A method for detailed determination of hospital surge capacity: a prerequisite for optimal preparedness for mass-casualty incidents.

BACKGROUND: Defined goals for hospitals' ability to handle mass-casualty incidents (MCI) are a prerequisite for optimal planning as well as training, and also as base for quality assurance and improvement. This requires methods to test individual hospitals in sufficient detail to numerically determine surge capacity for different components of the hospitals. Few such methods have so far been available. The aim of the present study was with the use of a simulation model well proven and validated for training to determine capacity-limiting factors in a number of hospitals, identify how these factors were related to each other and also possible measures for improvement of capacity. MATERIALS AND METHODS: As simulation tool was used the MACSIM® system, since many years used for training in the international MRMI courses and also successfully used in a pilot study of surge capacity in a major hospital. This study included 6 tests in three different hospitals, in some before and after re-organisation, and in some both during office- and non-office hours. RESULTS: The primary capacity-limiting factor in all hospitals was the capacity to handle severely injured patients (major trauma) in the emergency department. The load of such patients followed in all the tests a characteristic pattern with "peaks" corresponding to ambulances return after re-loading. Already the first peak exceeded the hospitals capacity for major trauma, and the following peaks caused waiting times for such patients leading to preventable mortality according to the patient-data provided by the system. This emphasises the need of an immediate and efficient coordination of the distribution of casualties between hospitals. The load on surgery came in all tests later, permitting either clearing of occupied theatres (office hours) or mobilising staff (non-office hours) sufficient for all casualties requiring immediate surgery. The final capacity-limiting factors in all tests was the access to intensive care, which also limited the capacity for surgery. On a scale 1-10, participating staff evaluated the accuracy of the methodology for test of surge capacity to MD 8 (IQR 2), for improvement of disaster plans to MD 9 (IQR 2) and for simultaneous training to MD 9 (IQR 3). CONCLUSIONS: With a simulation system including patient data with a sufficient degree of detail, it was possible to identify and also numerically determine the critical capacity-limiting factors in the different phases of the hospital response to MCI, to serve as a base for planning, training, quality control and also necessary improvement to rise surge capacity of the individual hospital.

How to Surge to Face the SARS-CoV-2 Outbreak: Lessons Learned From Lombardy, Italy.

Italy is fighting against one of the worst medical emergency since the 1918 Spanish Flu. Pressure on the hospitals is tremendous. As for official data on March 14th: 8372 admitted in hospitals, 1518 in intensive care units, 1441 deaths (175 more than the day before). Unfortunately, hospitals are not prepared: even where a plan for massive influx of patients is present, it usually focuses on sudden onset disaster trauma victims (the most probable case scenario), and it has not been tested, validated, or propagated to the staff. Despite this, the All Hazards Approach for management of major incidents and disasters is still valid and the "4S" theory (staff, stuff, structure, systems) for surge capacity can be guidance to respond to this disaster.

Assessment of the accuracy of the Medical Response to Major Incidents (MRMI) course for interactive training of the response to major incidents and disasters.

BACKGROUND AND AIMS: The benefit of simulation models for interactive training of the response to major incidents and disasters has been increasingly recognized during recent years and a variety of such models have been reported. However, reviews of this literature show that the majority of these reports have been characterized by significant limitations regarding validation of the accuracy of the training related to given objectives. In this study, precourse and postcourse self-assessment surveys related to the specific training objectives, as an established method for curriculum validation, were used to validate the accuracy of a course in Medical Response to Major Incidents (MRMI) developed and organized by an international group of experts under the auspices of the European Society for Trauma and Emergency Surgery. METHODS: The studied course was an interactive course, where all trainees acted in their normal roles during two full-day simulation exercises with real time and with simultaneous training of the whole chain of response: scene, transport, the different functions in the hospital, communication, coordination, and command. The key component of the system was a bank of magnetized casualty cards, giving all information normally available as a base for decisions on triage and primary management. All treatments were indicated with attachments on the cards and consumed time and resources as in reality. The trainees' performance was recorded according to prepared protocols and a measurable result of the response could be registered. This study was based on five MRMI courses in four different countries with altogether 235 participants from 23 different countries. In addition to conventional course evaluations and recording of the performance during the 2 exercise days, the trainees' perceived competencies related to the specific objectives of the training for different categories of staff were registered on a floating scale 1-10 in self-assessment protocols immediately before and after the course. The results were compared as an indicator of to which extent the training fulfilled the given objectives. These objectives were set by an experienced international faculty and based on experiences from recent major incident and disasters. RESULTS: Comparison of precourse and postcourse self-assessments of the trainees' perceived knowledge and skills related to the given objectives for the training showed a significant increase in all the registered parameters for all categories of participating staff. The average increase was for prehospital staff 74 percent (p<0.001), hospital staff 65 percent (p<0.001), and staff in coordinating/administrative functions 81 percent (p<0.001). CONCLUSIONS: The significant differences in the trainees' self-assessment of perceived competencies between the precourse and postcourse surveys indicated that the methodology in the studied course model accurately responded to the specific objectives for the different categories of staff.

Comparative study of physiological and anatomical triage in major incidents using a new simulation model.

OBJECTIVES: To develop and evaluate a simulation model making it possible to evaluate the accuracy and efficiency of different triage methods; to compare the results of physiological and anatomical triage performed by medical staff with different levels of skills with the use of this model. DESIGN AND OUTCOME MEASURES: A simulation model was created based on patient cards giving sufficient physiological data as a base for physiological triage and anatomical data as description of findings at exposure, providing a base for anatomical triage. Three groups with different skills in disaster medicine, nurse students (n = 23), ambulance nurses (n = 20), and surgeons (n = 30), performed triage based on the patient cards. The outcome was given as potential avoidable mortality. The results of the triage for the two methods were compared to the result of the same triage performed by an expert group. RESULTS: Differences in triage: Within the groups, the difference between the two triage methods was only significant for the surgeons (p < 0.001), who had a better result using the anatomical triage. For the "physiological triage," there were no significant differences between the three groups. Regarding the results for the "anatomical triage," there were significant differences between both the nurse students and the surgeons (p < 0.001) and the ambulance nurses and the surgeons (p < 0.05). Results in distribution of patients and potential avoidable mortality: Within the groups, the difference between the two methods was significant for all the groups (nurse students, p < 0.01; ambulance nurses, p < 0.01; and surgeons, p < 0.001). They all had a better outcome with anatomical triage (nurse students, 6.1 percent; ambulance nurses, 6.1 percent; and surgeons 19.5 percent less mortality than physiological triage). The group that made the best outcome from physiological triage was the ambulance nurses who had a significantly better result than both nurse students (p < 0.01) and surgeons (p < 0.001). The mean mortality rate for ambulance nurses was 31.1 percent, nurse students, 37 percent, and surgeons was 38.1 percent. Regarding the anatomical triage, there was a significant difference (p < 0.001) between the groups of nurse students (30.9 percent mortality) and surgeons (18.9 percent mortality). The differences between the rest of the groups were also significant (p < 0.05). CONCLUSIONS: The model developed for this study made it possible to compare different methods of triage and also triage performed by staff of different levels of training and experience. Anatomical triage for all test groups in this study gave significantly better results than physiological triage regarding calculated outcome and this difference increased with increasing experience.

Evaluation of the Response of the Swedish Healthcare System to the Tsunami Disaster in South East Asia.

OBJECTIVES: When the tsunami in South East Asia hit the coast of Thailand on December 26, 2004, approximately 20,000 Swedish tourists were in the disaster zone. Of these, 548 died or were lost and more than 1500 were injured. The aim of this study was to evaluate the response of the Swedish health care system to the disaster in terms of assessment and support in the disaster zone, evacuation back to Sweden and continued treatment in Sweden. METHODS: The evaluation was carried out based on (1) structured questionnaires to the staff of Thai hospitals, injured Swedish citizens and Swedish voluntary workers in the disaster zone; (2) semi-structured interviews with representatives of involved authorities, regional health care centres in Thailand and Sweden, hospital command centres, individuals treated for injuries and volunteer workers involved with supporting the injured; (3) on-site visits in the disaster zone; (4) analysis of reports following the tsunami. RESULTS: A total of 11,000 injured were treated during the first 3 days following the tsunami at the six major hospitals in the Phang Nga, Phuket and Krabi provinces where the majority of the Swedish citizens were primarily taken care of. Of these 11,000, 3000 required hospital admission against a total bed capacity of 1400. Almost 1500 surgical operations were performed during the first 3 days across 33 operating theatres. Thai health care representatives and staff confirmed the requirement for teams from countries with many tourists in the area for practical and psychological support, interpretation, assessment for evacuation and undertaking early evacuation to home nations to release local health care resources. This need was also supported by the injured. Sweden, having the highest number of injured citizens next to the host country, was very late compared to other countries in sending assessment teams to the area and in supplying the needed support. CONCLUSIONS: With increased international travelling, many countries today have large numbers of their citizens in other parts of the world. For Sweden, this has been estimated to be 400,000 at any one time, often in areas known to be risk zones for natural disasters and terrorism. This fact of modern-day life demands welldesigned plans to support both citizens in the area and the local health care in several ways: non-medical support by mediating contact between injured and local medical staff, psychological and practical support, support in evacuating own citizens from the area to release local health care and (under specific conditions) medical support. This planning has to include prepared assessment teams that can be rapidly deployed to the scene and a command structure permitting rapid and accurate decisions on a governmental level.

Protocol for Reports from Major Accidents and Disasters in the International Journal of Disaster Medicine.

The aim of this protocol is to achieve a prospective, standardized methodology for reporting results and experiences from major accidents and disasters so that the data can be used for analysis, to compare results, to exchange experiences and for international collaboration in methodological development. Using this form, the authors of the reports retain full credit for the data and the publication of them. At the same time, the data will be available in the journal and on the Internet (www.europeantrauma.net), thus providing the abovementioned possibilities for scientific analysis and development.

The effects of early rapid control of multiple bowel perforations after high-energy trauma to the abdomen: implications for damage control surgery.

BACKGROUND: This study evaluates the effects of early rapid control of multiple bowel perforations on cardiovascular and pulmonary function in high-energy traumatic shock compared with conventional small bowel resection anastomosis. METHODS: Fifteen anesthetized pigs, 10 to 12 weeks old, were exposed to a reproducible high-energy trauma and were divided into two groups. In the first group, the resection anastomosis group (RA, n = 8), small-bowel injuries were treated with resection and anastomosis; in the second group, the multiple bowel ligation group (BL, n = 7), small-bowel injuries were treated by resection and ligation. Repeated measurement analysis of variance was used to study the within group change overtime, the between group difference, and the interaction between them. Mean outcome measures were intravascular pressures, cardiac output, vascular resistance, lactic acid, and blood gases. RESULTS: The high-energy injuries caused traumatic shock in both groups with reduced cardiac output (p < 0.001) and lactic acidemia (p < 0.001). The BL group had a trend for higher cardiac output (p = 0.06). The rise in systemic and pulmonary vascular resistance was significantly reduced in the BL group compared with the RA group (p < 0.05). The BL group had a strong trend for higher oxygen extraction ratio (p = 0.06). There was a trend for less oxygen consumption in the BL group (p = 0.07). There was no difference in the lactic acidemia between the two groups. CONCLUSIONS: Early rapid control of multiple bowel perforations after high-energy trauma resulted in less impairment of cardiovascular function than conventional resection anastomosis of the bowel.

Role of histamine release in nonspecific vasodilatation during anodal and cathodal iontophoresis.

Nonspecific vasodilatation during iontophoresis is an important confounding factor in experimental pharmacology. In this investigation, we studied the involvement of sensory nerves and histamine-related reactions in causing nonspecific vasodilatation in a model of anodal and cathodal iontophoresis of sodium chloride. Firstly, we applied a mixture of local anesthetic (EMLA) cream to confirm its suppressive effect on nonspecific vasodilatation and to measure its efficacy in three different dosages (duration: 1, 2, and 3 h). We then investigated the role of histamine in nonspecific vasodilatation by giving an oral antihistamine drug (cetirizine) to subjects who had and had not been given EMLA. We found substantial suppression of the nonspecific vasodilatation in all EMLA-treated groups (all dosages) compared with untreated controls (with suppression rates of 60-65%). Dosage had no significant effect. A further suppression of nonspecific vasodilatation was seen after oral cetirizine during anodal and cathodal iontophoresis in both EMLA-treated and untreated groups. The antihistamine effect was most pronounced during anodal iontophoresis. These results suggest a histaminergic increase in perfusion that may be independent of neurogenic mechanisms and depend on polarity (anode or cathode). Local nerve blocks (EMLA) together with cetirizine may therefore be used to reduce nonspecific vasodilatation in both anodal and cathodal iontophoresis.

Establishment of a teaching animal model for sonographic diagnosis of trauma.

BACKGROUND: Ultrasound is widely accepted as a valuable diagnostic tool for detecting intra-abdominal and intrathoracic bleeding in trauma patients. Nevertheless, many doctors are reluctant to use it because they do not have sufficient training. This study aimed to define intra-abdominal and intrathoracic fluid volumes that can be detected by sonography and their relation to fluid width in pigs to establish a clinically relevant animal model for teaching and training. METHODS: Different volumes of normal saline were infused into the abdomen (50-2,000 mL) and chest (25-250 mL) in five anesthetized pigs. The maximum width of fluid as detected by ultrasound was recorded. The right upper quadrant, left upper quadrant, pelvis, and right paracolic section of the abdomen and right pleural cavity were studied. An experienced radiologist performed the studies. The effects on respiratory and cardiovascular functions were evaluated. RESULTS: The sonographic findings in the pig were similar to those in humans. Up to 50 mL of intra-abdominal fluid and up to 25 mL of intrathoracic fluid could be detected by ultrasound. There was a significant correlation between the volume infused and the fluid width detected. The respiratory and cardiovascular monitoring of the animals showed that the infused intrathoracic volumes mimicked a survivable hemothorax. CONCLUSION: The pig may serve as an excellent clinically relevant model with which to teach surgeons detection of different volumes of intra-abdominal and intrathoracic fluids. The value of this model as an educational tool has yet to be tested.

Trauma management and education in europe: a survey of twelve geographically and socioeconomically diverse European countries.

OBJECTIVE: To record the current standards of management and education in trauma surgery in 12 geographically and socioeconomically diverse countries in Europe. DESIGN: Questionnaire study. SETTING: Teaching hospital, Austria. INTERVENTION: Questionnaire sent to experts on trauma in Austria, France, Germany, Italy, The Netherlands, Norway, Portugal, Romania, Spain, Sweden, Turkey, and the United Kingdom. MAIN OUTCOME MEASURE: Comparison of management of patients before, during, and after admission to hospital, and opportunities for initial and in-service training. RESULTS: Management of patients and opportunities for training varied considerably from country to country, ranging from an organised trauma service throughout with specialised training to a haphazard and variable service that depended more on individual hospitals, doctors and patients. CONCLUSIONS: Standardisation of management and training would be desirable, and should be possible at least in countries that are members of the European Union.