Fiji consists of 110 populated islands over an area of 2,600,000 square kilometers and is prone to disasters such as tropical cyclones.1 To increase national capacity to respond to disasters and outbreak, the Fijian government, under the commissioning of Ministry of Transport and with technical guidance from the Ministry of Health, designed a medical ship called the MV Veivueti. During Fiji’s COVID-19 surge, MV Veivueti was utilized to provide operative health services during the surge in COVID-19 patients at other health facilities.2

To describe FEMAT’s COVID-19 response utilizing the medical ship, MV Veivueti, in Fiji’s Pacific island setting.

MV Veivueti has been used on multiple disaster responses, however the COVID-19 surge in mid-2021 was the first time the vessel was used during an outbreak to allow for the continuation of surgeries when other health facilities were overwhelmed with COVID-19 patients. The medical ship is staffed with a comprehensive team from Fiji’s EMT - FEMAT - including surgeons, pediatricians, obstetricians, a dentist, nurses, and other medical staff.

From May 5 through July 6, 2021, a 12-member medical team staffed the medical ship 24-hours a day, providing primarily operative management of cases that were referred from health facilities. COVID-19 screening and IPC measures were in place and a clear patient flow was designed for patient transferred to health care facilities.

The use of the MV Veivueti helped ensure continuity of critical health services during the peak of the Delta VOC outbreak in the Fiji Islands.

UK-Med, as part of our UK EMT project, deployed a team to respond to the overwhelming surge in COVID-19 cases in Papua New Guinea in late 2021. Such deployment was associated with several risks, including natural hazards; earthquakes; societal crisis; tribal fighting and civil unrest; and health risks such as extreme temperatures and poor sanitation infrastructure presented further hazards to personnel safety.

To share lessons learned on enhancing the well-being of an EMT in a challenging context such as PNG.

Satisfaction survey, bilateral meetings, in addition to weekly meetings with the headquarters held throughout the deployment.

All deployed team members felt exhausted early in the deployment, including an early lack of clarity on the deployment location which eventually ended up being Mount Hagen, a very risky area only accessible by plane. Utilizing emotional and social support, diversity acceptance within the team, and coherent coordination between team members the deployment delivered upon all agreed objectives. Local staff were integrated and a successful workplan was well-received and evaluated as making a real difference to the staff and patients, with a request for an extension of activities received from the Provincial Health Authority.

Considerations for staff well-being need to counter-balance the need for strict security protocols. Solid feedback mechanisms should be designed and implemented at an early stage of deployments to avoid any adverse effect on the team’s well-being. Deployment of an assessment team should strengthen coordination, ensuring required needs are being responded to and operational planning is location/context specific.

The Korea Disaster Relief Team (KDRT) was established in 2008 to systemize Korea’s overseas medical emergency response. Following multiple international deployments since 2008, KDRT embarked on its journey to achieve WHO Emergency Medical Team (EMT) Global Classification in 2017.

To outline the key success factors in KDRT’s work to reach classification as a Type 1 Fixed EMT.

As the Korean government dispatches KDRT, a multi-agency collaboration is essential to respond to overseas disasters. To this end, KDRT leveraged a formal collaborative approach, assigning specific roles for EMT development and deployment to several national agencies: The Republic of Korea Ministry of Foreign Affairs, the Ministry of Health and Welfare, the Ministry of National Defense, the Korea International Cooperation Agency, Korea’s National Medical Center, and the Korea Foundation for International Healthcare. This network prepared KDRT for WHO EMT Verification and developing Standard Operation Procedures for the EMT Type 1. Based on this SOP, KDRT repeated simulations for each element to strengthening capabilities and enable deployment ensuring strong coordination with national and international partners in response.

After initiating KDRT’s journey towards EMT classification 2017, KDRT formalized cooperation with multiple agencies, and codified these roles and responsibilities in formal/published SOPs. Finally, the KDRT was verified by WHO in June 2022.

This study provides a process within the operating system limited to the Republic of Korea, the country of the KDRT. However, it also can be used as a collaborative reference case in the EMT development and verification process.

The COVID-19 pandemic, especially in Africa, has increased the need for EMTs for surge management, clinical care, and capacity-building support for establishing national EMTs.

To analyze the implementation of EMTs deployments in the AFRO Region during the COVID-19 pandemic.

This is a retrospective policy analysis done from the perspective of the EMT policy implementor using Walt and Gilson’s policy triangle1 (capturing processes, the actors, the context, and the content). Data were collected through document reviews, key informant interviews, semi-structured in-depth interviews, and focus-group discussions. Analysis was done through a priori framework analysis.

Overall, 22 countries benefited from international EMT deployments since the onset of COVID-19, with deployment periods varying between six to 24 weeks. Development partners, governments, and local authorities supported deployments. Some deployments were hampered by inadequate knowledge of EMTs processes, bureaucratic and administrative barriers, and slow mobilization of resources. Other challenges were the lack of critical care equipment and teams facing resistance due to cultural differences. Some teams only worked in big cities rather than local regions with low capacity and high morbidities from COVID-19. Collaboration between international and national teams resulted in enhanced capacity building, optimistic volunteerism and resilience, and provision of clinical care in constraint settings to save lives.

The deployments were critical in saving lives in under-resourced settings despite the challenges. COVID-19 has provided an impetus to strengthen national public health response by providing training opportunities, twinning or exchange programs, building health infrastructure, and prepositioning supplies and equipment to ensure national reliance and sustainability.

The Commonwealth of the Northern Mariana Islands (CNMI), a chain of 14 Pacific islands with a population of around 50,000 and a United States territory, experienced two major typhoons exceeding 150 mph/240 kmph in three years. The resiliency of the people of the CNMI is evident, and has been supplemented through support from international Emergency Medical Teams (EMTs). As a US territory, support is available from the United States federal government and international partners, but an island territory far from the US mainland, the CNMI requires strong local emergency response capacity.

To describe:

• How the CNMI health system conducted an environmental scan to identify and address gaps in out-patient support in disasters;

• How the health system improved and expanded its capacity to respond to emergencies with a significant impact on the community’s health; and

• How leveraging the integration of clinical and public health capacities contributed to the development of a multidisciplinary local Type 1 EMT in the CNMI.

The CNMI brought together key local agencies involved in emergency response. Because of multiple recent disaster response efforts, agencies had deep knowledge and experience, and gaps were easily identified.

The territory’s experience with international EMTs guided the creation of a local EMT in the CNMI, engaging local agencies, physicians, nurses, and public health and preparedness staff from the territory’s health system to establish an EMT for local and potentially for regional response.

Building local capacity using multi-sectoral agencies and multi-disciplinary individuals improves health system resiliency in health emergency response.

Health care delivery in refugee camps is challenging; the setting of a refugee camp is a unique context that presents barriers and one of the main problems is the fragmentation and difficulty in communication and information sharing among HCWs deployed in a camp, especially in contexts where communication networks are not always available and accessible.

The overall objective of this project is to facilitate health communications among health care workers in a refugee camp where the communication network is not always available or accessible.

A mesh network communication system will be deployed, tested, and evaluated to assess and evaluate the usage, feasibility, and reliability of the system, testing the capacity of the message to reach different parts of the camp.

During the project’s initial phase, local health care workers (HCWs) will support the project in identifying instances when communication is challenging and will create injects/mock scenarios to use in the following phase. In the second phase, the application of the new technology is evaluated; experimental research will compare the “as is” of the system and the “to be” solution using the new technology measuring key performance indicators (KPIs) (eg, time needed to send/receive information).

The use of an available, affordable, and usable mobile and internet connectivity system in a context where communication networks are not always available or accessible will facilitate the communication among agencies, improve the coordination of health services, and improve the quality and timing of information sharing.

One of the most severe outcomes of the Ukraine war has been the systematic destruction of communities resulting in mass migration of people to Poland. Millions of affected people have arrived in Poland as war refugees requiring medical attention from a fragile health care system overburdened by the COVID-19 pandemic. This study assesses ED utilization in Polish hospitals by Ukrainian refugees.

To assess the impact of Ukrainian refugees on ED utilization in Poland.

Demographic data, chief presenting complaints, diagnosis, and the level of care needed were registered. Bivariate and multivariate logistic regression analysis were performed to yield odds ratios (OR) with a 95% confidence interval.

At the time of investigation, there were 4,000 Ukrainian refugees admitted to Polish hospitals, of which more than half were children. Results are forthcoming.

Although COVID-19 pandemic highlighted the insufficiency of the Polish health care system, resulting in delayed treatment for many patients, the current mass migration from Ukraine emphasizes the lack of a proper organization for crisis management in Poland. Facing an unprecedented and historic challenge, the Polish health care system, operating at the limit of its capacity, is stretched beyond capacity resulting in excess mortality, which exceeded 200,000 deaths during the pandemic. The impact was directly due to the pandemic or the delay in treating other diseases such as cardiovascular diseases and cancer. Inconsistency in medical decision making, lack of proper recommendations from the authorities, and organizational insufficiency requires a renewed focus on adaptive capacity and long-term solutions that promote systems resiliency.

EMT’s training is considered of high importance for disaster preparedness and response. The PT EMT, joined the TEAMS 3.0 Consortium, seeking to develop a universal training program for EMTs.

The purpose of this study is to evaluate the effectiveness of the PT EMT E-learning Course in preparing trainees for disaster during their EMT initial training.

The analyzed data were collected through the application of a final questionnaire, which aimed to assess the effectiveness of the topics covered and the self-perception of disaster preparedness. A total of 31 trainees attended the E-learning Course, but only 25 answers were collected.

The results showed that 92% of the trainees considered as the most important themes three areas: (1) Disaster and Humanitarian Principles; (2) Safety & Self-Protection; and (3) Disaster Logistics. The overall mean score was 4.52 points (SD = 0.770) out of five for the importance of this training for the performance of their mission roles and 4.48 points (SD = 0.770) in the contribution of these contents to their individual development. After completing this E-learning module, 88% consider themselves better prepared to disaster response and to attend the practical module of the initial training program.

The PT EMT E-learning Course, preceding the practical TEAMS 3.0 course, proved to be effective in the preparation of trainees for the practical training, but especially, it adds a huge variety of important knowledge, solidifying their preparedness for disaster response.

The development of common training bases for EMTs, with both modules, will improve the disaster preparedness and response.

There is an increasing global recognition that medical education systems world-wide have a major gap in training students for medical response to disasters. The IFMSA developed the International Training on Disaster Medicine (ITDM) project to address this gap.

To provide medical students with essential competencies in Disaster Medicine through a peer-to-peer approach.

Selected number of students go through a Training of Trainers course organized annually over four months, jointly with the Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health in Novara, Italy. Graduates then lead ITDM workshops world-wide. The workshop is based on peer-to-peer education and incorporates interactive exercises, simulating real-life scenarios. In the workshop, medical students are introduced to core concepts and skills in Disaster Medicine, public health in disaster settings, and disaster management frameworks.

The ToT course was organized first in 2015 in Italy. It has been held seven times, graduating 120 trainers from 55 countries. While the ITDM workshop was first organized in Malta in 2016, it has been conducted a total of 22 times in 19 different countries, building the capacity of more than 250 medical students world-wide. Furthermore, more than 500 medical students have been influenced by sporadic educational activities organized by ToT graduates.

The ITDM project aims to fill the gap in Disaster Medicine education in medical curricula. It has offered a much-needed space for the education and training of medical students, equipping them with basic competencies in responding to disasters to prepare them to act when needed.

Following a quarantine breach in April 2021, Fiji went from no cases of COVID-19 to having the highest number per capita in the world. Fiji was relatively well-prepared to respond to COVID-19 as it has strong emergency management response systems. Nevertheless, due to the rapid increase, the public health system was quickly overwhelmed. The problem was particularly acute at the main tertiary hospital in Suva.

To describe the effects of an overwhelming COVID-19 outbreak on nurses working in the Emergency Department of Colonial War Memorial Hospital in Fiji, in 2021.

To describe the lessons learned and recommendations for the future.

Focus Group Discussion with two groups of nurses: (1) ED nurse and (2) nurses seconded to provide a surge workforce in the most acute phase.

Preliminary findings show that nurses were lacking in confidence and frightened about the growing epidemic. Resources, material and human, were initially in short supply. The agency of the nurses as result of their post-graduate study and due to the collegial environment in ED resulted in increased supplies of PPE and changes to nursing practice (eg, web-based handover). Final results pending.

The preliminary findings of this research illustrate that even in low-resource settings, with the right support and effective nursing leadership, nurses can provide safe and effective care to patients. The research illustrates the benefits of sound, relevant education, the crucial importance of teamwork, the importance of networks, the important benefits of early deployment of the MET, and the need for effective nursing leadership.

To some planners, allocating resources for emergency response may look unnecessary if not wasteful. Low-probability events can be perceived as unlikely, and for that reason, not worth considering within the regular planning structure. This is almost a dictum when planners must operate in a low-resource setting, where competition for available resources favors an approach that focuses in addressing pressing, not eventual needs.

Understanding this context, it is also important for planners to consider the importance of systemic resiliency, implicit in the early utilization of Emergency Medical Teams for disasters mitigation, and for that reason, as necessary instruments to reduce impact - in terms of lives lost - and cost - financial and social - of medical emergencies that result from natural and man-made disasters.

Conducting an adverted DALYs cost analysis of a recent disaster is an instrument that could help policy, decision makers, and planners in general gain greater visualization of the potential social and financial costs reduction associated to the implementation of EMTs and, as a corollary, acknowledge the importance of preparation for necessary systemic resilience and its impact in equity and societal well-being.

Initial analysis shows that preparation for early responses by EMTs to mitigate disasters can result in lower costs while reducing overall mortality and morbidity and potentially favoring faster systemic recovery.

The approach utilized requires improvement and expanded discussion with experts and beneficiaries will most likely result in its refinement and advancement.

The Federated States of Micronesia (FSM) is a Pacific Island nation of just over 100,000 people, with 607 islands spread over an ocean territory of over 2.5 million square kilometers. The nation is regularly struck by disasters and outbreaks - most recently Typhoons Wutip and Maysak, which affected populations on hundreds of islands. To strengthen rapid response to future emergencies, the FSM Government, with support from WHO, Japan, and USAID, is now developing a national Emergency Medical Team.1

To describe the development of FSM’s national EMT.

FSM’s EMT development began with a workshop facilitated by WHO in November 2019, with participants from the National Department of Health & Social Affairs (DHSA) and representatives from all four of FSM’s State Health Departments. A national EMT focal point was jointly hired by WHO and FSM’s DHSA, a Technical Working Group was established, and SOPs developed. WHO initiated procurement of a tailored Pacific EMT cache for FSM’s EMT, along with other Pacific EMTs. FSM’s EMT development has been slowed by COVID-19, but there are plans to train team members from the country’s four States to be ready for self-sufficient national deployments by early 2023.

With support from partners, FSM is developing a self-sufficient national EMT capable of rapid response across hundreds of islands spread over a vast ocean territory.

FSM is strengthening readiness for future emergencies by developing a national EMT capable of rapid response to the most remote and austere post-disaster conditions, including throughout its remote outer islands.

The Minimum Data Set (MDS) has allowed governments of disaster-affected countries to collect, examine, and evaluate standardized medical data from Emergency Medical Teams in real-time. However, little study has been conducted on the use of MDS data to predict health care needs.

This research proposes an outlook on the use of machine learning and MDS data to predict the need for medical care in disaster-affected areas.

The characteristics of the data collected by MDS and the optimal machine learning model were discussed.

The primary causes of disease after disasters are trauma (MDS Nos. 4–8), which frequently occurs immediately after a disaster, and infectious diseases (MDS Nos. 9–18), which can increase due to decreasing hygiene conditions. Furthermore, certain infectious diseases can spread quickly because of living in congested evacuation centers, and early detection is crucial.

Therefore, predicting the need for medical care in a disaster area is complicated and requires a combination of many machine-learning models. Data-driven methods are mostly linear approaches and cannot capture the dynamics of infectious disease transmission. Additionally, statistical models depend heavily on assumptions, making real-time infection prediction challenging. Thus, deep learning is employed to model without losing the temporal component.

Real-time prediction of health care needs using machine learning and MDS can be useful to policymakers by enabling them to better deploy and allocate health care resources, which is useful to patients and front-line health care providers. More detailed predictions for regions and diseases are also anticipated.

Thailand Emergency Medical Team (Thailand EMT) was verified by the WHO in 2019 as a Type 1 fixed EMT. The second wave of COVID-19 hit the country in December 2020. Samut Sakhon province was the center of the spread with many migrant workers infected. Several field hospitals were set up, one being situated in the compound of a Buddhist Temple, Wat Krok Krak. Thailand EMT was tasked in setting up and running the operation here in the initial phase.

To describe Thailand EMT’s experience in operating a COVID-19 field hospital.

On December 30, 2020, 16 members of the Thailand EMT were deployed to the Wat Krok Krak Field Hospital. The team comprised of doctors, nurses, pharmacists, and emergency medical technicians who also functioned as logistic officers. Patients were admitted in groups every day. Physicians communicated with patients by using a telemedicine system to monitor patients clinically.

From December 31, 2020 through January 6, 2021, 143 COVID-19 patients were admitted. There were 104 female and 39 male patients. Patients were between 16 and 54 years of age, with a mean of 31.5 years. All were foreigner workers from nearby countries. Three patients had to be referred to a tertiary hospital. The rest of the patients were eventually discharged.

Thailand EMT was able to adapt and deployed to operate a COVID-19 field hospital. Collaboration with relevant agencies and local authorities played a key role. This deployment, although within Thailand, was a good learning opportunity for the team to prepare for future operations.

Tables and Figures (optional)

Health emergencies such as the COVID-19 pandemic strain health systems and emergency response mechanisms. Identifying critical points during the response cycle where emergency workforce and operational capacity can be improved can help break the protracted nature of responses. Global health emergency workforce, or health emergency and alert response teams such as multidisciplinary Public Health Rapid Response Teams (RRTs) and Emergency Medical Teams (EMTs), play critical roles in the response to public health emergencies.

The project aims to explore and understand how countries manage and operationalize their RRT and EMT programs. With anecdotal evidence of countries integrating the two historically disparate groups, we propose to examine how countries are jointly or separately addressing legal frameworks and policies; management practices; reporting processes and protocols; training; as well as program operations and standards.

Through existing global partnerships and networks, a convenience sample of national focal points responsible for the management of their RRT and EMT program are sent an online survey followed by participating in a one-on-one interview. Quantitative and qualitative analyses will be conducted.

Twelve countries representing all six World Health Organization regions with both RRT and EMT programs have been selected for engagement.

Factors contributing to or against countries integration of RRT and EMT programs will be identified. Areas of divergence or synergy of plans and standard operating procedures will be mapped. Recommendations for strengthening global health emergency alert and response teams will be generated.

Amidst the COVID-19 pandemic, the EU-MODEX exercise had to rethink its logistics in order to promote safer environments for its participants.1

To describe the Blended EU-MODEX exercise as a method to minimize the risk of COVID-19 contagion and the role of CRIMEDIM during such innovative approach.

The first post-COVID-19 EU-MODEX exercise was performed in October 2021. To avoid travels, three EMTs from Austria, Romania, and Estonia virtually deployed in a fictious country hit by a typhoon, operated independently in their own country. The Excon worked remotely from Germany. The interoperability among the EMTs was simulated using an online tool. When a patient, simulated by a local role player, needed a transfer from the EMT1 in Romania or Austria, all clinical information were shared online and a new role player was prepared with that information to continue the simulation in Estonia. CRIMEDIM personnel located at each EMT were tasked to ensure the consistency and the quality of all the clinical cases, matching the clinical information of the incoming patient with the new role player, especially regarding the treatment received and the makeup instruction.

During the exercise, 425 clinical cases were played by the three EMTs. The exercise lasted for 60 hours and provided unique challenges due to its blended nature. No COVID-19 outbreaks were registered following the exercise.

The experience of the Blended EU-MODEX exercise showed the potentiality of the virtual simulation environment as an effective alternative to avoid secondary contagion as well as reduce costs.

In Canada, access to health care is considered a universal right, however, many Indigenous communities exist in austere settings and the major health care provided is through a nursing station. As a result, they are vulnerable to developing acute staff shortages during COVID-19 outbreaks.

Trial the effectiveness of a Nomadic Medical Assistance Team (NoMAT) to mitigate sudden staff shortages caused by a COVID-19 outbreak in a remote Indigenous community served only by a nursing station.

Indigenous Services Canada funded a pilot and NoMAT was deployed from March 13 through April 2, 2022 to a small Indigenous community in remote Northern Ontario, Canada.

The team consisted of up to seven personnel: MD, Nurse, Nurse Practitioner, Physician Assistant, Paramedic, Data Support, and Logistics. Individuals served from one-to-two weeks of a three-week deployment. If there was a shortage, the MD could be virtual. Local health resources were used and the team resided at the local school.

The NoMAT rapidly: (1) worked with the local team to co-develop outbreak management; (2) identified high-risk patients for treatment; (3) supported non-COVID-19 patient care; and (4) reduced a backlog of care.

The NoMAT strategy is highly effective and efficient in mitigating the impact of both COVID-19 surges and reducing backlogs of care. The next step is developing a proposal for full-time teams.

Simulation is an “educational method that can be applied to the training of processes, technical, and non-technical skills.” Literature underlines how simulating with the maximum realism possible improves the quality of training.

To describe the methodology used by CRIMEDIM to create a high-quality database of clinical cases to improve the realism of the EU MODEX exercises.

In 2021, CRIMEDIM created a new database of clinical cases with disaster and non-disaster-related injuries and diseases to be used for the EU MODEX exercises. Each clinical case has four temporal stages: prehospital, T0, T1, and T2, and each of them has two possible variations: Type A (improvement) and Type B (deterioration). Timing and treatments received (or not received) determine the evolution between one step and the following one. Each clinical case consists of past medical history, disaster-related history, drugs, and allergies. There are also various exams (eg, blood tests [blood count, ABG, biochemical test, coagulation], imaging [ultrasound, XR, CT], and EKG) and other clinical information. The database allows printing casualty cards, each containing instructions for role players and make-up artists.

At this moment, the database consists of 1,174 clinical cases, with the possibility to create new cases according to different disaster scenarios, training needs, and learning objectives.

According to participants’ feedback, the introduction of such an innovative and comprehensive database seemed to have improved the quality and the realism of the Medical EU MODEX.

Moral distress is a well-described phenomenon in medical providers. It has been linked to mental health deterioration, decreased job satisfaction, and early retirement. No study has been done on the level of moral distress associated with treating patients in simultaneous disasters.

1. 1. To learn what is known about the experience of moral distress in frontline health care providers during the COVID-19 pandemic and the concurrent conflict in Armenia during 2020.

2. 2. To determine how WHO EMTs can support their frontline staff experiencing moral distress.

A survey was designed to test the moral distress felt by Armenian EMS providers who had cared for both COVID-19 and war casualty patients. This was adapted from the Moral Distress Scale Revised (MDS-R).

Of the questions asked, respondents most often responded that they were disturbed by: “Continuing to participate in care for a hopelessly ill or injured person who is being sustained on a ventilator when no one will make a decision to withdraw support” (Mean 2.68/Median 3/Mode 4); and “Initiated extensive life-saving actions when I think they only prolong death” (2.47/3/3), which caused the next most distress to subjects.

It is expected that some health care workers in Armenia are likely facing on-going consequences of the moral distress they faced during this unprecedented period of global pandemic and war. Clinics and teams who are more likely to encounter potentially morally distressing events, such as disaster medicine workers, need to address their moral distress mitigation plan by identifying strategies across the continuum of disaster management.

Emerging evidence is guiding changes in prehospital management of potential spinal injuries. The majority of settings related to current recommendations are in resource-rich environments (RREs), whereas there is a lack of guidance on the provision of spinal motion restriction (SMR) in resource-scarce environments (RSEs), such as: mass-casualty incidents (MCIs); low-middle income countries; complex humanitarian emergencies; conflict zones; and prolonged transport times. The application of Translational Science (TS) in the Disaster Medicine (DM) context was used to develop this study, leading to statements that can be used in the creation of evidence-based clinical guidelines (CGs).

What is appropriate SMR in RSEs?

The first round of this modified Delphi (mD) study was a structured focus group conducted at the World Association for Disaster and Emergency Medicine (WADEM) Congress in Brisbane Australia on May 9, 2019. The result of the focus group discussion of open-ended questions produced ten statements that were added to ten statements derived from Fischer (2018) to create the second mD round questionnaire.

Academic researchers and educators, operational first responders, or first receivers of patients with suspected spinal injuries were identified to be mD experts. Experts rated their agreement with each statement on a seven-point linear numeric scale. Consensus amongst experts was defined as a standard deviation ≤1.0. Statements that were in agreement reaching consensus were included in the final report; those that were not in agreement but reached consensus were removed from further consideration. Those not reaching consensus advanced to the third mD round.

For subsequent rounds, experts were shown the mean response and their own response for each of the remaining statements and asked to reconsider their rating. As above, those that did not reach consensus advanced to the next round until consensus was reached for each statement.

Twenty-two experts agreed to participate with 19 completing the second mD round and 16 completing the third mD round. Eleven statements reached consensus. Nine statements did not reach consensus.

Experts reached consensus offering 11 statements to be incorporated into the creation of SMR CGs in RSEs. The nine statements that did not reach consensus can be further studied and potentially modified to determine if these can be considered in SMR CGs in RSEs.