Hospitals are expected to continue to provide medical care during disasters. However, they often fail to function under these circumstances. Vulnerability to disasters has been shown to be related to the socioeconomic level of a country. This study compares hospital preparedness, as measured by functional capacity, between Iran and Sweden.

Hospital affiliation and size, and type of hazards, were compared between Iran and Sweden. The functional capacity was evaluated and calculated using the Hospital Safety Index (HSI) from the World Health Organization. The level and value of each element was determined, in consensus, by a group of evaluators. The sum of the elements for each sub-module led to a total sum, in turn, categorizing the functional capacity into one of three categories: A) functional; B) at risk; or C) inadequate.

The Swedish hospitals (n = 4) were all level A, while the Iranian hospitals (n = 5) were all categorized as level B, with respect to functional capacity. A lack of contingency plans and the availability of resources were weaknesses of hospital preparedness. There was no association between the level of hospital preparedness and hospital affiliation or size for either country.

The results suggest that the level of hospital preparedness, as measured by functional capacity, is related to the socioeconomic level of the country. The challenge is therefore to enhance hospital preparedness in countries with a weaker economy, since all hospitals need to be prepared for a disaster. There is also room for improvement in more affluent countries.

DjalaliA, CastrenM, KhankehH, GrythD, RadestadM, OhlenG, KurlandL. Hospital Disaster Preparedness as Measured by Functional Capacity: a Comparison between Iran and Sweden. Prehosp Disaster Med.2013;28(5):1-8.

This paper describes the two mass-casualty, terrorist attacks that occurred in Istanbul, Turkey in November 2003, and the resulting prehospital emergency response.

A complex, retrospective, descriptive study was performed, using open source reports, interviews, direct measurements of street distances, and hospital records from the American Hospital (AH) and Taksim Education and Research State Hospital (TERSH) in Istanbul.

On 15 November, improvised explosive devices (IEDs) in trucks were detonated outside the Neve Shalom and Beth Israel Synagogues, killing 30 persons and injuring an estimated additional 300. Victims were maldistributed to 16 medical facilities. For example, AH, a private hospital located six km from both synagogues, received 69 injured survivors, of which 86% had secondary blast injuries and 13% were admitted to the hospital. The TERSH, a government hospital located 1 km from both synagogues, received 48 injured survivors. On 20 November, IEDs in trucks were detonated outside the Hong Kong Shanghai Banking Corporation (HSBC) headquarters and the British Consulate (BC), killing 33 and injuring an estimated additional 450. Victims were maldistributed to 16 medical facilities. For example, TERSH, located 18 km from the HSBC site and 2 km from the the BC received 184 injured survivors, of which 93% had secondary blast injuries and 15% were hospitalized. The AH, located 9 km from the HSBC site and 6 km from the BC, received 16 victims.

The twin suicide truck bombings on 15 and 20 November 2003 were the two largest terrorist attacks in modern Turkish history, collectively killing 63 persons and injuring an estimated 750 others. The vast majority of victims had secondary blast injuries, which did not require hospitalization. Factors associated with the maldistribution of casualties to medical facilities appeared to include the distance from each bombing site, the type of medical facility, and the personal preference of injured survivors.

Large-scale events may overwhelm the capacity of even the most advanced emergency medical systems. When patient volume outweighs the number of available emergency medical services (EMS) providers, a mass-casualty incident may require the aid of non-medical volunteers. These individuals may be utilized to perform field disaster triage, lessening the burden on EMS personnel.

The purpose of this study was to evaluate the accuracy of triage decisions made by newly enrolled first-year medical students after receiving a brief educational intervention.

A total of 315 first-year medical students from two successive classes participated in START triage training and completed a paper-based triage exercise as part of orientation. This questionnaire consisted of 15 clinical scenarios providing brief but sufficient details for prioritization. Subjects assigned each scenario a triage category of Red, Yellow, Green, or Black, based on the START protocol and were allowed four minutes to complete the exercise. Participants from the Class of 2009 were provided with printed START reference cards, while those from the Class of 2008 were not. Two test types varying in the order of patient age values were created to determine whether patient age was a factor in triage assessment.

The mean accuracy score of triage assignment by medical student volunteers after a brief START training session was 64.3%. The overall rate of over-triage was 17.8%, compared to an under-triage rate of 12.6%. There were no significant differences in triage accuracy between subjects with and without printed materials (63.9% vs. 64.6%, p = 0.729) or those completing the age-variant test types (64.4% vs. 64.1%, p = 0.889).

First-year medical students who received brief START training achieved triage accuracy scores similar to those of emergency physicians, registered nurses, and paramedics in previous studies. Observed rates of underand over-triage suggest that a need exists for improving the accuracy of triage decisions made by medical and non-medical personnel. This study did not find that printed materials significantly improved triage accuracy, nor did it find that patient age affected the ability of participants to correctly assign triage categories. Future research might further evaluate disaster triage by non-medical volunteers.

On October 29th, 2012, Hurricane Sandy caused a storm surge interrupting electricity with disruption to Manhattan’s (New York, USA) health care infrastructure. Beth Israel Medical Center (BIMC) was the only fully functioning major hospital in lower Manhattan during and after Hurricane Sandy. The impact on emergency department (ED) and hospital use by geriatric patients in lower Manhattan was studied.

The trends of ED visits and hospitalizations in the immediate post-Sandy phase (IPS) during the actual blackout (October 29 through November 4, 2012), and the extended post-Sandy phase (EPS), when neighboring hospitals were still incapacitated (November 5, 2012 through February 10, 2013), were analyzed with baseline. The analysis was broken down by age groups (18-64, 65-79, and 80+ years old) and included the reasons for ED visits and admissions.

During the IPS, there was a significant increase in geriatric visits (from 11% to 16.5% in the 65-79 age group, and from 6.5% to 13% in the 80+ age group) as well as in hospitalizations (from 22.7% to 25.2% in the 65-79 age group, and from 17.6% to 33.8% in the 80+ age group). However, these proportions returned to baseline during the EPS. The proportions of the categories “dialysis,” “respiratory device,” “social,” and “syncope” in geriatric patients in ED visits were significantly higher than younger patients. The increases of the categories “medication,” “dialysis,” “respiratory device,” and “social” represented two-thirds of absolute increase in both ED visits and admissions for the 65-79 age group, and half of the absolute increase in ED visits for the 80+ age group. The categories “social” and “respiratory device” peaked one day after the disaster, “dialysis” peaked two days after, and “medication” peaked three days after in ED visit analysis.

There was a disproportionate increase in ED visits and hospitalizations in the geriatric population compared with the younger population during the IPS. The primary factor of the disproportionate impact on the geriatric population appears to be from indirect effects of the hurricane, mainly due to the subsequent power outages, such as “dialysis,” “respiratory device,” and “social.” Further investigation by chart review may provide more insights to better aid with future disaster preparedness.

GotandaH , FogelJ , HuskG , LevineJM , PetersonM , BaumlinK , HabbousheJ . Hurricane Sandy: Impact on Emergency Department and Hospital Utilization by Older Adults in Lower Manhattan, New York (USA). Prehosp Disaster Med. 2015;30(5):496–502.

Past history of mass casualties related to international football games brought the importance of practical planning, preparedness, simulation training, and analysis of potential patient presentations to the forefront of emergency research.

The Japanese Ministry of Health, Labor, and Welfare established the Health Research Team (HRT-MHLW) for the 2002 FIFA World Cup game (FIFAWC). The HRT-MHLW collected patient data related to the games and analyzed the related factors regarding patient presentations.

A total of 1,661 patients presented for evaluation and care from all 32 games in Japan. The patient presentation rate per 1,000 spectators per game was 1.21 and the transport-to-hospital rate was 0.05. The step-wise regression analysis identified that the patient presentations rate increased where access was difficult. As the number of total spectators increased, the patient presentation rate decreased. (p <0.0001, r = 0.823, r2 = 0.677).

In order to develop mass-gathering medical-care plans in accordance with the types and sizes of mass gatherings, it is necessary to collect data and examine risk factors for patient presentations for a variety of events.

Mobile health (mHealth) technology can play a critical role in improving disaster victim tracking, triage, patient care, facility management, and theater-wide decision-making.

To date, no disaster mHealth application provides responders with adequate capabilities to function in an austere environment.

The Operational Medicine Institute (OMI) conducted a qualitative trial of a modified version of the off-the-shelf application iChart at the Fond Parisien Disaster Rescue Camp during the large-scale response to the January 12, 2010 earthquake in Haiti.

The iChart mHealth system created a patient log of 617 unique entries used by on-the-ground medical providers and field hospital administrators to facilitate provider triage, improve provider handoffs, and track vulnerable populations such as unaccompanied minors, pregnant women, traumatic orthopedic injuries and specified infectious diseases.

The trial demonstrated that even a non-disaster specific application with significant programmatic limitations was an improvement over existing patient tracking and facility management systems. A unified electronic medical record and patient tracking system would add significant value to first responder capabilities in the disaster response setting.

Callaway DW, Peabody CR, Hoffman A, Cote E, Moulton S, Baez AA, Nathanson L. Disaster mobile health technology: lessons from Haiti. Prehosp Disaster Med. 2012;27(2):1-5.

The disruption of routine treatment, including the interruption of medication, exacerbates chronic conditions during disasters. However, the health consequences of the interruption of medication have not been fully examined. On 22 July 2006, a flash flood affected more than 3,000 households in five cities and four towns in the northern part of Kagoshima Prefecture in southwest Japan. The aims of this study are to describe the prevalence of the interruption of medication among the outpatients in the flood-affected area and to determine the risk and preventive factors for the interruption of medication.

This was a cross-sectional study using a self-administered questionnaire. The study subjects were the outpatients who visited nine of 15 medical facilities in the flood-affected area from 23 January and 31 January 2007. Of 810 valid respondents, 309 who received medication treatment before the event were eligible for the study. Information on socio-demographic factors, chronic health conditions, preparedness-related factors before the event and damage-related factors were collected. Overall and evacuation status-specific prevalence of interruption of medication were presented. For those evacuated, the associations between interruption of medication and relevant patient characteristics, as well as deterioration of health status after the event, were examined.

The prevalence of interruption of medication was 9% in total, but it increased up to 23% among the evacuated subjects. Interruption of medication was more likely among those aged ≥75 years (odds ratio [OR] = 3.6; 95% confidence interval [CI] = 1.0−12.6) and those receiving long-term care services (OR = 4.6; 95% CI = 1.1−19.1), while it was less likely among those with hypertension (OR = 0.2; 95% CI = 0.1−0.8) and those prepared to go out with medication (OR = 0.2; 95% CI = 0.03−0.8). Those who experienced interruption of medication were more likely to have deteriorated health status one month after the event (OR = 4.5; 95% CI = 1.2−17.6).

Interruption of medication occurred more commonly among the evacuated subjects. Among the evacuated, the elderly and those receiving longterm care services were at high risk for interruption of medication, while the preparedness behavior of “preparing to go out with medication” had preventive effect. Special attention must be paid to the high-risk subgroups, and some preventive behaviors should be recommended.

To describe the epidemiology of pediatric emergency medical services (EMS) practice in a large patient population from several geographic areas.

Retrospective computer analysis of EMS databases from four states using a common data set and analysis system.

Pennsylvania, Tennessee, Mississippi, and Nevada (except Clark County), 1990 through 1992.

All patient-care reports of patients 14 years old and younger were extracted from the EMS databases and analyzed for the following factors: age, gender, date, elapsed pre-hospital times, incident type, mechanism of injury, call disposition, illness or injuries encountered, severity of illness/injury (by abnormal vital signs), and basic life support (BLS) and advanced life support (ALS) treatment delivered.

A total of 1,512,907 patient care reports were reviewed. Those of 61,132 children were extracted for analysis. These children comprised about 4% of prehospital responses. Male subjects predominated (56%), and children aged 7 through 14 years represented 46% of cases. Most calls occurred in the evening and daylight hours. Children were transported by ambulance in 89% of cases, and care was refused in 7.7%. Mean response time was 9±16 minutes, mean scene time 12±14 minutes, and mean transport time 14±20 minutes. Traumatic incidents predominated at 42%, with motor vehicle accidents and falls the most common mechanisms. Blunt injuries accounted for 94% of trauma, whereas respiratory problems, seizures, and poisoning/overdose were the most common medical problems. Vital signs were obtained in 56% of cases. Abnormal vital signs were noted in 21% of these, and the presumptive causes were similar in distribution to those of the general population, with the addition of cardiac arrest. The most commonly used treatments were spinal immobilization, oxygen administration, intravenous access and several ALS medications. An ALS capability was available in more than half the runs, but ALS treatment was delivered in only 14% of those cases. Outcome data were not available.

This multistate analysis of pediatric EMS epidemiology confirms findings reported in smaller regional studies, with several exceptions. Excessive scene times were not noted. Few children had serious disorders as evidenced by abnormal vital signs. An ALS treatment, when available, was used infrequently. These findings have implications for EMS planners and educators.

Traffic crashes constitute a major, worldwide public-health problem that cause disabilities, life-long suffering, and huge economic losses. When a person is injured in a traffic crash, actions taken by bystanders often are of crucial importance. To perform first-aid actions in a correct manner, bystanders, often lay persons, need both the courage and the knowledge to do so. For preventive purposes, society spends large resources to inform and educate the public in order to enhance people's ability to take correct actions. However, there only is little information on the rate in a population of persons who have had first-aid training, have been bystanders at a traffic crash, on the actions taken by such persons, and on effects of first-aid training on patient care.

The aim of this study was to acquire knowledge about: (1) the prevalence of first-aid training; (2) the incidence of being a bystander and of the first aid provided at traffic crashes and other emergencies; and (3) the impact of first-aid training on the risks people take in road traffic.

A questionnaire was administered to 2,800 randomly selected persons aged 18–74 years.

The response rate was 67.5%. During the previous five years, 39% of the population had received first-aid training, with a higher rate among younger individuals and those with a higher education. After training, 30% of the respondents had used their skills, and 41% took fewer risks in traffic, particularly those who were older or had a lower level of education. Fourteen percent of those with training (significantly more men) had been bystanders at a traffic crash. At 20% of the crashes, a bystander had administered first aid, and one-third of those who provided such assistance had had use of their training. Conclusion: Intensified first-aid training of the general public could lead to citizens who are more cautious in traffic and to bystanders who provide more immediate and adequate first aid at traffic crashes and other emergencies.

First aid is the initial care of the ill or injured. It aims to preserve and protect life, prevent further injury or deterioration of illness, and help promote recovery. At major public events, there is a large gathering of people, physical spectacles, and equipment within a concentrated area, where organized first-aid care is provided.

To analyze the demand for primary medical care at a public event by identifying the patients and initial symptoms that may predict that demand, and to use such information to improve the efficiency and delivery of medical care.

A questionnaire was completed by St. John Operations Branch personnel after each patient consultation and a retrospective analysis of the data was conducted.

A total of 1,276 questionnaires were returned. Mean patient presentation rate (PPR) was 1.9±0.47 per 1,000 show attendees. This correlated best with the maximum daily temperature (r = 0.715, p <0.02) and show day (r = 0.615, p <0.05). There was poor correlation with daily attendance (r = −0.235, p >0.54). Mean presentation time was 15:13 h. Of those whose gender was recorded, 58.4% were females, and 41.6% were males. The most frequent age group was 13 to 20 years. The nature and number of initial symptoms are listed. Basic first-aid skills were used for 96.7% of symptoms; 2.4% of patients were referred to the hospital.

Temperature and show day significantly contributed to variability of PPR. These factors, together with an estimated PPR and predicted attendance, can be used to forecast demand. Most cases required only basic first-aid skills. Guidelines are suggested for management by nonmedical personnel. A medical officer's role is not reliably defined, but involvement in consultation is suggested.

This study attempted to determine the extent of training and emergency care knowledge of public school teachers in midwestern states. A secondary purpose was to assess the frequency of injury and illness in the school setting requiring the teacher to first respond.

A questionnaire and 14-item, scenario-based, emergency medical care test was developed and pretested. A discrimination index was used for validation of the instrument and a reliability coefficient of .82 was computed using the Kuder-Richardson Formula 20. A randomly recruited group of public school nurses from Arkansas, Kansas, and Missouri administered the instrument to 334 teachers who had no prior knowledge of the test. A random telephone survey of local school patrons also was completed to determine parental assumptions and expectations for emergency care and cardiopulmonary resuscitation (CPR) training in teachers.

One-third (112 teachers) had no specific training in first-aid and 40% never had been trained in CPR. However, most (87%) of the respondents strongly agreed that emergency care training should be required in teacher preparation programs. Eighteen percent of the teachers responded to more than 20 injured or ill students annually, and 17% reported that they had encountered at least one life-threatening emergency in a student during their career. The average score for all respondents on the emergency care test was 58% (X2 = 8.12±2.42). Those with prior first-aid training averaged 60.5% (X2 = 8.47±2.32). Significant deficiencies were noted for recognition and appropriate treatment of student emergencies involving basic life support (BLS) and airway interventions, diabetic emergencies, and treatment of profuse bleeding. Forty of the 50 (80%) parents surveyed assumed that all teachers were adequately trained in first-aid and CPR.

Public school teachers represent a potentially effective first-response component during disasters and isolated emergencies in the school environment. Overall, most of public school teachers in this study were deficient in both training and knowledge of emergency care and BLS modalities. Lack of effective, formal emergency care training in teacher preparation programs coupled with no continuing education requirement is a possible explanation of these results. Emergency medical services providers should seek opportunities to help with first-responder training and continuing education in their schools.

This study investigated the prevalence of post-traumatic stress symptoms among professional ambulance personnel in Sweden and investigated the question: “Does self-knowledge have influence on how well one copes with the effects of daily work exposure from such events?” Little is known about the variables that might be associated with post-traumatic stress symptoms in highrisk occupational groups such as ambulance service groups.

Data were gathered from ambulance personnel by means of an anonymous questionnaire. Survey responses of 362 ambulance personnel from the county of Västra Götaland were analyzed. A correlation was established between post-traumatic symptoms using the impact of event scale (IES-15) and the Professional Self-Description Form (PSDF).

Of those who reported a traumatic situation, 21.5% scored ≥ 26 on the IES-15 subscale. Scores >26 indicate “PTSD caseness”. There were significant differences on PSDF subscales between those presenting with or without posttraumatic symptoms.

The mental health and emotional well-being of ambulance personnel appear to be compromised by accident and emergency work. The high prevalence of PTSD symptoms in ambulance personnel indicates an inability to cope with post-traumatic stress caused by daily work experiences.

No universally accepted methods for objective evaluation of the function of the Incident Command System (ICS) in disaster exercises currently exist. An ICS evaluation method for disaster simulations was derived and piloted.

A comprehensive variable list for ICS function was created and four distinct ICS evaluation methods (quantitative and qualitative) were derived and piloted prospectively during an exercise. Delay times for key provider-victim interactions were recorded through a system of data collection using participant and observer-based instruments. Two different post exercise surveys (commanders, other participants) were used to assess knowledge and perceptions of assigned roles, organization, and communications. Direct observation by trained observers and a structured debriefing session also were employed.

A total of 45 volunteers participated in the exercise that included 20 mock victims. First, mean, and last victim delay times (from exercise initiation) were 2.1, 4.0, and 9.3 minutes (min) until triage, and 5.2, 11.9, and 22.0 min for scene evacuation, respectively. First, mean, and last victim delay times to definitive treatment were 6.0, 14.5, and 25.0 min. Mean time to triage (and range) for scene Zones I (nearest entrance), II (intermediate) and III (ground zero) were 2.9 (2.0–4.0), 4.1 (3.0–5.0) and 5.2 (3.0–9.0) min, respectively. The lowest acuity level (Green) victims had the shortest mean times for triage (3.5 min), evacuation (4.0 min), and treatment (10.0 min) while the highest acuity level (Red) victims had the longest mean times for all measures; patterns consistent with independent rather than ICS-directed rescuer activities. Specific ICS problem areas were identified.

A structured, objective, quantitative evaluation of ICS function can identify deficiencies that can become the focus for subsequent improvement efforts.