Interventions to improve the psychological well-being of healthcare workers in disasters, pandemics, and mass casualty events.

OBJECTIVES: This information paper will describe the current research and recommendations for improving healthcare worker's (HCW) mental health. Individual and organizational goals will be outlined with items broken up into the time frames of predisaster, during a disaster, and post-disaster. METHODS: A team of subject matter experts reviewed the current literature utilizing a search of PubMed, Google Scholar, relevant article reference lists, and subject matter interviews. RESULTS: Thirty-six distinct recommendations were identified and distributed into the time frames of predisaster, during a disaster, and post-disaster. Twenty-one of these are pertaining to organizational goals and factors. Fifteen recommendations are identified for individual HCWs. CONCLUSIONS: Additional institutional and government policies supporting the protection of HCW's mental health are required to reduce the stigma and fear, preventing frontline workers from seeking help with the psychological effects of disasters, mass casualty incidents, and pandemics. Further research dealing with ways to ameliorate the negative effects of the stress related to the duties and responsibilities of HCWs, which are exacerbated by disasters, is needed.

The Risk of Cancer from CT Scans and Other Sources of Low-Dose Radiation: A Critical Appraisal of Methodologic Quality.

INTRODUCTION: Concern exists that radiation exposure from computerized tomography (CT) will cause thousands of malignancies. Other experts share the same perspective regarding the risk from additional sources of low-dose ionizing radiation, such as the releases from Three Mile Island (1979; Pennsylvania USA) and Fukushima (2011; Okuma, Fukushima Prefecture, Japan) nuclear power plant disasters. If this premise is false, the fear of cancer leading patients and physicians to avoid CT scans and disaster responders to initiate forced evacuations is unfounded. STUDY OBJECTIVE: This investigation provides a quantitative evaluation of the methodologic quality of studies to determine the evidentiary strength supporting or refuting a causal relationship between low-dose radiation and cancer. It will assess the number of higher quality studies that support or question the role of low-dose radiation in oncogenesis. METHODS: This investigation is a systematic, methodologic review of articles published from 1975-2017 examining cancer risk from external low-dose x-ray and gamma radiation, defined as less than 200 millisievert (mSv). Following the PRISMA guidelines, the authors performed a search of the PubMed, Cochrane, Scopus, and Web of Science databases. Methodologies of selected articles were scored using the Newcastle Ottawa Scale (NOS) and a tool identifying 11 lower quality indicators. Manuscript methodologies were ranked as higher quality if they scored no lower than seven out of nine on the NOS and contained no more than two lower quality indicators. Investigators then characterized articles as supporting or not supporting a causal relationship between low-dose radiation and cancer. RESULTS: Investigators identified 4,382 articles for initial review. A total of 62 articles met all inclusion/exclusion criteria and were evaluated in this study. Quantitative evaluation of the manuscripts' methodologic strengths found 25 studies met higher quality criteria while 37 studies met lower quality criteria. Of the 25 studies with higher quality methods, 21 out of 25 did not support cancer induction by low-dose radiation (P = .0003). CONCLUSIONS: A clear preponderance of articles with higher quality methods found no increased risk of cancer from low-dose radiation. The evidence suggests that exposure to multiple CT scans and other sources of low-dose radiation with a cumulative dose up to 100 mSv (approximately 10 scans), and possibly as high as 200 mSv (approximately 20 scans), does not increase cancer risk.

Emergency Physician Disaster Deployment: Issues to Consider and a Model Policy.

Disaster responders are frequently emergency physicians (EPs). Effective response is enhanced by the strong support of home institutions and clear policies for backfill of regular duties. A group of disaster medicine responders and researchers worked with an academic department of emergency medicine to create a policy that addresses concerns of deploying physicians, colleagues remaining at the home institution, and administrators. This article describes the process and content of this policy development work. Kahn CA , Koenig KL , Schultz CH . Emergency physician disaster deployment: issues to consider and a model policy. Prehosp Disaster Med. 2017;32(4):462-464.

A Qualitative Analysis of the Spontaneous Volunteer Response to the 2013 Sudan Floods: Changing the Paradigm.

Introduction While the concept of community resilience is gaining traction, the role of spontaneous volunteers during the initial response to disasters remains controversial. In an attempt to resolve some of the debate, investigators examined the activities of a spontaneous volunteer group called Nafeer after the Sudan floods around the city of Khartoum in August of 2013. Hypothesis Can spontaneous volunteers successfully initiate, coordinate, and deliver sustained assistance immediately after a disaster? METHODS: This retrospective, descriptive case study involved: (1) interviews with Nafeer members that participated in the disaster response to the Khartoum floods; (2) examination of documents generated during the event; and (3) subsequent benchmarking of their efforts with the Sphere Handbook. Members who agreed to participate were requested to provide all documents in their possession relating to Nafeer. The response by Nafeer was then benchmarked to the Sphere Handbook's six core standards, as well as the 11 minimum standards in essential health services. RESULTS: A total of 11 individuals were interviewed (six from leadership and five from active members). Nafeer's activities included: food provision; delivery of basic health care; environmental sanitation campaigns; efforts to raise awareness; and construction and strengthening of flood barricades. Its use of electronic platforms and social media to collect data and coordinate the organization's response was effective. Nafeer adopted a flat-management structure, dividing itself into 14 committees. A Coordination Committee was in charge of liaising between all committees. The Health and Sanitation Committee supervised two health days which included mobile medical and dentistry clinics supported by a mobile laboratory and pharmacy. The Engineering Committee managed to construct and maintain flood barricades. Nafeer used crowd-sourcing to fund its activities, receiving donations locally and internationally using supporters outside Sudan. Nafeer completely fulfilled three of Sphere's core standards and partially fulfilled the other three, but none of the essential health services standards were fulfilled. Even though the Sphere Handbook was chosen as the best available "gold standard" to benchmark Nafeer's efforts, it showed significant limitations in effectively measuring this group. CONCLUSION: It appears that independent spontaneous volunteer initiatives, like Nafeer, potentially can improve community resilience and play a significant role in the humanitarian response. Such organizations should be the subject of increased research activity. Relevant bodies should consider issuing separate guidelines supporting spontaneous volunteer organizations. Albahari A , Schultz CH . A qualitative analysis of the spontaneous volunteer response to the 2013 Sudan floods: changing the paradigm. Prehosp Disaster Med. 2017;32(3):240-248.

Public Health and Disasters: An Emerging Translational and Implementation Science, Not "Lessons Learned".

Disaster Medicine is a relatively new multidisciplinary field of science with clear public health implications as it focuses on improving outcomes for populations rather than for individual patients. As with any other scientific discipline, the goal of public health and disaster research is to create new knowledge and transfer evidence-based data to improve public health. The phrase "lessons learned" has crept into the disaster lexicon but must be permanently erased as it has no place in the scientific method. The second edition of Koenig and Schultz's Disaster Medicine: Comprehensive Principles & Practice adds to the growing knowledge base of this emerging specialty and explains why "lessons learned" should be discarded from the associated vocabulary. (Disaster Med Public Health Preparedness. 2017;11:610-611).

Preparing an Academic Medical Center to Manage Patients Infected With Ebola: Experiences of a University Hospital.

As Ebola has spread beyond West Africa, the challenges confronting health care systems with no experience in managing such patients are enormous. Not only is Ebola a significant threat to a population's health, it can infect the medical personnel trying to treat it. As such, it represents a major challenge to those in public health, emergency medical services (EMS), and acute care hospitals. Our academic medical center volunteered to become an Ebola Treatment Center as part of the US effort to manage the threat. We developed detailed policies and procedures for Ebola patient management at our university hospital. Both the EMS system and county public health made significant contributions during the development process. This article shares information about this process and the outcomes to inform other institutions facing similar challenges of preparing for an emerging threat with limited resources. The discussion includes information about management of (1) patients who arrive by ambulance with prior notification, (2) spontaneous walk-in patients, and (3) patients with confirmed Ebola who are interfacility transfers. Hospital management includes information about Ebola screening procedures, personal protective equipment selection and personnel training, erection of a tent outside the main facility, establishing an Ebola treatment unit inside the facility, and infectious waste and equipment management. Finally, several health policy considerations are presented.

External factors impacting hospital evacuations caused by Hurricane Rita: the role of situational awareness.

INTRODUCTION: The 2005 Gulf Coast hurricane season was one of the most costly and deadly in US history. Hurricane Rita stressed hospitals and led to multiple, simultaneous evacuations. This study systematically identified community factors associated with patient movement out of seven hospitals evacuated during Hurricane Rita. METHODS: This study represents the second of two systematic, observational, and retrospective investigations of seven acute care hospitals that reported off-site evacuations due to Hurricane Rita. Participants from each hospital included decision makers that comprised the Incident Management Team (IMT). Investigators applied a standardized interview process designed to assess evacuation factors related to external situational awareness of community activities during facility evacuation due to hurricanes. The measured outcomes were responses to 95 questions within six sections of the survey instrument. RESULTS: Investigators identified two factors that significantly impacted hospital IMT decision making: (1) incident characteristics affecting a facility's internal resources and challenges; and (2) incident characteristics affecting a facility's external evacuation activities. This article summarizes the latter and reports the following critical decision making points: (1) Emergency Operations Plans (EOP) were activated an average of 85 hours (3 days, 13 hours) prior to Hurricane Rita's landfall; (2) the decision to evacuate the hospital was made an average of 30 hours (1 day, 6 hours) from activation of the EOP; and (3) the implementation of the evacuation process took an average of 22 hours. Coordination of patient evacuations was most complicated by transportation deficits (the most significant of the 11 identified problem areas) and a lack of situational awareness of community response activities. All evacuation activities and subsequent evacuation times were negatively impacted by an overall lack of understanding on the part of hospital staff and the IMT regarding how to identify and coordinate with community resources. CONCLUSION: Hospital evacuation requires coordinated processes and resources, including situational awareness that reflects the condition of the community as a result of the incident. Successful hospital evacuation decision making is influenced by community-wide situational awareness and transportation deficits. Planning with the community to create realistic EOPs that accurately reflect available resources and protocols is critical to informing hospital decision making during a crisis. Knowledge of these factors could improve decision making and evacuation practices, potentially reducing evacuation times in future hurricanes.

Initial management of hospital evacuations caused by Hurricane Rita: a systematic investigation.

INTRODUCTION: Hurricanes remain a major threat to hospitals throughout the world. The authors attempted to identify the planning areas that impact hospital management of evacuations and the challenges faced when sheltering-in-place. METHODS: This observational, retrospective cohort study examined acute care institutions from one hospital system impacted by Hurricane Rita in 2005. Investigators used a standardized survey instrument and interview process, previously used in the hospital evacuation context, to examine hospitals' initial internal situational awareness and subsequent decision making that resulted in evacuation due to Hurricane Rita. Participants from each hospital included representatives from senior leadership and clinical and nonclinical staff that comprised the Incident Management Team (IMT). The main measured outcomes were responses to 95 questions contained in the survey. RESULTS: Seven of ten eligible hospitals participated in the study. All facilities evacuated the sickest patients first. The most significant factors prompting evacuation were the issuing of mandatory evacuation orders, storm dynamics (category, projected path, storm surge), and loss of regional communications. Hospitals that sheltered-in-place experienced staff shortages, interruptions to electrical power, and loss of water supplies. Three fully-evacuated institutions experienced understaffing of 40%-60%, and four hospitals sustained depressed staffing levels for over four weeks. Five hospitals lost electricity for a mean of 4.8 days (range .5-11 days). All facilities continued to receive patients to their Emergency Departments (EDs) while conducting their own evacuation. CONCLUSION: Hospital EDs should plan for continuous patient arrival during evacuation. Emergency Operation Plans (EOPs) that anticipate challenges associated with evacuation will help to maximize initial decision making and management during a crisis situation. Hospitals that shelter-in-place face critical shortages and must provide independent patient care for prolonged periods.

Development of national standardized all-hazard disaster core competencies for acute care physicians, nurses, and EMS professionals.

The training of medical personnel to provide care for disaster victims is a priority for the physician community, the federal government, and society as a whole. Course development for such training guided by well-accepted standardized core competencies is lacking, however. This project identified a set of core competencies and performance objectives based on the knowledge, skills, and attitudes required by the specific target audience (emergency department nurses, emergency physicians, and out-of-hospital emergency medical services personnel) to ensure they can treat the injuries and illnesses experienced by victims of disasters regardless of cause. The core competencies provide a blueprint for the development or refinement of disaster training courses. This expert consensus project, supported by a grant from the Robert Wood Johnson Foundation, incorporated an all-hazard, comprehensive emergency management approach addressing every type of disaster to minimize the effect on the public's health. An instructional systems design process was used to guide the development of audience-appropriate competencies and performance objectives. Participants, representing multiple academic and provider organizations, used a modified Delphi approach to achieve consensus on recommendations. A framework of 19 content categories (domains), 19 core competencies, and more than 90 performance objectives was developed for acute medical care personnel to address the requirements of effective all-hazards disaster response. Creating disaster curricula and training based on the core competencies and performance objectives identified in this article will ensure that acute medical care personnel are prepared to treat patients and address associated ramifications/consequences during any catastrophic event.

Altering the standard of care in disasters--unnecessary and dangerous.

After September 11, 2001, the United States began examining approaches to the delivery of medical care during disasters when demand exceeds available resources. One seemingly popular option is the creation of "crisis" or "altered" care standards meant to reduce the legal standard or duty of care for medical responders. However, evidence supporting the need for reduced care standards is lacking. Concern for liability exists but it is not evidence based. The actual risk for litigation is minimal, according to experience with multiple disasters during the last 15 years. Even if a lower legal standard or duty of care were to be adopted, it is unlikely this would reduce the risk of liability because violation of this lower standard could still result in an allegation of malpractice. Creating algorithms to equitably and rationally allocate scarce resources is necessary and appropriate, but altering the legal standard of care will not contribute to this process. Rather than inhibiting the creation of these protocols, the current legal standard of care helps guarantee that disaster policies are created in an ethical and transparent manner. Adoption of a lower legal care standard would encourage implementation of less effective approaches and could undermine the impetus to constantly improve the care of disaster victims. Once lowering the legal standard of care becomes accepted practice, it becomes unclear what will prevent this process from moving downward indefinitely. The most rational approach buttressed by evidence to date supports maintaining the current legal standard of care defined by the actions of reasonably prudent physicians under the same or similar circumstances.

Intravenous paracetamol versus morphine for renal colic in the emergency department: a randomised double-blind controlled trial.

OBJECTIVE: To determine the analgesic efficacy and safety of intravenous single-dose paracetamol versus morphine in patients presenting to the emergency department with renal colic. METHODS: A randomised double-blind study was performed to compare the efficacy of intravenous paracetamol (1 g) and 0.1 mg/kg morphine in patients with renal colic. The efficacy of the study drugs was measured by a visual analogue scale and a verbal rating scale at baseline and after 15 and 30 min. The adverse effects and need for rescue medication (1 µg/kg intravenous fentanyl) were also recorded at the end of the study. RESULTS: 133 patients were eligible for enrolment in the study, with 73 patients included in the final analysis (38 in the paracetamol group and 35 in the morphine group). The mean±SD age of the subjects was 30.2±8.6 years and 51 (70%) were men. The mean reduction in scores at 30 min after study drug administration was 63.7 mm (95% CI 57 to 71) for paracetamol and 56.6 mm (95% CI 48 to 65) for morphine. The difference between pain reduction scores for the two groups at 30 min was 7.1 mm (95% CI -18 to 4), demonstrating no statistical or clinical significance. Two adverse events (5.3%) were recorded in the paracetamol group and five (14.3%) in the morphine group (difference 9%, 95% CI -7% to 26%). CONCLUSION: Intravenous paracetamol is effective in treating patients presenting with renal colic to the emergency department. CLINICAL TRIALS REGISTRATION NO: ClinicalTrials.gov ID number NCT01318187.

Ketamine with and without midazolam for emergency department sedation in adults: a randomized controlled trial.

STUDY OBJECTIVE: We assess whether midazolam reduces recovery agitation after ketamine administration in adult emergency department (ED) patients and also compared the incidence of adverse events (recovery agitation, respiratory, and nausea/vomiting) by the intravenous (IV) versus intramuscular (IM) route. METHODS: This prospective, double-blind, placebo-controlled, 2×2 factorial trial randomized consecutive ED patients aged 18 to 50 years to 4 groups: receiving either 0.03 mg/kg IV midazolam or placebo, and with ketamine administered either 1.5 mg/kg IV or 4 mg/kg IM. Adverse events and sedation characteristics were recorded. RESULTS: Of the 182 subjects, recovery agitation was less common in the midazolam cohorts (8% versus 25%; difference 17%; 95% confidence interval [CI] 6% to 28%; number needed to treat 6). When IV versus IM routes were compared, the incidences of adverse events were similar (recovery agitation 13% versus 17%, difference 4%, 95% CI -8% to 16%; respiratory events 0% versus 0%, difference 0%, 95% CI -2% to 2%; nausea/vomiting 28% versus 34%, difference 6%, 95% CI -8% to 20%). CONCLUSION: Coadministered midazolam significantly reduces the incidence of recovery agitation after ketamine procedural sedation and analgesia in ED adults (number needed to treat 6). Adverse events occur at similar frequency by the IV or IM routes.

Does START triage work? An outcomes assessment after a disaster.

STUDY OBJECTIVE: The mass casualty triage system known as simple triage and rapid treatment (START) has been widely used in the United States since the 1980s. However, no outcomes assessment has been conducted after a disaster to determine whether assigned triage levels match patients' actual clinical status. Researchers hypothesize that START achieves at least 90% sensitivity and specificity for each triage level and ensures that the most critical patients are transported first to area hospitals. METHODS: The performance of START was evaluated at a train crash disaster in 2003. Patient field triage categories and scene times were obtained from county reports. Patient medical records were then reviewed at all receiving hospitals. Victim arrival times were obtained and correct triage categories determined a priori using a combination of the modified Baxt criteria and hospital admission. Field and outcomes-based triage categories were compared, defining the appropriateness of each triage assignment. RESULTS: Investigators reviewed 148 records at 14 receiving hospitals. Field triage designations comprised 22 red (immediate), 68 yellow (delayed), and 58 green (minor) patients. Outcomes-based designations found 2 red, 26 yellow, and 120 green patients. Seventy-nine patients were overtriaged, 3 were undertriaged, and 66 patients' outcomes matched their triage level. No triage level met both the 90% sensitivity and 90% specificity requirement set forth in the hypothesis, although red was 100% sensitive (95% confidence interval [CI] 16% to 100%) and green was 89.3% specific (95% CI 72% to 98%). The Obuchowski statistic was 0.81, meaning that victims from a higher-acuity outcome group had an 81% chance of assignment to a higher-acuity triage category. The median arrival time for red patients was more than 1 hour earlier than the other patients. CONCLUSION: This analysis demonstrates poor agreement between triage levels assigned by START at a train crash and a priori outcomes criteria for each level. START ensured acceptable levels of undertriage (100% red sensitivity and 89% green specificity) but incorporated a substantial amount of overtriage. START proved useful in prioritizing transport of the most critical patients to area hospitals first.

International disaster medical sciences fellowship: model curriculum and key considerations for establishment of an innovative international educational program.

As recent events highlight, a global requirement exists for evidence-based training in the emerging field of Disaster Medicine. The following is an example of an International Disaster Medical Sciences Fellowship created to fill this need. We provide here a program description, including educational goals and objectives and a model core curriculum based on current evidence-based literature. In addition, we describe the administrative process to establish the fellowship. Information about this innovative educational program is valuable to international Disaster Medicine scholars, as well as U.S. institutions seeking to establish formal training in Disaster Medical Sciences.

Health care facility-based decontamination of victims exposed to chemical, biological, and radiological materials.

Since the US terrorist attacks of September 11, 2001, concern regarding use of chemical, biological, or radiological weapons is heightened. Many victims of such an attack would present directly to health care facilities without first undergoing field decontamination. This article reviews basic tenets and recommendations for health care facility-based decontamination, including regulatory concerns, types of contaminants, comprehensive decontamination procedures (including crowd control, triage, removal of contaminated garments, cleaning of body contaminants, and management of contaminated materials and equipment), and a discussion of methods to achieve preparedness.

Decisionmaking in hospital earthquake evacuation: does distance from the epicenter matter?

STUDY OBJECTIVE: Over large expanses, the risk for hospital damage from an earthquake attenuates as the distance from the epicenter increases, which may not be true within the immediate disaster zone (near field), however. The following study examines the impact of epicenter distance and ground motion on hospital evacuation and closure for those structures near the epicenter of the 1994 Northridge Earthquake and the implications for patient evacuation. METHODS: This is a retrospective case-control study of all hospitals reporting off-site evacuations or permanent closure because of damage from the January 17, 1994, earthquake in Northridge, CA. Control hospitals were randomly identified from those facilities that did not evacuate patients. Distances from the epicenter and peak ground accelerations were calculated for each hospital from Trinet ShakeMap data and compared. RESULTS: Eight hospitals evacuated patients (study group); 4 of these hospitals were condemned. These were compared to 8 hospitals that did not evacuate patients (control group). The median epicenter-to-hospital distance for evacuated facilities was 8.1 miles (interquartile range [IQRs] 4.0 to 17.2 miles), whereas that for nonevacuated facilities was 14.1 miles (IRQ 10.5 to 17.0 miles). The difference in the median distances was 6.0 miles (95% confidence interval -4.8 to 11.9 miles). The peak ground acceleration had a median of 0.77 g (IQR 0.53 to 0.85 g) for study hospitals and a median of 0.36 g (IQR 0.24 to 0.50 g) for control hospitals, where 1 g equals the force of gravity. The difference in median acceleration of 0.41 g (95% CI 0.14 to 0.55 g) was significant (P=.009). CONCLUSION: The distances from the epicenter for evacuated or condemned facilities and control hospitals do not appear to differ in the near field. Peak ground acceleration is a superior indicator of the risk for hospital damage and evacuation. Physicians can obtain these data in real time from the Internet and should transfer patients to facilities in areas of lower recorded peak ground acceleration regardless of distance from the epicenter.