To design and test a model to predict surge capacity bottlenecks at a large academic medical center in response to a mass-casualty incident (MCI) involving multiple burn victims.

Using the simulation software ProModel, a model of patient flow and anticipated resource use, according to principles of disaster management, was developed based upon historical data from the University Hospital of the University of Michigan Health System. Model inputs included: (a) age and weight distribution for casualties, and distribution of size and depth of burns; (b) rate of arrival of casualties to the hospital, and triage to ward or critical care settings; (c) eligibility for early discharge of non-MCI inpatients at time of MCI; (d) baseline occupancy of intensive care unit (ICU), surgical step-down, and ward; (e) staff availability—number of physicians, nurses, and respiratory therapists, and the expected ratio of each group to patients; (f) floor and operating room resources—anticipating the need for mechanical ventilators, burn care and surgical resources, blood products, and intravenous fluids; (g) average hospital length of stay and mortality rate for patients with inhalation injury and different size burns; and (h) average number of times that different size burns undergo surgery. Key model outputs include time to bottleneck for each limiting resource and average waiting time to hospital bed availability.

Given base-case model assumptions (including 100 mass casualties with an inter-arrival rate to the hospital of one patient every three minutes), hospital utilization is constrained within the first 120 minutes to 21 casualties, due to the limited number of beds. The first bottleneck is attributable to exhausting critical care beds, followed by floor beds. Given this limitation in number of patients, the temporal order of the ensuing bottlenecks is as follows: Lactated Ringer's solution (4 h), silver sulfadiazine/Silvadene (6 h), albumin (48 h), thrombin topical (72 h), type AB packed red blood cells (76 h), silver dressing/Acticoat (100 h), bismuth tribromophenate/Xeroform (102 h), and gauze bandage rolls/Kerlix (168 h). The following items do not precipitate a bottleneck: ventilators, topical epinephrine, staplers, foams, antimicrobial non-adherent dressing/Telfa types A, B, or O blood. Nurse, respiratory therapist, and physician staffing does not induce bottlenecks.

This model, and similar models for non-burn-related MCIs, can serve as a real-time estimation and management tool for hospital capacity in the setting of MCIs, and can inform supply decision support for disaster management.

AbirM, DavisMM, SankarP, WongAC, WangSC. Design of a Model to Predict Surge Capacity Bottlenecks for Burn Mass Casualties at a Large Academic Medical Center. Prehosp Disaster Med. 2013;28(1):1-10.

The global burden of cardiovascular mortality is increasing, as is the number of large-scale humanitarian emergencies. The interaction between these phenomena is not well understood. This review aims to clarify the relationship between humanitarian emergencies and cardiovascular morbidity and mortality.

With assistance from a research librarian, electronic databases (PubMed, Scopus, CINAHL, and Global Health) were searched in January 2014. Findings were supplemented by reviewing citations of included trials. Observational studies reporting the effect of natural disasters and conflict events on cardiovascular morbidity and mortality in adults since 1997 were included. Studies without a comparison group were not included. Double-data extraction was utilized to abstract information on acute coronary syndrome (ACS), acute decompensated heart failure (ADHF), and sudden cardiac death (SCD). Review Manager 5.0 (Version 5.2, The Nordic Cochrane Centre; Copenhagen Denmark,) was used to create figures for qualitative synthesis.

The search retrieved 1,697 unique records; 24 studies were included (17 studies of natural disasters and seven studies of conflict). These studies involved 14,583 cardiac events. All studies utilized retrospective designs: four were population-based, 15 were single-center, and five were multicenter studies. Twenty-three studies utilized historical controls in the primary analysis, and one utilized primarily geographical controls.

Conflicts are associated with an increase in long-term morbidity from ACS; the short-term effects of conflict vary by study. Natural disasters exhibit heterogeneous effects, including increased occurrence of ACS, ADHF, and SCD.

In certain settings, humanitarian emergencies are associated with increased cardiac morbidity and mortality that may persist for years following the event. Humanitarian aid organizations should consider morbidity from noncommunicable disease when planning relief and recuperation projects.

HaymanKG, SharmaD, WardlowRDII, SinghS. Burden of Cardiovascular Morbidity and Mortality Following Humanitarian Emergencies: A Systematic Literature Review. Prehosp Disaster Med. 2015;30(1):1-9.

In a cold, wet, or windy environment, cold exposure can be considerable for an injured or ill person. The subsequent autonomous stress response initially will increase circulatory and respiratory demands, and as body core temperature declines, the patient's condition might deteriorate. Therefore, the application of adequate insulation to reduce cold exposure and prevent body core cooling is an important part of prehospital primary care, but recommendations for what should be used in the field mostly depend on tradition and experience, not on scientific evidence.

The objective of this study was to evaluate the thermal insulation properties in different wind conditions of 12 different blankets and rescue bags commonly used by prehospital rescue and ambulance services.

The thermal manikin and the selected insulation ensembles were setup inside a climatic chamber in accordance to the modified European Standard for assessing requirements of sleeping bags. Fans were adjusted to provide low (< 0.5 m/s), moderate (2–3 m/s) and high (8–9 m/s) wind condi-tions. During steady state thermal transfer, the total resultant insulation value, Itr (m2 °C/Wclo; where °C = degrees Celcius, and W = watts), was calculated from ambient air temperature (°C), manikin surface temperature (°C), and heat flux (W/m2).

In the low wind condition, thermal insulation of the evaluated ensembles correlated to thickness of the ensembles, ranging from 2.0 to 6.0 clo (1 clo = 0.155 m2 °C/W), except for the reflective metallic foil blankets that had higher values than expected. In moderate and high wind conditions, thermal insulation was best preserved for ensembles that were windproof and resistant to the compressive effect of the wind, with insulation reductions down to about 60–80% of the original insulation capacity, whereas wind permeable and/or lighter materials were reduced down to about 30–50% of original insulation capacity.

The evaluated insulation ensembles might all be used for prehospital protection against cold, either as single blankets or in multiple layer combinations, depending on ambient temperatures. However, with extended outdoor, on-scene durations, such as during prolonged extrications or in mul-tiple casualty situations, the results of this study emphasize the importance of using a windproof and compression resistant outer ensemble to maintain adequate insulation capacity.

The human impact of the tsunami that occurred on 26 December 2004 was enormous, with Indonesia bearing a huge proportion of the losses. The aftermath brought predictions of communicable disease outbreaks and widespread fear of epidemics. However, evidence from previous disasters due to natural hazards does not support all of these predictions. The objectives of this study were to: (1) describe the relative importance of infectious diseases and injuries as a consequence of a disaster due to natural hazards; and (2) identify key recommendations for the improvement of control and surveillance of these diseases during and after disasters.

A team from the Center for Research on the Epidemiology of Disasters visited Jakarta and Banda Aceh from 11–23 January 2005, and collected data from the Central and Provincial Ministries of Health (MOH), the World Health Organization (WHO), and a field hospital from the International Committee of the Red Cross in Banda Aceh. The epidemiological profiles of diseases before and after the tsunami were compared. Cholera, tetanus, wounds and wound infections, acute respiratory infections, malaria, and dengue were included in this analysis.

Certain diseases (e.g., cholera, malaria, dengue) are not always an immediate priority post-disaster. Rates of disaster-related health conditions requiring emergency response fell by half, and became negligible around four weeks after the precipitating events. Some conditions, such as aspiration pneumonia and tetanus, which normally are rare, require special preparedness for emergency personnel. In addition, resistant and rare pathogens are associated with disasters due to natural hazards in the tropics and require specialized knowledge for the rapid and successful treatment of related infections.

Within the first four weeks of a disaster, international humanitarian agencies in the health sector should start working with the MOH. The WHO surveillance system established immediately after the tsunami offers lessons for developing a prototype for future emergencies. Guidelines for tetanus and aspiration pneumonia should be included in disaster medicine handbooks, and humanitarian aid groups should be prepared to provide emergency obstetrics and post-natal services. Relief funding after naturally occurring disasters should consider funding sustainability. Donors should know when to stop providing emergency relief funds and transition to recovery/development strategies.

Health care institutions constantly must be prepared for disaster response. However, there are deficiencies in the current level of preparedness. The aim of this study was to investigate the factors affecting the perception of health care workers (HCWs) towards individual and institutional preparedness for a disaster.

A survey on disaster incident preparedness was conducted among doctors, nurses, and allied health workers over a period of two months in 2010. The survey investigated perceptions of disaster preparedness at the individual and institutional level. Responses were measured using a five-point Likert scale. The primary outcomes were factors affecting HCWs’ perception of institution and individual preparedness. Secondary outcomes were the proportions of staff willing to participate and to place importance on disaster response training and their knowledge of access to such training. Data was analyzed using descriptive statistics. Logistic regression was performed to determine the factors that influenced the HCWs’ perception of their individual and institutional readiness. Odd ratios (ORs) of such factors were reported with their 95% confidence intervals (CIs).

Of 1700 HCWs, 1534 (90.2%) completed the survey. 75.3% (1155/1534) felt that the institution was ready for a disaster incident, but only 36.4% (558/1534) felt that they (as individuals) were prepared. Some important factors associated with a positive perception of institution preparedness were leadership preparedness (OR = 13.19; 95% CI, 9.93-17.51), peer preparedness (OR = 6.11; 95% CI, 4.27-8.73) and availability of training opportunities (OR = 4.76; 95% CI, 3.65-6.22). Some important factors associated with a positive perception of individual preparedness were prior experience in disaster response (OR = 2.80; 95% CI, 1.99-3.93), institution preparedness (OR = 3.71; 95% CI, 2.68-5.14), peer preparedness (OR = 3.49; 95% CI, 2.75-4.26), previous training in disaster response (OR = 3.48; 95% CI, 2.76-4.39) and family support (OR = 3.22; 95% CI, 2.54-4.07). Most (80.7%, 1238/1534) were willing to participate in future disaster incident response training, while 74.5% (1143/1534) felt that being able to respond to a disaster incident constitutes part of their professional competency. However, only 27.8% (426/1534) knew how to access these training opportunities.

This study demonstrated that HCWs fare poorly in their perception of their individual preparedness. Important factors that might contribute to improving this perception at the individual and institution level have been identified. These factors could guide the review and implementation of future disaster incident response training in health care institutions.

LimGH, LimBL, VasuA. Survey of Factors Affecting Health Care Workers’ Perception Towards Institutional and Individual Disaster Preparedness. Prehosp Disaster Med. 2013;28(4):1-6.

At 08:53 hours on 26 January 2001, an earthquake measuring 6.9 on the Richter scale devastated a large, drought-affected area of northwestern India, the state of Gujarat. The known number killed by the earthquake is 20,005, with 166,000 injured, of whom 20,717 were “seriously” injured. About 370,000 houses were destroyed, and another 922,000 were damaged.

A community health worker using the local language interviewed all of the patients admitted to the Gandhi-Lincoln hospital with an on-site, oral, real-time, Victim Specific Questionnaire (VSQ).

The census showed a predominance of women, children, and young adults, with the average age being 28 years. The majority of the patients had other family members who were also injured (84%), but most had not experienced deaths among family members (86%). Most of the patients (91%) had traveled more than 200 kilometers using their family cars, pick-ups, trucks, or buses to reach the buffer zone hospitals. The daily hospital admission rate returned to pre-event levels five days after the event, and all of the hospital services were restored by nine days after the quake. Most of the patients (83%) received definitive treatment in the buffer zone hospitals; 7% were referred to tertiary-care centers; and 9% took discharge against medical advice.

The entrapped village folk with their traditional architecture had lesser injuries and a higher rescue rate than did the semi-urban townspeople, who were trapped in collapsed concrete masonry buildings and narrow alleys. However, at the time of crisis, aware townspeople were able to tap the available health resources better than were the poor. There was a low incidence of crush injuries. Volunteer doctors from various backgrounds teamed up to meet the medical crisis. International relief agencies working through local groups were more effective. Local relief groups needed to coordinate better. Disaster tourism by various well-meaning agencies took a toll on the providers. Many surgeries may have contributed to subsequent morbidity.

The injury profile was similar to that reported for most other daytime earthquakes. Buffer zone treatment outcomes were better than were the field and damaged hospital outcomes.

Road traffic collisions are a common cause of injuries and injury-related deaths in sub-Saharan Africa (SSA). Basic prehospital care can be the difference between life and death for injured drivers, passengers, and pedestrians.

This study examined the challenges associated with current first response practices in Malawi.

In April 2014, focus groups were conducted in two areas of Malawi: Karonga (in the Northern Region) and Blantyre (in the Southern Region; both are along the M1 highway), and a qualitative synthesis approach was used to identify themes. All governmental and nongovernmental first response organizations identified by key informants were contacted, and a checklist was used to identify the services they offer.

Access to professional prehospital care in Malawi is almost nonexistent, aside from a few city fire departments and private ambulance services. Rapid transportation to a hospital is usually the primary goal of roadside care because of limited first aid knowledge and a lack of access to basic safety equipment. The key informants recommended: expanding community-based first aid training; emphasizing umunthu (shared humanity) to inspire bystander involvement in roadside care; empowering local leaders to coordinate on-site responses; improving emergency communication systems; equipping traffic police with road safety gear; and expanding access to ambulance services.

Prehospital care in Malawi would be improved by the creation of a formal network of community leaders, police, commercial drivers, and other lay volunteers who are trained in basic first aid and are equipped to respond to crash sites to provide roadside care to trauma patients and prepare them for safe transport to hospitals.

ChokothoL, MulwafuW, SinginiI, NjalaleY, Maliwichi-SenganimalunjeL, JacobsenKH. First Responders and Prehospital Care for Road Traffic Injuries in Malawi. Prehosp Disaster Med. 2017;32(1):14–19.

Current research of moral distress is mainly derived from challenges within high-resource health care settings, and there is lack of clarity among the different definitions. Disaster responders are prone to a range of moral challenges during the work, which may give rise to moral distress. Further, organizations have considered increased drop-out rates and sick leaves among disaster responders as consequences of moral distress. Therefore, initiatives have been taken to address and understand the impacts of moral distress and its consequences for responders. Since there is unclarity among the different definitions, a first step is to understand the concept of moral distress and its interlinkages within the literature related to disaster responders.

To examine how disaster responders are affected by moral challenges, systematic knowledge is needed about the concepts related to moral distress. This paper aims to elucidate how the concept of moral distress in disaster response is defined and explained in the literature.

The paper opted to systematically map the existing literature through the methods of a scoping review. The searches derived documents which were screened regarding specific inclusion criteria. The included 16 documents were analyzed and collated according to their definitions of moral distress or according to their descriptions of moral distress.

The paper provides clarity among the different concepts and definitions of moral distress within disaster response. Several concepts exist that describe the outcomes of morally challenging situations, centering on situations when individuals are prevented from acting in accordance with their moral values. Their specific differences suggest that to achieve greater clarity in future work, moral stress and moral distress should be distinguished.

Based on the findings, a conceptual model of the development of moral distress was developed, which displays a manifestation of moral distress with the interplay between the responder and the context. The overview of the different concepts in this model can facilitate future research and be used to illuminate how the concepts are interrelated.

Previous oil spills and disasters from other human-made events have shown that mental health effects to the affected population are widespread and can be significant.

There has been concern regarding the likelihood that existing public health surveillance was not capturing the mental health effects to the population affected by the Gulf Coast oil spill. The objectives of this study were to assess the mental health needs of coastal communities in the states of Alabama and Mississippi following the Deepwater Horizon oil spill.

A cluster sampling methodology was used to assess the mental health status of coastal residents in three counties in Alabama four months following the 2010 Deepwater Horizon oil spill, and in the Gulf Coast counties in Mississippi 5.5 months after the oil spill.

A total of 469 residents of the selected areas were interviewed. Between 15.4 and 24.5% of the respondents reported depressive symptoms, with 21.4-31.5% reporting symptoms consistent with an anxiety disorder, and 16.3-22.8% reporting ≥14 mentally unhealthy days within the past 30 days. Overall, there were more negative quality of life indicators and negative social context outcomes than in the state's Behavioral Risk Factor Surveillance System (BRFSS) survey. Between 32.1% and 35.7% of all households reported decreased income since the oil spill, and 35.5-38.2% of all households reported having been exposed to oil.

The proportion of respondents reporting negative mental health parameters in the affected Alabama and Mississippi coastal communities is higher than the proportion reported in the 2008 and 2009 BRFSS state reports, suggesting that the public health response to the Deepwater Horizon oil spill should focus on mental health services in these communities.

ButtkeD , VagiS , BayleyegnT , SircarK , StrineT , MorrisonM , AllenM , WolkinA . Mental Health Needs Assessment After the Gulf Coast Oil Spill—Alabama and Mississippi, 2010. Prehosp Disaster Med.2012;27(5):1-8.

In Latin America, there is a preponderance of prehospital trauma deaths. However, scarce resources mandate that any improvements in prehospital medical care must be cost-effective. This study sought to evaluate the costeffectiveness of several approaches to improving training for personnel in three ambulance services in Mexico.

In Monterrey, training was augmented with PreHospital Trauma Life Support (PHTLS) at a cost of [US]$150 per medic trained. In San Pedro, training was augmented with Basic Trauma Life Support (BTLS), Advanced Cardiac Life Support (ACLS), and a locally designed airway management course, at a cost of $400 per medic. Process and outcome of trauma care were assessed before and after the training of these medics and at a control site.

The training was effective for both intervention services, with increases in basic airway maneuvers for patients in respiratory distress in Monterrey (16% before versus 39% after) and San Pedro (14% versus 64%). The role of endotrachal intubation for patients with respiratory distress increased only in San Pedro (5% versus 46%), in which the most intensive Advanced Life Support (ALS) training had been provided. However, mortality decreased only in Monterrey, where it had been the highest (8.2% before versus 4.7% after) and where the simplest and lowest cost interventions were implemented. There was no change in process or outcome in the control site.

This study highlights the importance of assuring uniform, basic training for all prehospital providers. This is a more cost-effective approach than is higher-cost ALS training for improving prehospital trauma care in environments such as Latin America.

Emergency response relies on the assumption that essential health care services will continue to operate and be available to provide quality patient care during and after a patient surge. The observed successes and failures of health care systems during recent mass-casualty events and the concern that these assumptions are not evidence based prompted this review.

The aims of this systematic review were to explore the factors associated with the intention of health care personnel (HCP) to respond to uncommon events, such as a natural disaster or pandemic, determine the state of the science, and bolster evidence-based measures that have been shown to facilitate staff response.

Authors of the 70 studies (five mixed-methods, 49 quantitative, 16 qualitative) that met inclusion criteria reported a variety of variables that influenced the intent of HCP to respond. Current evidence suggests that four primary factors emerged as either facilitating or hindering the willingness of HCP to respond to an event: (1) the nature of the event; (2) competing obligations; (3) the work environment and climate; and (4) the relationship between knowledge and perceptions of efficacy.

Findings of this study could influence and strengthen policy making by emergency response planners, staffing coordinators, health educators, and health system administrators.

ConnorSB . When and Why Health Care Personnel Respond to a Disaster: The State of the Science. Prehosp Disaster Med. 2014;29(3):1-5.

The blackout in North America of August 2003 was one of the worst on record. It affected eight United States states and parts of Canada for >24 hours. Additionally, two large United States cities, Detroit, Michigan and Cleveland, Ohio, suffered from a loss of water pressure and a subsequent ban on the use of public supplies of potable water that lasted four days. A literature review revealed a paucity of literature that describes blackouts and how they may affect the medical community.

This paper includes a review of after-action reports from four inner-city, urban hospitals supplemented accounts from the authors' hospital's emergency operations center (emergency operations center).

Some of the problems encountered, included: (1)lighting; (2) elevator operations; (3) supplies of water; (4) communication operations; (5) computer failure; (6) lack of adequate supplies of food; (7) mobility to obtain Xray studies; (8) heating, air condition, and ventilation; (9) staffing; (10) pharmacy; (11) registration of patients; (12) hospital emergency operations center; (13) loss of isolation facilities; (14) inadequate supplies of paper; (15) impaired ability to provide care for non-emergency patients; (16) sanitation; and (17) inadequate emergency power.

The blackout of 2003 uncovered problems within the United States hospital system, ranging from staffing to generator coverage. This report is a review of the effects that the blackout and water ban of 2003 had on hospitals in a large inner-city area. Also discussed are solutions utilized at the time and recommendations for the future.

The blackout of 2003 was an excellent test of disaster/emergency planning, and produced many valuable lessons to be used in future events.