Complex emergencies (conflicts or disasters caused by natural events) do not recognize borders. The connection between conflict and trauma regarding psychosocial development and well being has long been established as emergencies expose and exacerbate existing individual and societal problems.

An extensive literature search, including nongovernmental organizations'“grey” literature, was performed. Articles were analyzed for key contributions, available programs, and mental health measurement indicators.

Analysis revealed that the emergency mental health services are not integrated into emergency relief response and/or are insufficient. Provision of early mental health interventions reduces the burden on a country's health facilities and/or relief responses. In order to achieve integrated physical and mental health services (a key World Hearth Organization goal) alternative strategies are proposed.

Establishing a referral network among relief organizations stimulates collaboration and sharing of best practices. The recent publication of the Inter-Agency Standing Committee (IASC) Guidelines offers concrete strategies for ensuring that emergency care is effective, inclusive, and culturally appropriate. Training relief workers in the use of psychological first aid and mental health needs assessments provides opportunities to raise awareness about these guidelines. The training sessions reinforces cooperation established by the referral network. With greater appreciation of the necessity to integrate emergency mental health services, relief workers become advocates for change within their own organizations, and together, within the political arena. With concrete guidelines to assist them in articulating specific funding priorities to politicians and measurement indicators to ensure accountability, advocating for changes will be more meaningful and persuasive.

In recent years, the number of the relief efforts has increased, especially after the Marmara and Duzce Earthquakes that occurred in Turkey in 1999. The plight of the relief workers during and after disasters has been a main point of focus in Ministry of Health (MoH) and one of the major fields in disaster management.

A questionnaire was developed pertaining to demographic information; range of relief workers'numbers, professions, training experience, and working experience in a disaster; stress factors and symptoms; self-help strategies during the disaster work; and the motivation sources of being a relief worker. This questionnaire was distrubuted to 551 medical rescue workers that participated in the 3rd National Medical Rescue Training and Practicing Programme held in Bursa, Turkey in 2007.

All the data were analyzed using SPSS Pocket Programme 11.5. The results showed that the ability to train and work under stress are the basic factors of being an adequate relief worker. The major stress factors are taking extreme risks and being an eyewitness to the death or injury of a relief worker.

A supportive approach for relief workers should be a main component of disaster management. Identifying the expectations of relief workers is extremely important for effectively working in disaster area.

To demonstrate features of the mental health care during the acute phase of a disaster due to natural hazards in Japan. This report will discuss issues in devastated area of Chuetsu in Niigata Prefecture after an offshore earthquake.

The earthquake of 16 July 2007 had a magnitude 6.8. It injured 2,153 people, including 192 with severe injuries, and caused 14 deaths. The Tokyo Medical Association (TMA) deployed disaster medical relief teams on the day of the event, and performed mental care in internally displaced person (IDP) camps. Other mental care teams took over the mission three days after the event.

There were 27 medical teams was 27. They visited 88 IDP camps. Medical teams treated 2,288 cases during first four days. Forty-seven cases included psychiatric problems. Three of 13 refugees who had psychiatric symptoms needed new mediane. Four were under psychiatric treatment and could continue their treatment with their attending physicians.

Earthquake victims displayed the following characteristics during the acute phase: (1) poor adaptation in the elderly; (2) fluctuation of compliance for medications; (3) occult anxiety and complaints; and (4) unconsciousness of sleep disturbance.

The development and education of liaison methods about mental health care during the acute phase of a disaster is needed for emergency physicians and general surgeons of Disaster Medical Assistance Team and Medical Association relief teams that perform treatment during the acute phase of disaster. They must understand and have skills for triage of different mental health cases.

Vital signs (VS) data collected in prehospital care and recorded in trauma registries are often missing or unreliable as it is difficult to record dynamic changes while performing resuscitation and stabilization. The purpose of this study was to test the hypothesis that analysis of continuous vital signs improves data quality, and predicts life-saving interventions (LSI) better than use of retrospectively compiled Trauma Registry (TR) data.

After Institutional Review Board approval, six emergency medical services helicopters were equipped with a Vital Signs Data Recorder (VSDR) to capture continuous VS from the patient onto a handheld personal digital assistant (PDA). Prehospital LSIs (fluid bolus, cardiopul-monary resuscitation, drugs, intubation, etc.) and those performed within two hours after arrival in the trauma resuscitation unit were considered outcome variables. The VSDR and TR data were compared using Bland-Altman method. A multivariate analysis was performed to determine which VS variable best predicted LSIs using the values in the TR and the VSDR.

Prehospital VSDR data were collected from 177 patients. There was a significant difference between the highest and lowest heart rate, systolic blood pressure (SBP), and oxygen saturation between the VSDR and the TR data (p <0.001).The VSDR highest heart rate and lowest oxygen saturation recorded predicted LSIs while none of the TR vital signs did so in a multivariate model. The SBP was not an independent predictor of LSI.

The VSDR data increased the odds of predicting LSIs compared to the TR data. Using continuous vital signs in prehospital care may lead to the development of better trauma prognostic models.

Triage is an effective method to streamline patient flow and shorten the delay for definitive care. We studied the effects of shift duties and patient volume on triage.

Patients presenting to the emergency department were tagged with a red, yellow, or green wristband as per the Simple Triage and Rapid Treatment (START) protocol. A mass-casualty incident (MCI) was defined as ≥7 red patients or ≥20 patients at one time. The data was analyzed using SPSS version 10.

Out of 25,928 patients, triage was performed for 25,468 (98.2%); 8,390 (32.3%) presented during the morning shift (08:00–14:00 hours), 7,119 (27.5%) during the evening shift (14:00–20:00 h); and 10,185 (39.2%) during the night shift (20:00–08:00 h). Of the patients, 8,303 were triaged during the morning shift, 6,994 during the evening shift, and 9,978 during the night shift. Of the subjects, 1,431 (5.6%) were tagged red, 10,634 (41.7%) with yellow, and 13,424 (52.7%) were tagged green. Of the patients, 694 (2.7%) were retriaged. During the morning shift, 327 were tagged as red, 3,512 as yellow, and 4,465 as green, and 243 were retriaged. During the evening shift, 383 were tagged as red, 2,918 as yellow, and 3,685 as green, and 194 were retriage. During the night shift, 705 patients were tagged as red, 4,116 as yellow, and 5,165 as green. Sixteen MCIs occurred during the night shift, four during the morning shift, and one during the evening. Total numbers of patients presented during a MCI were 1,227. Of these, 102 were tagged as red, 463 as yellow, and 642 as green, and 79 were re-triaged.

High patient volume during the night shift hampers triage during peace time and MCIs.

A multi-disciplinary team was formed to review the Department of Emergency Medicine process in Singapore.

The team set the current Department of Emergency Medicine performance as the baseline, and after analysis, met with management and agreed to work toward three main objectives: (1) reducing patient waiting time; (2) improving the staffing and workload; and (3) improving key patient concerns by reducing the number of steps in the process and increasing communication. A patient and information flow analysis chart was mapped to scrutinize the entire process and to identify opportunities for improvement. Triage before registration was identified as one of the key initiatives. This eliminates the need to register and wait before the first point of clinical contact (triage). Visits were made to other hospitals to gain fresh insights and current literature was studied to learn more about worldwide trends and improvements. Weekly meetings were held to craft the implementation plan. Presentations were made to the Department of Emergency Medicine staff and management to get feedback and buy-in.

Triage before registration would reduce the waiting time by approximately seven minutes for each patient (with potential for further savings with the streamlining of the triage process). Resuscitation and critical care patients who require more expeditious treatment also will be identified earlier, leading to a better clinical outcome. Triage before registration also results in patients that are seen earlier by a staff nurse who can order tests and treatment as the patient waits for consultation. The empowerment of nurses to initiate more tests and treatment before consultation will improve patient experience and reduce downstream delays. The Patient Care Assistant at the test/treatment station will reduce the workload of the triage nurse conducting additional tests and speed up the triage process. Patient flow is streamlined and congestion at the waiting area is reduced.

Triage before registration significantly reduces overall waiting time and improves patient experience.

Triage in emergency departments is performed by nurses. In recent years, hospital triage has developed in Iran, and few studies have addressed nurses' competency in triage. Objective: The objective of this study was to assess the knowledge of nurses about triage in hospitals of Sistan-va-Balouchestan state in Iran.

A survey was conducted among nurses in emergency departments (n = 10). The questionnaire was composed of factual knowledge questions about triage (n = 15) and triage decision-making questions (n = 10). Seventy nurses working in hospitals in Sistan-va-Balouchestan state participated. The questionnaire reliability was 0.60 using the test-re-test method. Content validity was considered based on Canadian Triage and Acuity Scale.

The response rate was 68% (70/102). Nurses proved to be unfamiliar with triage. Only 28% of their responses were correct. Only three emergency departments have specified special nurses to perform triage. Inter-rater agreement between nurses for all was r = 0.56 and for each nurse was r = 0.12.

Emergency departments were not committed to a valid, reliable triage scale. Specialized education about hospital triage with a new approach is recommended. Further research on emergency department triage scales, standards, and guidelines is recommended.

Mass-casualty triage is a critical skill. The are any systems exist to guide providers in making triage decisions, however, there is little scientific literature to validate current systems. There are no internationally agreed upon categories or color. The lack of standardization in triage can lead to confusion.

An expert panel reviewed existing triage systems. Each member was assigned a triage system and asked to conduct an exhaustive literature review and Internet search and to develop a report to the panel. Each system had two or more members assigned to conduct a review.

The committee identified nine existing mass casualty triage systems, including two pediatric-specific systems. The systems were noted to be similar in naming and color representations, but differed on the inclusion of an expectant category. Studies that compared the various mass casualty triage systems and found that the ability to obey commands and systolic blood pressure were the best predictors were identified.

The committee concluded that no one system could be embraced as a validated system. The committee decided to use the best available scientific information and consensus opinion to develop a system that could serve as a proposed national guideline. The group discussed each component until consensus was reached. The guideline incorporates pieces of most existing triage systems; it was given the name SALT Triage (sort, assess, lifesaving interventions, and treatment and/or transport). This guideline is intended for use on-scene in all-hazards events for both adults and children.

The objective of this study was to determine providers' opinions of SALT Triage after receiving training and using it during a simulated mass-casualty incident.

A survey was conducted of trainees in a disaster course. Trainees were given a-30 minute lecture on SALT (sort, assess, life-saving interventions, treatment and/or transport) Triage and then used it during a drill. After the drill, trainees were asked to complete the survey. Results were analyzed using descriptive statistics.

Thirty trainees (11 medical doctors (MDs), six registered nurses (RNs), eight emergency medical technicians (EMTs), one RN/EMTs, four other) participated in the course. Of these participants, 67% had prior drill experience (mean: 10 drills) and 37% had prior mass-casualty incident experience (mean: four experiences). Prior to the drill: 7% reported that they felt very confident using SALT Triage, 33% were confident, 30% were somewhat confident, and 30% were not confident. After the drill: none reported not feeling confident using SALT Triage, 27% were at the same level of confidence, 73% felt more confident, and none felt less confident. Before the drill: 52% of respondents felt SALT Triage was easier to use than their current disaster triage protocol, 44% felt it was similar, and 4% felt it was more difficult. After the drill: 67% did not change how easy they felt SALT Triage was to use, 26% thought it was easier to use, and 3% thought it was similar.

Providers felt confident using SALT triage after a 30-minute training session and found it was similar or easier to use than their current triage protocol. Using SALT Triage during a drill improved confidence.

Triage criteria rely on physiologic, anatomic, and mechanistic indicators of injury to minimize over-triage and under-triage, which remain persistendy high (35%—65%). The Visensia Index Score (VIS) is a proprietary algorithm in a bedside monitor (OBS Medical, IN) mat integrates five vital signs: (1) heart rate; (2) respiratory rate; (3) blood pressure; (4) pulse oximetry; and (5) temperature. It calculates a score ranging from 1 (no abnormality) to 5 (severe abnormalities). The aim of this study was to explore the utility of VIS in identifying trauma patients likely to have a poor prognosis on arrival to the emergency departments.

After Institutional Review Board approval, the trauma registry was used to review 117 patients admitted to a Level-1 Trauma Center over a six month period. The first set of vital signs was obtained upon arrival to the emergency department. An initial VIS and a mean VIS (based on multiple VS) was calculated. The analysis included a multivariate mathematical technique and k-means cluster analysis. Clusters of populations with different Visensia scores were compared and differences in their outcomes were analyzed.

Two major clusters were identified: VIS Scores >3 increased the risk of mortality as compared to those with scores <3; odds ratio 3.3 [1.04–10.3; p <0.001). There was no association with length of intensive care unit stay, hospital days; or Injury Severity Scale (ISS) scores.

Cluster analysis, a novel multidimensional approach, shows association of a higher VIS (>3) as a useful point-of-care parameter to identify trauma patients likely to have a poorer prognosis, much more than retrospectively computed ISS and Trauma and Injury Severity Scores (TRISS).

The Sacco Triage Method (STM) is a mathematical model of resource-constrained triage. The objective of this presentation is to apply STM-Age, an age-augmented version of STM, to blunt trauma victims and compare it to Simple Triage and Rapid Treatment (START) and START-like protocols.

The objective of STM is to maximize the number of expected survivors given constraints on the timing and availability of resources. The STM incorporates estimates of time-dependent victim survival probabilities based on an initial assessment and expected deteriorations.

For the STM-Age application, an “RPM-Age” score (based on respiratory rate, pulse rate, best motor response, and coded age) was used to estimate survival probability. Logistic function-generated survival probability estimates for RPM-Age values were determined from 76,444 patients with blunt injuries from the Pennsylvania Trauma Outcome Study. The Delphi Method provided expert consensus on victim deterioration rates, and the model was solved using linear programming.

The STM-Age was compared to START and START-like methods with respect to process and to outcome, as measured by expected number of survivors, in simulated resource-constrained casualty incidents.

The RPM-Age was a more accurate predictor of survivability for blunt trauma than RPM, as measured by calibration and discrimination statistics. In simulations, STM-Age exhibited substantially more expected survivors than START and START-like protocols.

Resource-constrained triage is modeled precisely as an evidence-based, outcome-driven method (STM-Age) that maximizes expected survivors in consideration of resources. The STM-Age offers life-saving and operational advantages over current methods.

The objective of this study was to compare the operational viability and performance of the Sacco Triage Method (STM) to that of the Simple Triage and Rapid Treatment (START) protocol.

Following a 20-minute review of the mandated START protocol and a 20-minute training session of STM, parallel disaster exercises were conducted. Emergency responded used START in the morning and STM in the afternoon on a simulated building collapse involving 99 victims. Data were collected on the accuracy of patient assessment (START) and scoring (STM), the timeliness in clearing the scene, and me prioritization of patients leaving the scene.

The STM scoring was more accurate than START assessments at 91.7% and 71.0%, respectively. The time to clear the scene was 16% less using STM than START (53 minutes and 63 minutes, respectively). The 13 most seriously injured patients left the scene in the first seven ambulances using STM; while only two of the 13 most seriously injured patients left the scene in the first 13 ambulances under START, and the three most serious patients were transported by bus. Surveyed providers preferred START to STM and believed it to be more accurate, faster, and better able to identify the most serious patients.

Emergency responders did not implement START successfully Despite refresher training and 12 years of using START as their statewide protocol, tagging was inaccurate and patient prioritization was poor. In comparison, STM was implemented after 20 minutes of introductory training, was shown to be operationally viable, and outperformed START in all objectives.