The introduction of advanced practitioner roles has challenged the traditional boundaries of health care. While studies have been undertaken to understand the role of physicians in respect of mass-gathering medicine, the role of advanced nurse practitioners (ANPs) has not been investigated.

Does the presence of an ANP reduce the referral rates of patients presenting for medical care at mass-gathering events to external health care resources?

A prospective observational study was undertaken to determine whether the presence of an ANP would reduce the patient referral rate to external health care services by first aiders and paramedics working within an event medical team. Patients identified as requiring referral were reviewed by an ANP as part of the on-site medical provision for four mass-gathering events in the south of England. Additionally, information was gathered identifying which patients would have been transported to hospital by ambulance compared to those actually transported following ANP review. Statistical analysis was undertaken for three key measures (referrals to all local health resources, referrals to hospital-based acute services, and transfers to hospital by ambulance).

A rounded total of 842,000 people attended four mass-gathering events held over 14 days. Of these, 652 presented for medical care, many self-referring.

Using a one-tailed Fisher’s Exact Test and Phi analysis, this study demonstrated statistically significant reductions in the overall referral of patients to all external health care resources (P<.001; φ=0.44), to the emergency department (ED; P<.001; φ=0.43), and a reduction in ambulance transport (P<.001; φ=0.42). Effect size analysis demonstrated a medium-sized effect evident for all of the above, which was also demonstrated in economic terms.

The event medical team would have referred 105 (16.3%) of the 652 patient presentations to external health care services; 47 (7.2%) would have been transported by ambulance. In comparison, the ANP referred 23 patients (3.5%) with 11 (1.7%) being transported by ambulance. It also was noted that the first aiders and paramedics could be more selective in their referral habits that were focused primarily on the ED.

Appropriately trained and experienced ANPs working within event medical teams have a positive impact on referral rates from mass-gathering events.

KempAE . Mass-gathering Events: The Role of Advanced Nurse Practitioners in Reducing Referrals to Local Health Care Agencies. Prehosp Disaster Med. 2016;31(1):58–63.

The objective of this study was to assess the public’s experience, expectations, and perceptions related to Emergency Medical Services (EMS).

A population-based telephone interview of adults in the United States was conducted. The survey instrument consisted of 112 items. Demographic variables including age, race, political beliefs, and household income were collected. Data collection was performed by trained interviewers from Kent State University’s (Kent, Ohio USA)Social Research Laboratory. Descriptive statistics were calculated. Comparative analyses were conducted between those who used EMS at least once in the past five years and those who did not use EMS using χ2 and t tests.

A total of 2,443 phone calls were made and 1,348 individuals agreed to complete the survey (55.2%). There were 297 individuals who requested to drop out of the survey during the phone interview, leaving a total of 1,051 (43.0%) full responses. Participants ranged in age from 18 to 94 years with an average age of 57.5 years. Most were Caucasian or white (83.0%), married (62.8%), and held conservative political beliefs (54.8%). Three-fourths of all respondents believed that at least 40% of patients survive cardiac arrest when EMS services are received. Over half (56.7%) believed that Emergency Medical Technician (EMT)-Basics and EMT-Paramedics provide the same level of care. The estimated median hours of training required for EMT-Basics was 100 hours (IQR: 40-200 hours), while the vast majority of respondents estimated that EMT-Paramedics are required to take fewer than 1,000 clock hours of training (99.3%). The majority believed EMS professionals should be screened for illegal drug use (97.0%), criminal background (95.9%), mental health (95.2%), and physical fitness (91.3%). Over one-third (37.6%) had used EMS within the past five years. Of these individuals, over two-thirds (69.6%) rated their most recent experience as “excellent.” More of those who used EMS at least once in the past five years reported a willingness to consent to participate in EMS research compared with those who had not used EMS (69.9% vs. 61.4%, P=.005).

Most respondents who had used EMS services rated their experience as excellent. Nevertheless, expectations related to survival after cardiac arrest in the out-of-hospital setting were not realistic. Furthermore, much of the public was unaware of the differences in training hour requirements and level of care provided by EMT-Basics and EMT-Paramedics.

CroweRP, LevineR, RodriguezS, LarrimoreAD, PirralloRG. Public Perception of Emergency Medical Services in the United States. Prehosp Disaster Med. 2016;31(Suppl. 1):s112–s117.

Bystander cardiopulmonary resuscitation (CPR) improves survival after prehospital cardiac arrest. While community CPR training programs have been implemented across the US, little is known about their acceptability in non-US Latino populations.

The purpose of this study was to identify barriers to enrolling in CPR training classes and performing CPR in San José, Costa Rica.

After consulting 10 San José residents, a survey was created, pilot-tested, and distributed to a convenience sample of community members in public gathering places in San José. Questions included demographics, CPR knowledge and beliefs, prior CPR training, having a family member with heart disease, and prior witnessing of a cardiac arrest. Questions also addressed barriers to enrolling in CPR classes (cost/competing priorities). The analysis focused on two main outcomes: likelihood of registering for a CPR class and willingness to perform CPR on an adult stranger. Odds ratios and 95% CIs were calculated to test for associations between patient characteristics and these outcomes.

Among 371 participants, most were male (60%) and <40 years old (77%); 31% had a college degree. Many had family members with heart disease (36%), had witnessed a cardiac arrest (18%), were trained in CPR (36%), and knew the correct CPR steps (70%). Overall, 55% (95% CI, 50-60%) indicated they would “likely” enroll in a CPR class; 74% (95% CI, 70-78%) would perform CPR on an adult stranger. Cardiopulmonary resuscitation class enrollment was associated with prior CPR training (OR: 2.6; 95% CI, 1.6-4.3) and a prior witnessed cardiac arrest (OR: 2.0; 95% CI, 1.1-3.5). Willingness to perform CPR on a stranger was associated with a prior witnessed cardiac arrest (OR: 2.5; 95% CI, 1.2-5.4) and higher education (OR: 1.9; 95% CI, 1.1-3.2). Believing that CPR does not work was associated with a higher likelihood of not attending a CPR class (OR: 2.4; 95% CI, 1.7-7.9). Fear of performing mouth-mouth, believing CPR is against God’s will, and fear of legal risk were associated with a likelihood of not attending a CPR class and not performing CPR on a stranger (range of ORs: 2.4-3.9).

Most San José residents are willing to take CPR classes and perform CPR on a stranger. To implement a community CPR program, barriers must be considered, including misgivings about CPR efficacy and legal risk. Hands-only CPR programs may alleviate hesitancy to perform mouth-to-mouth.

SchmidKM, Mould-MillmanNK, HammesA, KroehlM, Quiros GarcíaR, Umaña McDermottM, LowensteinSR. Barriers and Facilitators to Community CPR Education in San José, Costa Rica. Prehosp Disaster Med. 2016;31(5):509–515.

The objective of this study was to assess the accuracy and safety of two pre-defined checklists to identify prehospital post-ictal or hypoglycemic patients who could be discharged at the scene.

A retrospective cohort study of lower acuity, adult patients attended by paramedics in 2013, and who were either post-ictal or hypoglycemic, was conducted. Two self-care pathway assessment checklists (one each for post-ictal and hypoglycemia) designed as clinical decision tools for paramedics to identify patients suitable for discharge at the scene were used. The intention of the checklists was to provide paramedics with justification to not transport a patient if all checklist criteria were met. Actual patient destination (emergency department [ED] or discharge at the scene) and subsequent events (eg, ambulance requests) were compared between patients who did and did not fulfill the checklists. The performance of the checklists against the destination determined by paramedics was also assessed.

Totals of 629 post-ictal and 609 hypoglycemic patients were identified. Of these, 91 (14.5%) and 37 (6.1%) patients fulfilled the respective checklist. Among those who fulfilled the checklist, 25 (27.5%) post-ictal and 18 (48.6%) hypoglycemic patients were discharged at the scene, and 21 (23.1%) and seven (18.9%) were admitted to hospital after ED assessment. Amongst post-ictal patients, those fulfilling the checklist had more subsequent ambulance requests (P=.01) and ED attendances with seizure-related conditions (P=.04) within three days than those who did not. Amongst hypoglycemic patients, there were no significant differences in subsequent events between those who did and did not meet the criteria. Paramedics discharged five times more hypoglycemic patients at the scene than the checklist predicted with no significant differences in the rate of subsequent events. Four deaths (0.66%) occurred within seven days in the hypoglycemic cohort, and none of them were attributed directly to hypoglycemia.

The checklists did not accurately identify patients suitable for discharge at the scene within the Emergency Medical Service. Patients who fulfilled the post-ictal checklist made more subsequent health care service requests within three days than those who did not. Both checklists showed similar occurrence of subsequent events to paramedics’ decision, but the hypoglycemia checklist identified fewer patients who could be discharged at the scene than paramedics actually discharged. Reliance on these checklists may increase transportations to ED and delay initiation of appropriate treatment at a hospital.

TohiraH , FatovichD , WilliamsTA , BremnerA , ArendtsG , RogersIR , CelenzaA , MountainD , CameronP , SprivulisP , AhernT , FinnJ . Paramedic Checklists do not Accurately Identify Post-ictal or Hypoglycaemic Patients Suitable for Discharge at the Scene. Prehosp Disaster Med. 2016;31(3):282–293.

In resource-constrained environments, appropriately employing triage in disaster situations is crucial. Although both case-based learning (CBL) and simulation exercises (SEs) commonly are utilized in teaching disaster preparedness to adult learners, there is no substantial evidence supporting one as a more efficacious methodology. This randomized controlled trial (RCT) evaluated the effectiveness of CBL versus SEs in addition to standard didactic instruction in knowledge attainment pertaining to disaster triage preparedness.

This RCT was performed during a one-day disaster preparedness course in Lucknow, India during October 2014. Following provision of informed consent, nursing trainees were randomized to knowledge assessment after didactic teaching (control group); didactic plus CBL (Intervention Group 1); or didactic plus SE (Intervention Group 2). The educational curriculum used the topical focus of triage processes during disaster situations. Cases for the educational intervention sessions were scripted, identical between modalities, and employed structured debriefing. Trained live actors were used for SEs. After primary assessment, the groups underwent crossover to take part in the alternative educational modality and were re-assessed. Two standardized multiple-choice question batteries, encompassing key core content, were used for assessments. A sample size of 48 participants was calculated to detect a ≥20% change in mean knowledge score (α=0.05; power=80%). Robustness of randomization was evaluated using X2, anova, and t-tests. Mean knowledge attainment scores were compared using one- and two-sample t-tests for intergroup and intragroup analyses, respectively.

Among 60 enrolled participants, 88.3% completed follow-up. No significant differences in participant characteristics existed between randomization arms. Mean baseline knowledge score in the control group was 43.8% (standard deviation=11.0%). Case-based learning training resulted in a significant increase in relative knowledge scores at 20.8% (P=0.003) and 10.3% (P=.033) in intergroup and intragroup analyses, respectively. As compared to control, SEs did not significantly alter knowledge attainment scores with an average score increase of 6.6% (P=.396). In crossover intra-arm analysis, SEs were found to result in a 26.0% decrement in mean assessment score (P < .001).

Among nursing trainees assessed in this RCT, the CBL modality was superior to SEs in short-term disaster preparedness educational translation. Simulation exercises resulted in no detectable improvement in knowledge attainment in this population, suggesting that CBL may be utilized preferentially for adult learners in similar disaster training settings.

AluisioAR, DanielP, GrockA, FreedmanJ, SinghA, PapanagnouD, ArquillaB. Case-based Learning Outperformed Simulation Exercises in Disaster Preparedness Education Among Nursing Trainees in India: A Randomized Controlled Trial. Prehosp Disaster Med. 2016;31(5):516–523.

Violence against women (VAW) is one of the most widespread violations of human rights and a major barrier to achieving gender equality. Violence against women is increased in disaster-stricken communities. Violence experiences, cases, and lessons-learned concerning Iran’s disasters have not been investigated, documented, or shared so far. To fill this knowledge gap, this qualitative study aimed to explore types of VAW and girls after the recent quakes and floods in Iran.

The objective for this study was exploring the manifestations of VAW after the natural disasters in Iran.

A qualitative approach was used for this study. Data were collected by in-depth, unstructured interviews and field observations in three affected regions of Iran, including East Azerbaijan, Bushehr, and Mazandaran. A total of 15 participants, eight damaged women as well as seven key informants, were interviewed. A content analysis using Graneheim approach was performed for analyzing transcribed interviews.

Two main themes were extracted from data, including domestic violence and violence within community. The first theme included three categories: physical, psychological, and sexual violence. Psychological violence and sexual harassment were two categories of violence within the community concept.

Different types of violence emerged from the present research that can be anticipated and integrated into future disaster medicine plans, public health reforms, and national rules of Iran. Improving women’s knowledge on their rights to have a life without violence, and participation of both women and men in violence reduction projects, can be considered in all disaster management phases.

SohrabizadehS . A Qualitative Study of Violence Against Women after the Recent Disasters of Iran. Prehosp Disaster Med. 2016;31(4):407–412.

Disaster and humanitarian responders are at-risk of experiencing a wide range of physical and psychological health conditions, from minor injuries to chronic mental health problems and fatalities. This article reviews the current literature on the major health outcomes of responders to various disasters and conflicts in order to better inform individuals of the risks and to inform deploying agencies of the health care needs of responders.

In March 2014, an EMBASE search was conducted using pre-defined search criteria. Two reviewers screened the resultant 2,849 abstracts and the 66 full-length manuscripts which are included in the review.

The majority of research on health outcomes of responders focused on mental health (57 of 66 articles). Posttraumatic stress disorder (PTSD) and depression were the most studied diagnoses with prevalence of PTSD ranging from 0%-34% and depression from 21%-53%. Physical health outcomes were much less well-studied and included a wide range of environmental, infectious, and traumatic conditions such as heat stroke, insect bites, dermatologic, gastrointestinal, and respiratory diseases, as well as burns, fractures, falls, and other traumatic injuries.

The prevalence of mental health disorders in responders may vary more and be higher than previously suggested. Overall health outcomes of responders are likely poorly monitored and under-reported. Improved surveillance systems and risk mitigation strategies should be employed in all disaster and conflict responses to better protect individual responders.

GarbernSC , EbbelingLG , BartelsSA . A Systematic Review of Health Outcomes Among Disaster and Humanitarian Responders. Prehosp Disaster Med. 2016;31(6):635–642.

Paramedicine is experiencing significant growth in scope of practice, autonomy, and role in the health care system. Despite clinical governance models, the degree to which paramedicine ultimately can be safe and effective will be dependent on the individuals the profession deems suited to practice. This creates an imperative for those responsible for these decisions to ensure that assessments of paramedic competence are indeed accurate, trustworthy, and defensible.

The purpose of this study was to explore and synthesize relevant theoretical foundations and literature informing best practices in performance-based assessment (PBA) of competence, as it might be applied to paramedicine, for design or evaluation of assessment programs.

A narrative review methodology was applied to focus intentionally, but broadly, on purpose relevant, theoretically derived research that could inform assessment protocols in paramedicine. Primary and secondary studies from a number of health professions that contributed to and informed best practices related to the assessment of paramedic clinical competence were included and synthesized.

Multiple conceptual frameworks, psychometric requirements, and emerging lines of research are forwarded. Seventeen practice implications are derived to promote understanding as well as best practices and evaluation criteria for educators, employers, and/or licensing/certifying bodies when considering the assessment of paramedic competence.

The assessment of paramedic competence is a complex process requiring an understanding, appreciation for, and integration of conceptual and psychometric principles. The field of PBA is advancing rapidly with numerous opportunities for research.

TavaresW , BoetS . On the Assessment of Paramedic Competence: A Narrative Review with Practice Implications. Prehosp Disaster Med. 2016;31(1):64–73.

Though the US civilian trauma care system plays a critical role in disaster response, there is currently no systems-based strategy that enables hospital emergency management and local and regional emergency planners to quantify, and potentially prepare for, surges in trauma care demand that accompany mass-casualty disasters.

A proof-of-concept model that estimates the geographic distributions of patients, trauma center resource usage, and mortality rates for varying disaster sizes, in and around the 25 largest US cities, is presented. The model was designed to be scalable, and its inputs can be modified depending on the planning assumptions of different locales and for different types of mass-casualty events.

To demonstrate the model’s potential application to real-life planning scenarios, sample disaster responses for 25 major US cities were investigated using a hybrid of geographic information systems and dynamic simulation-optimization. In each city, a simulated, fast-onset disaster epicenter, such as might occur with a bombing, was located randomly within one mile of its population center. Patients then were assigned and transported, in simulation, via the new model to Level 1, 2, and 3 trauma centers, in and around each city, over a 48-hour period for disaster scenario sizes of 100, 500, 5000, and 10,000 casualties.

Across all 25 cities, total mean mortality rates ranged from 26.3% in the smallest disaster scenario to 41.9% in the largest. Out-of-hospital mortality rates increased (from 21.3% to 38.5%) while in-hospital mortality rates decreased (from 5.0% to 3.4%) as disaster scenario sizes increased. The mean number of trauma centers involved ranged from 3.0 in the smallest disaster scenario to 63.4 in the largest. Cities that were less geographically isolated with more concentrated trauma centers in their surrounding regions had lower total and out-of-hospital mortality rates. The nine US cities listed as being the most likely targets of terrorist attacks involved, on average, more trauma centers and had lower mortality rates compared with the remaining 16 cities.

The disaster response simulation model discussed here may offer insights to emergency planners and health systems in more realistically planning for mass-casualty events. Longer wait and transport times needed to distribute high numbers of patients to distant trauma centers in fast-onset disasters may create predictable increases in mortality and trauma center resource consumption. The results of the modeled scenarios indicate the need for a systems-based approach to trauma care management during disasters, since the local trauma center network was often too small to provide adequate care for the projected patient surge. Simulation of out-of-hospital resources that might be called upon during disasters, as well as guidance in the appropriate execution of mutual aid agreements and prevention of over-response, could be of value to preparedness planners and emergency response leaders. Study assumptions and limitations are discussed.

CarrBG, WalshL, WilliamsJC, PryorJP, BranasCC. A Geographic Simulation Model for the Treatment of Trauma Patients in Disasters. Prehosp Disaster Med.2016;31(4):413–421.

This study aimed to review available disaster training options for health care providers, and to provide specific recommendations for developing and delivering a disaster-response-training program for non-disaster-trained emergency physicians, residents, and trainees prior to acute deployment.

A comprehensive review of the peer-reviewed and grey literature of the existing training options for health care providers was conducted to provide specific recommendations.

A comprehensive search of the Pubmed, Embase, Web of Science, Scopus, and Cochrane databases was performed to identify publications related to courses for disaster preparedness and response training for health care professionals. This search revealed 7,681 unique titles, of which 53 articles were included in the full review. A total of 384 courses were found through the grey literature search, and many of these were available online for no charge and could be completed in less than six hours. The majority of courses focused on management and disaster planning; few focused on clinical care and acute response.

There is need for a course that is targeted toward emergency physicians and trainees without formal disaster training. This course should be available online and should utilize a mix of educational modalities, including lectures, scenarios, and virtual simulations. An ideal course should focus on disaster preparedness, and the clinical and non-clinical aspects of response, with a focus on an all-hazards approach, including both terrorism-related and environmental disasters.

HansotiB, KelloggDS, AberleSJ, BroccoliMC, FedenJ, FrenchA, LittleCM, MooreB, SabatoJJr., SheetsT, WeinbergR, ElmesP, KangC. Preparing Emergency Physicians for Acute Disaster Response: A Review of Current Training Opportunities in the US. Prehosp Disaster Med. 2016;31(6):643–647.

As attention to emergency preparedness becomes a critical element of health care facility operations planning, efforts to recognize and integrate the needs of vulnerable populations in a comprehensive manner have lagged. This not only results in decreased levels of equitable service, but also affects the functioning of the health care system in disasters. While this report emphasizes the United States context, the concepts and approaches apply beyond this setting.

This report: (1) describes a conceptual framework that provides a model for the inclusion of vulnerable populations into integrated health care and public health preparedness; and (2) applies this model to a pilot study.

The framework is derived from literature, hospital regulatory policy, and health care standards, laying out the communication and relational interfaces that must occur at the systems, organizational, and community levels for a successful multi-level health care systems response that is inclusive of diverse populations explicitly. The pilot study illustrates the application of key elements of the framework, using a four-pronged approach that incorporates both quantitative and qualitative methods for deriving information that can inform hospital and health facility preparedness planning.

The conceptual framework and model, applied to a pilot project, guide expanded work that ultimately can result in methodologically robust approaches to comprehensively incorporating vulnerable populations into the fabric of hospital disaster preparedness at levels from local to national, thus supporting best practices for a community resilience approach to disaster preparedness.

KreisbergD , ThomasDSK , ValleyM , NewellS , JanesE , LittleC . Vulnerable Populations in Hospital and Health Care Emergency Preparedness Planning: A Comprehensive Framework for Inclusion. Prehosp Disaster Med. 2016;31(2):211–219.

Survivors of natural disasters in the United States experience significant health ramifications. Women particularly are vulnerable to both post-disaster posttraumatic stress disorder (PTSD) and depression, and research has documented that these psychopathological sequelae often are correlated with increased incidence of intimate partner violence (IPV). Understanding the link between these health concerns is crucial to informing adequate disaster response and relief efforts for victims of natural disaster.

The purpose of this review was to report the results of a scoping review on the specific mental health effects that commonly impact women following natural disasters, and to develop a conceptual framework with which to guide future research.

A scoping review of mental and physical health effects experienced by women following natural disasters in the United States was conducted. Articles from 2000-2015 were included. Databases examined were PubMed, PsycInfo, Cochrane, JSTOR, Web of Science, and databases available through ProQuest, including ProQuest Research Library.

A total of 58 articles were selected for inclusion, out of an original 149 that were selected for full-text review. Forty-eight articles, or 82.8%, focused on mental health outcomes. Ten articles, or 17.2%, focused on IPV.

Certain mental health outcomes, including PTSD, depression, and other significant mental health concerns, were recurrent issues for women post-disaster. Despite the strong correlation between experience of mental health consequences after disaster and increased risk of domestic violence, studies on the risk and mediating factors are rare. The specific challenges faced by women and the interrelation between negative mental health outcomes and heightened exposure to IPV following disasters require a solid evidence base in order to facilitate the development of effective interventions. Additional research informed by theory on probable health impacts is necessary to improve development/implementation of emergency relief policy.

BellSA, FolkerthLA. Women’s Mental Health and Intimate Partner Violence Following Natural Disaster: A Scoping Review. Prehosp Disaster Med. 2016;31(6):648–657.