There is no standard guidance for strategies for hospitals to use to coordinate with other agencies during a disaster.

This study analyzes successful strategies and barriers encountered by hospitals across the nation in coordinating and collaborating with other response agencies.

Quantitative and qualitative data were collected from a web-based study from 577 acute care hospitals sampled from the 2013 American Hospital Association (AHA) database. The results were analyzed using descriptive statistics.

The most common barriers to collaboration are related to finances, ability to communicate, and personnel.

AdelaineSA , ShoafK , HarveyC . An Assessment of Collaboration and Disasters: A Hospital Perspective. Prehosp Disaster Med. 2016;31(2):121–125.

Children, with their specific vulnerabilities and needs, make up to more than 20% of society, so they are at risk of getting involved in disasters. Are the specialists treating them for medical problems in daily life also capable to deal with them in disaster situations?

The goals of this study were to evaluate perceived knowledge and capability of tertiary pediatricians to deal with disasters, to identify promoting factors, and to evaluate education need and willingness to work.

A survey looking for demographics, hospital disaster planning, estimated risk and capability for disasters, training, and willingness to work, and a set of six content assessment questions to evaluate knowledge, were presented to emergency pediatricians and pediatric emergency physicians in specialized tertiary centers.

The response rate was 51%. Thirty-five percent had disaster training and 53% felt that disaster education should be obligatory in their curriculum. Risk for disasters was estimated from 2.4/10 for nuclear incidents to 7.6/10 for major trauma. Self-estimated capability for these situations ranged from 1.8/10 in nuclear incidents to 7.6/10 in major trauma. Unconditional willingness to work ranged from 37% in nuclear situations to 68% in pandemics. Mean score on the questions was 2.06/6. Training, knowledge of antidote and personal protective equipment (PPE) use, self-estimated capability, and exposure were significant predictors for higher scores. Willingness to work correlated significantly with age, self-estimated capability, and risk estimation. In case of chemical and nuclear incidents, there was correlation with knowledge on the use of decontamination, PPE, and radio-detection devices.

Despite a clear perception of the risks and a high willingness to work, preparedness is limited. The major conclusion is that basics of disaster management should be included in pediatric training.

MortelmansLJM , MaebeS , DieltiensG , AnseeuwK , SabbeMB , Van de VoordeP . Are Tertiary Care Paediatricians Prepared for Disaster Situations?Prehosp Disaster Med. 2016;31(2):126–131.

With the increase in natural and manmade disasters, preparedness remains a vital area of concern. Despite attempts by government and non-government agencies to stress the importance of preparedness, national levels of preparedness remain unacceptably low. A goal of commands and installations is to ensure that US Navy beneficiaries are well prepared for disasters. This especially is critical in active service members to meet mission readiness requirements in crisis settings.

To evaluate active duty Navy personnel, dependents, veterans, and retirees regarding disaster preparedness status.

The authors conducted an anonymous 29-question survey for US Navy active duty, dependents, veterans, and retirees of the Greater San Diego Region (California, USA) evaluating actual basic disaster readiness as determined by the Federal Emergency Management Agency (FEMA) standards of 3-day minimum supply of emergency stores and equipment. Descriptive statistics and regression analysis were used to analyze data.

One thousand one hundred and fifty surveys were returned and analyzed. Nine hundred and eight-three were sufficiently complete for logistic regression analysis with 394 responding “Yes” to having a 72-hour disaster kit (40.1%) while 589 had “No” as a response (59.9%).

The surveyed population is no more prepared than the general public, though surveyed beneficiaries overall are at an upper range of preparedness. Lower income and levels of education were associated with lack of preparedness, whereas training in disaster preparedness or having been affected by disasters increased the likelihood of being adequately prepared. Unlike results seen in the general public, those with chronic health care needs in the surveyed population were more, rather than less, likely to be prepared and those with minor children were less likely, rather than more likely, to be prepared. Duty status was assessed and only veterans were emphatically more probable than most to be prepared.

AnnisH , JacobyI , DeMersG . Disaster Preparedness among Active Duty Personnel, Retirees, Veterans, and Dependents. Prehosp Disaster Med.2016;31(2):132–140.

Emergency Medical Services (EMS) preparedness and availability of essential medications are important to reduce morbidity and mortality from mass-casualty incidents (MCIs).

This study describes prehospital medication administration during MCIs by different EMS service levels.

The US National EMS Public-Release Research Dataset maintained by the National Emergency Medical Services Information System (NEMSIS) was used to carry out the study. Emergency Medical Services activations coded as MCI at dispatch, or by EMS personnel, were included. The Center for Medicare and Medicaid Services (CMS) service level was used for the level of service provided. A descriptive analysis of medication administration by EMS service level was carried out.

Among the 19,831,189 EMS activations, 53,334 activations had an MCI code, of which 26,110 activations were included. There were 8,179 (31.3%) Advanced Life Support (ALS), 5,811 (22.3%) Basic Life Support (BLS), 399 (1.5%) Air Medical Transport (AMT; fixed or rotary), and 38 (0.2%) Specialty Care Transport (SCT) activations. More than 80 different medications from 18 groups were reported. Seven thousand twenty-one activations (26.9%) had at least one medication administered. Oxygen was most common (16.3%), followed by crystalloids (6.9%), unknown (5.2%), analgesics (3.2%) mainly narcotics, antiemetics (1.5%), cardiac/vasopressors/inotropes (0.9%), bronchodilators (0.9%), sedatives (0.8%), and vasodilators/antihypertensives (0.7%). Overall, medication administration rates and frequencies of medications groups significantly varied between EMS service levels (P<.01) except for “Analgesia (other)” (P=.40) and “Pain medications (nonsteroidal anti-inflammatory drug; NSAID)” (P=.07).

Medications are administered frequently in MCIs, mainly Oxygen, crystalloids, and narcotic pain medications. Emergency Medical Services systems can use the findings of this study to better prepare their stockpiles for MCIs.

El SayedM , TamimH , MannNC . Description of Medication Administration by Emergency Medical Services during Mass-casualty Incidents in the United States. Prehosp Disaster Med. 2016;31(2):141–149.

During mass-casualty incidents (MCIs), patient volume often overwhelms available Emergency Medical Services (EMS) personnel. First responders are expected to triage, treat, and transport patients in a timely fashion. If other responders could triage accurately, prehospital EMS resources could be focused more directly on patients that require immediate medical attention and transport.

Triage accuracy, error patterns, and time to triage completion are similar between second-year primary care paramedic (PCP) and fire science (FS) students participating in a simulated MCI using the Sort, Assess, Life-saving interventions, Treatment/Transport (SALT) triage algorithm.

All students in the second-year PCP program and FS program at two separate community colleges were invited to participate in this study. Immediately following a 30-minute didactic session on SALT, participants were given a standardized briefing and asked to triage an eight-victim, mock MCI using SALT. The scenario consisted of a four-car motor vehicle collision with each victim portrayed by volunteer actors given appropriate moulage and symptom coaching for their pattern of injury. The total number and acuity of victims were unknown to participants prior to arrival to the mock scenario.

Thirty-eight PCP and 29 FS students completed the simulation. Overall triage accuracy was 79.9% for PCP and 72.0% for FS (∆ 7.9%; 95% CI, 1.2-14.7) students. No significant difference was found between the groups regarding types of triage errors. Over-triage, under-triage, and critical errors occurred in 10.2%, 7.6%, and 2.3% of PCP triage assignments, respectively. Fire science students had a similar pattern with 15.2% over-triaged, 8.7% under-triaged, and 4.3% critical errors. The median [IQR] time to triage completion for PCPs and FSs were 142.1 [52.6] seconds and 159.0 [40.5] seconds, respectively (P=.19; Mann-Whitney Test).

Primary care paramedics performed MCI triage more accurately than FS students after brief SALT training, but no difference was found regarding types of error or time to triage completion. The clinical importance of this difference in triage accuracy likely is minimal, suggesting that fire services personnel could be considered for MCI triage depending on the availability of prehospital medical resources and appropriate training.

LeeCWC , McLeodSL , Van AarsenK , KlingelM , FrancJM , PeddleMB . First Responder Accuracy Using SALT during Mass-casualty Incident Simulation. Prehosp Disaster Med. 2016;31(2):150–154.

Influenza is a major concern for Emergency Medical Services (EMS); EMS workers’ (EMS-Ws) vaccination rates remain low despite promotion. Determinants of vaccination for seasonal influenza (SI) or pandemic influenza (PI) are unknown in this setting.

The influence of the H1N1 pandemic on EMS-W vaccination rates, differences between SI and PI vaccination rates, and the vaccination determinants were investigated.

A survey was conducted in 2011 involving 65 Swiss EMS-Ws. Socio-professional data, self-declared SI/PI vaccination status, and motives for vaccine refusal or acceptation were collected.

Response rate was 95%. The EMS-Ws were predominantly male (n=45; 73%), in good health (87%), with a mean age of 36 (SD=7.7) years. Seventy-four percent had more than six years of work experience. Self-declared vaccination rates were 40% for both SI and PI (PI+/SI+), 19% for PI only (PI+/SI-), 1.6% for SI only (PI-/SI+), and 39% were not vaccinated against either (PI-/SI-). Women’s vaccination rates specifically were lower in all categories but the difference was not statistically significant. During the previous three years, 92% of PI+/SI+ EMS-Ws received at least one SI vaccination; it was 8.3% in the case of PI-/SI- (P=.001) and 25% for PI+/SI- (P=.001). During the pandemic, SI vaccination rate increased from 26% during the preceding year to 42% (P=.001). Thirty percent of the PI+/SI+ EMS-Ws declared that they would not get vaccination next year, while this proportion was null for the PI-/SI- and PI+/SI- groups. Altruism and discomfort induced by the surgical mask required were the main motivations to get vaccinated against PI. Factors limiting PI or SI vaccination included the option to wear a mask, avoidance of medication, fear of adverse effects, and concerns about safety and effectiveness.

Average vaccination rate in this study’s EMS-Ws was below recommended values, particularly for women. Previous vaccination status was a significant determinant of PI and future vaccinations. The new mask policy seemed to play a dual role, and its net impact is probably limited. This population could be divided in three groups: favorable to all vaccinations; against all, even in a pandemic context; and ambivalent with a “pandemic effect.” These results suggest a consistent vaccination pattern, only altered by exceptional circumstances.

MoserA, MabireC, HugliO, DorriboV, ZanettiG, Lazor-BlanchetC, CarronPN. Vaccination Against Seasonal or Pandemic Influenza in Emergency Medical Services. Prehosp Disaster Med. 2016;31(2):155–162.

The worldwide use of rail transport has increased, and the train speeds are escalating. Concurrently, the number of train disasters has been amplified globally. Consequently, railway safety has become an important issue for the future. High-velocity crashes increase the risk for injuries and mortality; nevertheless, there are relatively few studies on high-speed train crashes and the influencing factors on travelers’ injuries occurring in the crash phase. The aim of this study was to investigate the fatal and non-fatal injuries and the main interacting factors that contributed to the injury process in the crash phase of the 2013 high-velocity train crash that occurred at Angrois, outside Santiago de Compostela, Spain.

Hospital records (n=157) of all the injured who were admitted to the six hospitals in the region were reviewed and compiled by descriptive statistics. The instant fatalities (n=63) were collected on site. Influencing crash factors were observed on the crash site, by carriage inspections, and by reviewing official reports concerning the approximated train speed.

The main interacting factors that contributed in the injury process in the crash phase were, among other things, the train speed, the design of the concrete structure of the curve, the robustness of the carriage exterior, and the interior environment of the carriages. Of the 222 people on board (218 passengers and four crew), 99% (n=220) were fatally or non-fatally injured in the crash. Thirty-three percent (n=72) suffered fatal injuries, of which 88% (n=63) died at the crash site and 13% (n=9) at the hospital. Twenty-one percent (n=32) of those admitted to hospital suffered multi-trauma (ie, extensive, severe, and/or critical injuries). The head, face, and neck sustained 42% (n=123) of the injuries followed by the trunk (chest, abdomen, and pelvis; n=92; 32%). Fractures were the most frequent (n=200; 69%) injury.

A mass-casualty incident with an extensive amount of fatal, severe, and critical injuries is most probable with a high-velocity train; this presents prehospital challenges. This finding draws attention to the importance of more robust carriage exteriors and injury minimizing designs of both railway carriages and the surrounding environment to reduce injuries and fatalities in future high-speed crashes.

ForsbergR , VázquezJAI . A Case Study of the High-speed Train Crash Outside Santiago de Compostela, Galicia, Spain. Prehosp Disaster Med. 2016;31(2);163–168.

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.

To compare the state of chemical hazard preparedness in emergency departments (EDs) in Michigan, USA between 2005 and 2012.

This was a longitudinal study involving a 30 question survey sent to ED directors at each hospital listed in the Michigan College of Emergency Physician (MCEP) Directory in 2005 and in 2012. The surveys contained questions relating to chemical, biological, radiological, nuclear, and explosive events with a focus on hazardous material capabilities.

One hundred twelve of 139 EDs responded to the 2005 survey compared to 99/136 in 2012. Ten of 27 responses were statistically significant, all favoring an enhancement in disaster preparedness in 2012 when compared to 2005. Questions with improvement included: EDs with employees participating in the Michigan voluntary registry; EDs with decontamination rooms; MARK 1 and cyanide kits available; those planning to use dry decontamination, powered air purifiers, surgical masks, chemical gloves, and surgical gowns; and those wishing for better coordination with local and regional resources. Forty-two percent of EDs in 2012 had greater than one-half of their staff trained in decontamination and 81% of respondents wished for more training opportunities in disaster preparedness. Eighty-four percent of respondents believed that they were more prepared in disaster preparedness in 2012 versus seven years prior.

Emergency departments in Michigan have made significant advances in chemical hazard preparedness between 2005 and 2012 based on survey responses. Despite these improvements, staff training in decontamination and hazardous material events remains a weakness among EDs in the state of Michigan.

BelskyJB, KlausnerHA, KarsonJ, DunneRB. Survey of Emergency Department Chemical Hazard Preparedness in Michigan, USA: A Seven Year Comparison. Prehosp Disaster Med. 2016;31(2):224–227.

With increasing attendance and media attention, large-scale electronic dance music events (EDMEs) are a subset of mass gatherings that have a unique risk profile for attendees and promoters. Shambhala Music Festival (Canada) is a multi-day event in a rural setting with a recognized history of providing harm reduction (HR) services alongside medical care.

This manuscript describes the medical response at a multi-day electronic music festival where on-site HR interventions and dedicated medical care are delivered as parallel public health measures.

This study was a descriptive case report. Medical encounters and event-related data were documented prospectively using an established event registry database.

In 2014, Shambhala Music Festival had 67,120 cumulative attendees over a 7-day period, with a peak daily attendance of 15,380 people. There were 1,393 patient encounters and the patient presentation rate (PPR) was 20.8 per one thousand. The majority of these (90.9%) were for non-urgent complaints. The ambulance transfer rate (ATR) was 0.194 per one thousand and 0.93% of patient encounters were transferred by ambulance. No patients required intubation and there were no fatalities.

Harm reduction services included mobile outreach teams, distribution of educational materials, pill checking facilities, a dedicated women’s space, and a “Sanctuary” area that provided non-medical peer support for overwhelmed guests. More than 10,000 encounters were recorded by mobile and booth-based preventive and educational services, and 2,786 pills were checked on-site with a seven percent discard rate.

Dedicated medical and HR services represent two complementary public health strategies to minimize risk at a multi-day electronic music festival. The specific extent to which HR strategies reduce the need for medical care is not well understood. Incorporation of HR practices when planning on-site medical care has the potential to inform patient management, reduce presentation rates and acuity, and decrease utilization and cost for local, community-based health services.

MunnMB , LundA , GolbyR , TurrisSA . Observed Benefits to On-site Medical Services during an Annual 5-day Electronic Dance Music Event with Harm Reduction Services. Prehosp Disaster Med. 2016;31(2):228–234.