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Disasters are high-stakes, low-frequency events. Telemedicine may offer a useful adjunct for paramedics performing disaster triage. The objective of this study was to determine the feasibility of telemedicine in disaster triage, and to determine whether telemedicine has an effect on the accuracy of triage or the time needed to perform triage.
Methods
This is a feasibility study in which an intervention team of two paramedics used the mobile device Google Glass (Google Inc; Mountain View, California USA) to communicate with an off-site physician disaster expert. The paramedic team triaged simulated disaster victims at the triennial drill of a commercial airport. The simulated victims had preassigned expected triage levels. The physician had an audio-video interface with the paramedic team and was able to observe the victims remotely. A control team of two paramedics performed disaster triage in the usual fashion. Both teams used the SMART Triage System (TSG Associates LLP; Halifax, England), which assigns patients into Red, Yellow, Green, and Black triage categories. The paramedics were video recorded, and their time required to triage was logged. It was determined whether the intervention team and the control team varied regarding accuracy of triage. Finally, the amount of time the intervention team needed to triage patients when telemedicine was used was compared to when that team did not use telemedicine.
Results
The two teams triaged the same 20 patients. There was no significant difference between the two groups in overall triage accuracy (85.7% for the intervention group vs 75.9% for the control group; P = .39). Two patients were triaged with telemedicine. For the intervention group, there was a significant difference in time to triage patients with telemedicine versus those without telemedicine (35.5 seconds; 95% CI, 72.5-143.5 vs 18.5 seconds; 95% CI, 13.4-23.6; P = .041).
Conclusion
There was no increase in triage accuracy when paramedics evaluating disaster victims used telemedicine, and telemedicine required more time than conventional triage. There are a number of obstacles to available technology that, if overcome, might improve the utility of telemedicine in disaster response.
CiceroMX, WalshB, SoladY, WhitfillT, PaesanoG, KimK, BaumCR, ConeDC. Do You See What I See? Insights from Using Google Glass for Disaster Telemedicine Triage. Prehosp Disaster Med. 2015;30(1):1-5.
The Sendai Framework for Disaster Risk Reduction (DRR) 2015-2030 is the first of three United Nations (UN) landmark agreements this year (the other two being the Sustainable Development Goals due in September 2015 and the climate change agreements due in December 2015). It represents a step in the direction of global policy coherence with explicit reference to health, economic development, and climate change. The multiple efforts of the health community in the policy development process, including campaigning for safe schools and hospitals, helped to put people’s mental and physical health, resilience, and well-being higher up the DRR agenda compared with its predecessor, the 2005 Hyogo Framework for Action. This report reflects on these policy developments and their implications and reviews the range of health impacts from disasters; summarizes the widened remit of DRR in the post-2015 world; and finally, presents the science and health calls of the Sendai Framework to be implemented over the next 15 years to reduce disaster losses in lives and livelihoods.
Aitsi-SelmiA, MurrayV. Protecting the Health and Well-being of Populations from Disasters: Health and Health Care in The Sendai Framework for Disaster Risk Reduction 2015-2030. Prehosp Disaster Med. 2016;31(1):74–78.
Forced separation from one's home may trigger emotional distress. People who remain in their homes may experience emotional distress due to living in a severely damaged environment. These people experience a type of ‘homesickness’ similar to nostalgia because the land around them no longer resembles the home they knew and loved. What they lack is solace or comfort from their home; they long for the home environment to be the way it was before. “Solastalgia” is a term created to describe feelings which arise in people when an environment changes so much that it negatively affects an individual's quality of life. Such changed environments may include drought-stricken areas and open-cut mines. The aim of this article is to describe how solastalgia, originally conceptualized as the result of man-made environmental change, can be similarly applied to the survivors of natural disasters. Using volcanic eruptions as a case example, the authors argue that people who experience a natural disaster are likely to suffer from solastalgia for a number of reasons, which may include the loss of housing, livestock and farmland, and the ongoing danger of living in a disaster-prone area. These losses and fears challenge people's established sense of place and identity and can lead to feelings of helplessness and depression.
WarsiniS, MillsJ, UsherK. Solastalgia: Living With the Environmental Damage Caused By Natural Disasters. Prehosp Disaster Med. 2014:29(1);1-4.
Emergency response relies on the assumption that essential health care services will continue to operate and be available to provide quality patient care during and after a patient surge. The observed successes and failures of health care systems during recent mass-casualty events and the concern that these assumptions are not evidence based prompted this review.
Method
The aims of this systematic review were to explore the factors associated with the intention of health care personnel (HCP) to respond to uncommon events, such as a natural disaster or pandemic, determine the state of the science, and bolster evidence-based measures that have been shown to facilitate staff response.
Results
Authors of the 70 studies (five mixed-methods, 49 quantitative, 16 qualitative) that met inclusion criteria reported a variety of variables that influenced the intent of HCP to respond. Current evidence suggests that four primary factors emerged as either facilitating or hindering the willingness of HCP to respond to an event: (1) the nature of the event; (2) competing obligations; (3) the work environment and climate; and (4) the relationship between knowledge and perceptions of efficacy.
Conclusions
Findings of this study could influence and strengthen policy making by emergency response planners, staffing coordinators, health educators, and health system administrators.
ConnorSB. When and Why Health Care Personnel Respond to a Disaster: The State of the Science. Prehosp Disaster Med. 2014;29(3):1-5.
Health care institutions constantly must be prepared for disaster response. However, there are deficiencies in the current level of preparedness. The aim of this study was to investigate the factors affecting the perception of health care workers (HCWs) towards individual and institutional preparedness for a disaster.
Methods
A survey on disaster incident preparedness was conducted among doctors, nurses, and allied health workers over a period of two months in 2010. The survey investigated perceptions of disaster preparedness at the individual and institutional level. Responses were measured using a five-point Likert scale. The primary outcomes were factors affecting HCWs’ perception of institution and individual preparedness. Secondary outcomes were the proportions of staff willing to participate and to place importance on disaster response training and their knowledge of access to such training. Data was analyzed using descriptive statistics. Logistic regression was performed to determine the factors that influenced the HCWs’ perception of their individual and institutional readiness. Odd ratios (ORs) of such factors were reported with their 95% confidence intervals (CIs).
Results
Of 1700 HCWs, 1534 (90.2%) completed the survey. 75.3% (1155/1534) felt that the institution was ready for a disaster incident, but only 36.4% (558/1534) felt that they (as individuals) were prepared. Some important factors associated with a positive perception of institution preparedness were leadership preparedness (OR = 13.19; 95% CI, 9.93-17.51), peer preparedness (OR = 6.11; 95% CI, 4.27-8.73) and availability of training opportunities (OR = 4.76; 95% CI, 3.65-6.22). Some important factors associated with a positive perception of individual preparedness were prior experience in disaster response (OR = 2.80; 95% CI, 1.99-3.93), institution preparedness (OR = 3.71; 95% CI, 2.68-5.14), peer preparedness (OR = 3.49; 95% CI, 2.75-4.26), previous training in disaster response (OR = 3.48; 95% CI, 2.76-4.39) and family support (OR = 3.22; 95% CI, 2.54-4.07). Most (80.7%, 1238/1534) were willing to participate in future disaster incident response training, while 74.5% (1143/1534) felt that being able to respond to a disaster incident constitutes part of their professional competency. However, only 27.8% (426/1534) knew how to access these training opportunities.
Conclusions
This study demonstrated that HCWs fare poorly in their perception of their individual preparedness. Important factors that might contribute to improving this perception at the individual and institution level have been identified. These factors could guide the review and implementation of future disaster incident response training in health care institutions.
LimGH, LimBL, VasuA. Survey of Factors Affecting Health Care Workers’ Perception Towards Institutional and Individual Disaster Preparedness. Prehosp Disaster Med. 2013;28(4):1-6.
Unacceptable practices in the delivery of international medical assistance are reported after every major international disaster; this raises concerns about the clinical competence and practice of some foreign medical teams (FMTs). The aim of this study is to explore and analyze the opinions of disaster management experts about potential deficiencies in the art and science of national and FMTs during disasters and the impact these opinions might have on competency-based education and training.
Method
This qualitative study was performed in 2013. A questionnaire-based evaluation of experts’ opinions and experiences in responding to disasters was conducted. The selection of the experts was done using the purposeful sampling method, and the sample size was considered by data saturation. Content analysis was used to explore the implications of the data.
Results
This study shows that there is a lack of competency-based training for disaster responders. Developing and performing standardized training courses is influenced by shortcomings in budget, expertise, and standards. There is a lack of both coordination and integration among teams and their activities during disasters. The participants of this study emphasized problems concerning access to relevant resources during disasters.
Conclusion
The major findings of this study suggest that teams often are not competent during the response phase because of education and training deficiencies. Foreign medical teams and medically related nongovernmental organizations (NGOs) do not always provide expected capabilities and services. Failures in leadership and in coordination among teams are also a problem. All deficiencies need to be applied to competency-based curricula.
DjalaliA, IngrassiaPL, Della CorteF, FolettiM, Ripoll GallardoA, RagazzoniL, KaptanK, LupescuO, ArculeoC, von ArnimG, FriedlT, AshkenaziM, HeselmannD, HreckovskiB, Khorrram-ManeshA, KomadinaR, LechnerK, PatruC, BurkleFMJr., FisherP. Identifying Deficiencies in National and Foreign Medical Team Responses Through Expert Opinion Surveys: Implications for Education and Training. Prehosp Disaster Med. 2014;29(4):1-5.
Studies have reported a sex bias in case fatalities of COVID-19 patients. Moreover, it is observed that men have a higher risk of developing a severe form of the disease compared to women, highlighting the importance of disaggregated data of male and female COVID-19 patients. On the other hand, other factors (eg, hormonal levels and immune functions) also need to be addressed due to the effects of sex differences on the outcomes of COVID-19 patients. An insight into the underlying causes of sex differences in COVID-19 patients may provide an opportunity for better care of the patients or prevention of the disease. The current study reviews the reports concerning with the sex differences in COVID-19 patients. It is explained how sex can affect angiotensin converting enzyme-2 (ACE2), that is a key component for the pathogenesis of COVID-19, and summarized the gender differences in immune responses and how sex hormones are involved in immune processes. Furthermore, the available data about the impact of sex hormones on the immune functions of COVID-19 cases are looked into.
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.
Methods
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.
Results
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.
Conclusion
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.
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.
Methods
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.
Results
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.
Conclusions
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.
In recent years, effective models of disaster medicine curricula for medical schools have been established. However, only a small percentage of medical schools worldwide have considered at least basic disaster medicine teaching in their study program. In Italy, disaster medicine has not yet been included in the medical school curriculum. Perceiving the lack of a specific course on disaster medicine, the Segretariato Italiano Studenti in Medicina (SISM) contacted the Centro di Ricerca Interdipartimentale in Medicina di Emergenza e dei Disastri ed Informatica applicata alla didattica e alla pratica Medica (CRIMEDIM) with a proposal for a nationwide program in this field. Seven modules (introduction to disaster medicine, prehospital disaster management, definition of triage, characteristics of hospital disaster plans, treatment of the health consequences of different disasters, psychosocial care, and presentation of past disasters) were developed using an e-learning platform and a 12-hour classroom session which involved problem-based learning (PBL) activities, table-top exercises, and a computerized simulation (Table 1). The modules were designed as a framework for a disaster medicine curriculum for undergraduates and covered the three main disciplines (clinical and psychosocial, public health, and emergency and risk management) of the core of “Disaster Health” according to the World Association for Disaster and Emergency Medicine (WADEM) international guidelines for disaster medicine education. From January 2011 through May 2013, 21 editions of the course were delivered to 21 different medical schools, and 524 students attended the course. The blended approach and the use of simulation tools were appreciated by all participants and successfully increased participants’ knowledge of disaster medicine and basic competencies in performing mass-casualty triage. This manuscript reports on the designing process and the initial outcomes with respect to learners' achievements and satisfaction of a 1-month educational course on the fundamentals of disaster medicine. This experience might represent a valid and innovative solution for a disaster medicine curriculum for medical students that is easily delivered by medical schools.Table 1
List of Modules and Topics
Module
Topics
1. Introduction to disaster medicine and public health during emergencies
- Modern taxonomy of disaster and common disaster medicine definitions
- Differences between disaster and emergency medicine
- Principles of public health during disasters
- Different phases of disaster management
2. Prehospital disaster management
- Mass-casualty disposition, treatment area, and transport issues
- Disaster plans and command-and-control chain structure
- Functional response roles
3. Specific disaster medicine and triage procedures in the
- Mass-casualty triage definitions and principles
management of disasters
- Different methodologies and protocols
- Patient assessment, triage levels and tags
4. Hospital disaster preparedness and response
- Hospital disaster laws
- Hospital preparedness plans for in-hospital and out-hospital disasters with an all-hazard approach
- Medical management for a massive influx of casualties
5. Health consequences of different disasters
- Characteristics of different types of disasters
- Health impact of natural and man-made disasters
- Disaster-related injury after exposure to a different disasters with an all-hazard approach
6. Psychosocial care
- Techniques to deal with psychic reactions caused by exposure to disaster scenarios
- Treatment approaches to acute and delayed critical incident stress reactions
7. Presentation of past disasters and public health emergencies, and
Case study:
review of assistance experiences
- Haiti earthquake
- Cholera outbreaks in Haiti
- National and international disaster response mechanism
IngrassiaPL, RagazzoniL, TengattiniM, CarenzoL, Della CorteF. Nationwide Program of Education for Undergraduates in the Field of Disaster Medicine: Development of a Core Curriculum Centered on Blended Learning and Simulation Tools. Prehosp Disaster Med. 2014;29(5):1-8.
How the burden of disease varies during different phases after floods and after storms is essential in order to guide a medical response, but it has not been well-described. The objective of this review was to elucidate the health problems following flood and storm disasters.
Methods
A literature search of the databases Medline (US National Library of Medicine, National Institutes of Health; Bethesda, Maryland USA); Cinahl (EBSCO Information Services; Ipswich, Massachusetts USA); Global Health (EBSCO Information Services; Ipswich, Massachusetts USA); Web of Science Core Collection (Thomson Reuters; New York, New York USA); Embase (Elsevier; Amsterdam, Netherlands); and PubMed (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA) was conducted in June 2015 for English-language research articles on morbidity or mortality and flood or storm disasters. Articles on mental health, interventions, and rescue or health care workers were excluded. Data were extracted from articles that met the eligibility criteria and analyzed by narrative synthesis.
Results
The review included 113 studies. Poisonings, wounds, gastrointestinal infections, and skin or soft tissue infections all increased after storms. Gastrointestinal infections were more frequent after floods. Leptospirosis and diabetes-related complications increased after both. The majority of changes occurred within four weeks of floods or storms.
Conclusion
Health changes differently after floods and after storms. There is a lack of data on the health effects of floods alone, long-term changes in health, and the strength of the association between disasters and health problems. This review highlights areas of consideration for medical response and the need for high-quality, systematic research in this area.
SaulnierDD, Brolin RibackeK, von SchreebJ. No Calm After the Storm: A Systematic Review of Human Health Following Flood and Storm Disasters. Prehosp Disaster Med. 2017;32(5):568–579.
An increasing number of people are affected worldwide by the effects of disasters, and the United Nations International Strategy for Disaster Reduction (UNISDR) has recognized the need for a radical paradigm shift in the preparedness and combat of the effects of disasters through the implementation of specific actions. At the governmental level, these actions translate into disaster and risk reduction education and activities at school. Fifteen years after the UNISDR declaration, there is a need to know if the current methods of disaster education of the teenage population enhance their knowledge, knowledge of skills in disasters, and whether there is a behavioral change which would improve their chances for survival post disaster. This multidisciplinary systematic literature review showed that the published evidence regarding enhancing the disaster-related knowledge of teenagers and the related problem solving skills and behavior is piecemeal in design, approach, and execution in spite of consensus on the detrimental effects on injury rates and survival.
There is some evidence that isolated school-based intervention enhances the theoretical disaster knowledge which may also extend to practical skills; however, disaster behavioral change is not forthcoming. It seems that the best results are obtained by combining theoretical and practical activities in school, family, community, and self-education programs.
There is a still a pressing need for a concerted educational drive to achieve disaster preparedness behavioral change. School leavers’ lack of knowledge, knowledge of skills, and adaptive behavioral change are detrimental to their chances of survival.
CodreanuTA, CelenzaA, JacobsI. Does Disaster Education of Teenagers Translate into Better Survival Knowledge, Knowledge of Skills, and Adaptive Behavioral Change? A Systematic Literature Review. Prehosp Disaster Med. 2014;29(6):1-14.
Medical responders are at-risk of experiencing a wide range of negative psychological health conditions following a disaster.
Aim:
Published literature was reviewed on the adverse psychological health outcomes in medical responders to various disasters and mass casualties in order to: (1) assess the psychological impact of disasters on medical responders; and (2) identify the possible risk factors associated with psychological impacts on medical responders.
Methods:
A literature search of PubMed, Discovery Service, Science Direct, Google Scholar, and Cochrane databases for studies on the prevalence/risk factors of posttraumatic stress disorder (PTSD) and other mental disorders in medical responders of disasters and mass casualties was carried out using pre-determined keywords. Two reviewers screened the 3,545 abstracts and 28 full-length articles which were included for final review.
Results:
Depression and PTSD were the most studied outcomes in medical responders. Nurses reported higher levels of adverse outcomes than physicians. Lack of social support and communication, maladaptive coping, and lack of training were important risk factors for developing negative psychological outcomes across all types of disasters.
Conclusions:
Disasters have significant adverse effects on the mental well-being of medical responders. The prevalence rates and presumptive risk factors varied among three different types of disasters. There are certain high-risk, vulnerable groups among medical responders, as well as certain risk factors for adverse psychological outcomes. Adapting preventive measures and mitigation strategies aimed at high-risk groups would be beneficial in decreasing negative outcomes.
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.
Purpose
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.
Methods
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.
Results
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.
Discussion
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.
The International Council of Nurses (ICN; Geneva, Switzerland) and the World Association for Disaster and Emergency Medicine (WADEM; Madison, Wisconsin USA) joined together in 2014 to review the use of the ICN Framework of Disaster Nursing Competencies. The existing ICN Framework (version 1.10; dated 2009) formed the starting point for this review. The key target audiences for this process were members of the disaster nursing community concerned with pre-service education for professional nursing and the continuing education of practicing professional nurses. To minimize risk in the disaster nursing practice, competencies have been identified as the foundation of evidence-based practice and standard development. A Steering Committee was established by the WADEM Nursing Section to discuss how to initiate a review of the ICN Framework of Disaster Nursing Competencies. The Steering Committee then worked via email to develop a survey to send out to disaster/emergency groups that may have nurse members who work/respond in disasters. Thirty-five invitations were sent out with 20 responses (57%) received. Ninety-five percent of respondents knew of the ICN Framework of Disaster Nursing Competencies, with the majority accessing these competencies via the Internet. The majority of those who responded said that they make use of the ICN Framework of Disaster Nursing Competencies with the most common use being for educational purposes. Education was done at a local, national, and international level. The competencies were held in high esteem and valued by these organizations as the cornerstone of their disaster education, and also were used for the continued professional development of disaster nursing. However, respondents stated that five years on from their development, the competencies also should include the psychosocial elements of nurses caring for themselves and their colleagues. Additionally, further studies should explore if there are other areas related to the disaster nursing practice (in addition to psychosocial concerns) that may be missing or not fully developed. Finally, the authors of this report recommend that future research explore how the ICN Framework of Disaster Nursing Competencies do or do not assist in maintaining best practices in this field and improve outcomes for victims of disaster.
HuttonA, VeenemaTG, GebbieK. Review of the International Council of Nurses (ICN) Framework of Disaster Nursing Competencies. Prehosp Disaster Med. 2016;31(6):680–683.
