Chemical, biological, radiological, and nuclear mass casualty medicine: a review of lessons from the Salisbury and Amesbury Novichok nerve agent incidents

On March 4, 2018, two casualties collapsed on a park bench in Salisbury, Wiltshire, UK. They were later discovered to have been the victims of an attempted murder using the Soviet-era Novichok class of nerve agent. The casualties, along with three further critically ill patients, were cared for in Salisbury District Hospital's Intensive Care Unit. Before the COVID-19 pandemic, the Salisbury and Amesbury incidents were the longest-running major incidents in the history of the UK National Health Service. This narrative review seeks to reflect on the lessons learned from these chemical incidents, with a particular focus on hospital and local organisational responses.

Evaluating the Effectiveness of the Chemical-Mass Casualty Incident Response Education Module (C-MCIREM): A Pilot Simulation Study With a Before and After Design

Background

With the occurrence of a number of major disasters around the world, there is growing interest in chemical disaster medicine. In South Korea, there is a training program for mass casualty incidents (MCI) and backup by legal regulations by the Framework Act on the Management of Disasters and Safety. However, there is no program focusing on chemical disasters. Thus, the authors newly created a program, the Chemical-Mass Casualty Incident Response Education Module (C-MCIREM) in September 2019. This was a pilot study to verify the educational effect of the program.

Method

A pre/post study was conducted of a chemical MCI training program based on simulation. A total of 25 representative and qualified participants were recruited from fire departments, administrative staff of public health centers, and healthcare workers of hospitals in the Gyeonggi-do province of South Korea. They participated in a one-day training program. A knowledge test and confidence survey were provided to participants just before training, and again immediately following the training online. The authors compared improvements of pre/post-test results. In the tabletop drill exercise, quantified qualitative analyses were used to measure the educational effect on the participants.

Results

In the knowledge test, the mean (standard deviation) scores for all 25 participants at baseline and after training were 41.72 (15.186) and 77.96 (11.227), respectively (p < 0.001). In the confidence survey for chemical MCI response for all 25 participants, all the sub-items concerning personal protective equipment selection, antidote selection, antidote stockpiling and passing on knowledge to colleagues, zone setup and decontamination, and chemical triage were improved compared to the baseline score (p < 0.001). The tabletop exercise represented a prehospital setting and had 11 participants. The self-efficacy qualitative survey showed pre- and post-exercise scores of 64/100 and 84/100 respectively. For a hospital setting exercise, it had 14 participants. The survey showed pre/post-exercise scores of 26/100 and 73/100 respectively. Twenty-two (88%) participants responded to the final satisfaction survey, and their overall mean scores regarding willingness to recommend this training program to others, overall satisfaction with theoretical education, overall satisfaction with tabletop drill simulation, and opinion about whether policymakers need this training were all over 8 out of 10 respectively.

Conclusion

C-MCIREM, the newly created chemical MCI program, provided effective education to the selected 25 participants among Korean chemical MCI responders in terms of both knowledge and practice at a single pilot trial. Participants were highly satisfied with the educational material and their confidence in disaster preparedness was clearly improved. In order to prove the universal educational effect of this C-MCIREM in the future, more education is needed.

Adaptations to practice and resilience in a paediatric major trauma centre during a mass casualty incident

BACKGROUND

Innovation and human adaptation in the face of unfolding catastrophe is the cornerstone of an effective systemwide response. Capturing, analysing, and disseminating this is fundamental in developing resilience for future events. The aim of this study was to understand the characteristics of adaptations to practice early in a paediatric major trauma centre during a mass casualty incident.

METHODS

A qualitative interview study of 40 healthcare staff at a paediatric major trauma centre in the immediate aftermath of a terrorist bombing was conducted. An inductive thematic analysis approach was used, followed by a deductive analysis of the identified adaptations informed by constructs of resilience engineering.

RESULTS

Five themes of adaptations to practice that enhanced the resilient performance of the hospital were identified: teamworking; psychologically supporting patients, families, and staff; reconfiguring infrastructure; working around the hospital electronic systems; and maintaining hospital safety. Examples of resilience potential in terms of respond, monitor, anticipate, and learn are presented.

CONCLUSIONS

Our study shows how adaptations to practice sustained the resilient performance of a paediatric major trauma centre during a mass casualty incident. Rapid, early capture of these data during a mass casualty incident provides key insights into enhancing future emergency preparedness, response, and resilience planning.

Development and Validation of a Scoring Assessment Tool for Hospital Safety: A Pilot Study Comparing Hospital Preparedness in Thailand

Introduction

Safe hospitals are crucial in the management of major incidents and disasters. A hospital self-assessment tool was developed for Thailand to identify gaps and shortcomings in hospital preparedness. However, this tool lacks the ability to determine the level of preparedness and cannot be used to standardize hospital readiness and enable continuous quality control.

Objective

The aim of this study was to test a developed scoring hospital assessment tool to evaluate the level of hospital preparedness and enable quality control and compare the results of various hospitals.

Material and Methods

Using the nominal group technique, three experts evaluated all sections of the previously developed hospital self-assessment tool and recognized that each element could be answered by one of the three options: Yes, Not Known, and No. A pilot study was conducted in 11 hospitals to evaluate the feasibility of the tool. The number of Yes responses was divided by the total number of elements to represent the level of hospital preparedness and reported as either low (0‒59), average (60‒79), or good (80‒100). The results identified areas for improvement.

Results

Eleven out of 13 hospitals (85% response rate) in two provinces were enrolled in the study. The results showed various levels of preparedness in all the investigated hospitals. Two hospitals had low preparedness and needed great improvements. The remaining nine hospitals in the two provinces had average preparedness levels and needed improvements. One of the nine hospitals had a score very close to achieving good preparedness. No significant parameters were associated with the preparedness level.

Conclusion

The developed scoring assessment tool for hospital safety demonstrated high utilization feasibility and indicated preparedness levels. The scoring tool also provided assessment levels that could enable continuous quality evaluation and improvements.

Development of Hospital MCI and Disaster Preparedness Assessment Tool for Thailand

Introduction

Hospital preparedness is a key component to mitigate the effects of mass casualty incidents (MCIs) and disasters. Improving hospital preparedness requires an assessment of the country's current health system capacity, readiness, and preparedness. Although a variety of assessment tools exist, none are entirely suitable for Thailand's healthcare system.

Objective

To develop an assessment tool to evaluate hospital preparedness for MCI and disaster in Thailand.

Methods

A cross-sectional study was conducted from 1 March 2015 to December 2016. The contents of the first drafted tool were prepared based on evidence from a systematic search of electronic databases published up to 31 December 2014. Key elements identification, extraction, and further organization were based on the World Health Organization health system framework. Validity was tested by experts and emergency management personnel in four domains using a 5-point scale evaluation form. The feasibility of using this assessment tool was carried out in 41 hospitals on a voluntary basis. The tool was considered valid if the item-objective congruence (IOC) index results were at least 0.6 and feasible for median values of at least 4.

Results

Seventy-six full texts and guidelines out of 5869 titles and abstracts from a systematic search were enrolled in the study. A constructive literature review was performed to develop a hospital assessment tool. The IOC index results of the assessment tool components were 1.0, 0.9, 0.7, and 1.0 in framework appropriateness, relevance of items, clearness, and usefulness, respectively. The median (interquartile range) values of framework appropriateness, relevance of items, clearness, and usefulness were 4.0 (4.0‒5.0), 4.3 (4.3‒4.5), 4.0 (4.0‒4.0), and 5.0 (4.0‒5.0), respectively.

Conclusion

An assessment tool to evaluate hospital MCI and disaster preparedness based on the WHO health system framework was valid and feasible at the national level of Thailand.

Columbia Icefield Bus Rollover: A Case Study of Wilderness Mass Casualty Triage, Treatment, and Transport

Mass casualty incidents (MCIs) are rare in wilderness and mountain settings. Few case studies have reported the response of such events within jurisdictions with well-developed trauma and emergency medical services systems (EMS). Here we explore a MCI in a wilderness setting on the Columbia Icefield inside the Jasper National Park within the Canadian Rocky Mountains. An all-terrain bus was involved that had rolled over while transporting tourists to explore the glacier. The bus rolled multiple times down the slope adjacent to the road, leading to 3 deceased and 21 patients requiring transport. A massive pre-hospital response ensued.Due to the location, extreme environment, and unusual complexities, the response involved significant use of aeromedical resources, physician field deployment, and centralized coordination centers. Readers are reminded of the importance of aeromedical surge capacity in allowing for effective distribution of patients to multiple receiving facilities. Our experience aligns with and reinforces many of the recommendations for wilderness MCI management; however, future research should focus on determining optimal triage strategies for mountain MCIs. Furthermore, future research should explore optimal strategies for developing a rescue chain given the availability of mixed transport resources, as well as the role of physicians in MCI response and where they are best placed in the incident command system.

Staff Perspectives of Mass Casualty Incident Preparedness

Introduction Mass casualty incidents (MCI) are low-frequency, high-risk events that disrupt the day-to-day operations of medical centers. Day-to-day protocols are insufficient for effectively managing MCI events, creating a need to develop and test MCI-specific protocols. The aim of this project was to utilize interviews to gain insight into staff experience and perspective on MCIs and their institution's response plans. Methods Staff members who participated in an MCI drill were asked semi-structured interview questions regarding their perspectives on their current priorities, the information needed to perform their role, and their greatest concerns about an MCI. This quality improvement (QI) project utilized a qualitative methodology to thematically organize the results of the staff responses. Results A total of 64 staff members with various levels of patient care experience were interviewed to reach thematic saturation. The use of staff interviews helped to identify the four primary themes that emerged, which were: 1) process, 2) supplies and resources, 3) communication, and 4) roles. Furthermore, each theme also included a number of subthemes. Conclusions This project demonstrated the importance of staff experiences related to MCI simulation training and preparedness, which may be useful for future training and emergency response planning. Additionally, the results may be helpful for other institutions when building a robust MCI simulation training program or designing an emergency response plan.

Prehospital Triage by Lay Person First Responders: A Scoping Review and Proposal for a new Prehospital Triage Tool

OBJECTIVE

The primary aim of this study is to review the available tools for prehospital triage in case of mass casualty incidents and secondly, to develop a tool which enables lay person first responders (LPFRs) to perform triage and start basic life support in mass casualty incidents.

METHODS

In July 2019, online databases were consulted. Studies addressing prehospital triage methods for lay people were analyzed. Secondly, a new prehospital triage tool for LPFRs was developed. Therefore, a search for prehospital triage models available in literature was conducted and triage actions were extracted.

RESULTS

The search resulted in 6188 articles, and after screening, a scoping review of 4 articles was conducted. All articles stated that there is great potential to provide accurate prehospital triage by people with no healthcare experience. Based on these findings, and combined with the pre-existing prehospital triage tools, we developed a, not-yet validated, prehospital triage tool for lay people, which may improve disaster awareness and preparedness and might positively contribute to community resilience.

CONCLUSION

The prehospital triage tool for lay person first responders may be useful and may help professional medical first responders to determine faster, which casualties most urgently need help in a mass casualty incident.

Prehospital Trauma Care in Disasters and Other Mass Casualty Incidents - A Proposal for Hospital-Based Special Medical Response Teams

Current mass casualty incident (MCI) response in the United States calls for rapid deployment of first responders, such as law enforcement, fire, and emergency medical services personnel, to the incident and simultaneous activation of trauma center disaster protocols. Past investigations demonstrated that the incorporation of advanced trauma-trained physicians and paramedics into prehospital teams resulted in improved mortality during routine emergency medical care in Europe and in the combat setting. To date, limited research exists on the incorporation of advanced trauma-trained physicians and paramedics into prehospital teams for civilian MCIs.

We proposed the concept of Special Medical Response Teams, which would rapidly deploy advanced trauma-trained physicians and paramedics to deliver a higher level of medical and surgical care in the prehospital setting during civilian mass casualty incidents.

Going vertical: triage flags improve extraction times for priority patients

OBJECTIVE

The number of mass casualty incidents (MCIs) has been steadily increasing. High-priority MCI patient outcomes are highly dependent on rapid identification, treatment, and transport. Although there are several methods used to mark patients for rapid extraction, most current methods utilize low-profile tags, with no gold standard. This study examines if the use of a vertical cue, a triage flag, to identify high priority MCI patients results in faster extraction times than those with a wrist triage tag alone.

METHODS

A prospective randomized crossover study was conducted with medical students trained in basic disaster life support, who completed 2 extraction simulations. Two fields were each arranged with 32 randomly placed, pretriaged manikins (10 red, 17 yellow, 5 black). The manikins were marked with either triage tags alone or with triage tags and flags. The total time elapsed for participants to report all high-priority manikin triage tag numbers was recorded.

RESULTS

Eighty-two participants completed both simulations. The average completion time for the "tags-only" simulation was 94.5 seconds (±16.4 seconds) compared to 70.7 seconds (±13.2 seconds) for the flags and tags simulation. This corresponds to an average decrease of 23.8 seconds (P < 0.0001), or a 25.2% reduction in time.

CONCLUSION

Using a vertical cue decreased the time required to identify high-priority patients. This suggests that a rapidly deployable and visually apparent triage marker may allow faster identification and extraction of patients across a field of victims with varying injury severities than a flat horizontal triage tag, thereby potentially improving patient outcomes.

Pilot study of a longitudinal integrated disaster and military medicine education program for undergraduate medical students

Disaster medicine education in medical curricula is scarce and frequently nonexistent. It is reasonable to initiate educational approaches for physicians in this field at the medical school level. An understanding of disaster medicine and the health care system during massive casualty incidents has been recommended as an integral part of the medical curriculum in the United States and Germany.The goal of the reformed curriculum was to develop a longitudinal integrated disaster and military medicine education program extending from the first year to the sixth year based on previously separated clinical and military medicine topics. Emergency medicine physicians, military emergency medical technicians, and Tactical Combat Casualty Care instructors formed an interprofessional faculty group and designed a learning curriculum.A total of 230 medical students participated in the revised disaster preparedness curriculum. Satisfaction survey response rates were high (201/230, 87.4%). Most of the free-text comments on the program were highly appreciative. The students considered the number of teaching hours for the whole program to be adequate. The students showed significant improvements in knowledge and judgment regarding disaster medicine after the program.We found that medical students were highly interested, were appreciative of, and actively participated in this longitudinal integrated disaster and military medicine education program, but gaps existed between the students' scores and the educators' expectations. The educators believed that the students needed more disaster preparedness knowledge and skills.

Back to Basics: Mass Casualty Incidents

Terrorist attacks, mass shootings, violent crimes, and other disasters may leave those affected feeling afraid and overwhelmed with emotion. It has been more than 17 years since the attacks on the World Trade Center in New York City killed almost 3,000 people. Since that time, the world has experienced a profuse number of mass casualty events; they are becoming commonplace and a risk that everyone recognizes as part of daily life. When disasters occur, health care providers may be required to mobilize and should be prepared for anything. Regardless of the size of the facility or the trauma level designation, perioperative nurses need to be aware of how they may be affected by traumatic events. This Back to Basics article reviews some significant mass casualty incidents and explores strategies for perioperative staff members to execute a successful response.

Maintaining Preparedness to Severe Though Infrequent Threats-Can It Be Done?

Background: A mass casualty incident (MCI) caused by toxicological/chemical materials constitutes a potential though uncommon risk that may cause great devastation. Presentation of casualties exposed to such materials in hospitals, if not immediately identified, may cause secondary contamination resulting in dysfunction of the emergency department. The study examined the impact of a longitudinal evaluation process on the ongoing emergency preparedness of hospitals for toxicological MCIs, over a decade. Methods: Emergency preparedness for toxicological incidents of all Israeli hospitals were periodically evaluated, over ten years. The evaluation was based on a structured tool developed to encourage ongoing preparedness of Standard Operating Procedures (SOPs), equipment and infrastructure, knowledge of personnel, and training and exercises. The benchmarks were distributed to all hospitals, to be used as a foundation to build and improve emergency preparedness. Scores were compared within and between hospitals. Results: Overall mean scores of emergency preparedness increased over the five measurements from 88 to 95. A significant increase between T1 (first evaluation) and T5 (last evaluation) occurred in SOPs (p = 0.006), training and exercises (p = 0.003), and in the overall score (p = 0.004). No significant changes were found concerning equipment and infrastructure and knowledge; their scores were consistently very high throughout the decade. An interaction effect was found between the cycles of evaluation and the hospitals’ geographical location (F _(1,20) = 3.0, p = 0.056), proximity to other medical facilities (F _(1,20) = 10.0 p = 0.005), and type of area (Urban vs. Periphery) (F _(1,20) = 13.1, p = 0.002). At T5, all hospitals achieved similar high scores of emergency preparedness. Conclusions: Use of accessible benchmarks, which clearly delineate what needs to be continually implemented, facilitates an ongoing sustenance of effective levels of emergency preparedness. As this was demonstrated for a risk that does not frequently occur, it may be assumed that it is possible and practical to achieve and maintain emergency preparedness for other potential risks.

Mass Casualty Imaging-Policy, Planning, and Radiology Response to Mass Casualty Incidents

A mass casualty incident (MCI) is an event that generates more patients at one time than locally available resources can manage using routine procedures. By their nature, many of these incidents have no prior notice but result in large numbers of casualties with injuries that range in severity. They can happen anywhere and at any time and regional hospitals and health-care providers have to mount a response quickly and effectively to save as many lives as possible. Radiologists must go from passenger to pilot when it comes to MCI planning. When involved at the hospital-wide planning stage, they can offer valuable expertise on how radiology can improve triage accuracy and at what cost in terms of time and resources and thereby contribute a pragmatic understanding of radiology's role and value during MCIs. By taking ownership of MCI planning in their own departments, radiologists can ensure that the radiology department can respond quickly and effectively to unforeseen emergencies. Well-designed radiology protocols will save lives in an MCI setting.

Designing and executing a functional exercise to test a novel informatics tool for mass casualty triage

OBJECTIVE

The testing of informatics tools designed for use during mass casualty incidents presents a unique problem as there is no readily available population of victims or identical exposure setting. The purpose of this article is to describe the process of designing, planning, and executing a functional exercise to accomplish the research objective of validating an informatics tool specifically designed to identify and triage victims of irritant gas syndrome agents.

MATERIALS AND METHODS

During a 3-year time frame, the research team and partners developed the Emergency Department Informatics Computational Tool and planned a functional exercise to test it using medical records data from 298 patients seen in 1 emergency department following a chlorine gas exposure in 2005.

RESULTS

The research team learned valuable lessons throughout the planning process that will assist future researchers with developing a functional exercise to test informatics tools. Key considerations for a functional exercise include contributors, venue, and information technology needs (ie, hardware, software, and data collection methods).

DISCUSSION

Due to the nature of mass casualty incidents, testing informatics tools and technology for these incidents is challenging. Previous studies have shown a functional exercise as a viable option to test informatics tools developed for use during mass casualty incidents.

CONCLUSION

Utilizing a functional exercise to test new mass casualty management technology and informatics tools involves a painstaking and complex planning process; however, it does allow researchers to address issues inherent in studying informatics tools for mas casualty incidents.

Estimating the cost impact of dressing choice in the context of a mass burns casualty event

Mass casualty burn events (MCBs) require intense and complex management. Silver-infused longer use dressings might help optimise management of burns in an MCB setting. We developed a model estimating the impact of dressing choice in the context of an MCB. The model was developed in Excel in collaboration with experienced emergency response clinicians. The model compares use of silver-infused dressings with use of traditional dressings in patients with partial thickness burns covering 30% of their body. Costs were estimated from a UK perspective as a proxy for a funded emergency response team and limited to cost of dressings, bandages, padding, analgesia and staff time. Expected patient costs and resource use were summarised over an acute 2-week intervention period and extrapolated to estimate possible time savings in a hypothetical MCB. Per patient costs were estimated at £2,002 (silver) and £1,124 (traditional) (a daily additional spend of £63). Per patient staff time was estimated at 864 minutes (silver) and 1,200 minutes (traditional) (a daily time saving of 24 minutes). Multiplying up to a possible MCB population of 20 could result in a saving equivalent to 9 staff shifts over the 2-week intervention period. The model was sensitive to type of silver dressing, frequency of dressing change and staff costs. We found increased costs through use of silver dressings but time savings that might help optimise burns management in an MCB. Exploring the balance between costs and staff time might help future MCB response preparation.

The Value of Functional Exercise in Pediatric Mass- Casualty Incident Training

BACKGROUND

Hospital staff in Taiwan practice mass casualty incident (MCI) management through full-scale exercise (FSE). However, FSE is generally resource-intensive and time-consuming. As an alternative, functional exercise (FE) may be more cost-effective with a similar effect in certain aspects. Hence, we aimed to evaluate the FE value in MCI training. We investigated whether FE can increase the familiarity of pediatric MCI response and the effect in different groups.

METHODS

A new emergency operation plan (EOP) of nontraumatic pediatric MCI was developed in 2018 for our Children's Hospital. An FE was conducted to assess the plan. In addition to the emergency department staff, head nurses, supervisors, and physicians of Children's Hospital also participated in the exercise. Pre- and post-exercise questionnaires were designed, and participants were asked to evaluate their familiarity with pediatric MCI response pre- and post-exercise. Participants' reading experience of the new EOP, previous training level, occupation position, and whether they were using a computer during the exercise were also noted in the questionnaires. Data were analyzed using paired t-test and Fisher's exact test.

RESULTS

Among 49 participants, 16 participants completed the pre- and post-exercise questionnaires. The post-exercise familiarity score was found to be significantly higher than that of pre-exercise (p < 0.05). There were no significant differences among the relationships between familiarity increase and participants' reading experience of the new EOP, previous training level, occupation position, and whether they were using a computer during the exercise.

CONCLUSIONS

FE can significantly increase the familiarity of the hospital staff with pediatric MCI response and may be applied as a new training method of hospital disaster preparedness.

Coping With a Mass Casualty: Insights into a Hospital's Emergency Response and Adaptations After the Formosa Fun Coast Dust Explosion

OBJECTIVE

The study provides a comprehensive insight into how an initial receiving hospital without adequate capacity adapted to coping with a mass casualty incident after the Formosa Fun Coast Dust Explosion (FFCDE).

METHODS

Data collection was via in-depth interviews with 11 key participants. This was combined with information from medical records of FFCDE patients and admission logs from the emergency department (ED) to build a detailed timeline of patients flow and ED workload changes. Process tracing analysis focused on how the ED and other units adapted to coping with the difficulties created by the patient surge.

RESULTS

The hospital treated 30 victims with 36.3% average total body surface area burn for over 5 hours alongside 35 non-FFCDE patients. Overwhelming demand resulted in the saturation of ED space and intensive care unit beds, exhaustion of critical materials, and near-saturation of clinicians. The hospital reconfigured human and physical resources differently from conventional drills. Graphical timelines illustrate anticipatory or reactive adaptations. The hospital's ability to adapt was based on anticipation during uncertainty and coordination across roles and units to keep pace with varying demands.

CONCLUSION

Adapting to beyond-surge capacity incident is essential to effective disaster response. Building organizational support for effective adaptation is critical for disaster planning.

The Mass Casualty Incident in Turin, 2017: A Case Study of Disaster Responders' Mental Health in an Italian Level I Hospital

OBJECTIVE

To assess the psychological impact of a mass casualty incident (MCI) in a subset of personnel in a level I hospital.

METHODS

Emergency department staff responded to an MCI in June 2017 in Turin, Italy by an unexpected sudden surge of casualties following a stampede (mass escape). Participants completed the Psychological Simple Triage and Rapid Treatment Responder Self-Triage System (PsySTART-R), which classified the potential risk of psychological distress in "no risk" versus "at risk" categorization and identified a range of impacts aggregated for the population of medical responders. Participants were administered a questionnaire on the perceived effectiveness of management of the MCI. Two months later, the participants were evaluated using the Hospital Anxiety and Depression Scale (HADS), the Kessler Psychological Distress Scale (K6), and the Posttraumatic Stress Disorder Checklist (PCL-5).

RESULTS

The majority of the responders were classified as "no risk" by the PsySTART-R; no significant differences on HADS, K6, and PCL-5 were found in the participants grouped by the PsySTART-R categories. The personnel acquainted to work in emergency contexts (emergency department and intensive care unit) scored significantly lower in the HADS than the personnel usually working in other wards. The number of positive PsySTART-R criteria correlated with the HADS depression score.

CONCLUSIONS

Most of the adverse psychological implications of the MCI were well handled and averted by the responders. A possible explanation could be related to factors such as the clinical condition of the victims (most were not severely injured, no fatalities), the small number of casualties (87) brought to the hospital, the event not being considered life-threatening, and its brief duration, among others. Responders had mainly to cope with a sudden surge in casualties and with organizational issues.

Design Strategies to Improve Emergency Departments' Performance During Mass Casualty Incidents: A Survey of Caregivers

OBJECTIVES

To identify effective facility design strategies to improve the performance of healthcare providers and patient flow during mass casualty incidents (MCIs) in emergency departments.

BACKGROUND

Emergency departments (EDs) are the first line of medical care in MCIs. While operational surge management plans are well described in literature, physical design strategies to improve performance and patient flow during disasters are discussed scarcely.

METHOD

An online questionnaire was sent to EDs' caregivers nationwide asking them to rate the effectiveness of nine physical design strategies, discussed in the literature, to improve caregivers' performance and patient flow during MCIs. Assessed strategies were about providing expandable departments and care areas, alternate care facilities for the least sick to maximize care areas for critical patients, care areas from nonemergency units, increased number of decontamination units, dedicated isolation units, within-hospital and close emergency operation centers, and within-hospital media areas.

RESULTS

All suggested strategies were rated as effective. The most effective and agreed-upon solution was identified as maximizing the care area for critical patients by establishing an alternate care facility with separate entrance and exit doors from the emergency department for the least critical patients. The least effective and agreed-upon strategy was identified as locating a media unit within the hospital outside of the ED.

CONCLUSIONS

Caregivers who work in EDs consider design strategies to be effective in surge management during disasters. Designers can consider implementing identified strategies in designing new emergency departments or expansion and renovation projects.

The crowd-out effect of a mass casualty incident: Experience from a dust explosion with multiple burn injuries

A mass casualty incident (MCI) can have an enormous impact on an already crowded emergency department (ED), affecting the quality of health care provided to non-MCI ED patients. On June 26, 2015, a burn MCI (BMCI) occurred due to a cornstarch explosion at a party at a water park. The competing needs of the BMCI patients might have crowded out the needs of the non-BMCI patients. Although crowd-out effects have been previously documented in a variety of health care situations, they have not been extensively evaluated during MCIs. We aimed to determine whether the outcomes of the non-MCI patients were compromised during this incident.We conducted a retrospective observational study comparing several health care parameters and outcomes between non-BMCI patients and historical controls during the designated period using institutional electronic records and the National Health Insurance Research Database.On the night of the incident, 53 patients were sent to our ED; most of them arrived within 3 hours after the BMCI. There was a significant increase in the wait time for ICU beds among non-BMCI patients compared to the wait times during the corresponding week of the previous year (8.09 ± 4.21 hours vs 3.77 ± 2.15 hours, P = .008). At the hospital level, there was a significantly increased length of hospital stay (LOS) in the ICU after the MCI compared with the LOS in the ICU in the same week of the preceding year (median days: 15 vs 8, P ≤ .001). At the regional level, there were no significant differences between the 2 periods in the LOS in acute care, LOS in the ICU or mortality rates at the involved medical centers.Crowd-out effects from the MCI occurred in the ED and at the institutional level. Although there was an increased wait time for admission to the ICU and a longer LOS in the ICU, the LOS in acute care beds, treatment of time-sensitive diseases, and mortality rates were not compromised by the current MCI protocol at either the institutional or regional levels.

Wearable Proximity Sensors for Monitoring a Mass Casualty Incident Exercise: Feasibility Study

BACKGROUND

Over the past several decades, naturally occurring and man-made mass casualty incidents (MCIs) have increased in frequency and number worldwide. To test the impact of such events on medical resources, simulations can provide a safe, controlled setting while replicating the chaotic environment typical of an actual disaster. A standardized method to collect and analyze data from mass casualty exercises is needed to assess preparedness and performance of the health care staff involved.

OBJECTIVE

In this study, we aimed to assess the feasibility of using wearable proximity sensors to measure proximity events during an MCI simulation. In the first instance, our objective was to demonstrate how proximity sensors can collect spatial and temporal information about the interactions between medical staff and patients during an MCI exercise in a quasi-autonomous way. In addition, we assessed how the deployment of this technology could help improve future simulations by analyzing the flow of patients in the hospital.

METHODS

Data were obtained and collected through the deployment of wearable proximity sensors during an MCI functional exercise. The scenario included 2 areas: the accident site and the Advanced Medical Post, and the exercise lasted 3 hours. A total of 238 participants were involved in the exercise and classified in categories according to their role: 14 medical doctors, 16 nurses, 134 victims, 47 Emergency Medical Services staff members, and 27 health care assistants and other hospital support staff. Each victim was assigned a score related to the severity of his/her injury. Each participant wore a proximity sensor, and in addition, 30 fixed devices were placed in the field hospital.

RESULTS

The contact networks show a heterogeneous distribution of the cumulative time spent in proximity by the participants. We obtained contact matrices based on the cumulative time spent in proximity between the victims and rescuers. Our results showed that the time spent in proximity by the health care teams with the victims is related to the severity of the patient's injury. The analysis of patients' flow showed that the presence of patients in the rooms of the hospital is consistent with the triage code and diagnosis, and no obvious bottlenecks were found.

CONCLUSIONS

Our study shows the feasibility of the use of wearable sensors for tracking close contacts among individuals during an MCI simulation. It represents, to our knowledge, the first example of unsupervised data collection-ie, without the need for the involvement of observers, which could compromise the realism of the exercise-of face-to-face contacts during an MCI exercise. Moreover, by permitting detailed data collection about the simulation, such as data related to the flow of patients in the hospital, such deployment provides highly relevant input for the improvement of MCI resource allocation and management.

Technical Support by Smart Glasses During a Mass Casualty Incident: A Randomized Controlled Simulation Trial on Technically Assisted Triage and Telemedical App Use in Disaster Medicine

Background

To treat many patients despite lacking personnel resources, triage is important in disaster medicine. Various triage algorithms help but often are used incorrectly or not at all. One potential problem-solving approach is to support triage with Smart Glasses.

Objective

In this study, augmented reality was used to display a triage algorithm and telemedicine assistance was enabled to compare the duration and quality of triage with a conventional one.

Methods

A specific Android app was designed for use with Smart Glasses, which added information in terms of augmented reality with two different methods—through the display of a triage algorithm in data glasses and a telemedical connection to a senior emergency physician realized by the integrated camera. A scenario was created (ie, randomized simulation study) in which 31 paramedics carried out a triage of 12 patients in 3 groups as follows: without technical support (control group), with a triage algorithm display, and with telemedical contact.

Results

A total of 362 assessments were performed. The accuracy in the control group was only 58%, but the assessments were quicker (on average 16.6 seconds). In contrast, an accuracy of 92% (P=.04) was achieved when using technical support by displaying the triage algorithm. This triaging took an average of 37.0 seconds. The triage group wearing data glasses and being telemedically connected achieved 90% accuracy (P=.01) in 35.0 seconds.

Conclusions

Triage with data glasses required markedly more time. While only a tally was recorded in the control group, Smart Glasses led to digital capture of the triage results, which have many tactical advantages. We expect a high potential in the application of Smart Glasses in disaster scenarios when using telemedicine and augmented reality features to improve the quality of triage.