coordination with disaster management agencies.

Access to palliative care, and more specifically the alleviation of avoidable physical and psychosocial suffering is increasingly recognized as necessary in humanitarian response. Palliative approaches to care can meet the needs of patients for whom curative treatment may not be the aim, not just at the very end of life but also more broadly. Humanitarian organizations and sectoral initiatives have taken steps to develop guidance and policies to support integration of palliative care. However, it is still sometimes regarded as unfeasible or aspirational in crisis contexts; particularly where care for persons with life threatening conditions or injuries is logistically, legally, and ethically challenging. We present a synthesis of findings from five qualitative sub-studies within a R2HC-funded research program on palliative care provision in humanitarian crises that sought to better understand the ethical and practical dimensions of humanitarian organizations integrating palliative care into emergency responses.

A multi-disciplinary, multi-national team conducted an exploratory mixed-methods study and presented findings from semi-structured interviews with international and local health care providers, patients, and families that explored experiences of palliative care in different humanitarian responses: protracted refugee crisis (Rwanda n=17), acute refugee crises (Jordan and Bangladesh n=20), a public health emergency (Guinea n=16), and natural disasters (various countries n =17)

Four themes emerged from descriptions of the struggles and successes of applying palliative care in humanitarian settings: 1) justification and integration of palliative care into humanitarian response, 2) contextualizing palliative care approaches to crisis settings, 3) the importance of being attentive to the ‘situatedness of dying’, and 4) the need for retaining a holistic approach to care. The findings are discussed relation to the ideals embraced in palliative care and corresponding humanitarian values.

Though challenging, palliative care in humanitarian response is essential for responding to avoidable pain and suffering consistent with humanitarian principles.

Collecting real-time individual health data of all disaster-affected populations is usually considered impossible. The University of Kochi's team and its partners conceived a novel health assessment system named "Community Oriented Approach for Comprehensive Healthcare in Emergency Situations (COACHES)." It collects individual health data anonymously and records such data in a cloud-based database. The system runs on any personal mobile device by scanning a personal identification code (QR code). It is expected that anyone on site with qualifications in healthcare will run this system as a volunteer to ensure data reliability. The COACHES app development is in process, and its prototype is currently available. This study aimed to assess how people react to the novel system and see the feasibility of installation in Japan.

Two focus group interviews (FGI) were conducted in a small coastal village in western Japan. The village anticipates severe damages with days of isolation once a large-scale earthquake followed by a tsunami hits the area. The first FGI was held with nine purposively recruited participants. The second FGI was held one month after and included seven of the first FGI participants with one of the absent participants providing a written response. FGI was for one-hour each, with discussion following the system demonstration. The voice data during the FGI were recorded and analyzed. The research was approved by the University of Kochi IRB.

Some showed intense interest in the system, whereas concerns such as the privacy violation for using personal devices, the availability of healthcare personnel, or a fear that anonymous data collection may delay identifying a person in need of assistance.

Further studies are proposed, particularly in recruiting volunteers, data storage in case of technical damage, and how to make people with limited IT literacy comfortable using the new system.

Burn mass casualty incident (BMCI) planning efforts have been in practice and publication for 40+ years. While COVID-19 has no direct connection to burn injuries, the impact of COVID-19 on the healthcare system including burn care was and remains significant.

A retrospective analysis of data was conducted voluntarily submitted to the American Burn Association from March 2020 to June 2021 which generally coincides with the first three waves of the pandemic. We focused on the self-reported data specific to the three critical components in managing a surge of patients: staffing, space, and supplies (to include pharmaceuticals and equipment).

Staff: These data were collected over a period that coincided with the first three waves seen in the USA. Staffing shortages were noted during each of the surges but were most excessive when a regional surge paralleled surges in other parts of the country (November-December 2020).

Space: Late November and early December 2020, space was in short supply with the surge of patients for more of the region than at any other time during the 28 weeks of reporting. While single facilities reported other episodes of limited space or supplemented with temporary structures, the peak was early December.

Supplies: As the first surge began to subside, the supply shortages were abated. However, as additional surges occurred; the supply chain had not recovered. Supply shortages were reported in greater numbers than either space or staffing needs through the multiple waves of the pandemic.

The COVID-19 pandemic directly led to a diminished available capacity for burn care in such a way that it compromised the ability to confront a surge of burn-injured patients. Future BMCI planning efforts must consider this aspect of the process. Crisis Standards of Care may come into play during such an event.

Patients refusing transportation is common EMS practice with potentially fatal outcomes. Determining which patients are at high risk for poor outcomes is poorly defined. This study described patients who experienced an out-of-hospital cardiac arrest (OHCA) within 24 hours of refusing transportation.

This is a retrospective, descriptive study of patients who had an OHCA within 24 hours of refusing EMS transportation between 2019 to 2021. Data was obtained from a large, urban medical control authority seeing 175,000 EMS calls annually. We reviewed patient demographics, EMS events when transportation was refused, and cardiac arrest outcome.

There were 6, 30, and 28 EMS refusals resulting in OHCA in 2019, 2020, and 2021. Patients who had OHCA were 65.7 (range 28-103) years old, and African American (54/64). Patients had HTN (36/64), diabetes (19/64), COPD (11/64), and CHF (7/64). Common complaints included breathing problems (17/64), near syncope (8/64) however chest pain was uncommon (4/64). One (28/64) or two (13/64) abnormal vital signs were present and missing vital signs (28/64) were common. Tachycardia (32.8%, 21/64), HTN (29.7%, 19/64), and hypotension (17.2%, 11/64) were more prevalent in the OHCA population compared to all refusal patients (Tachycardia 0.33% [1,978/598,416], HTN 2.27% [13,601/598,416], and hypotension 0.04% [218/598,416]). Patients were seen by both ALS (29/64) and BLS (35/64) providers. Most providers documented risk including death (38/64) though few contacted medical control (14/64). Return encounter for OHCA resulted in obvious deaths (23/64) or field termination (20/64). Few patients achieved ROSC (7/64).

Patients who had an OHCA within 24 hours of refusing transport had underlying comorbidities and abnormal or missing vital signs. The patients experienced tachycardia, hypertension, and hypotension at a higher rate than the overall refusal population. Few patients obtained ROSC. Further research is needed to determine methods to mitigate poor outcomes and decrease refusals.

While the importance of pharmacists' involvement in disaster management is becoming increasingly recognized in the literature, there are few mechanisms by which pharmacists can prepare themselves for emergencies. This project aimed to determine the effectiveness of a disaster tabletop exercise (TTX) in preparing pharmacy staff for disasters.

A TTX was held at the American Society of Health-System Pharmacists Summer Meeting which was held in Phoenix, Arizona in June 2022. The workshop incorporated an evolving emergency scenario in which participants worked through activities pertaining to the mitigation, preparedness, response, and recovery cycle. The scenario involved a hypothetical storm and landside scenario across fictional towns in Arizona, US. Workshop attendees worked in small groups on one of two provided hospital profiles. The attendees were invited to complete a pre-post survey assessing their perceptions of disaster management including perceived preparedness. This survey was previously developed, piloted, and published. The paper surveys were collected at the end of the workshop and inputted into RedCap. Data were descriptively summarized using SPSS, and pre-post survey results were compared using appropriate statistical tests.

The workshop was attended by 40 pharmacy personnel and 31 completed the survey. All participants agreed that the exercise was well structured, realistic, allowed them to test their response plans and systems, and helped improve their understanding of their role and function in disaster response. After the workshop, participants' perceptions of their ability to prevent, respond, and recover from a disaster all significantly improved (p=0.004, 0.013, and 0.013 respectively). However, perceptions of their preparedness for a disaster did not significantly change (p=0.197).

This study adds to the evidence of the effectiveness in training and preparing the pharmacy workforce. The TTX improved the understanding and perceived capabilities of pharmacy personnel in responding and recovering from emergencies.

The Israeli health system had a critical role in leading the response to the COVID-19 pandemic facing a wide-range of challenges following the length and the unique characteristics of this health emergency. This study evaluated the weaknesses and strengths of the different parts of the system, relying on WHO building blocks to promote better coping with large-scale health emergencies.

The experiences of 13 high-level senior experts in the Israeli health system who directly managed COVID-19 were examined, using in-depth semi-structured interviews conducted during 2021. Critical and snowball sampling were used to select participants. Interviews were recorded and transcribed. Data analysis was conducted using ATLS.TI 22 software and reviewed by peers. The interviews were analyzed using the thematic analysis method. A theme expresses a broad central idea that tends to appear and reoccur in the analytical material in different forms of expression. Specifications and ideas were discussed among the researchers while engaging in repeated rereading of the transcriptions until saturation was achieved with the final themes.

The role of the Ministry of Health in integrating the health response and importance of spokespersons providing professional information increase trust as a crucial role of community health services in emergencies having political tensions reflected in the medical response. The Israeli Health system differ from hospital systems abroad by the relationships between preparedness during routine and emergency response. The importance of trust was highlighted.

The study demonstrates a deep understanding of the way the Israeli health system dealt with the pandemic, revealing needs, resources, weaknesses and strengths. The results offer a rare opportunity to learn how integration of service-delivery can be improved within the health system in all levels. These lessons should be translated to advance better handling of future emergencies.

The COVID-19 pandemic and the countermeasures taken form a threat to the physical and mental health of the population, especially for more vulnerable groups. In this study, which is part of the Integrated Health Monitor COVID-19, the impact of the COVID-19 pandemic on the healthcare use of the Dutch population and specific vulnerable groups was examined.

In this study two data-sources were combined. The first consists of electronic patient records of general practices (GP) participating in the Nivel Primary Care Database. These records are representative of the Dutch population and provide insight into acute complaints, chronic conditions, medication prescriptions and primary care use. For the current study, primary care use in pre-COVID years (2018 and 2019) was compared to that in 2021. This data was coupled with microdata from Statistics Netherlands, containing such information as socio-economic status and migration background. Analyses were conducted using longitudinal mixed-effects regression models.

Results show that risk factors play a role in the utilization of primary care. Women and those with a low household income visited the GP more often for mental complaints. Individuals with a migrant background visited the GP more often for coughing, fatigue, and social problems. Those with pre-existing chronic physical conditions were seen less often by their GP for shortness of breath. Among those with pre-existing mental problems GPs more often registered shortness of breath, yet less problems with access to care or social problems.

Combining GP registry data with relevant background data has deepened our understanding of changes in health problems and healthcare use among the general population during the COVID-19 pandemic. This study provides insight into how specific vulnerable groups are affected more strongly, and emphasizes the importance of monitoring these groups during a health crisis.