Terrorism and natural catastrophes have made disaster preparedness a critical issue. Despite the documented vulnerabilities of children during and following disasters, gaps remain in health care systems regarding pediatric disaster preparedness. This research study examined changes in knowledge acquisition of pediatric disaster preparedness among medical and non-medical personnel at a children’s hospital who completed an online training course of five modules: planning, triage, age-specific care, disaster management, and hospital emergency code response.

A multi-disciplinary team within the Pediatric Disaster Resource and Training Center at Children’s Hospital Los Angeles (Los Angeles, California USA) developed an online training course. Available archival course data from July 2009 to August 2012 were analyzed through linear growth curve multi-level modeling, with module total score as the outcome (0 to 100 points), attempt as the Level 1 variable (any module could be repeated), role in the hospital (medical or non-medical) as the Level 2 variable, and attempt by role as the cross-level effect.

A total of 44,115 module attempts by 5,773 course participants (3,686 medical personnel and 2,087 non-medical personnel) were analyzed. The average module total score upon first attempt across all participants ranged from 60.28 to 80.11 points, and participants significantly varied in how they initially scored. On average in the planning, triage, and age-specific care modules: total scores significantly increased per attempt across all participants (average rate of change ranged from 0.59 to 1.84 points) and medical personnel had higher total scores initially and through additional attempts (average difference ranged from 13.25 to 16.24 points). Cross-level effects were significant in the disaster management and hospital emergency code response modules: on average, total scores were initially lower among non-medical personnel compared to medical personnel, but non-medical personnel increased their total scores per attempt by 3.77 points in the disaster management module and 6.40 points in the hospital emergency code response module, while medical personnel did not improve their total scores through additional attempts.

Medical and non-medical hospital personnel alike can acquire knowledge of pediatric disaster preparedness. Key content can be reinforced or improved through successive training in an online course.

PhamPK, BeharSM, BergBM, UppermanJS, NagerAL. Pediatric Online Disaster Preparedness Training for Medical and Non-Medical Personnel: A Multi-Level Modeling AnalysisPrehosp Disaster Med.2018;33(4):349–354.

The most commonly used methods for triage in mass-casualty incidents (MCIs) rely upon providers to take exact counts of vital signs or other patient parameters. The acuity and volume of patients which can be present during an MCI makes this a time-consuming and potentially costly process.

This study evaluates and compares the speed of the commonly used Simple Triage and Rapid Treatment (START) triage method with that of an “intuitive triage” method which relies instead upon the abilities of an experienced first responder to determine the triage category of each victim based upon their overall first-impression assessment. The research team hypothesized that intuitive triage would be faster, without loss of accuracy in assigning triage categories.

Local adult volunteers were recruited for a staged MCI simulation (active-shooter scenario) utilizing local police, Emergency Medical Services (EMS), public services, and government leadership. Using these same volunteers, a cluster randomized simulation was completed comparing START and intuitive triage. Outcomes consisted of the time and accuracy between the two methods.

The overall mean speed of the triage process was found to be significantly faster with intuitive triage (72.18 seconds) when compared to START (106.57 seconds). This effect was especially dramatic for Red (94.40 vs 138.83 seconds) and Yellow (55.99 vs 91.43 seconds) patients. There were 17 episodes of disagreement between intuitive triage and START, with no statistical difference in the incidence of over- and under-triage between the two groups in a head-to-head comparison.

Significant time may be saved using the intuitive triage method. Comparing START and intuitive triage groups, there was a very high degree of agreement between triage categories. More prospective research is needed to validate these results.

HartA, NammourE, MangoldsV, BroachJ. Intuitive versus Algorithmic TriagePrehosp Disaster Med.2018;33(4):355–361.

Mass gatherings are common in Australia. The interplay of variables, including crowd density and behavior, weather, and the consumption of alcohol and other drugs, can pose a unique set of challenges to attendees’ well-being. On-site health services are available at most mass gatherings and reduce the strain on community health facilities. In order to efficiently plan and manage these services, it is important to be able to predict the number and type of presenting problems at mass gatherings.

There is a lack of reliable tools to predict patient presentations at mass gatherings. While a number of factors have been identified as having an influence on attendees’ health, the exact contribution of these variables to patient load is poorly understood. Furthermore, predicting patient load at mass gatherings is an inherently nonlinear problem, due to the nonlinear relationships previously observed between patient presentations and many event characteristics.

Data were collected at 216 Australian mass gatherings and included event type, crowd demographics, and weather. Nonlinear models were constructed using regression trees. The full data set was used to construct each model and the model was then used to predict the response variable for each event. Nine-fold cross validation was used to estimate the error that may be expected when applying the model in practice.

The mean training errors for total patient presentations were very high; however, the distribution of errors per event was highly skewed, with small errors for the majority of events and a few large errors for a small number of events with a high number of presentations. The error was five or less for 40% of events and 15 or less for 85% of events. The median error was 6.9 presentations per event.

This study built on previous research by undertaking nonlinear modeling, which provides a more realistic representation of the interactions between event variables. The developed models were less useful for predicting patient presentation numbers for very large events; however, they were generally useful for more typical, smaller scale community events. Further research is required to confirm this conclusion and develop models suitable for very large international events.

Arbon P, Bottema M, Zeitz K, Lund A, Turris S, Anikeeva O, Steenkamp M. Nonlinear modelling for predicting patient presentation rates for mass gatherings. Prehosp Disaster Med. 2018;33(4):362–367

Mass gatherings are complex events that present a unique set of challenges to attendees’ health and well-being. There are numerous factors that influence the number and type of injuries and illnesses that occur at these events, including weather, event and venue type, and crowd demographics and behavior.

While the impact of some factors, such as weather conditions and the availability of alcohol, on patient presentations at mass gatherings have been described previously, the influence of many other variables, including crowd demographics, crowd behavior, and event type, is poorly understood. Furthermore, a large number of studies reporting on the influence of these variables on patient presentations are based on anecdotal evidence at a single mass-gathering event.

Data were collected by trained fieldworkers at 15 mass gatherings in South Australia and included event characteristics, crowd demographics, and weather. De-identified patient records were obtained from on-site health care providers. Data analysis included the calculation of patient proportions in each variable category, as well as the total number of patient presentations per event and the patient presentation rate (PPR).

The total number of expected attendees at the 15 mass gatherings was 303,500, of which 146 presented to on-site health care services. The majority of patient presentations occurred at events with a mean temperature between 20°C and 25°C. The PPR was more than double at events with a predominantly male crowd compared to events with a more equal sex distribution. Almost 90.0% of patient presentations occurred at events where alcohol was available.

The results of the study suggest that several weather, crowd, and event variables influence the type and number of patient presentations observed at mass-gathering events. Given that the study sample size did not allow for these interactions to be quantified, further research is warranted to investigate the relationships between alcohol availability, crowd demographics, crowd mobility, venue design, and injuries and illnesses.

Anikeeva O, Arbon P, Zeitz K, Bottema M, Lund A, Turris S, Steenkamp M. Patient presentation trends at 15 mass-gathering events in South Australia. Prehosp Disaster Med. 2018;33(4):368–374.

The proliferation of unmanned aerial vehicle (UAV) technology has the potential to change the way medical incident commanders (ICs) respond to mass-casualty incidents (MCIs) in triaging victims. The aim of this study was to compare UAV technology to standard practice (SP) in triaging casualties at an MCI.

A randomized comparison study was conducted with 40 paramedic students from the Holland College Paramedicine Program (Charlottetown, Prince Edward Island, Canada). Using a simulated motor vehicle collision (MVC) with moulaged casualties, iterations of 20 students were used for both a day and a night trial. Students were randomized to a UAV or a SP group. After a brief narrative, participants either entered the study environment or used UAV technology where total time to triage completion, GREEN casualty evacuation, time on scene, triage order, and accuracy were recorded.

A statistical difference in the time to completion of 3.63 minutes (95% CI, 2.45 min-4.85 min; P=.002) during the day iteration and a difference of 3.49 minutes (95% CI, 2.08 min-6.06 min; P=.002) for the night trial with UAV groups was noted. There was no difference found in time to GREEN casualty evacuation, time on scene, or triage order. One-hundred-percent accuracy was noted between both groups.

This study demonstrated the feasibility of using a UAV at an MCI. A non-clinical significant difference was noted in total time to completion between both groups. There was no increase in time on scene by using the UAV while demonstrating the feasibility of remotely triaging GREEN casualties prior to first responder arrival.

Jain T, Sibley A, Stryhn H, Hubloue I.Comparison of unmanned aerial vehicle technologyassisted triage versus standard practice in triaging casualties by paramedic students in a mass-casualty incident scenario. Prehosp Disaster Med. 2018;33(4):375–380

While the art and science of disaster triage continue to evolve, the education of the US health care student in matters pertaining to disaster preparedness and response remains stifled. Unfortunately, these students will be assuming major decision-making responsibilities regarding catastrophes that will be complicated by climate change, nuclear threats, global terrorism, and pandemics. Meanwhile, Sort, Assess, Life-Saving Interventions, Treatment, and/or Transport (SALT) triage is being advocated over the globally popular Simple Triage and Rapid Treatment (START) algorithm for multiple reasons: (1) it’s an all-hazard approach; (2) it has four medical interventions; and (3) it has an additional triage color for victims with non-survivable injuries.

As present-day threats become more ominous and health care education emphasizes the needs of vulnerable populations and palliative care, the authors hypothesize that, when given a choice, health care students will prefer SALT triage.

A convenience sample of 218 interprofessional, disaster-naïve health care students received just-in-time, unbiased education on both START and SALT triage systems. Students then completed a survey asking them to decide which triage system they believe would be most effective in their community.

A total of 123 health care students (56.4%) preferred SALT while 95 (43.6%) preferred START; however, only the physician assistant students showed a statistically significantly preference (28 versus six, respectively; P=.042). Interestingly, there was also a statistically significant difference in preference by gender (Chi-square=5.02; P=.025) of the observed distribution versus expected distribution in SALT and START. The females preferred SALT (61.0%) while the males preferred START (55.9%).

Among those who preferred START, START being easier to learn was the most important reason cited. Among those who preferred SALT, the most important reason cited was that the number of patient triage categories seemed more logical, comprehensible, and consistent with traditional medical care.

While SALT’s preference among females and physician assistant students was based on the addition of medical interventions and the provision of palliative care, START’s preference was related to expediency. Based on this research, incorporating disaster concepts into US health care students’ curricula encourages thoughtful consideration among the future health care leaders about the most effective approach to triage care. It is critical that further research be completed to determine, without reservation, which triage system will not only save the most lives but provide the most humane care to victims.

Fink BN, Rega PP, Sexton ME, Wishner C. START versus SALT triage: which is preferred by the 21st century health care student? Prehosp Disaster Med. 2018;33(4):381–386

The central question this study sought to answer was whether the team members of Strategic Crisis Teams (SCTs) participating in mass-casualty incident (MCI) exercises in the Netherlands learn from their participation.

Evaluation reports of exercises that took place at two different times were collected and analyzed against a theoretical model with several dimensions, looking at both the quality of the evaluation methodology (three criteria: objectives described, link between objective and items for improvement, and data-collection method) and the learning effect of the exercise (one criterion: the change in number of items for improvement).

Of all 32 evaluation reports, 81% described exercise objectives; 30% of the items for improvement in the reports were linked to these objectives, and 22% of the 32 evaluation reports used a structured template to describe the items for improvement. In six evaluation categories, the number of items for improvement increased between the first (T1) and the last (T2) evaluation report submitted by hospitals. The number of items remained equal for two evaluation categories and decreased in six evaluation categories.

The evaluation reports do not support the ideal-typical disaster exercise process. The authors could not establish that team members participating in MCI exercises in the Netherlands learn from their participation. More time and effort must be spent on the development of a validated evaluation system for these simulations, and more research into the role of the evaluator is needed.

Verheul MLMI, Dückers MLA, Visser BB, Beerens RJJ, Bierens JJLM. Disaster exercises to prepare hospitals for mass-casualty incidents: does it contribute to preparedness or is it ritualism? Prehosp Disaster Med. 2018;33(4):387–393

Training students has been proven to be the optimal way to deliver cardiopulmonary resuscitation (CPR) skills. However, it is somehow unknown whether or not the current recommendations appropriate for Caucasian students are also suitable for East Asian students. The purpose of this study is to explore the best age for East Asian students to receive CPR training.

Students were recruited from six schools. Students participated in a standard CPR training program provided by tutors. Each student attended a 60-minute training session with a manikin. After being trained, within one hour, the student’s compression quality was assessed.

A total of 360 students who constituted 12 continuous grades were recruited for this study. Adequate compression depth and satisfactory compression rate with correct hand position could be achieved since the age of 12. However, successful compression rate and complete release could be achieved since the younger age of six.

Current recommendations for Caucasian students to cultivate a full-capacity CPR rescuer at the age of 12 are also appropriate for East Asian students. However, the optimal age for students to receive CPR training should be decided based on evidence and importance assessment of CPR.

He D, Huang K, Yang Y, Jiang W, Yang N, Yang H. What is the optimal age for students to receive cardiopulmonary resuscitation training? Prehosp Disaster Med. 2018;33(4):394–398.

Implementation of high-quality, dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) is critical to improving survival from out-of-hospital cardiac arrest (OHCA). However, despite some studies demonstrating the use of a metronome in a stand-alone setting, no research has yet demonstrated the effectiveness of a metronome tool in improving DA-CPR in the context of a realistic 911 call or using instructions that have been tested in real-world emergency calls.

Use of the metronome tool will increase the proportion of callers able to perform CPR within the target rate without affecting depth.

The prospective, randomized, controlled study involved simulated 911 cardiac arrest calls made by layperson-callers and handled by certified emergency medical dispatchers (EMDs) at four locations in Salt Lake City, Utah USA. Participants were randomized into two groups. In the experimental group, layperson-callers received CPR pre-arrival instructions with metronome assistance. In the control group, layperson-callers received only pre-arrival instructions. The primary outcome measures were correct compression rate (counts per minute [cpm]) and depth (mm).

A total of 148 layperson-callers (57.4% assigned to experimental group) participated in the study. There was a statistically significant association between the number of participants who achieved the target compression rate and experimental study group (P=.003), and the experimental group had a significantly higher median compression rate than the control group (100 cpm and 89 cpm, respectively; P=.013). Overall, there was no significant correlation between compression rate and depth.

An automated software metronome tool is effective in getting layperson-callers to achieve the target compression rate and compression depth in a realistic DA-CPR scenario.

Scott G, Barron T, Gardett I, Broadbent M, Downs H, Devey L, Hinterman EJ, Clawson J, Olola C. Can a software-based metronome tool enhance compression rate in a realistic 911 call scenario without adversely impacting compression depth for dispatcher-assisted CPR? Prehosp Disaster Med. 2018;33(4):399–405

Rapid identification of esophageal intubations is critical to avoid patient morbidity and mortality. Continuous waveform capnography remains the gold standard for endotracheal tube (ETT) confirmation, but it has limitations. Point-of-care ultrasound (POCUS) may be a useful alternative for confirming ETT placement. The objective of this study was to determine the accuracy of paramedic-performed POCUS identification of esophageal intubations with and without ETT manipulation.

A prospective, observational study using a cadaver model was conducted. Local paramedics were recruited as subjects and each completed a survey of their demographics, employment history, intubation experience, and prior POCUS training. Subjects participated in a didactic session in which they learned POCUS identification of ETT location. During each study session, investigators randomly placed an ETT in either the trachea or esophagus of four cadavers, confirmed with direct laryngoscopy. Subjects then attempted to determine position using POCUS both without and with manipulation of the ETT. Manipulation of the tube was performed by twisting the tube. Descriptive statistics and logistic regression were used to assess the results and the effects of previous paramedic experience.

During 12 study sessions, from March 2014 through December 2015, 57 subjects participated, evaluating a total of 228 intubations: 113 tracheal and 115 esophageal. Subjects were 84.0% male, mean age of 39 years (range: 22 - 62 years), with median experience of seven years (range: 0.6 - 39 years). Paramedics correctly identified ETT location in 158 (69.3%) cases without and 194 (85.1%) with ETT manipulation. The sensitivity and specificity of identifying esophageal location without ETT manipulation increased from 52.2% (95% confidence interval [CI], 43.0-61.0) and 86.7% (95% CI, 81.0-93.0) to 87.0% (95% CI, 81.0-93.0) and 83.2% (95% CI, 0.76-0.90) after manipulation (P<.0001), without affecting specificity (P=.45). Subjects correctly identified 41 previously incorrectly identified esophageal intubations. Paramedic experience, previous intubations, and POCUS experience did not correlate with ability to identify tube location.

Paramedics can accurately identify esophageal intubations with POCUS, and manipulation improves identification. Further studies of paramedic use of dynamic POCUS to identify inadvertent esophageal intubations are needed.

LemaPC, O’BrienM, WilsonJ, St. JamesE, LindstromH, DeAngelisJ, CaldwellJ, MayP, ClemencyB.Avoid the Goose! Paramedic Identification of Esophageal Intubation by Ultrasound. Prehosp Disaster Med.2018;33(4):406–410

Natural and man-made disasters are becoming global concerns. Natural disasters appear to be growing in number and intensity due to global warming, population explosion, increased travel, and overcrowding of cities. In addition, man-made disasters do not seem to be diminishing.

At disaster sites, an immediate response is needed. National and international organizations; nongovernmental, military, and commercial organizations; and even private donors enlist to provide humanitarian and medical support and to send supplies, shelters, and temporary health care facilities to disaster zones.

The literature is sparse regarding the design of portable health care facilities intended for disaster zones and their adaptability to the tasks required and site areas.

Data were collected from peer-reviewed literature, scientific reports, magazines, and websites regarding health care facilities at rescue and salvage situations. Information was grouped according to categories of structure and properties, and relative strengths and weaknesses. Next, suggestions were made for future directions.

Permanent structures and temporary constructed facilities were the two primary categories of health care facilities functioning at disaster zones. Permanent hospitals were independent functioning medical units that were moved or transported to and from disaster zones as complete units, as needed. These facilities included floating hospitals, flying (airborne) hospitals, or terrestrial mobile facilities. Thus, these hospitals self-powered and contained mobility aids within their structure using water, air, or land as transporting media.

Temporary health care facilities were transported to disaster zones as separate, nonfunctioning elements that were constructed or assembled on site and were subsequently taken apart. These facilities included the classical soft-type tents and solid containers that were organized later as hospitals in camp configurations. The strengths and weaknesses of the diverse hospital options are discussed.

Future directions include the use of innovative materials, advanced working methods, and integrated transportation systems. In addition, a holistic approach should be developed to improve the performance, accessibility, time required to function, sustainability, flexibility, and modularity of portable health care facilities.

Bitterman N, Zimmer Y. Portable health care facilities in disaster and rescue zones: characteristics and future suggestions. Prehosp Disaster Med. 2018;33(4):411–417

The impact of disasters and large-scale crises continues to increase around the world. To mitigate the potential disasters that confront humanity in the new millennium, an evidence-informed approach to disaster management is needed. This study provides the platform for such an evidence-informed approach by identifying peer-reviewed disaster management publications from 1947 through July 2017.

Peer-reviewed disaster management publications were identified using a comprehensive search of: MEDLINE (US National Library of Medicine, National Institutes of Health; Bethesda, Maryland USA); CINAHL (EBSCO Information Services; Ipswich, Massachusetts USA); EMBASE (Elsevier; Amsterdam, Netherlands); PsychInfo (American Psychological Association; Washington DC, USA); and the Cochrane Library (The Cochrane Collaboration; Oxford, United Kingdom).

A total of 9,433 publications were identified. The publications were overwhelmingly descriptive (74%) while 18% of publications reported the use of a quantitative methodology and eight percent used qualitative methodologies. Only eight percent of these publications were classified as being high-level evidence. The publications were published in 918 multi-disciplinary journals. The journal Prehospital and Disaster Medicine (World Association for Disaster and Emergency Medicine; Madison, Wisconsin USA) published the greatest number of disaster-management-related publications (9%). Hurricane Katrina (2005; Gulf Coast USA) had the greatest number of disaster-specific publications, followed by the September 11, 2001 terrorist attacks (New York, Virginia, and Pennsylvania USA). Publications reporting on the application of objective evaluation tools or frameworks were growing in number.

The “science” of disaster management is spread across more than 900 different multi-disciplinary journals. The existing evidence-base is overwhelmingly descriptive and lacking in objective, post-disaster evaluations.

SmithEC, BurkleFMJr, AitkenP, LeggattP. Seven Decades of Disasters: A Systematic Review of the Literature. Prehosp Disaster Med. 2018;33(4):418–423

Improving medical record keeping is a key part of the World Health Organization’s (WHO’s; Geneva, Switzerland) drive to standardize and evaluate emergency medical team (EMT) response to sudden onset disasters (SODs).

In response to the WHO initiative, the UK EMT is redeveloping its medical record template in line with the WHO minimum dataset (MDS) for daily reporting. When changing a medical record, it is important to understand how well it functions before it is implemented.

The redeveloped medical record was piloted at a UK EMT deployment course using simulated patients in order to examine ease of use by practitioners, and rates of data capture for key MDS variables.

Some parts of the form were consistently poorly filled in, and the way in which the form was completed suggested that the flow of the form did not align with the recorder’s natural thought processes when under pressure.

Piloting of a single-sheet triplicate medical record during an EMT deployment simulation led to significant modifications to improve data capture and function.

Jafar AJN, Fletcher RJ, Lecky F, Redmond AD. A pilot of a UK emergency medical team (EMT) medical record during a deployment training course. Prehosp Disaster Med. 2018;33(4):441–447.