Reduction in Hospital Transfers at a US COVID-19 Alternate Care Site: Maintaining Surge Capacity Support in Imperial County, California.

OBJECTIVE: The transfer rate for patients from an Alternate Care Site (ACS) back to a hospital may serve as a metric of appropriate patient selection and the ability of an ACS to treat moderate to severely ill patients accepted from overwhelmed health-care systems. During the coronavirus infectious disease 2019 (COVID-19) pandemic, hospitals worldwide experienced acute surges of patients presenting with acute respiratory failure. METHODS: An ACS in Imperial County, California was re-established in November 2020 to help decompress 2 local hospitals experiencing surges of COVID-19 cases. The patients treated often had multiple comorbid illnesses and required a median supplemental oxygen of 3 L/min (LPM) on admission. Numerous interventions were initiated during a 2-wk period to improve clinical care delivery. RESULTS: The objectives of this retrospective observational study are to evaluate the impact of these clinical and staff interventions at an ACS on the transfer rate and to provide issues to consider for future ACS sites managing COVID-19 patients. CONCLUSIONS: The data suggest that continuous, real-time process-improvement interventions helped reduce the transfer rate back to hospitals from 36.7% to 14.5% and that an ACS is a viable option for managing symptomatic COVID-19 positive patients requiring hospital-level care when hospitals are overburdened.

Opportunities to Strengthen the National Disaster Medical System: The Military-Civilian NDMS Interoperability Study.

The definitive care component of the National Disaster Medical System (NDMS) may not be able to effectively manage tens of thousands of casualties resulting from a catastrophic disaster incident or overseas conflict. To address this potential national security threat, Congress authorized the US Secretary of Defense to conduct the NDMS Pilot Program to improve the interoperability, special capabilities, and patient capacity of the NDMS. The pilot's first phase was the Military-Civilian NDMS Interoperability Study, designed to identify broad themes to direct further NDMS research. Researchers conducted a series of facilitated discussions with 49 key NDMS federal and civilian (private sector) stakeholders to identify and assess weaknesses and opportunities for improving the NDMS. After qualitative analysis, 6 critical themes emerged: (1) coordination, collaboration, and communication between federal and private sector NDMS partners; (2) funding and incentives for improved surge capacity and preparedness for NDMS partners; (3) staffing capacity and competencies for government and private NDMS partners; (4) surge capacity, especially at private sector healthcare facilities; (5) training, education, and exercises and knowledge sharing between federal and private sector NDMS partners; and (6) metrics, benchmarks, and modeling for NDMS partners to track their NDMS-related capabilities and performance. These findings provide a roadmap for federal-level changes and additional operations research to strengthen the NDMS definitive care system, particularly in the areas of policy and legislation, operational coordination, and funding.

Mass casualty incidents during the ten years of telemedical maritime assistance service in Gdynia, Poland.

Mass casualty incident (MCI) is one of the most difficult situation in emergency medicine. Due to the specific conditions, MCIs occurring at sea are usually far more demanding than those happening on land. In this paper the authors would like to describe the MCIs, which have happened during almost 10 years of functioning of the Polish Telemedical Maritime Assistance Service (TMAS). First incident concerned a group of migrants floating on a raft on the Gulf of Mexico. The cause of the second incident was acute organophosphate intoxication among the crew of the merchant ship. The third incident was triggered by the coronavirus disease 2019 (COVID-19). It is important to emphasize, that triage system may help in proper management of MCIs. Cooperation of the medical services, such as TMAS, local emergency medical staff, Search and Rescue (SAR) service and military force seems to be crucial in MCI managements occuring at sea. In case of any doubts, change of a course and heading to the nearest port or immediate evacuation should be taken into consideration. The authors believe that analysis of these incidents may help TMAS personnel all over the world to handle MCIs in the future. Med Pr. 2023;74(2):145-50.

COVID-19: A Comprehensive Analysis of the Pandemic's Effect on an Emergency Department.

OBJECTIVE: Coronavirus disease 2019 (COVID-19, caused by severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) is a historic pandemic severely impacting health care. This study examines its early effect on a busy academic emergency department. METHODS: A retrospective analysis of patients from an academic tertiary care Level I trauma, cardiac and stroke center's emergency department seeing an average of 54,000 adults and 21,000 pediatric patients per year. Total visits, reasons for patient visits, demographics, disposition, and length of stay were analyzed from January through July 2020 and compared with the same time period in the previous 2 y. RESULTS: From March through July 2020 there were statistically significant decreases in the total number of patient visits (-47%) especially among pediatric (-73%) and elderly (-43%) patients and those with cardiovascular (-39%), neurological (-63%) complaints, headaches (-60%), back pain (-64%), abdominal pain (-51%), and minor trauma (-71%). There was, however, a significant increase in pulmonary complaints (+54%), as well as admissions (+32%), and length of stay (+40%). CONCLUSIONS: There was a significant drop in overall patients and select groups early in the pandemic, while admissions and emergency department length of stay both increased. This has implications for future pandemic planning.

Beirut Blast: The Experiences of Acute Care Hospitals.

Mass Casualty Incidents recently increased in intensity and frequency at an unprecedented rate globally. On August 4, 2020, a massive blast hit the Port of Beirut severely damaging its healthcare sector. This study aims to provide a comprehensive understanding of the impact of the Beirut blast on acute care hospitals in the Beirut area, with a focus on understanding healthcare professionals' (HCPs) responses and encountered challenges. A qualitative research design method was adopted to evaluate the experiences of HCPs at acute hospitals located within 5 kilometers of the blast epicenter. 9 hospitals participated in the study. 11 semi-structured interviews were conducted with key informant HCPs using a designed interview guide. HCPs reported severe infrastructural damages in their corresponding hospitals, and 2 were completely non-functional post-blast. Other than physical injuries sustained by HCPs, the blast imposed substantial strains on their mental health, exacerbated by the ongoing socio-economic crises in Lebanon. Moreover, the findings revealed critical challenges which hindered hospitals' emergency responses at the level of communication, coordination, and human resources, as well as supplies. Participants urged for the need to conduct proper triage, arrange emergency operating centers, and deploy outdoor treatment tents among others, to effectively respond to future disasters. The Beirut blast overwhelmed the Lebanese healthcare system and challenged its level of emergency preparedness. This generated evidence to address the deficiencies and strengthen the existing hospitals' emergency response plans. Future efforts should include prioritizing hospitals' emergency preparedness to ensure the provision of care at increased capacity following the impact of a large-scale disaster.

Using the National Incident Management System to Prepare Physicians for Rapid Responses: A Pilot Study.

OBJECTIVE: The study objective was to determine the feasibility of training physicians in the principles of the National Incident Management System (NIMS) and Incident Command System (ICS) as applied to in-hospital rapid responses and to assess physicians' attitudes regarding rapid responses. METHODS: This was an educational pilot study. Resident physicians completed a pre-survey, followed by online training in the principles of NIMS and ICS, a knowledge test, and a post-survey. RESULTS: The number of residents who participated was 22. In the pre-survey, most (20/22) did not have a working understanding of NIMS/ICS. Participants (21/22) agreed that residents should have more training in resource organization. On the knowledge test, the median score was 9.5/10. In the post-survey, participants felt more comfortable clearing extra resources from the scene (P < 0.001) and that it would be easier to keep track of resources (P < 0.001). Most indicated that they had a working understanding of NIMS/ICS (P < 0.001) and felt more comfortable establishing command using NIMS/ICS (P < 0.001). All agreed that they would consider using an NIMS/ICS-based structure on their next rapid response. CONCLUSIONS: Training physicians in the principles of NIMS/ICS as they pertain to rapid responses is feasible and appears to change residents' attitudes about rapid responses.

A Scoping Review of Pediatric Mass-Casualty Incident Triage Algorithms.

OBJECTIVE: For the pediatric population, there is no consensus on which triage system to use for mass-casualty incidents (MCI). A scoping review was conducted to identify the most accurate triage system for pediatric patients in MCIs. METHODS: MEDLINE (NLM, Bethesda, MA, USA), Embase (Elsevier Inc., Amsterdam, Netherlands), CINAHL (EBSCO Information Services, Ipswitch, MA, USA), and The Cochrane CENTRAL Register of Controlled Trials (John Wiley & Sons, Hoboken, NJ, USA), as well as Scopus (Elsevier Inc., Amsterdam, Netherlands), Global Health (Centre for Agriculture and Bioscience International, Wallingford, UK), Global Health Archive (Centre for Agriculture and Bioscience International, Wallingford, UK), and Global Index Medicus (World Health Organization, Geneva, Switzerland) were searched for relevant studies that were divided into 3 categories: accuracy of a single system, comparison of 2 or more primary triage system and comparison of secondary triage systems. Grey literature was also searched. RESULTS: 996 studies were identified from which 18 studies were included. Systems studied were found to have poor inter-rater reliability, had a low level of agreement between providers, had missed critically ill patients or were not externally validated. 11 studies compared pediatric MCI triage algorithms using different strategies and the most accurate algorithm was not identified. A recently developed secondary triage system, specifically for pediatric patients, was found to perform better than the comparison triage system. CONCLUSION: Although some algorithms performed better than others, no primary triage algorithm was accurate enough for the pediatric population. However, only 1 secondary triage algorithm was found to be superior to the others.

[Medical civil protection in Germany-a Greek tragedy?] / Medizinischer Bevölkerungsschutz in Deutschland ­ eine griechische Tragödie?

In terms of civil protection, there is nothing against self-critical reflection of events, such as the coronavirus disease 2019 pandemic, and learning lessons from them. In the past, however, this has often not led to anticipating future situations, their consequences, and better preparation. To some extent, this seems like a Greek tragedy: conscious disregard-except that this must not be fate. In addition to pandemics, important scenarios for which civil protection in Germany is inadequately prepared, according to the author's assessment, include attacks and accidents involving CBRN (chemical, biological, radiological, nuclear) hazardous substances, mass casualties in the event of a terror attack with hospitals or rescue services as the target of the attacks, as well as prolonged power or drinking water failures, and disruptions in information and communication structures following cyberattacks. There is an urgent need to identify existing problems and demand functional concepts for hospitals, rescue services, and rapid response teams. Responsible authorities, in turn, must develop, finance, and implement concepts.

Response to Mass-Casualty Incidents and Outbreaks: A Prehospital Disaster Training Package Developed for the National Emergency Medical Service in Sierra Leone.

Sierra Leone is a country highly prone to disasters, still recovering from the catastrophic 2014 Ebola epidemic. In 2018, the country launched its first National Emergency Medical Service (NEMS) aiming to strengthen the provision of essential health services to the population with the long-term goal of creating a resilient health system able to effectively respond to and recover from emergencies. The Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health (CRIMEDIM), together with the Italian NGO Doctors with Africa (CUAMM), under the direct supervision of the Ministry of Health and Sanitation (MoHS), developed a prehospital Disaster Training Package (DTP) to be delivered to all NEMS personnel to boost the prehospital management of mass-casualty incidents (MCIs) and outbreaks. The DTP included a first phase in which NEMS local trainers underwent a training-of-trainers (ToT) course, enabling them to deliver cascade trainings to 16 district ambulance supervisors, 441 paramedics, 441 ambulance drivers, and 36 operators working in the NEMS operation center. This on-going training package represents the first Disaster Medicine training course for prehospital health professionals in Sierra Leone.

Israeli trauma system: On constant alert

A trauma system is a chain of activities to provide quality response to the injured from the site of injury to the appropriate hospital and rehabilitation. Israel has a unique trauma system developed from the experience gained in peace and in war. It is characterized by a central national organization responsible for management, coordination, and ongoing quality control. Because of the unique situation, the Israeli Defense Forces has a significant role in the system. In order to develop an effective trauma system, it is important to devote sufficient resources in education, training, motivation, team-work, and creation of public volunteers for capacity building. An effective trauma system manages mass casualty incidence (MCI) better. System quickly reorganized in order to accommodate the sudden needs of patients with coronavirus disease 2019 (COVID-19), while being able to maintain the routine surgical and medical requirements of the community. The aim of this article is to present the main components of the Israeli trauma model. © 2022 Emergency and Critical Care Medicine.All right reserved.

Implementation of a unique mass casualty and emergency preparedness longitudinal learning experience for postgraduate year 2 pharmacy residents.

BACKGROUND AND PURPOSE: The American Society of Health-System Pharmacists (ASHP) postgraduate year 2 (PGY2) critical care pharmacy residency program offers an elective competency area, E3: Mass Casualty. Similar elective competencies are also available for PGY2 emergency medicine and postgraduate year 1/2 pharmacotherapy programs. Because of the COVID-19 pandemic, pharmacist proficiency in the management of disasters is even more urgent. However, few residency programs require or include a specific learning experience to achieve this competency. This article provides examples of opportunities that residency programs can implement to offer an Emergency Preparedness/Mass Casualty (EP/MC) learning experience. EDUCATIONAL ACTIVITY AND SETTING: A longitudinal EP/MC learning experience was integrated into a PGY2 critical care program. FINDINGS: A longitudinal EP/MC learning experience within the PGY2 critical care, emergency medicine, and pharmacotherapy residency program curricula is achievable and promotes resident development. Learning experience components included topic discussions, participation on local and state-level emergency preparedness (EP) committees, completion of certification programs, projects, and participation on statewide emergency response teams. SUMMARY: Implementation of a longitudinal EP/MC learning experience formalizes topics and activities that support achievement of the ASHP elective competency area of Mass Casualty for PGY2 residency programs. EP/MC goals and objectives should be a requirement for critical care, emergency medicine, pharmacotherapy, and health-system pharmacy administration and leadership PGY2 programs. By formalizing training, pharmacists can be better prepared for EP and more integrated into multidisciplinary disaster response teams.

Effect of Coronavirus Disease 2019 (Covid-19), a Nationwide Mass Casualty Disaster on Intensive Care Units: Clinical Outcomes and Associated Cost-of-Care.

OBJECTIVE: The COVID-19 pandemic resulted in millions of deaths worldwide and is considered a significant mass-casualty disaster (MCD). The surge of patients and scarcity of resources negatively impacted hospitals, patients and medical practice. We hypothesized ICUs during this MCD had a higher acuity of illness, and subsequently had increased lengths of stay (LOS), complication rates, death rates and costs of care. The purpose of this study was to investigate those outcomes. METHODS: This was a multicenter, retrospective study that compared intensive care admissions in 2020 to those in 2019 to evaluate patient outcomes and cost of care. Data were obtained from the Vizient Clinical Data Base/Resource Manager (Vizient Inc., Irvine, Texas, USA). RESULTS: Data included the number of ICU admissions, patient outcomes, case mix index and summary of cost reports. Quality outcomes were also collected, and a total of 1304981 patients from 333 hospitals were included. For all medical centers, there was a significant increase in LOS index, ICU LOS, complication rate, case mix index, total cost, and direct cost index. CONCLUSION: The MCD caused by COVID-19 was associated with increased adverse outcomes and cost-of-care for ICU patients.

Mass casualty event scenarios and political shifts: 2020 election outcomes and the U.S. COVID-19 pandemic

COVID-19 models indicate a mass casualty event may potentially occur in the United States. Among numerous social and economic changes, the potential to reshape the political landscape exists. The theoretical perspective of politics-administration dichotomy is used to examine the rhetoric, power, and authority of public health messages during the pandemic. This study considers political shifts using state-level data on population, historical voter turnout, and projected COVID-19 cases number coupled with national-level data on voter participation by age group and COVID-19 fatality rates. Developing a formula to calculate these data, we project the extent to which the number of voters from each party could diminish. The analysis shows the potential for significant political changes due to the disproportionate loss of older voters in key swing states in the months leading to the 2020 presidential election.

A Qualitative Assessment of Studies Evaluating the Classification Accuracy of Personnel Using START in Disaster Triage: A Scoping Review.

Background: Mass casualty incidents (MCIs) can occur as a consequence of a wide variety of events and often require overwhelming prehospital and emergency support and coordinated emergency response. A variety of disaster triage systems have been developed to assist health care providers in making difficult choices with regards to prioritization of victim treatment. The simple triage and rapid treatment (START) triage system is one of the most widely used triage algorithms; however, the research literature addressing real-world or simulation studies documenting the classification accuracy of personnel using START is lacking. Aims and Objectives: To explore the existing literature related to the current state of knowledge about studies assessing the classification accuracy of the START triage system. Design: Scoping review based on Arksey and O'Malley's methodological framework and narrative synthesis based on methods described by Popay and colleagues were performed. Results: The literature search identified 1,820 citations, of which 32 studies met the inclusion criteria. Thirty were peer-reviewed articles and 28 published in the last 10 years (i.e., 2010 and onward). Primary research studies originated in 13 countries and included 3,706 participants conducting triaging assessments involving 2,950 victims. Included studies consisted of five randomized controlled trials, 17 non-randomized controlled studies, eight descriptive studies, and two mixed-method studies. Simulation techniques, mode of delivery, contextual features, and participants' required skills varied among studies. Overall, there was no consistent reporting of outcomes across studies and results were heterogeneous. Data were extracted from the included studies and categorized into two themes: (1) typology of simulations and (2) START system in MCIs simulations. Each theme contains sub-themes regarding the development of simulation employing START as a system for improving individuals' preparedness. These include types of simulation training, settings, and technologies. Other sub-themes include outcome measures and reference standards. Conclusion: This review demonstrates a variety of factors impacting the development and implementation of simulation to assess characteristics of the START system. To further improve simulation-based assessment of triage systems, we recommend the use of reporting guidelines specifically designed for health care simulation research. In particular, reporting of reference standards and test characteristics need to improve in future studies.

Assessing Hospital Adaptive Resource Allocation Strategies in Responding to Mass Casualty Incidents.

BACKGROUND: Hospitals are expected to operate at a high performance level even under exceptional conditions of peak demand and resource disruptions. This understanding is not mature yet and there are wide areas of possible improvement. In particular, the fast mobilization and reconfiguration of resources frequently result into the severe disruption of elective activities, worsening the quality of care. This becomes particularly evident during the on-going coronavirus disease 2019 (COVID-19) pandemic. More resilient resource allocation strategies, that is, which adapt to the dynamics of the prevailing circumstance, are needed to maximize the effectiveness of health-care delivery. In this study, a simulation approach was adopted to assess and compare different hospital's adaptive resource allocation strategies in responding to a sudden onset disaster mass casualty incident (MCI). METHODS: A specific set of performance metrics was developed to take into consideration multiple objectives and priorities and holistically assess the effectiveness of health-care delivery when coping with an MCI event. Discrete event simulation (DES) and system dynamics (SD) were used to model the key hospital processes and the MCI plan. RESULTS: In the daytime scenario, during the recovery phase of the disaster, a gradual disengagement of resources from the emergency department (ED) to restart ordinary activities in operating rooms and wards returned the best performance. In the night scenario, the absorption capacity of the ED was evaluated by identifying the current bottleneck and assessment of the benefit of different resource mobilization strategies. CONCLUSIONS: The present study offers a robust approach, effective strategies and new insights to design more resilient plans to cope with MCIs. It becomes particularly relevant when considering the risk of indirect damage of emergencies, where all the available resources are shifted from the care of the ordinary to the "disaster" patients, like during the on-going COVID-19 pandemic. Future research is needed to widen the scope of the analysis and take into consideration additional resilience capacities such as operational coordination mechanisms among multiple hospitals in the same geographic area.

Developing pre-registration nurses' resilience to mass casualty situations through the pedagogy of simulation.

Simulation has become a core component of nursing curricular worldwide. Within a three-year, pre-registration degree typically students would not be exposed to disaster type situations and it was believed that a well-coordinated simulation exercise could replicate this. It was hoped that the simulation would require students to think quickly on their feet and transfer acquired skills. Worldwide disasters including the current novel coronavirus have, heightened the need for well-prepared resilient health professionals capable of responding to many different types of emergencies including mass casualty situations. The simulated event involved 80 adult field student nurses, 19 probationer police officers, 6 photojournalism students, 2 Welsh Ambulance paramedics, 5 staff from 203 Field Hospital, 2 St John Cymru Wales Officers, 1 community first responder and 6 Fire and Rescue personnel. All these individuals came together to undertake a simulated emergency response to a mass casualty incident. Behaviours and clinical skills were observed throughout the event along with interprofessional interactions.

Hospital Pharmacy Preparedness and Pharmacist Role During Disaster in Saudi Arabia.

BACKGROUND: In case of emergencies, the number and severity of mass casualties may exceed medical services resources. Saudi Arabia is prone to different disasters, and all medical resources should be ready and prepared to serve during disasters. Pharmacists are essential during disasters; however, their roles have not been well studied during disasters in Saudi Arabia. METHODS: An observational cross-sectional study targeted tertiary hospitals in Jeddah. An electronic survey, consisting of 34 questions, was developed and distributed to pharmacy directors or their representatives to investigate the hospital pharmacies' preparedness and pharmacist roles during disasters in the city of Jeddah. RESULTS: Six hospitals participated in the survey, with a 100% response rate. All respondents confirmed the presence of disaster plans involving pharmacy departments. Hospital committee consensuses determined which medication to stock in five hospitals (83.3%). All six respondents (100%) agreed that the following medication supplies were adequate in the event of disasters: analgesics, rapid sequence intubation medications (ie, sedatives and paralytics), respiratory medications, antimicrobials, and maintenance intravenous (IV) fluids. There was disagreement on the adequacy of wound infection prophylaxis, vasopressors/inotropes, antiemetic medications, ophthalmic medications, and antidotes for chemical weapons. There were discrepancies on pharmacist roles during disaster, but hospitals agreed on the following roles: maintain effective distribution and control, collaborate on medication management, and develop and maintain first-aid skills. CONCLUSION: All included facilities have emergency preparedness plans for the hospitals and the pharmacy departments. However, the type and quantities of stocked medications, as well as pharmacist roles, are not well recognized. The results highlight the need for national guidance to enhance and support the preparedness of healthcare facilities.

Preparing for mass casualty events despite COVID-19.

Preparedness for mass casualty events is essential at local, national, and global levels. Much more needs to be done by all stakeholders to avoid unnecessary morbidity and mortality despite the challenges that COVID-19 continues to present. In this editorial, we highlight the challenges and solutions for mass casualty incident preparations.

Preparedness for a 'no-notice' mass-casualty incident: a nuclear detonation scenario.

PURPOSE: An effective response for a mass-casualty incident requires understanding the relevant basic science and physical impact; detailed preparedness among jurisdictions; and clear, sequential response planning, including formal operational exercises, logistics, interagency, and public-private coordination, rapid activation of resilience, and continual improvement from lessons learned and new knowledge. This ConRad 2021 meeting report describes steps for civilian medical and public health response planning for a nuclear detonation; the utility of this type of planning for broader application; and extension of this planning to the international community. CONCLUSION: A nuclear detonation requires a response within minutes to what will be a large-scale disaster complicated by radiation, including some elements that are similar to a broad range of incidents. The response could be further complicated if multiple incidents occur simultaneously. Required are detailed planning, preparedness and scripting for an immediate operational response, addressing clinical manifestations of evolving radiation illness, and flexibility to adapt to a rapidly changing situation. This need translates into the use of just-in-time information; effective, credible communication; situational awareness on a global scale; and a template upon which to apply capabilities in a multi-sector response. This effort is greatly facilitated using a 'playbook' approach, the basics of which are presented.