Accidental hypothermia remains an important contributory factor to the mortality of trauma patients in both civilian and military environments. As a component of the ‘lethal triad’ it poses a significant problem in patients at risk of hemorrhage from traumatic injuries. Systems used to mitigate hypothermia in the prehospital environment must strike a balance between weight: size ratio and optimal performance.

This study compared three hypothermia mitigation systems; two leading products and the novel Xtract™SR Heatsaver, over a three-day trial period. Seven subjects were placed in a closed system, held at around 0°C, to promote the onset of mild hypothermia. Individuals with a tympanic temperature recording of < or = 35°C were placed into one of the three systems. Recordings of aural temperature and a numerical perceived comfort score were made every 15-20 minutes to assess rate of rewarming and subject’s perceptions of the process. An additional study was carried out by an experienced consultant in military and civilian emergency medicine, on day three of the trial, to determine the ease of clinical assessment of individuals placed inside the Xtract™SR Heatsaver prototype.

On all three days, subjects placed in the Xtract™SR Heatsaver recovered from their hypothermic state faster than those placed in the other systems. Clinical assessment could easily be performed on a patient placed in the Xtract™SR Heatsaver system.

Results demonstrate that the new Xtract™SR Heatsaver system is superior with regards to reducing heat loss, increasing patient comfort and allowing for clinical assessment. The study also highlights the importance of the use of adjuncts such as heat cell blankets and insulation matts alongside hypothermia mitigation systems deployed in the prehospital environment. Furthermore, data gathered provides scope for future research into nuances surrounding the effects and onset of hypothermia.

Ambulatory care sensitive conditions (ACSCs) are health conditions for which appropriate primary care intervention could prevent hospital admission. ACSC hospitalization rates are a well established parameter for assessing the performance of primary health care (PHC). Although this indicator has been extensively used to monitor the performance of PHC systems in peacetime, its consideration during disasters has been neglected. The World Health Organization (WHO) has acknowledged the importance of PHC in guaranteeing continuity of care during and after a disaster for avoiding negative health outcomes.

A systematic review was conducted to evaluate the extent and nature of research activity on the use of ACSCs during disasters, with an eye toward finding innovative ways to assess the level of PHC function at times of crisis. Online databases were searched to identify papers.

A final list of nine publications was retrieved. The analysis of the reviewed articles confirmed that ACSCs can serve as a useful indicator of PHC performance during disasters, with several caveats that must be considered.

The reviewed articles cover several disaster scenarios and a wide variety of methodologies showing the connection between ACSCs and health system performance. The strengths and weaknesses of using different methodologies are explored and recommendations are given for using ACSCs to assess PHC performance during disasters.

Emergency Medicine (EM) physicians are crucial members of the disaster medical response. In Singapore, the EM residency program spans five years, with junior residents (JRs) progressing to senior residents (SRs) in three years after passing the MRCEM exam or its local equivalent. This study aims to assess the knowledge, attitudes and perceptions toward disaster medicine among EM residents in Singapore.

A cross-sectional study was performed for 90 EM residents for the academic year 2020/2021. A self-administered, 44-item online questionnaire based on the Emergency Preparedness Information Questionnaire (EPIQ) was delivered via GoogleForms™. This assessed familiarity through 10 dimensions, with a minimal score of one and a maximal score of five. The survey also included questions on attitudes towards emergency preparedness and preferred learning methods. Data was collected from May 2020 to November 2020, and analyzed with SPSS.

The response rate was 41%. Of these, 75% were JRs and 25% SRs. The overall mean familiarity with disaster preparedness was 2.43 ± 0.90. There was no statistically significant difference of overall mean familiarity between JRs and SRs. Overall, they fared best in the dimension on isolation & quarantine with a mean score of 2.91 ±1.05 and worst in the dimension on psychological issues with a mean score of 2.34 ±0.95.

Residents felt that disaster medicine was relevant to their practice with a mean score of 4.22 ± 0.98. They also felt that it was necessary to learn more about it, with a mean score of 4.16 ±0.90. The highest ranked preferred learning method was workshop/simulation training (45.5%), followed by lectures (23.4%).

EM Residents have a poor overall familiarity with emergency preparedness, however, they recognized its importance and relevance. The preferred formats of learning were simulation/workshop training. More must be done to improve the overall competency of EM residents in disaster medical response.

Civilians constitute a significant wartime target, and trauma accounts for most of their injuries. Air raid sirens have long been used to alert civilians of incoming attacks and have since expanded to warn of natural disasters. Sirens are known to cause significant emotional distress and physiological changes. Injuries inflicted from trauma during a run for shelter have yet to be described in the medical literature.

During the recent Israel-Gaza conflict of May 2021, most of Israel's population experienced rocket warning sirens. We collected all adult patients arriving at a major tertiary medical center emergency department (ED), attesting to having suffered their injury while running for shelter. Clinical and demographic data were retrieved and analyzed.

A total of 48 patients were identified, with a mean age of 59.6±20.0. Ten (21%) patients were admitted, and their mean length of stay was 4.4±3.7 days. Women had a higher probability of being hospitalized (42.9% vs. 5.9%, p=0.04), and those hospitalized tended to be older (68.8±16.4 vs. 54.8±20.8, p=0.06). Extremity injuries were most common (50%), before head trauma (29%), and torso injuries (25%). Most patients (38/48, 79.2%) were discharged from the ED, and the rest were hospitalized for observation or surgery. One patient died from a head injury.

This study implies that injuries while running for shelter were the most significant cause of physical injury to Israeli civilians during the Israel-Gaza 2021 conflict. Warning siren injuries should be given appropriate attention from prevention by directed media campaigns to post-conflict reimbursement.

On August 29, 2021 Hurricane Ida struck New Orleans with Category 4 winds. While the most severe weather occurred during a 24-hr period on August 29, the city suffered significant damage to telecommunication systems, medical facilities, and infrastructure for several weeks afterward. At the height of the storm, multiple events affected routine deployment of EMS, including damage to transmission lines causing interruption of the 911 system, and suspension of ambulance travel for safety when the winds exceeded 50 mph. These factors, as well as pre-storm preparations, affected utilization of EMS by residents and thus a “peri-hurricane” period was examined to determine the overall effect of Hurricane Ida on New Orleans EMS operations.

Run sheets for calls to NOEMS between August 26-September 9, 2021 were analyzed to assess the most frequently reported medical complaint just prior to and after the hurricane. Run sheets were also evaluated to determine average time from call to arrival on scene, time to arrival at patient (“response time”), and time from leaving scene to arrival at destination (“transport time”). To account for the atypical period during which EMS response was suspended due to wind, both mean and median times were calculated. Data was compared to a control period of Aug 26-Sept 9, 2022.

During the study period, 1,971 calls were received, with trauma and respiratory the most common complaints. The mean call-to-arrival time was one hour, although the median time was 15 minutes. Response time was 34 minutes compared to 21 minutes in 2022, and median response time was comparable to the control period. Transport time mean and median were 12.3 and 11.3 minutes, also similar to 2022.

Despite citywide infrastructure failures and suspension of operations for over 12 hours during landfall, multiple mitigation strategies enabled NOEMS to quickly resume operations and minimize impact on patient care times.

At mass casualty incidents (MCIs) medical needs exceed available resources, requiring prioritization of response efforts and materials. Principles of triage have evolved since the 18th century into several modern-day algorithms that sort casualties into priority groups based on clinical parameters. It is unclear, however, if such algorithms are effective and practical during real-world MCIs. This analysis reviews the literature on use and efficacy of prehospital MCI triage algorithms.

The MEDLINE, Scopus, and Google Scholar databases were searched for peer-reviewed and grey literature on prehospital MCI medical response. Articles discussing MCI triage concepts, triage at MCIs, or algorithm efficacy were included. Articles were excluded if they described law enforcement, ethical, psychological or epidemiological perspectives without detailing the medical response.

Frequently-cited MCI triage algorithms include START (Simple Triage & Rapid Treatment); Triage Sieve; CareFlight; SALT (Sort, Assess, Lifesaving Interventions, Treatment/Transport); and RAMP (Rapid Assessment of Mentation & Pulse). They differ in the physiologic parameters assessed, inclusion of numerical measurements, and number of triage categories. Surveyed providers were less likely to have performed full triage at MCIs (16%) than in training (69%), and more likely to have performed no triage (29% vs. 1%). In retrospective trauma registry analyses, algorithms were generally poorly predictive of the need for life-saving interventions (13-58% sensitive, 72-97% specific) in one study, and variably predictive of critical injury (45-85% sensitive, 86-96% specific) in another. The Glasgow Coma Scale motor component was associated with critical injury (73% sensitive, 96% specific if <6); other physiologic variables had sensitivities under 40%. In prospective studies, algorithms were accurate for 36-52% of adults and 56-59% of children. Some suggest clinician judgment may be similarly effective.

Multiple algorithms exist for MCI triage, but they are infrequently utilized and may be inaccurate. Simpler, more realistic, scalable, and widely accepted response systems need to be instituted.

The Covid-19 pandemic strained health care organizations to their limits, and sometimes beyond. Different countries took different approaches to minimize the effects of the pandemic, both to protect public health and to safeguard the capability of the health care system.

A collaborative project between Sweden and Bosnia-Hercegovina with the aim to share and learn from experiences of managing the COVID-19 pandemic from a medical command and control perspective, initiated in 2021.

The project departed from three theoretical stances: sociotechnical systems perspective, experiential learning theory, and organizational learning theory. Framing the problem using a holistic systems approach, compared to focusing on individual experts, allows for understanding interactions on a system level. Hence, could these theories contribute to supporting individuals' learning and organizational change?

A two-day workshop involving participants from both Swedish and Bosnian (N=21) medical command and control allowed for the exchange of experiences and another's perspective on similar challenges. During the workshop, two themes were addressed: common operational picture and evaluation. First, an introductory presentation was held, then the theme was discussed and reflected upon in small groups. After this, the groups presented their conclusions, and a full group discussion was moderated.

The discussions resulted in participants sharing perspectives on the selected themes, providing personal insights and experience, allowing for deepened and increased understanding of the theme. In spite of major differences between the Swedish and the Bosnian health care systems and Covid-19 approaches, several shared conclusions were identified. For example, reflections on decision processes and strategies, as well as interest in improving the crisis organization.

Exposing participants to different views on well-known processes and challenges allows for reflecting, verbalizing, and reaching a deeper understanding. By displaying a culturally differently organized way of approaching the challenges the contrast is even more evident.

In addition to national nuclear disaster training, local training is conducted once a year to identify issues with training.

The facility is located in the urgent protective action planning zone (UPZ), an exposure medical facility was built in 2015 and has conducted four trainings so far. The fifth training was conducted this time to develop human resources (training), manage equipment and materials, receive medical teams, collaborate with the Advanced Radiation Medical Support Center, review manuals, and inform local residents.

There are currently eleven nurses registered as nuclear disaster response nurses at the facility, and two nurses participate in the national nuclear disaster training program each year. On the other hand, unlike physicians and other professionals, the number of nurses enrolled for reasons such as relocation has not increased. The facility also functions as a core hospital in the event of a disaster, and currently has about 30 nurses who are willing to be dispatched in the event of a disaster. It was found that even in core facilities for nuclear disaster response, awareness of nuclear disasters within the facilities is low and few personnel are willing to work there. Previous studies have shown that they are anxious about radiation, the possibility of late effects from low-dose exposure, and concerns about the genetic effects of exposure and its effects on themselves in nursing.

As a core facility for nuclear disasters, issues were reported on and identified through training, such as human resource development, management of materials and equipment, and review of manuals.

Multiple triage algorithms have been proposed to optimize the allocation of medical resources in mass casualty incidents. Despite attempts at standardization, first responders often assign patients to triage categories that deviate from those prescribed by these algorithms. This study seeks to understand what patient level factors cause these deviations, and identify clinical factors which cause variance toward over or under triage. Rather than evaluate these decisions against a gold standard, we instead seek to identify patients that cause controversy among first responders with respect to their choices.

This will be an online survey distributed to EMT and Paramedic students in the US. They will be provided with fifty patient cards containing a clinical vignette including description of injuries and vital signs. For each vignette, they will select a triage category (Red, Yellow, Green, or Black.) We will analyze responses to identify areas of controversy, where triage classification showed a significant split between respondents. We can then evaluate these patients for clinical trends.

Data collection and analysis are planned for completion by March 30, 2023.

Identifying patient-level characteristics that contribute to triage variance can allow emergency managers to anticipate under-triage and over-triage following an MCI. This can aid emergency providers as they plan to receive an influx of patients. It also addresses the sub-cognitive biases that impact first responders decision-making, which may aid EMS educators who train first responders in triage.

At the beginning of the COVID-19 pandemic, Italian emergency departments (EDs) had to hastily implement current surge response plans or create new ones. The objectives of this study are to quantitatively assess ED performance improvements between selected non-pandemic and pandemic periods at Sant’Anna hospital in Como, Italy, and to relate these to adopted and adapted surge response actions.

The average length of stay (LOS), time-to-physician initial assessment (TPIA) and left-without-being seen (LWBS) rates were calculated during two ED periods prior to the pandemic and then three periods during the pandemic in the COVID ED (C-ED) dedicated to treat COVID patients, and the COVID-free ED (NC-ED) dedicated to treat all other patients. Then quantitative data analysis based on hypothesis testing was performed.

A qualitative theme and subtheme data analysis based on the Hospital Surge Preparedness and Response Index (HSPRI) was performed on baseline strategies before each pandemic period and on the actions implemented in the subsequent period.

The LOS increased across all periods, while the TPIA decreased in the first two pandemic periods in comparison to pre-pandemic periods. The NC-ED LOS was lower than the C-ED LOS, and the C-ED TPIA was lower than the NC-ED TPIA in all three pandemic periods. The LWBS decreased between pre-pandemic and pandemic periods, with an increasing trend towards pre-pandemic levels in the last pandemic period. Of the 20 action items listed in the HSPRI, six were implemented in the first pandemic period, eight in the second and one in the third.

The LOS, TPIA and LWBS rates are useful indicators to rapidly obtain an overview of ED performance but failed to provide an exhaustive assessment because ED performance depends on countless external and internal variables. Close collaboration of ED leaders with other healthcare agencies is critical to respond to a pandemic surge.

On March 11, 2011, the Great East Japan Earthquake with a 9.0 magnitude struck the northeastern coast of Japan. The death toll reached 15,892 and 2,576 people were reported missing. Tohoku University and Fukushima Medical University, both of which are located in the affected prefectures, responded massively to the disaster.

To deal with the next disaster, both universities established the “Conductor type Human Resources Development” (CHRD) program for Disaster Medicine and Health Care in 2019, not only for doctors, but also other medical professionals (such as dentists, nurses, pharmacists, etc.) supported by the Japanese government. The main course of CHRD program, “Disaster Management course,” which is also a certification program at Tohoku University, comprises 14 practical educational contents (seven practical trainings and seven lectures) based on the work experience of both universities in collaboration with various organizations.

To date, 59 students have enrolled in the Disaster Management course, two students are enrolled in the board-certified physician in public health and social medicine acquisition course, three students are enrolled in the master's course, a Tohoku University Graduate School of Medicine course, and two students are enrolled in the doctoral course. Until October 2022, a total of 17 people were certified to have completed the "Disaster Management course," and one person completed the board-certified physician in public health and social medicine acquisition course. A total of 68 practical trainings and lectures were held until 2021, the total number of times this program was attended by students until 2021 was 916. Average comprehension rate and satisfaction rate with practical trainings and lectures by students are 97.2% and 98.3%, respectively.

All the students who complete the CHRD program are believed to acquire comprehensive skills related to disaster health and medical care and will be able to respond effectively in all phases.

Children, who comprise 25% of the US population, are frequently victims of disasters and have special needs during these events. To prepare NYC for a large-scale Pediatric Disaster, NYCPDC has worked with an increasing number of providers that initially included only a small number of hospitals and agencies. Through a cooperative team approach, stakeholders now include local public health, emergency management and emergency medical services, 28 hospitals, community-based providers, and the Medical Reserve Corps.

The NYCPDC utilized an inclusive iterative process model whereby a desired plan was achieved by stakeholders reviewing the literature and current practice through repeated discussion and consensus building. NYCPDC used this model in developing a comprehensive regional pediatric disaster plan.

The plan included disaster scene triage (adapted for pediatric use) to transport (with prioritization) to surge and evacuation. Additionally, site-specific plans utilizing guidelines and templates now include Pediatric Long-Term Care Facilities, Hospital Pediatric Departments including Pediatric and Neonatal Intensive Care Services and Outpatient/Urgent Care Centers. A force multiplier course in critical care for non-intensivists has been provided. An extensive Pediatric Exercise program has been used to develop, operationalize and revise plans based on lessons learned. This initially included pediatric tabletop, functional and full-scale exercises at individual hospitals leading to citywide exercises at 13 and subsequently all 28 hospitals caring for children.

The NYCPDC has comprehensively planned for the special needs of children during disasters utilizing a pediatric coalition based regional approach that matches pediatric resources to needs to provide best outcomes.

The NYCPDC has responded to real time events (H1N1, Haiti Earthquake, Superstorm Sandy, Ebola), and participated in local (NYC boroughs and executive leadership) and nationwide coalitions (including the National Pediatric Disaster Coalition). The NYCPDC has had the opportunity to present their Pediatric Disaster Planning and Response efforts at local, national and International conferences.

In Japan, the Disaster Medical Assistance Team (DMAT) is dispatched as an Emergency Medical Team (EMT) in major disasters. DMAT consists of a physician, nurse, and operations coordinators. The operations coordinators include all occupations other than physicians and nurses, and are responsible for activities to facilitate medical treatment, gathering information, establishing communications, and ensuring transportation. Therefore, the operations coordinator must have in-depth knowledge of all aspects. Operations coordinators with this knowledge are qualified as logistics team members in addition to DMAT certification. Paramedics receive pre-graduate training in medical care, transport, and coordination with other organizations, and many of their daily duties are related to these areas. However, there are few opportunities to learn about logistics. If paramedics are effectively trained in logistics, they are likely to play an active role as operational coordinators. However, logistics covers a wide range of topics, and there are few studies on items that require focused education. Therefore, this study examines the level of understanding of each logistics item among paramedics active in the field of disaster medicine to identify items that should be emphasized.

A questionnaire survey of 36 paramedics was conducted, all of whom hold both DMAT and logistics team certifications, to determine their level of understanding and the importance of each logistics item. The logistics items used in the survey are specified in the Logistics Specialist Certification System of the Japanese Society of Disaster Medicine. The collected questionnaire results were analyzed using SPSS statistical software.

Characteristic trends were obtained in the logistics items required of paramedics. Trends were also analyzed according to the age and work history of paramedics.

The logistics education for paramedics needs to be enhanced in accordance with the trends obtained from the study. Specific studies on the means and timing of education will be needed in the future.

COVID-19 resulted in 1.8 million reported deaths in 2020 and an excess mortality of at least 3,000,000 to date. Following the announcement of emergency measures mandating various public health interventions, international studies demonstrated a decline in ED attendances, potentiating a delay in seeking health services.

The objective was to examine ED attendance trends by age group and to categorize the attendances following the implementation of regulations related to COVID-19.

A single-center retrospective observational study of ED attendances from 2014 to 2022 at Wexford General Hospital, a 225-bed acute general hospital. Monthly attendance trends were analyzed covering all phases of the national response. Information was extracted from the electronic health record system iPMS.

Overall attendances decreased by 11.5% {42,637 (2019) to 37,751 (2020)}, well below expected annual growth projections from 2019 to 2020. A significant reduction in pediatric attendance (≤16 years) occurred, with 31.68% negative growth (10,351 to 7,071) in 2020 and sustained decrease of 15.3% (8,767 attendances) in 2021. In contrast, geriatric (≥65 years) attendances were unchanged in 2020 (17,751), with a surge of 8.9% to 19,333 attendances in 2021, the largest year-on-year growth since 2018. Comparisons of month-to-month trends in relation to public health measures correlated to a marked decline in attendances at the extremes of age during “lockdown” periods.

The reduction in attendances is likely multifactorial, such as a reduction in school-related stress and patients deciding to stay home for fear of attending during the pandemic with non-emergent conditions. The increase in geriatric presentations in 2021 may reflect continuing restricted access to primary care and GP services, or neglect of prior conditions. Examining changing demographic attendances may offer opportunities to develop alternative ways of supporting frail populations and families in community care avoiding ED presentations.

Japan Disaster Medical Assistance Team (JDMAT) consists of four personnel. They are selected in 47 local governments in Japan, and after the completion of a four day boot camp, they are registered in the list of JDMAT. Hyogo Emergency Medical Center (HEMC) has been playing an important role as one of the oldest boot camps with Disaster Medical Center in Tachikawa. The boot camp's significance is obvious, but the JDMAT system requires a trainer for the course. Many courses were discontinued and affected by the COVID-19 Pandemic.

Retrospective, single institute data, observed in the number of participants for instruction. The periods are from March 2019 to September 2022. Instructing members of this boot camp consist of three categories of Drs, Nurses, and logisticians.

In FY2019, from April to March during the pre-pandemic year, a boot camp was held nine times. During those days, the total number of instructors, including potential ones, was 659 persons, and fortunately 75 people participated for the very first time. However, during the Corona era, in FY2020, the boot camp was held only four times. The total number of instructors was 161 persons, and 14 people participated for the first time. In FY2021, the boot camp was held only three times. The total number of instructors was 141 persons, and 11 people participated for the first time. In FY2022, after two quarters passed, the boot camp was held five times according to the schedule. The total number of instructors was 256 persons, and 18 people participated for the very first time.

Officers were not trained for future disaster response for two years because of the pandemic.

The number of deaths from natural disasters that have occurred in Japan since 1989 is in the order of (1) the Great East Japan Earthquake, (2) the Great Hanshin-Awaji Earthquake, and (3) the Kumamoto Earthquake, but the ratio of related deaths to the total number of deaths was highest for the Kumamoto earthquake.

In the case of the Kumamoto earthquake, an inland earthquake of the same scale as the Great Hanshin-Awaji Earthquake, direct deaths due to the earthquake were suppressed, but related deaths are thought to have increased due to the effects of evacuation life and other factors. According to a report by Kumamoto Prefecture, the majority of direct deaths from the Kumamoto earthquake were caused by trauma such as excessive pressure or asphyxiation. As for related deaths, most of the victims were aged 60 years or older, more than 80% of them had pre-existing medical conditions, and respiratory and circulatory system diseases were the most common causes of death.

A survey of victims transported by ambulance from evacuation centers to medical institutions after the Kumamoto earthquake showed that a large number of victims were transported in the acute phase after the disaster. The reasons for transport are diverse injuries and illnesses, including trauma from falls, dyspnea, impaired consciousness, and fever, suggesting that stress from the earthquake and problems in the living environment of the evacuation centers had an impact on the deterioration of health conditions.

It is important to identify issues and consider countermeasures based on past experiences in order to prevent health hazards in evacuation centers.

This report describes the response, action plan, and after-action changes adopted by the Louisiana State University New Orleans (LSU-NO)–Emergency Medicine (EM) Residency Program in response to Hurricane Ida, which occurred in New Orleans, Louisiana in late August through early September 2021. Summarized are the redistribution of emergency department (ED) residents within the primary clinical site, University Medical Center New Orleans (UMCNO); the daily communication flow from chief residents and program leadership; and discussions pertaining to procedural revisions instituted following investigation of pre- and post-hurricane operations.

Small-group debrief sessions and after-action reports were conducted post-storm to discuss perceived deficiencies from a resident stand-point. Debriefing occurred between chief residents and individual classes through standardized residency forums. Additionally, an after-action committee, comprised of senior residents, academic faculty, and ancillary personnel, convened a separate counsel with hospital administration-level leadership to analyze retrospective limitations that occurred both during, and immediately following, Code Grey activation.

Following data collection and analysis from the various feedback channels, several changes were made to the residency’s Code Grey activation plan going into the 2022-2023 academic residency year. The information obtained was used to develop a more formalized Code Grey process, and to create more robust orientation and education materials for residents.

Throughout the events of Hurricane Ida, the LSU-NO Emergency Medicine Department at University Medical Center New Orleans managed a substantial intensification in daily emergency medical activity, while contending with a near-immediate reduction in available resources. Consequently, our program has formalized a more durable residency response to future disasters, including real-time, evolving evacuation correspondence and modernized protocols for rapid re-distribution of resident-power. These procedures are now distributed and practiced throughout each residency year and reinforced on an ad hoc basis in advance of any major weather-related events predicted to impact the greater New Orleans metropolitan area.

An effective response to CBRNE requires that frontline staff, such as nurses, are adequately trained in Emergency Preparedness (EP). Understanding the current gaps in nursing knowledge of CBRNE is the first step in creating an effective training program. This study assessed EP training gaps and needs among nursing staff.

A web-based survey was distributed to all hospital nursing staff. The survey evaluated the CBRNE training that nurses received. Staff listed the types of training they had received and were asked to rate their confidence in performing various disaster-related competencies or capabilities. Competency confidence levels were also surveyed as those who feel; not at all confident or not very confident.

The survey assessed previous EP training. 572/763 Nursing Staff had completed the survey, for a response rate of 75%. Of the nurses who responded, areas in which they have been trained included: preparedness for radiological and nuclear agents (17.66% trained), preparedness for biological agents (22.20% trained), preparedness for chemical agents (27.45% trained), hazardous materials and patient decontamination (25% trained), and their own role within the hospital's ICS (31.29% trained), Patient evacuation (63.61% trained) and the hospital's EP plan (54.55% trained). The survey also assessed respondents' confidence in performing EP activities. The respondents reported lacking confidence in treating patients exposed to a radioactive material (59.9%), treating patients exposed to a biological agent (57.17%), and performing decontamination procedures (54.71%). The respondents reported having confidence in evacuating patients from units, departments, or hospitals (69.1%). The top incentives for participating in “nonrequired” training were no costs to complete the training (83.1%) and receiving continuing education credits (79.2%).

A majority of nurses reported inadequate training in CBRNE events with a self-reported lack of confidence in responding to these events. A targeted and educational CBRNE curriculum and materials to enhance EP among nursing professionals are clearly indicated.

As the COVID-19 pandemic started, the NO-FEAR project shifted to real-time experience sharing to improve response to an unknown new threat. The lessons observed during more than 20 webinars were collected and analyzed at the end of 2019 to identify those relevant for future preparedness and response to another outbreak or new threats.

A questionnaire using a 0-4 Likert scale was distributed to the wider NO-FEAR community, where they were asked to identify the relevance of the item for future preparedness. Later the results were discussed by the consortium and put for feedback in a large meeting in Madrid in March 2022. The 78 observations were clustered into five categories: 1) The human factor (23) 2) Knowledge sharing, cooperation and coordination (11) 3) Equipment and supplies (15) 4) Standard Operating Procedures (SOP) (20) 5) PPE (9).

The Top-rated observations were the following:

• The human factor: 2.3 need for updated, trustful information sharing with personnel (e.g. regarding treatment protocols, PPE, updates, etc.) to allow them a comprehensive understanding of the situation (3.73).

• Personal Protective Equipment (PPE): 6.1 need for PPE stockpile management, considering transportation, storage space, and risk of throwing away out-of-date PPE (3.63).

• Equipment and supplies: 4.3 need for solutions to increase equipment and beds capacity (3.56).

• The human factor: 2.22 need for management of fake news and mitigation of violent incidents against healthcare personnel (3.56).

• Knowledge sharing, cooperation and coordination: 3.5 need to collect data, needs, gaps, and lessons in preparation for future outbreaks (3.56).

Better integrating health care into crisis management structures was highlighted during the Madrid conference.

NO-FEAR highlighted the importance of real-time international real-time knowledge sharing in a crisis, the need to better address the needs of the personnel during a long-term crisis, and better integrate health into crisis management structures

A disaster involving significant casualties in a populated area demands the rapid development of a field hospital with personnel specialized in Disaster Medicine. In this scenario, the clinical response of Emergency Medical Teams should be guided by the knowledge of how the medical needs of the population change after the disaster itself. In order to reduce the loss of life and prevent long-term disability, it is essential to have the right tools to treat critical patients. In fact, disasters cause a variety of conditions ranging from minor to life-threatening injuries requiring admission to Intensive Care Unit (ICU).

A systematic review was carried out and electronic healthcare databases were searched using terms such as “Disaster” or “Flood” or “Storm” or “Earthquake” or “Mass Casualty Incidents” and “Intensive Care Unit” or “Intensive Care” or “Health Impact”. Articles that met the search criteria, published in the last 15 years in the English language, were analyzed and summarized. The objective of the review was to identify the main health problems following disasters and, in particular, the diseases that may require intensive care in order to assess the need to include ICU in the minimum technical standard for Emergency Medical Teams type 2.

The review included 12 studies identified as relevant and significant for our purpose. Health problems were sorted for disaster type and severity of the injury. The review demonstrates that health problems after a disaster are different depending on disaster type, but in all the scenarios there are diseases that potentially may require timely intensive care.

The presence of an ICU within an Emergency Medical Team type 2 (according to WHO EMT classification) is an essential part of disaster management plans as ICU plays an irreplaceable role in saving lives and in reducing the health impact of a disaster.