Pandemic influenza and major disease outbreak preparedness in US emergency departments: A survey of medical directors and department chairs.

STUDY OBJECTIVES: To quantify the readiness of individual academic emergency departments (EDs) in the United States for an outbreak of pandemic influenza. Methods, design, and setting: Cross-sectional assessment of influenza pandemic preparedness level of EDs in the United States via survey of medical directors and department chairs from the 135 academic emergency medicine departments in the United States. Preparedness assessed using a novel score of 15 critical preparedness indicators. Data analysis consisted of summary statistics, χ2, and ANOVA. PARTICIPANTS: ED medical directors and department chairs. RESULTS: One hundred and thirty academic emergency medicine departments contacted; 66 (50.4 percent) responded. Approximately half (56.0 percent) stated their ED had a written plan for pandemic influenza response. Mean preparedness score was 7.2 (SD = 4.0) out of 15 (48.0 percent); only one program (1.5 percent) achieved a perfect score. Respondents from programs with larger EDs (=30 beds) were more likely to have a higher preparedness score (p < 0.035), an ED pandemic preparedness plan (p = 0.004) and a hospital pandemic preparedness plan (p = 0.007). Respondents from programs with larger EDs were more likely to feel that their ED was prepared for a pandemic or other major disease outbreak (p = 0.01). Only one-third (34.0 percent) felt their ED was prepared for a major disease outbreak, and only 27 percent felt their hospital was prepared to respond to a major disease outbreak. CONCLUSIONS: Significant deficits in preparedness for pandemic influenza and other disease outbreaks exist in US EDs, relative to HHS guidelines, which appear to be related in part to ED size. Further study should be undertaken to determine the barriers to appropriate pandemic preparedness, as well as to develop and validate preparedness metrics.

Pandemic influenza and major disease outbreak preparedness in US emergency departments: A selected survey of emergency health professionals.

OBJECTIVE: To assess the level of pandemic preparedness at emergency departments (EDs) around the country and to better understand current barriers to preparedness in the United States represented by health professionals in the American College of Emergency Physician (ACEP) Disaster Medicine Section (DMS). Methods, design, and setting: A cross-sectional survey of ACEP DMS members was performed. A total of 300 members were surveyed both via e-mail and with paper surveys during the 2009 ACEP Scientific Assembly DMS Meeting. An optional comments section was included for section members' perspectives on barriers to preparedness. A 15-item pandemic preparedness score was calculated for each respondent based on key preparedness indicators as defined by the authors. Results were analyzed with descriptive statistics, χ2 analysis, Cochran-Armitage trend test, and analysis of variance. Free text comments were coded and subjected to frequency-based analysis. RESULTS: A total of 92 DMS members completed the survey with a response rate of 31 percent. Although 85 percent of those surveyed indicated that their hospital had a plan for pandemic influenza response and other infectious disease threats, only 68 percent indicated that their ED had a plan, and 52 percent indicated that their hospital or ED had conducted disaster preparedness drills. Only 57 percent indicated that there was a plan to augment ED staff in the event of a staffing shortage, and 63 percent indicated that there were adequate supplies of personal protective equipment. While 63 percent of respondents indicated that their ED had a plan for distribution of vaccines and antivirals, only 32 percent of EDs had a plan for allocation of ventilators. A total of 42 percent of respondents felt that their ED was prepared in the event of a pandemic influenza or other disease outbreak, and only 35 percent felt that their hospital was prepared. The average pandemic preparedness score among respondents was 8.30 of a total of 15. Larger EDs were more likely to have a higher preparedness score (p = 0.03) and more likely to have a pandemic preparedness plan (p = 0.037). Some major barriers to preparedness cited by section members included lack of local administration support, challenges in funding, need for dedicated disaster preparedness personnel, staffing shortages, and a lack of communication among disaster response agencies, particularly at the federal level. CONCLUSIONS: There appear to be significant gaps in pandemic influenza and other infectious disease outbreak planning among the hospitals where ACEP DMS members work. This may reflect a broader underlying inadequacy of preparedness measures.

Developments in Surge Research Priorities: A Systematic Review of the Literature Following the Academic Emergency Medicine Consensus Conference, 2007-2015.

OBJECTIVES: In 2006, Academic Emergency Medicine (AEM) published a special issue summarizing the proceedings of the AEM consensus conference on the "Science of Surge." One major goal of the conference was to establish research priorities in the field of "disasters" surge. For this review, we wished to determine the progress toward the conference's identified research priorities: 1) defining criteria and methods for allocation of scarce resources, 2) identifying effective triage protocols, 3) determining decision-makers and means to evaluate response efficacy, 4) developing communication and information sharing strategies, and 5) identifying methods for evaluating workforce needs. METHODS: Specific criteria were developed in conjunction with library search experts. PubMed, Embase, Web of Science, Scopus, and the Cochrane Library databases were queried for peer-reviewed articles from 2007 to 2015 addressing scientific advances related to the above five research priorities identified by AEM consensus conference. Abstracts and foreign language articles were excluded. Only articles with quantitative data on predefined outcomes were included; consensus panel recommendations on the above priorities were also included for the purposes of this review. Included study designs were randomized controlled trials, prospective, retrospective, qualitative (consensus panel), observational, cohort, case-control, or controlled before-and-after studies. Quality assessment was performed using a standardized tool for quantitative studies. RESULTS: Of the 2,484 unique articles identified by the search strategy, 313 articles appeared to be related to disaster surge. Following detailed text review, 50 articles with quantitative data and 11 concept papers (consensus conference recommendations) addressed at least one AEM consensus conference surge research priority. Outcomes included validation of the benchmark of 500 beds/million of population for disaster surge capacity, effectiveness of simulation- and Internet-based tools for forecasting of hospital and regional demand during disasters, effectiveness of reverse triage approaches, development of new disaster surge metrics, validation of mass critical care approaches (altered standards of care), use of telemedicine, and predictions of optimal hospital staffing levels for disaster surge events. Simulation tools appeared to provide some of the highest quality research. CONCLUSION: Disaster simulation studies have arguably revolutionized the study of disaster surge in the intervening years since the 2006 AEM Science of Surge conference, helping to validate some previously known disaster surge benchmarks and to generate new surge metrics. Use of reverse triage approaches and altered standards of care, as well as Internet-based tools such as Google Flu Trends, have also proven effective. However, there remains significant work to be done toward standardizing research methodologies and outcomes, as well as validating disaster surge metrics.

Case report: ovarian torsion in pregnancy - diagnosis and management.

BACKGROUND: Ovarian torsion (OT) is one of the most common gynecologic surgical emergencies. All age groups can be affected, but ovarian stimulation, as found during early pregnancy or infertility treatment, is a major risk factor. OBJECTIVE: Diagnosing OT in early pregnancy can be challenging. Patients frequently present with abdominal pain and non-specific symptoms. Missed diagnosis of OT could lead not only to ovarian necrosis and sepsis, but also threaten the pregnancy. The objective of this article is to present a case of OT in early pregnancy and to review its epidemiology, diagnosis, and treatment. CASE REPORT: A 30-year-old woman at 10 weeks gestational age presented to the Emergency Department (ED) with 2 h duration of abdominal pain, nausea, and vomiting. The patient was not on ovarian stimulation treatments. A bedside ED ultrasound showed an enlarged edematous right ovary with a large cyst, but without flow on color Doppler. Immediate obstetric consultation was initiated. Eventual radiology ultrasound showed decreased but present flow in the right ovary. The patient underwent emergent laparoscopic surgery, during which the necrotic right ovary was removed. She was placed on progesterone therapy upon hospital discharge and eventually delivered a healthy term infant. CONCLUSIONS: Ovarian torsion in pregnancy is increasing in frequency due to the growing prevalence of ovarian stimulation treatment. Although diagnostic ultrasound is a frequently used imaging tool in patients with suspected OT, the mere presence of blood flow on Doppler ultrasonography of the adnexa has a poor negative predictive value. A high clinical suspicion and early laparoscopic management correlate with favorable maternal and fetal outcomes.

Agreement between routine emergency department care and clinical decision support recommended care in patients evaluated for mild traumatic brain injury.

OBJECTIVES: Emergency department (ED) computed tomography (CT) use has increased significantly during the past decade. It has been suggested that adherence to clinical decision support (CDS) may result in a safe decrease in CT ordering. In this study, the authors quantified the percentage agreement between routine and CDS-recommended care and the anticipated consequence of strict adherence to CDS on CT use in mild traumatic brain injury (mTBI). METHODS: This was a prospective observational study of patients with mTBI who presented to an urban academic ED of a tertiary care hospital. Patients 18 years or older, presenting within 24 hours of nonpenetrating trauma to the head, from August 2010 to July 2011, were eligible for enrollment. Structured data forms were completed by trained research assistants (RAs). The primary outcome was the percentage agreement between routine head CT use and CDS-recommended head CT use. CDS examined were: the 2008 American College of Emergency Physicians [ACEP] neuroimaging, the New Orleans rule, and the Canadian head CT rule. Differences between outcome groups were assessed using the chi-square test for categorical variables and the Kruskal-Wallis rank test for continuous variables. The percentage agreement between routine practice and CDS-recommended practice was calculated. RESULTS: Of the 169 patients enrolled, 130 (76.9%) received head CT scans, and five of the 130 (3.8%) had acute traumatic intracranial findings. For all subjects, agreement between routine practice and CDS-recommended practice was 77.5, 65.7, and 78.1%, for the ACEP, Canadian, and New Orleans CDS, respectively. Strict adherence to the 2008 ACEP neuroimaging CDS would result in no statistically significant difference in head CT use (routine care, 76.9%; CDS-recommended, 82.8%; p = 0.17). Strict adherence to the New Orleans CDS would result in an increase in head CT use (routine care, 76.9%; CDS-recommended, 94.1%; p < 0.01). Strict adherence to the Canadian CDS would result in a decrease in head CT use (routine care, 76.9%; CDS-recommended, 56.8%; p < 0.01). CONCLUSIONS: There is a 60% to 80% agreement between routine and CDS-recommended head CT use. Of the three CDS systems examined, the only one that may result in a reduction in head CT use if strictly followed was the Canadian head CT CDS. Further studies are needed to examine reasons for the less than optimal agreement between routine care and care recommended by the Canadian head CT CDS.

Characterizing hospital workers' willingness to respond to a radiological event.

INTRODUCTION: Terrorist use of a radiological dispersal device (RDD, or "dirty bomb"), which combines a conventional explosive device with radiological materials, is among the National Planning Scenarios of the United States government. Understanding employee willingness to respond is critical for planning experts. Previous research has demonstrated that perception of threat and efficacy is key in the assessing willingness to respond to a RDD event. METHODS: An anonymous online survey was used to evaluate the willingness of hospital employees to respond to a RDD event. Agreement with a series of belief statements was assessed, following a methodology validated in previous work. The survey was available online to all 18,612 employees of the Johns Hopkins Hospital from January to March 2009. RESULTS: Surveys were completed by 3426 employees (18.4%), whose demographic distribution was similar to overall hospital staff. 39% of hospital workers were not willing to respond to a RDD scenario if asked but not required to do so. Only 11% more were willing if required. Workers who were hesitant to agree to work additional hours when required were 20 times less likely to report during a RDD emergency. Respondents who perceived their peers as likely to report to work in a RDD emergency were 17 times more likely to respond during a RDD event if asked. Only 27.9% of the hospital employees with a perception of low efficacy declared willingness to respond to a severe RDD event. Perception of threat had little impact on willingness to respond among hospital workers. CONCLUSIONS: Radiological scenarios such as RDDs are among the most dreaded emergency events yet studied. Several attitudinal indicators can help to identify hospital employees unlikely to respond. These risk-perception modifiers must then be addressed through training to enable effective hospital response to a RDD event.

Pandemic influenza and major disease outbreak preparedness in US emergency departments: a selected survey of emergency health professionals.

OBJECTIVE: To assess the level of pandemic preparedness at emergency departments (EDs) around the country and to better understand current barriers to preparedness in the United States represented by health professionals in the American College of Emergency Physician (ACEP) Disaster Medicine Section (DMS). METHODS, DESIGN, and SETTING: A cross-sectional survey of ACEP DMS members was performed. A total of 300 members were surveyed both via e-mail and with paper surveys during the 2009 ACEP Scientific Assembly DMS Meeting. An optional comments section was included for section members'perspectives on barriers to preparedness. A 15-item pandemic preparedness score was calculated for each respondent based on key preparedness indicators as defined by the authors. Results were analyzed with descriptive statistics, Chi2 analysis, Cochran-Armitage trend test, and analysis of variance. Free text comments were coded and subjected to frequency-based analysis. RESULTS: A total of 92 DMS members completed the survey with a response rate of31 percent. Although 85 percent of those surveyed indicated that their hospital had a plan for pandemic influenza response and other infectious disease threats, only 68 percent indicated that their ED had a plan, and 52 percent indicated that their hospital or ED had conducted disaster preparedness drills. Only 57 percent indicated that there was a plan to augment ED staff in the event of a staffing shortage, and 63 percent indicated that there were adequate supplies of personal protective equipment. While 63 percent of respondents indicated that their ED had a plan for distribution of vaccines and antivirals, only 32 percent ofEDs had a plan for allocation of ventilators. A total of 42 percent of respondents felt that their ED was prepared in the event of a pandemic influenza or other disease outbreak, and only 35 percent felt that their hospital was prepared. The average pandemic preparedness score among respondents was 8.30 of a total of 15. Larger EDs were more likely to have a higher preparedness score (p=0.03) and more likely to have a pandemic preparedness plan (p=0.037). Some major barriers to preparedness cited by section members included lack of local administration support, challenges in funding, need for dedicated disaster preparedness personnel, staffing shortages, and a lack of communication among disaster response agencies, particularly at the federal level. CONCLUSIONS: There appear to be significant gaps in pandemic influenza and other infectious disease outbreak planning among the hospitals where ACEP DMS members work. This may reflect a broader underlying inadequacy of preparedness measures.

Dilemmas and controversies within civilian and military organizations in the execution of humanitarian aid in Iraq: a review.

Civilian humanitarian assistance organizations and military forces are working in a similar direction in many humanitarian operations around the world. However, tensions exist over the role of the military in such operations. The purpose of this article is to review cultural perspectives of civilian and military actors and to discuss recent developments in civil-military humanitarian collaboration in the provision of health services in Iraq for guiding such collaborative efforts in postconflict and other settings in future. Optimal collaborative efforts are most likely to be achieved through the following tenets: defining appropriate roles for military forces at the beginning of humanitarian operations (optimally the provision of transportation, logistical coordination, and security), promoting development of ongoing relationships between civilian and military agencies, establishment of humanitarian aid training programs for Department of Defense personnel, and the need for the military to develop and use quantitative aid impact indicators for assuring quality and effectiveness of humanitarian aid.

Pandemic influenza and major disease outbreak preparedness in US emergency departments: a survey of medical directors and department chairs.

STUDY OBJECTIVES: To quantify the readiness of individual academic emergency departments (EDs) in the United States for an outbreak of pandemic influenza. METHODS, DESIGN, AND SETTING: Cross-sectional assessment of influenza pandemic preparedness level of EDs in the United States via survey of medical directors and department chairs from the 135 academic emergency medicine departments in the United States. Preparedness assessed using a novel score of 15 critical preparedness indicators. Data analysis consisted of summary statistics, chi2, and ANOVA. PARTICIPANTS: ED medical directors and department chairs. RESULTS: One hundred and thirty academic emergency medicine departments contacted; 66 (50.4 percent) responded. Approximately half (56.0 percent) stated their ED had a written plan for pandemic influenza response. Mean preparedness score was 7.2 (SD = 4.0) out of 15 (48.0 percent); only one program (1.5 percent) achieved a perfect score. Respondents from programs with larger EDs (= 30 beds) were more likely to have a higher preparedness score (p < 0.035), an ED pandemic preparedness plan (p = 0.004) and a hospital pandemic preparedness plan (p = 0.007). Respondents from programs with larger EDs were more likely to feel that their ED was prepared for a pandemic or other major disease outbreak (p = 0.01). Only one-third (34.0 percent) felt their ED was prepared for a major disease outbreak, and only 27 percent felt their hospital was prepared to respond to a major disease outbreak. CONCLUSIONS: Significant deficits in preparedness for pandemic influenza and other disease outbreaks exist in US EDs, relative to HHS guidelines, which appear to be related in part to ED size. Further study should be undertaken to determine the barriers to appropriate pandemic preparedness, as well as to develop and validate preparedness metrics.

Ethical issues in conduct of research in combat and disaster operations.

BACKGROUND: The conduct of research in the combat and disaster environments shares many of the same fundamental principles and regulations that govern civilian biomedical research. However, Department of Defense research protocols stipulate additional requirements designed to preserve servicemembers' informed consent rights, uphold ethical standards, and protect sensitive or classified information. The authors reviewed studies that have been approved for the conduct of research in current combat operations and also discuss their applicability in disaster settings. METHODS: This is a descriptive, retrospective study of protocols that have currently been approved for conduct of research in Operation Iraqi Freedom and Operation Enduring Freedom. RESULTS: During the period of July 2005 through October 2007, 38 retrospective chart review protocols, seven prospective studies requiring consent or an alteration of the consent document and 12 prospective observational studies were submitted through the Deployed Research Committee in Iraq for review and approval at the Brooke Army Medical Center Institutional Review Board (IRB). A total of 55 protocols were approved by the IRB for implementation in the Iraq combat theater. Most of these protocols involved trauma care treatment. One prospective study investigating the effects of blast-concussive injuries on US Soldiers in Iraq requiring informed consent was reviewed and approved. CONCLUSIONS: The conduct of military medical research has, and will make, significant and lasting contributions to the practice of both civilian and military medicine. Although policies and regulations to conduct research and release-associated findings often seem cumbersome and stringent, these added hurdles serve not only to ensure protection of the rights of human subjects during a time of potentially increased vulnerability, but also to protect the security interests of US troops. Many of these principles and practices are directly applicable in disaster research environments.

Use of ultrasound to assess acute fracture reduction in emergency care settings.

OBJECTIVE: There is a need to develop tools for the rapid diagnosis and treatment of fractures and intraosseous pathology in remote and austere environments. Several emergency and orthopedic studies have demonstrated ultrasound to be a reliable tool in diagnosing these conditions in both adult and pediatric patients. The purpose of this pilot study is to assess the ability of the ultrasound to assess in "real-time" the success of fracture reduction in adult patients in the emergency department (ED), in comparison with the accepted standard, plain film radiography, for the purposes of future application in austere environments. DESIGN: Case series. SETTING: Emergency department at an academic medical center. PATIENTS/PARTICIPANTS: Convenience sample of five patients presenting to an ED with clinical evidence of fractures (three radial, one phalangeal, and one metacarpal). INTERVENTIONS: A Sonosite Titan portable ultrasound system with L38/10-5:38-mm broadband linear array transducer was used to assess prereduction and postreduction angulations and alignment. Alignment was reconfirmed with use of fluoroscopy and plain radiography. RESULTS: The ultrasound confirmed proper reduction and realignment in all five cases, from an average prereduction angle of alignment of 37.4 degrees to an average postreduction angle of 4.4 degrees. The use of the ultrasound resulted in adequate visualization of the reduction in all cases. Regional anesthesia or sedation and limited pressure with the probe resulted in no verbalization of pain by any of the subjects. CONCLUSIONS: In this pilot study, emergency physicians demonstrated the use of ultrasound in place of traditional radiography to either confirm adequate reduction or assess the need for further manipulation. Our pilot study suggests that ultrasound has a possible future role in fracture reduction management in both the ED as well as "austere"prehospital locations.