Triage is the systematic prioritization of casualties when there is an imbalance between the needs of these casualties and resource availability. The triage sieve is a recognized process for prioritizing casualties for treatment during mass-casualty incidents (MCIs). While the application of a triage sieve generally is well-accepted, the measurement of its accuracy has been somewhat limited. Obtaining reliable measures for triage sieve accuracy rates is viewed as a necessity for future development in this area.

The goal of this study was to investigate how theoretical knowledge acquisition and the practical application of an aide-memoir impacted triage sieve accuracy rates.

Two hundred and ninety-two paramedics were allocated randomly to one of four separate sub-groups, a non-intervention control group, and three intervention groups, which involved them receiving either an educational review session and/or an aide-memoir. Participants were asked to triage sieve 20 casualties using a previously trialed questionnaire.

The study showed the non-intervention control group had a correct accuracy rate of 47%, a similar proportion of casualties found to be under-triaged (37%), but a significantly lower number of casualties were over-triaged (16%). The provision of either an educational review or aide-memoir significantly increased the correct triage sieve accuracy rate to 77% and 90%, respectively. Participants who received both the educational review and aide-memoir had an overall accuracy rate of 89%. Over-triaged rates were found not to differ significantly across any of the study groups.

This study supports the use of an aide-memoir for maximizing MCI triage accuracy rates. A “just-in-time” educational refresher provided comparable benefits, however its practical application to the MCI setting has significant operational limitations. In addition, this study provides some guidance on triage sieve accuracy rate measures that can be applied to define acceptable performance of a triage sieve during a MCI.

CuttanceG, DansieK, RaynerT. Paramedic Application of a Triage Sieve: A Paper-Based Exercise. Prehosp Disaster Med. 2017;32(1):3–13.

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

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

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

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

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

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

Previous studies have illustrated pediatric knowledge deficits among Emergency Medical Services (EMS) providers. The purpose of this study was to identify perspectives of a diverse group of EMS providers regarding pediatric prehospital care educational deficits and proposed methods of training improvements.

Purposive sampling was used to recruit EMS providers in diverse settings for study participation. Two separate focus groups of EMS providers (administrative and non-administrative personnel) were held in three locations (urban, suburban, and rural). A professional moderator facilitated focus group discussion using a guide developed by the study team. A grounded theory approach was used to analyze data.

Forty-two participants provided data. Four major themes were identified: (1) suboptimal previous pediatric training and training gaps in continuing pediatric education; (2) opportunities for improved interactions with emergency department (ED) staff, including case-based feedback on patient care; (3) barriers to optimal pediatric prehospital care; and (4) proposed pediatric training improvements.

Focus groups identified four themes surrounding preparation of EMS personnel for providing care to pediatric patients. These themes can guide future educational interventions for EMS to improve pediatric prehospital care.

BrownSA , HaydenTC , RandellKA , RappaportL , StevensonMD , KimIK . Improving Pediatric Education for Emergency Medical Services Providers: A Qualitative Study. Prehosp Disaster Med. 2017;32(1):20–26.

Survival rates after out-of-hospital cardiac arrest (OHCA) vary considerably among regions. The chance of survival is increased significantly by lay rescuer cardiopulmonary resuscitation (CPR) before Emergency Medical Services (EMS) arrival. It is well known that for bystanders, reasons for not providing CPR when witnessing an OHCA incident may be fear and the feeling of being exposed to risk. The aim of this study was to gain a better understanding of why barriers to providing CPR are overcome.

Using a semi-structured interview guide, 10 lay rescuers were interviewed after participating in eight OHCA incidents. Qualitative content analysis was used. The lay rescuers were questioned about their CPR-knowledge, expectations, and reactions to the EMS and from others involved in the OHCA incident. They also were questioned about attitudes towards providing CPR in an OHCA incident in different contexts.

The lay rescuers reported that they were prepared to provide CPR to anybody, anywhere. Comprehending the severity in the OHCA incident, both trained and untrained lay rescuers provided CPR. They considered CPR provision to be the expected behavior of any community citizen and the EMS to act professionally and urgently. However, when asked to imagine an OHCA in an unclear setting, they revealed hesitation about providing CPR because of risk to their own safety.

Mutual trust between community citizens and towards social institutions may be reasons for overcoming barriers in providing CPR by lay rescuers. A normative obligation to act, regardless of CPR training and, importantly, without facing any adverse legal reactions, also seems to be an important factor behind CPR provision.

MathiesenWT, BjørsholCA, HøylandS, BrautGS, SøreideE. Exploring How Lay Rescuers Overcome Barriers to Provide Cardiopulmonary Resuscitation: A Qualitative Study. Prehosp Disaster Med. 2017;32(1):27–32.

Makkah (Mecca) is a holy city located in the western region of the Kingdom of Saudi Arabia. Each year, millions of pilgrims visit Makkah. These numbers impact both routine health care delivery and disaster response. This study aimed to evaluate hospitals’ disaster plans in the city of Makkah.

Study investigators administered a questionnaire survey to 17 hospitals in the city of Makkah. Data on hospital characteristics and three key domains of disaster plans (general evaluation of disaster planning, structural feasibility of the hospitals, and health care worker knowledge and training) were collated and analyzed.

A response rate of 82% (n=14) was attained. Ten (71%) of the hospitals were government hospitals, whereas four were private hospitals. Eleven (79%) hospitals had a capacity of less than 300 beds.

Only nine (64%) hospitals reviewed their disaster plan within the preceding two years. Nine (64%) respondents were drilling for disasters at least twice per year. The majority of hospitals did not rely on a hazard vulnerability analysis (HVA) to develop their Emergency Operations Plan. Eleven (79%) hospitals had the Hospital Incident Command Systems (HICS) present in their plans.

All hospitals described availability of some supplies required for the first 24 hours of a disaster response, such as: N95 masks, antidotes for nerve agents, and antiviral medications. Only five (36%) hospitals had a designated decontamination area. Nine (64%) hospitals reported ability to re-designate inpatient wards into an intensive care unit (ICU) format. Only seven (50%) respondents had a protocol for increasing availability of isolation rooms to prevent the spread of airborne infection. Ten (71%) hospitals had a designated disaster-training program for health care workers.

Makkah has experienced multiple disaster incidents over the last decade. The present research suggests that Makkah hospitals are insufficiently prepared for potential future disasters. This may represent a considerable threat to the health of both residents and visitors to Makkah. This study demonstrated that there is significant room for improvement in most aspects of hospital Emergency Operations Plans, in particular: reviewing the plan and increasing the frequency of multi-agency and multi-hospital drills. Preparedness for terrorism utilizing chemical, biologic, radiation, nuclear, explosion (CBRNE) and infectious diseases was found to be sub-optimal and should be assessed further.

Al-ShareefAS , AlsulimaniLK , BojanHM , MasriTM , GrimesJO , MolloyMS , CiottoneGR . Evaluation of Hospitals’ Disaster Preparedness Plans in the Holy City of Makkah (Mecca): A Cross-Sectional Observation Study. Prehosp Disaster Med. 2017;32(1):33–45.

There have been numerous initiatives by government and private organizations to help hospitals become better prepared for major disasters and public health emergencies. This study reports on efforts by the US Department of Veterans Affairs (VA), Veterans Health Administration, Office of Emergency Management’s (OEM) Comprehensive Emergency Management Program (CEMP) to assess the readiness of VA Medical Centers (VAMCs) across the nation.

This study conducts descriptive analyses of preparedness assessments of VAMCs and examines change in hospital readiness over time.

To assess change, quantitative analyses of data from two phases of preparedness assessments (Phase I: 2008-2010; Phase II: 2011-2013) at 137 VAMCs were conducted using 61 unique capabilities assessed during the two phases. The initial five-point Likert-like scale used to rate each capability was collapsed into a dichotomous variable: “not-developed=0” versus “developed=1.” To describe changes in preparedness over time, four new categories were created from the Phase I and Phase II dichotomous variables: (1) rated developed in both phases; (2) rated not-developed in Phase I but rated developed in Phase II; (3) rated not-developed in both phases; and (4) rated developed in Phase I but rated not- developed in Phase II.

From a total of 61 unique emergency preparedness capabilities, 33 items achieved the desired outcome – they were rated either “developed in both phases” or “became developed” in Phase II for at least 80% of VAMCs. For 14 items, 70%-80% of VAMCs achieved the desired outcome. The remaining 14 items were identified as “low-performing” capabilities, defined as less than 70% of VAMCs achieved the desired outcome.

Measuring emergency management capabilities is a necessary first step to improving those capabilities. Furthermore, assessing hospital readiness over time and creating robust hospital readiness assessment tools can help hospitals make informed decisions regarding allocation of resources to ensure patient safety, provide timely access to high-quality patient care, and identify best practices in emergency management during and after disasters. Moreover, with some minor modifications, this comprehensive, all-hazards-based, hospital preparedness assessment tool could be adapted for use beyond the VA.

Der-MartirosianC, RadcliffTA, GableAR, RiopelleD, HagigiFA, BrewsterP, DobalianA. Assessing Hospital Disaster Readiness Over Time at the US Department of Veterans Affairs. Prehsop Disaster Med. 2017;32(1):46–57.

Deaths at music festivals are not infrequently reported in the media; however, the true mortality burden is difficult to determine as the deaths are not yet systematically documented in the academic literature.

This was a literature search for case examples using academic and gray literature sources, employing both retrospective and prospective searches of media sources from 1999-2014.

The gray literature documents a total of 722 deaths, including traumatic (594/722; 82%) and non-traumatic (128/722; 18%) causes. Fatalities were caused by trampling (n=479), motor-vehicle-related (n=39), structural collapses (n=28), acts of terror (n=26), drowning (n=8), assaults (n=6), falls (n=5), hanging (n=2), and thermal injury (n=2). Non-traumatic deaths included overdoses (n=96/722; 13%), environmental causes (n=8/722; 1%), natural causes (n=10/722; 1%), and unknown/not reported (n=14/722; 2%). The majority of non-trauma-related deaths were related to overdose (75%).

The academic literature documents trauma-related deaths (n=368) and overdose-related deaths (n=12). One hundred percent of the trauma-related deaths reported in the academic literature also were reported in the gray literature (n=368). Mortality rates cannot be reported as the total attendance at events is not known.

The methodology presented in this manuscript confirms that deaths occur not uncommonly at music festivals, and it represents a starting point in the documentation and surveillance of mortality.

TurrisSA , LundA . Mortality at Music Festivals: Academic and Grey Literature for Case Finding. Prehosp Disaster Med. 2017;32(1):58–63.

Prehospital care is one of the many issues that require addressing by lower-middle income countries (LMICs) where approximately 90% of global injuries occur. This may arise from more traffic in LMICs, poor road conditions, lack of public awareness of the importance of road safety, and the lack of ability to provide first aid to the victims. However, prehospital care in LMICs remains underdeveloped.

There is insufficient evidence regarding the development of prehospital care among LMICs. Thus, the objective of this study was to investigate the status of Emergency Medical Services (EMS) systems in these countries.

A review of medical-related electronic databases was designed to identify the development of EMS systems in LMICs. A search of the literature was undertaken using three electronic databases, CINAHL, Ovid Medline, and EMBASE via Ovid, from their commencement date until the end of July 2015. The grey literature was searched using Google Scholar. Articles were included if they reported on the establishment and current status of an EMS system and were excluded if they were letters to the editor, articles focusing on disaster management, a combination of more than one country if the other country was not a LMIC, written in a language other than English or Bahasa Indonesia, and/or focusing only on in-hospital care.

There were 337 articles identified in CINAHL, 731 in Ovid Medline, 891 in EMBASE via Ovid, and 41 in Google Scholar. Based on the title and abstract, 31 articles from CINAHL, 40 from Ovid Medline, 43 from EMBASE, and 11 from Google Scholar were retrieved for further review. There were 92 articles that met the inclusion criteria with 35 articles removed, as they were duplicated, leaving 57 articles to be reviewed. From those 48 countries categorized as LMICs, there were 16 (33.3%) countries that had information about an EMS system, including injury types, patient demographic, prehospital transport, and the obstacles in implementing the prehospital care system.

The implementation and development of an EMS system is varied among LMICs. Many LMICs lack an organized EMS system with most ambulances used purely for transport and not as an emergency care vehicle. Financial issues are the most common problems faced by LMICs with support from developed countries a necessity.

Suryanto, PlummerV, BoyleM. EMS Systems in Lower-Middle Income Countries: A Literature Review. Prehosp Disaster Med. 2017;32(1):64–70.

During a mass gathering, some participants may receive health care for injuries or illnesses that occur during the event. In-event first responders provide initial assessment and management at the event. However, when further definitive care is required, municipal ambulance services provide additional assessment, treatment, and transport of participants to acute care settings, such as hospitals. The impact on both ambulance services and hospitals from mass-gathering events is the focus of this literature review.

This literature review aimed to develop an understanding of the impact of mass gatherings on local health services, specifically pertaining to in-event and external health services.

This research used a systematic literature review methodology. Electronic databases were searched to find articles related to the aim of the review. Articles focused on mass-gathering health, provision of in-event health services, ambulance service transportation, and hospital utilization.

Twenty-four studies were identified for inclusion in this review. These studies were all case-study-based and retrospective in design. The majority of studies (n=23) provided details of in-event first responder services. There was variation noted in reporting of the number and type of in-event health professional services at mass gatherings. All articles reported that patients were transported to hospital by the ambulance service. Only nine articles reported on patients presenting to hospital. However, details pertaining to the impact on ambulance and hospital services were not reported.

There is minimal research focusing on the impact of mass gatherings on in-event and external health services, such as ambulance services and hospitals. A recommendation for future mass-gathering research and evaluation is to link patient-level data from in-event mass gatherings to external health services. This type of study design would provide information regarding the impact on health services from a mass gathering to more accurately inform future health planning for mass gatherings across the health care continuum.

RanseJ, HuttonA, KeeneT, LensonS, LutherM, BostN, JohnstonANB, CrillyJ, CannonM, JonesN, HayesC, BurkeB. Health Service Impact from Mass Gatherings: A Systematic Literature Review. Prehosp Disaster Med. 2017;32(1):71–77.

This study aimed to document the growth and challenges encountered in the decade since inception of the National Ambulance Service (NAS) in Ghana, West Africa. By doing so, potentially instructive examples for other low- and middle-income countries (LMICs) planning a formal prehospital care system or attempting to identify ways to improve existing emergency services could be identified.

Data routinely collected by the Ghana NAS from 2004-2014 were described, including: patient demographics, reason for the call, response location, target destination, and ti1mes of service. Additionally, the organizational structure and challenges encountered during the development and maturation of the NAS were reported.

In 2004, the NAS piloted operations with 69 newly trained emergency medical technicians (EMTs), nine ambulances, and seven stations. The NAS expanded service delivery with 199 ambulances at 128 stations operated by 1,651 EMTs and 47 administrative and maintenance staff in 2014. In 2004, nine percent of the country was covered by NAS services; in 2014, 81% of Ghana was covered. Health care transfers and roadside responses comprised the majority of services (43%-80% and 10%-57% by year, respectively). Increased mean response time, stable case holding time, and shorter vehicle engaged time reflect greater response ranges due to increased service uptake and improved efficiency of ambulance usage. Specific internal and external challenges with regard to NAS operations also were described.

The steady growth of the NAS is evidence of the need for Emergency Medical Services and the effects of sound planning and timely responses to changes in program indicators. The way forward includes further capacity building to increase the number of scene responses, strengthening ties with local health facilities to ensure timely emergency medical care and appropriateness of transfers, assuring a more stable funding stream, and improving public awareness of NAS services.

ZakariahA , StewartBT , BoatengE , AchenaC , TansleyG , MockC . The Birth and Growth of the National Ambulance Service in Ghana. Prehosp Disaster Med. 2017;32(1):83–93.

A model prepared by National Civil Defense (INDECI; Lima, Peru) estimated that an earthquake with an intensity of 8.0 Mw in front of the central coast of Peru would result in 51,019 deaths and 686,105 injured in districts of Metropolitan Lima and Callao. Using this information as a base, a study was designed to determine the characteristics of the demand for treatment in public hospitals and to estimate gaps in care in the hours immediately after such an event.

A probabilistic model was designed that included the following variables: demand for hospital care; time of arrival at the hospitals; type of medical treatment; reason for hospital admission; and the need for specialized care like hemodialysis, blood transfusions, and surgical procedures. The values for these variables were obtained through a literature search of the databases of the MEDLINE medical bibliography, the Cochrane and SciELO libraries, and Google Scholar for information on earthquakes over the last 30 years of over magnitude 6.0 on the moment magnitude scale.

If a high-magnitude earthquake were to occur in Lima, it was estimated that between 23,328 and 178,387 injured would go to hospitals, of which between 4,666 and 121,303 would require inpatient care, while between 18,662 and 57,084 could be treated as outpatients. It was estimated that there would be an average of 8,768 cases of crush syndrome and 54,217 cases of other health problems. Enough blood would be required for 8,761 wounded in the first 24 hours. Furthermore, it was expected that there would be a deficit of hospital beds and operating theaters due to the high demand.

Sudden and violent disasters, such as earthquakes, represent significant challenges for health systems and services. This study shows the deficit of preparation and capacity to respond to a possible high-magnitude earthquake. The study also showed there are not enough resources to face mega-disasters, especially in large cities.

BambarénC, UyenA, RodriguezM. Estimation of the Demand for Hospital Care After a Possible High-Magnitude Earthquake in the City of Lima, Peru. Prehosp Disaster Med. 2017;32(1):106–111.