Prehospital Mass Casualty Incident Response to a Fire in a Nursing Home in Milan, Italy: Actions Taken and Shortcomings

On July 7, 2023, at 1:21 am, a fire was declared in a retirement home in Milan, Italy. The number of casualties (n = 87) according to the Simple Triage and Rapid Treatment (START) triage system was categorized as 65 green, 14 yellow, 2 red, and 6 black; 75% were women, and the mean age was 85.1 years (± 9). Most patients were unable to walk. A total of 30 basic life support (BLS) ambulances, 3 advanced cardiac life support (ACLS) teams on fast cars, 2 buses, and 1 coordination team were deployed. A scoop and run approach was adopted with patients being transported to 15 health care facilities. The event was terminated at 5:43 am. Though the local mass casualty incident (MCI) response plan was correctly applied, the evacuation of the building was difficult due to the age and comorbidities of the patients. START failed to correctly identify patients categorized as minor. Communication problems arose on site that led to the late evacuation of critical patients.

Beirut Port Blast 2020: New Lessons Learned in Mass Casualty Incident Management in the Emergency Department

BACKGROUND

On August 4, 2020, Lebanon suffered its largest mass casualty incident (MCI) to date: the Beirut Port blast. Hospital emergency response to MCIs is particularly challenging in low- and middle-income countries, where emergency medical services are not well developed and where hospitals have to rapidly scale up capacity to receive large influxes of casualties. This article describes the American University of Beirut Medical Center (AUBMC) response to the Beirut Port blast and outlines the lessons learned.

DISCUSSION

The Beirut Port blast reinforced the importance of proper preparedness and flexibility in managing an MCI. Effective elements of AUBMC's MCI plan included geographic-based activation criteria, along with use of Wi-Fi messaging systems for timely notification of disaster teams. Crowd control through planned facility closures allowed medical teams to focus on patient care. Pre-identified surge areas with prepared disaster cart deployment allowed the teams to scale up quickly. Several challenges were identified related to electronic medical records (EMRs), including patient registration, staff training on EMR disaster modules, and cumbersome EMR admission process workflows. Finally, this experience highlights the importance of psychological debriefs after MCIs.

CONCLUSIONS

Hospital MCI preparedness plans can integrate several strategies that are effective in quickly scaling up capacity to respond to large MCIs. These are especially necessary in countries that lack coordinated prehospital systems.

Factors Associated With Delayed Pre-Hospital Times During Trauma-Related Mass Casualty Incidents: A Systematic Review

OBJECTIVE

Critically injured patients have experienced delays in being transported to hospitals during Mass Casualty Incidents (MCIs). Extended pre-hospital times (PHTs) are associated with increased mortality. It is not clear which factors affect overall PHT during an MCI. This systematic review aimed to investigate PHTs in trauma-related MCIs and identify factors associated with delays for triaged patients at incident scenes.

METHODS

This systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Web of Science, CINAHL, MEDLINE, and EMBASE were searched between January and February 2022 for evidence. Research studies of any methodology, and grey literature in English, were eligible for inclusion. Studies were narratively synthesized according to Cochrane guidance.

RESULTS

Of the 2025 publications identified from the initial search, 12 papers met the inclusion criteria. 6 observational cohort studies and 6 case reports described a diverse range of MCIs. PHTs were reported variably across incidents, from a median of 35 minutes to 8 hours, 8 minutes. Factors associated with prolonged PHT included: challenging incident locations, concerns about scene safety, and adverse decision-making in MCI triage responses. Casualty numbers did not consistently influence PHTs. Study quality was rated moderate to high.

CONCLUSION

PHT delays of more than 2 hours were common. Future MCI planning should consider responses within challenging environments and enhanced timely triage decision-making.

Determining surgical surge capacity with a hybrid simulation exercise

Background

To help test and improve surgical surge capacity, mass casualty incident (MCI) exercises generate valuable information. Both large scale table-top exercises (TTX) and full-scale exercises (FSX) have limitations if you want to test an organisation's capability and structure. A hybrid exercise incorporating the advantages of TTX and FSX is a possible way forward, but is no standardised exercise method, yet. This study aims at evaluating the exercise results to determine the feasibility of a hybrid TTX/FSX exercise for an organization's capability and structure.

Methods

A hybrid MCI simulation using moulaged figurants and simulation cards was designed, where the emergency department of a level 1 trauma centre receives 103 casualties over 4 h. After registration and triage, all casualties are expected to be resuscitated in real time and are transferred for further treatment inside the hospital (radiology, operating theatres, intensive care unit (ICU)/postop and wards). When reaching operation theatre, ICU or ward, figurants are replaced by simulation cards. Observers ensured that those procedures performed were adequate and adhered to realistic times. Use of resources (materials, drugs etc.) were registered. Primary endpoint was average time spent in the emergency department, from time of arrival, to transfer out. Secondary endpoints were related to patient flow and avoidable fatalities.

Results

The hospital managed to deal with the flow of patients without collapse of existing systems. Operating theatres as well as ICU and ward beds were available at the end of the exercise. Several details in the hospital response were observed that had not been noticed during previous TTX.

Conclusion

FSX have a valuable role in training, equipping, exercising, and evaluating MCI management. Hybrid simulations combining both FSX and TTX may optimise resource utilisation and allow more frequent exercises with similar organisational benefit.

Multiple Hospital In-Situ Mass Casualty Incident Training Simulation for Emergency Medicine Residents: A Sarin Bomb Scenario

INTRODUCTION

We simulated an on-site, multi-hospital mass casualty incident (MCI) to educate emergency medicine providers in the principles of trauma resuscitation and collaboration with administration and staff during an MCI.

METHODS

We implemented high-fidelity manikins, inflatable manikins, and actors to simulate a sarin gas bombing. Learners triaged patients at a decontamination tent using the simple triage and rapid treatment (START) tool, or they participated in a simulation in a resuscitation bay.

RESULTS

Forty participants anonymously rated the learning impact of the exercise, the clinical relevance to emergency medicine, and the effectiveness of the faculty facilitation and debriefing on a 1-5 Likert scale. The average responses to all questions were 4.45 or greater, and 98% of respondents recommended adding the scenario to the standard curriculum.

DISCUSSION

We successfully executed a novel, multi- hospital, MCI drill that was rated to be a better alternative to sequential simulation in a simulation center.

Can Live-Actor Patients in a Mass Casualty Incident Exercise Benefit as Exercise Players?

OBJECTIVES

In a mass casualty incident (MCI) exercise, live-actor patients (LAPs) simulated different scenarios in the exercise. This study compared the benefit to LAPs with that to exercise players (EPs) and nonparticipants (NPs).

METHODS

An MCI exercise was conducted in 2018. Emergency department (ED) nurses were assigned as EPs, LAPs, or NPs and asked to attend a pre-exercise lecture. A pre-exercise survey evaluated all ED nurses' background, confidence level, and knowledge of MCI management. Knowledge assessment included disaster medicine knowledge (DMK) and on emergency operation plan familiarity (EOPF). The same survey was conducted again after the exercise. A paired t-test was used to analyze the difference before and after the exercise in the 3 groups.

RESULTS

Twenty-nine ED nurses completed both surveys. Confidence improved significantly for both the EP and LAP groups. The DMK of the LAP group improved significantly. EOPF also improved significantly for all 3 groups. A comparison of the improvement levels showed no significant difference between the EP and LAP groups for confidence, DMK, and EOPF.

CONCLUSIONS

ED nurses can benefit from participating as LAPs in full-scale MCI exercises. Having ED nurses act as LAPs makes it possible to train more staff in 1 exercise.

Pediatric Emergency Medicine Didactics and Simulation: JumpSTART Secondary Triage for Mass Casualty Incidents

Mass casualty incidents (MCI), particularly involving pediatric patients, are high-risk, low-frequency occurrences that require exceptional emergency arrangements and advanced preparation. In the aftermath of an MCI, it is essential for medical personnel to accurately and promptly triage patients according to their acuity and urgency for care. As first responders bring patients from the field to the hospital, medical personnel are responsible for prompt secondary triage of these patients to appropriately delegate hospital resources. The JumpSTART triage algorithm (a variation of the Simple Triage and Rapid Treatment, or START, triage system) was originally designed for prehospital triage by prehospital providers but can also be used for secondary triage in the emergency department setting. This technical report describes a novel simulation-based curriculum for pediatric emergency medicine residents, fellows, and attendings involving the secondary triage of patients in the aftermath of an MCI in the emergency department. This curriculum highlights the importance of the JumpSTART triage algorithm and how to effectively implement it in the MCI setting.

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

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

Use of a Nerve Agent Antidote-Dosing Tool for Mass Casualty Incident Emergency Preparedness

OBJECTIVE

Nerve agent attacks pose a serious threat worldwide and ensuring optimal readiness is essential to management. We review a mass casualty incident (MCI) drill in a busy urban New York City Emergency Department incorporating an antidote-dosing tool.

METHODS

Emergency Management and Preparedness planned an MCI drill involving a nerve agent exposure and engaged the pharmacy department to participate on a more comprehensive level. The clinical pharmacist prepared a treatment tool with antidote dosing recommendations to distribute to team members participating in the drill.

RESULTS

During the launch of the exercise, all clinicians involved reviewed the antidote-dosing tool with the pharmacy team members. Because of the ease of use, limited time was necessary to review the dosing tool before the start of the exercise. After the exercise, feedback regarding the use of the tool was very positive and participants appreciated the tool for use in a theoretical emergency that they have had limited experience managing.

CONCLUSIONS

Optimizing team preparedness with accessible and practical dosing tools may be a helpful addition to emergency preparedness for chemical and biological events with the potential for many casualties.

Collaborative Interprofessional Health Science Student Led Realistic Mass Casualty Incident Simulation

In collaboration, a health science university and a fire department offered a mass casualty incident (MCI) simulation. The purpose of this study was to evaluate a cross-section of student health care providers to determine their working knowledge of an MCI. Students were given a pretest using the Emergency Preparedness Information Questionnaire (EPIQ) and the Simple Triage and Rapid Transport (START) Quiz. The EPIQ instrument related to knowledge of triage, first aid, bio-agent detection, critical reporting, incident command, isolation/quarantine/decontamination, psychological issues, epidemiology, and communications. The START Quiz gave 10 scenarios. Didactic online content was given followed by the simulation a few weeks later. A posttest with the same instruments was given after the simulation. Participants were majority female (81.7%), aged between 25-34 (41.7%), and 61.7% (n = 74) had undergraduate or post-graduate degrees. The overall pretest mean was 2.92 and posttest mean was 3.64. The START Quiz found participants struggled to correctly assign triage levels. Students also experienced challenges correctly assigning patients to specific triage categories. Findings will assist educators to understand knowledge gaps, so revisions can be made to enhance learning in disaster management. Concentration in proper field triage is also a needed focus.

Blast Injuries by an Improvised Explosive Device in Japan: A Case Report

Blast injuries caused by an improvised explosive device (IED) are becoming more common in civilian settings. However, physicians may not be familiar with the treatment and management of blast-injured victims. To the best of our knowledge, this is the first case report of a blast injury caused by an IED in Japan. A 64-year-old man was admitted to our hospital's emergency department after sustaining a blast injury. His vital signs were stable, but he had multiple small wounds with embedded foreign bodies that were consistent with injuries sustained by IED victims. The patient was treated for his injuries and was moved to another hospital on day 37. Knowledge about blast injuries caused by IEDs and management strategies for mass casualties are both necessary.

Risk Factors for Death or Meningitis in Adults Hospitalized for Cutaneous Anthrax, 1950-2018: A Systematic Review

BACKGROUND

Cutaneous anthrax accounts for approximately 95% of anthrax cases worldwide. About 24% of untreated patients die, and many cases are complicated by meningitis. Here, we explore clinical features of cutaneous disease associated with poor outcomes.

METHODS

A systematic review identified 303 full-text articles published from 1950 through 2018 that met predefined inclusion criteria. Cases were abstracted, and descriptive analyses and univariate logistic regression were conducted to identify prognostic indicators for cutaneous anthrax.

RESULTS

Of 182 included patients, 47 (25.8%) died. Previously reported independent predictors for death or meningitis that we confirmed included fever or chills; nausea or vomiting; headache; severe headache; nonheadache, nonmeningeal signs; leukocytosis; and bacteremia. Newly identified predictors included anxiety, abdominal pain, diastolic hypotension, skin trauma, thoracic edema, malignant pustule edema, lymphadenopathy, and evidence of coagulopathy (all with P < .05).

CONCLUSIONS

We identified patient presentations not previously associated with poor outcomes.

Making Space to Save Lives: A Critical Role for the Hospitalist During Mass Casualty Incidents

OBJECTIVE

An effective hospital response to mass casualty incidents (MCIs) requires rapid mobilization of personnel capable of caring for critically ill trauma patients and availability of resuscitation resources.

METHODS

Hospitals facing an MCI wrestle with the challenge of immediately adjusting their overextended clinical operations to resuscitate a large number of rapidly arriving patients without compromising the care of existing patients.

RESULTS

Hospitalists are well positioned to add significant value by off-loading the emergency department (ED) given their broad clinical expertise. We describe our institution's protocol to generate immediate and sustained surge capacity by integrating our hospitalist service into MCI response.

CONCLUSIONS

Our protocol details the safe and rapid transfer of care of existing ED patients to hospitalist teams to make ED staff and space available to care for incoming MCI patients.

Expression of ethical principles in Australia's disaster plans

OBJECTIVE

This qualitative study explores whether Australian mass casualty and disaster plans explicitly acknowledge or implicitly draw upon ethical principles.

METHODS

Federal, state and territory governmental websites were searched to identify mass casualty incident and/or disaster plans. The authors examined the documents to identify whether ethical principles were overtly stated or implied, and what those values or principles were.

RESULTS

Ten governmental documents were identified - two federal and one for each of the eight States and Territories. One of the documents had an explicit statement of the ethical values that informed the mass casualty and disaster planning decisions which were present. Utilitarianism was the dominant ethical principle informing the document in another seven documents.

CONCLUSION

In Australian government documents for mass casualty and disaster management, although ethics is definitely considered, the ethical principles on which decisions are made are rarely explicit. Mass casualty and disaster decision-making could be improved by making the ethical basis for decision-making clear, transparent and comprehensively reasoned.

Toward Building Surge Capacity: Potentially Effective Spatial Configurations in Emergency Departments

BACKGROUND

Emergency departments (EDs) have been struggling with overcrowding issues for years. Some spatial configurations have been proposed to improve ED performance in facing overcrowding. Despite similarities with mass casualty incidents (MCIs), when demand for care exceeds the capacity, little is documented about the application of the proposed configurations during MCIs to improve surge capacity.

OBJECTIVES

We aimed to explore the potential of spatial configurations that have been proposed to handle ED overcrowding in daily operations so as to improve surge capacity during MCIs.

METHODS

Using an online Likert-scale survey, 11 spatial design strategies were rated by ED care teams in terms of their potential to improve surge capacity during MCIs.

RESULTS

Responses from 72 participants revealed that establishing an in-house lab was perceived as the most potential strategy, followed by rapid care area, internal waiting rooms, and in-house imaging. In contrast, separate entrance and exit doors, as well as decentralized nurse stations, were perceived as the least potential strategies but also exhibited the most variance in response. Respondents' comments implied that their choice of in-house ancillary services was primarily to improve communication and to reduce turnaround time and risk of errors. Their choice of rapid care and internal waiting areas related to improved flexibility.

CONCLUSIONS

Understanding clinicians' perspectives on potentially effective spatial configurations aids in implementing balanced strategies to better equip EDs to handle overcrowding in daily operations and manage surges during MCIs.

A Region-Wide All-Hazard Training Program for Prehospital Mass Casualty Incident Management: A Real-World Case Study

OBJECTIVE

We report the development, implementation, and results of a sustainable region-wide mass-casualty management prehospital training program implemented by the Regione Lombardia emergency medical services (EMS) agency AREU in Italy.

METHODS

The educational program learning objectives are: (1) command and control, communications, and resource management; (2) mass casualty triage and the START triage protocol; (3) on-scene management; (4) Regione Lombardia and AREU Mass Casualty standard operating procedures; and (5) inter-agency communications and relations. For each course edition data on participants' summative assessment, participants' feedback and costs were collected.

RESULTS

Between June 26, 2013, and December 31, 2020, a total of 84 editions of the provider training event were delivered, training an overall 1329 prehospital providers; 1239 (93%) passed the summative assessment and were qualified as being operationally "ready." Regarding participant feedback, the overall program was rated 4.4 ± 0.7 out of 5. The overall cost of running the provider program during the study period was €321 510 (circa US $382 000). The average cost per edition was €3828 and €242 per participant.

CONCLUSIONS

We have described a simple yet interactive simulation and blended-learning approach, which has yielded good pass rates, good participant satisfaction, and contained costs to systematically train emergency medical service personnel.

Impact of Point-of-Care Ultrasound on Secondary Triage: A Pilot Study

OBJECTIVES

In mass casualty scenarios, patients with apparent hemodynamic and respiratory stability might have occult life-threatening injuries. These patients could benefit from more accurate triage methods. This study assessed the impact of point-of-care ultrasound on the accuracy of secondary triage conducted at an advanced medical post to enhance the detection of patients who, despite their apparent clinically stable condition, could benefit from earlier evacuation to definitive care or immediate life-saving treatment.

METHODS

A mass casualty simulated event consisting of a bomb blast in a remote area was conducted with 10 simulated casualties classified as YELLOW at the primary triage scene; patients were evaluated by 4 physicians at an advanced medical post. Three patients had, respectively, hemoperitoneum, pneumothorax, and hemothorax. Only 2 physicians had sonographic information.

RESULTS

All 4 physicians were able to suspect hemoperitoneum as a possible critical condition to be managed first, but only physicians with additional sonographic information accurately detected pneumothorax and hemothorax, thus deciding to immediately evacuate or treat.

Mass casualty medicine: time for a 21st century refresh

Mass casualty events are on the rise globally, as we face increasing pressures from scarcity of resources, population growth, systemic inequalities, geopolitical instabilities, and polarised discourse. Although they are rare events for an individual practitioner, they are going to happen to someone, somewhere, this week, this month, this year. And whilst they are often the last consideration for healthcare systems under constant pressures from daily routine work, individuals, departments, hospitals, and systems have to step up effectively in times of crisis. Failure to do so can lead to suboptimal outcomes for casualties, and even perceived failures can have crippling consequences on staff, families, and communities for years.

Provision of pre-hospital medical care for terrorist attacks

The delivery of medical care to the severely injured during major incidents and mass casualty events has been a recurring challenge for decades across the world. From events in resource-poor developing countries, through richly funded military conflicts, to the most equipped of developed nations, the provision of rapid medical care to the severely injured during major incidents and mass casualty events has been a priority for healthcare providers. This is often under the most difficult of circumstances.^1,2 Whilst mass casualty events are a persistent global challenge, it is clear in developed countries that patients and their families demand and expect a high standard of care from their rescuers, that this care should be delivered rapidly, and this should be of the highest quality possible.³ Whilst there is respect afforded to those who 'run towards danger' during a high-threat situation, first responders are subjected to a high degree of scrutiny for their actions, even when the circumstances they are presented with are considered to be extraordinary.⁴ Likewise, even for those who are catastrophically injured beyond salvage, society expects the response to be dignified, calculated, and thorough.³.

Improving mass casualty planning in low resource settings: Médecins Sans Frontières and International Committee of the Red Cross perspective

Mass casualty events occur on a regular although unpredictable basis within the contexts of both Mèdecins Sans Frontières (MSF) and the International Committee of the Red Cross (ICRC) activities. The frequency of both natural disasters and other mass casualty incidents is increasing with urbanisation and industrialisation, compounded by climate change and conflict. Both organisations have recognised that the historical training focus on full-scale mass casualty simulations has not always been followed through to the resolution of action points and dissemination of learning. Staff training for mass casualty management has been variable. This led MSF and ICRC to develop a multimodal approach to assist development of mass casualty plans and preparedness. Capitalising on our presence in these contexts we are incorporating our experience of quality improvement and change management to complement simulation to 'stress and test' systems. We examine the challenges and share our efforts to improve training of staff in field projects across both MSF and ICRC and discussing future innovations.

Embracing uncertainty in mass casualty incidents

Uncertainty is the defining state of the first minutes and hours of a mass casualty event, yet decisions must be taken and actions must happen before the picture is complete. To move forwards in face of uncertainty, we must acknowledge that there will be insufficient information for us to be comfortable in our decisions and actions. We discuss here a range of solutions that allow us to tolerate, even flourish, in the midst of uncertainty.

Exercising for mass casualty preparedness

Exercising for mass casualty incidents is mandated by governing organisations with the aim of maintaining readiness within the healthcare sector for the many challenges these incidents bring. This readiness is delivered through a combination of discussion-based and operation-based exercises that are targeted to the needs of both the individuals delivering care and the needs of the overall system of patient flow and treatment. Although exercising for disaster preparedness is resource intensive, it is the repetitive, iterative nature that allows for wide staff capture and exposure along with continual improvement of plans. Having been recently involved in exercising is also likely to increase the confidence of staff and makes them feel better prepared. Exercising should be tailored to the needs and likely challenges of each healthcare system. A cycle of design, challenge, and redesign should target areas of greatest need and greatest benefit. The conventional advice, when introducing exercising, is to start small and build up over time with repeated exercises that demonstrate increasing response capability. However, some organisations would benefit from an exercise that lays bare shortcomings and acts to galvanise change.

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.