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Mass gatherings can be disruptive to the daily operations of any emergency department (ED). These events usually are spontaneous and sudden. Therefore, operational processes must be effective and concise when dealing with a sudden surge. This study examines the Tan Tock Seng Hospital (TTSH) ED response process to a gastroenteritis (GE) outbreak. Prompt identification and establishment of a casualty holding and treatment area ensured smooth operational capacity, which allowed these patients to be segregated from the mainstream ED crowd and more specific care to be rendered. Entrance and exit points of the designated area were established with controlled access to prevent cross-contamination with the mainstream patient load. Patients with GE who presented with acute symptoms required immediate assessment and intervention, placing stress on existing personnel. Hence, adequate personnel was an important factor that could not be disregarded. Staff burnout was a plausible issue that was recognized from the start and attempts were made to prevent burnout by creating an encouraging work environment and allowing frequent relieving of duties. Communicating the event to relevant departments ensured that the ED was adequately supported during the GE outbreak, both administratively and logistically. This was a reflection of the established communication channels. Leadership also had an essential and crucial role to play as the nursing and medical leaders had to be decisive, delegate roles and give concise instructions during the chaotic situation. The availability and access to ample logistical supplies saves on precious time, which allowed more focus on patients. In summary, procedures and protocols, together with staff preparedness, enhances an ED operational capability of effectively responding to mass gatherings.
Ultrasonography of optic nerve sheath diameter (ONSD) may be useful in detecting raised intracranial pressure (ICP) in head injury (HI). There is limited data from India.
Objective
The objective of this study was to evaluate the utility of measuring ONSD for diagnosis of raised intracranial pressure in HI victims in the emergency department.
Methods
Fifty-two HI patients presenting between February to August 2009 were included, A CT head scan was performed and simultaneous ocular ultrasound was done by an emergency physician who had underwent goal-directed training in ophthalmic sonography by a linear probe of 10 MHz. An ONSD greater than > 5 mm for patients > 15 years of age, 4.5 mm for 1–15 years of age, and 4 mm for infants were considered abnormal. The two modalities of diagnosis were compared.
Results
The median age was 30 years (Range = 0.25–72 years). A total of 90.4% were male and 9.6% were female. A total of 71.2% had severe HI, 19.2% had moderate HI, and 9.6% had mild HI. A raised ICP based on CT findings was present in 42 (80.8%) patients. Mean optic nerve diameter in patients with raised ICP was 5.11 + 1.56 mm compared to 5.04 + 1.6 mm in patients with no features of raised ICP. Sensitivity and specificity of ONSD as a screening test for detection of raised intracranial pressure were 57.1% and 40%, respectively with a positive predictive value and negative predictive value of 80% and 18.1%, respectively.
Conclusions
The evaluation of the ONSD diameter is a simple and non-invasive potential tool in initial assessment of raised intracranial pressure.
South Australia is often referred to as the driest state in the driest continent on earth and the community expects summers to be hot. However since 2007 South Australia has experienced several periods of extreme heat which have challenged and required the emergency services including health to consider a new preparedness approach. Any extreme weather condition can cause disruption to the community and the effects of such events as extreme heat are not always immediately obvious. However these effects can silently cause death and an increase to the health burden of the community.
Discussion
In South Australia the term ‘Extreme Heat’ as opposed to ‘Heatwave’ has been quite deliberately chosen as this describes more accurately an unusual climatic situation characterised by higher temperatures and greater length of time than normally expected. A number of studies have been undertaken to consider the impact on the health of the South Australian community and its health services and specfic action plans and communication strategies have been developed to respond to extreme heat and encourage an increasing level of community resilience. This paper will describe recent events, some of the research undertaken and the preparedness, planning and response strategies implemented to reduce and manage the risk.
Conclusion
The response strategies introduced in South Australia have been recognised for their excellence and in 2010 SA Health was the recipient of several awards at both state and national level for this work.
In the last 50 years of modern-era cardiopulmonary resuscitation (CPR), survival rates remain dismal, worldwide. International CPR guidelines recommended a compression rate of at least 100 per minute. There is little evidence documenting if and to what extent high compression rates affect the quality of chest compressions.
Objectives
An objective of this study was to evaluate the effect mean compression rate (MCR) had on the overall quality of chest compressions. Investigators hypothesized that MCRs > 110 would result in a smaller percentage of adequate: compressions (PAC); depth (PAD); and recoil (PAR).
Methods
In this observational pilot study, basic life support providers were recruited from prehospital and in-hospital settings to provide 10 minutes of continuous chest compressions, based on the 2005 American Heart Association guidelines. An adequate compression was defined as a compression that was > 35 mm, had full recoil, and correct hand position. Data were recorded using the Laerdal PC Skill reporting System.
Results
Ninety four (91.3%) of 103 participants completed 10 minutes of compressions. Rescuers represented a variety of backgrounds, average age of 35.5 ± 11.0 years. Fifty eight (56.2%) rescuers had performed CPR in the last two years, and 54 (52.4%) practiced prehospital EMS. Providers that did not complete the entire 10 minutes tended to have a higher MCR than those completing 10 minutes, 114.2 ± 19.3 vs. 105.8 ± 15.4 respectively. Within the first two minutes, rescuers with a MCR > 110 delivered 45% of their compressions adequately, compared to 60% when a rescuer's MCR was < 110. This initial disparity was primarily due to decreased PAR, not decreased PAD. After 2 minutes, higher MCRs correlated with decreased PAC, due to decreased PAD.
Conclusions
Data indicates a higher MCR results in decreased PAC, PAD, and PAR, likely attributed to increased rescuer fatigue.
A pilot admission leadership physician (ALP) program was experimented within a 693-bed, tertiary medical center with a 60-bed emergency department. This trial was intended to investigate whether having a physician triage potential patients would shorten patients' length-of-stay in the emergency department. After a emergency physician evaluated patients, ALP triaged them. The ALP ordered the appropriate bed for the patients if they qualified for the inpatient criteria, choosing among medical, medical telemetry, cardiac telemetry, intermediate care, or intensive care bed. The mean patient door-to-bed order time (time between patients reaching the emergency department to time to bed ordered by ALP) is 330.7 minutes (n = 234, SD = 151.68, 95% CI = 310.21–351.28) with ALP involvement. Compared with the mean door-to-bed order time of 337.8 minutes (n = 827, SD = 149.71, 95%CI = 326.98–348.57) without ALP, ALP shortened the waiting time by 7.09 minutes. During the same period, the door-to-physician time was 41.38 minutes (SD = 38.87 95%CI = 36.38–46.39), compared with 39.52 minutes (SD = 40.32, 95%CI = 36.77–42.27) before ALP. The time for patients waiting in the emergency department for other services such as surgery, psychiatry, and pediatrics also have decreased accordingly. Incorrect medical admissions such as scrambling to get the patient to the intensive care unit right after seeing patients has decreased (data not provided). Identifying physicians as physicians in the emergency department who triage potential admissions also has improved efficiencies within the hospital medicine group and bonding with ER physicians.
To longitudinally investigates the Survivors' daily lives and healthy condition after Sichuan earthquake in China. This study identifies Survivors' daily lives and health conditions for 3-years.
Ethical Consideration
The study was conducted after obtaining approval in Ethical Review Board of Sichuan University.
Method
The study was conducted for the survivors who experienced the earthquake and aged 18 years and over, and joined the 1st year and 2nd year study. Questionnaire included the survivors' socio-demographics, impact of disaster and the health status after disaster. The date was analyzed using SPSS 13.0 software.
Results
Results showed the follow-up date which was results of 3-years. The changes of daily lives of survivors for 3-years were fluctuations. As their health conditions in the 3rd year, the following symptoms were decreased: locomotors system disease, respiratory disease, Autoimmunity and endocrine diseases, asthma and allergy, Gout, Irregular menstruation/dysmenorrheal, kidney disease and the others. In contrast, the following symptoms were increased: cardiac disease, weight gain/less, hypertension, diabetes, and liver disease. About their self-rated health, “Not healthy” at 3rd year was 26.4%. Compared with the 1st year and 2nd year results, it has taken a turn for the significantly better (1st year 49.9%; 2nd year 35.1%). With regard to the psychological condition, the Positive response of IES-R at 3rd year was 11.6%. Compared with the 1st year and 2nd year results, the Positive response of IES-R significantly decrease (1st year 49.8; 2nd year 31.8%. p < 0.001, by Pearson Chi-square).
Conclusion
After 3rd year of the Sichuan earthquake disaster, the survivors' physical and psychological conditions have improved compared to 1st year and 2nd year results. However most of the survivors still had some health problems in their health. Our local nursing authorities still need to go on their health promotion, which can further improve the survivors' health status.
The earthquake in Haiti and its consequences highlighted the need to enhance knowledge and skills for community intervention in situations of disaster and acute trauma. The large number of homeless people concentrated in enormous refugee camps has made such an investigation possible. In the lecture, we will present a model for empowerment intervention with victims of community disasters. The model is based on analyses of three cases in which psychosocial interventions were conducted by the investigators: the Tsunami in Sri Lanka, work at refugee camps in Georgia, and the earthquake in Haiti. Principles of the Model The more extensive the casualties are, the less relevant individual intervention will be. Entering an unfamiliar culture requires collaborative professional work with local residents. Intervention in a large-scale disaster needs to be based on an interdisciplinary perspective in terms of planning, preparation, and implementation. It is assumed that the intervention will be short-term, and a specific length of time is allocated for therapeutic agents to provide assistance. This approach was adopted in light of the limited resources at our disposal, and in an attempt to minimize dependence in the relationships between the therapeutic agents and the victims. An attempt is made to enhance efficacy for effective coping with changing needs that emerge in the wake of the disaster. An attempt is made to prevent CPTSD, which can inhibit the functioning of the community residents. We will present these principles and describe how they were implemented in community intervention at two refugee camps in Haiti following the earthquake there, and at a refugee camp in Georgia.
Decision-making is the major component in triaging EDs patients. EDs Triage systems have applied different approaches to triaging intoxicated patients. Pros & Cons for these approaches need to be identified. Aim is to analysis management of intoxicated patients during various triage process.
Methods
Critical review includes five triage systems, Emergency Severity Index, Australasian Triage Scale, Canadian triage and Acuity Scale, Manchester Triage System and 5-tier Triage protocol. These systems have been analyzed via meta-synthesis in terms of evidence-based criteria, inclusiveness, specific application and practicability.
Results
General physiologic signs & symptoms were the gold standard for determining acuity in patients that have been applied by all triage systems. Conscious level, air way, respiratory status and circulation assessment were identified as major criteria in decision-making. 5-tier Triage protocol showed the most comprehensiveness characteristics to prioritizing intoxicated patients.
Discussion
Resources necessary for evidence-based performance to support nursing decisions in triaging intoxicated patients needs fundamentally to be developed. It`s necessary to develop National Triage Scale to approach intoxicated patients effectively.
The objective of this study was to identify the daily lives and health conditions of survivors of the Sichuan Earthquake after two years.
Methods
The study was conducted for the survivors ≥ 18 years of age who experienced the earthquake. The questionnaire included the survivors' socio-demographics, impact of the disaster, and their health status after the disaster.
Results
Approximately 65% of respondents said that their conditions were healthy in the second year after the earthquake. The changes of daily lives among the survivors were increased from 1st year to 2nd year, as follows: diet (1st year; 24.5%–2nd year; 14.1%), sleep (29.4%–23.6%), entertainments (9.6%–15.1%). As health conditions, the following symptoms were increased; diabetes (2.8%–3.5%), cardiac disease (2.9%–5.0%), functional disturbances of body's joints and muscles (18%–21%). In contrast, the following symptoms were decreased; obesity/skinny (5%–3.5%), kidney disease (4.4%–1.6%), asthma and allergy (7.2%–5.6%). The current health conditions of the survivors included: headache, eyestrain, hand, foot, and/or joint's ache, sleep disorder. With regard to the psychological condition, the mean value of IES-R score was 22.2 ± 11.8. Compared with the 1st year results, the mean value IES-R score significantly decreased (1st year; 30.8 ± 16.8, p < 0.001, by paired t-test).
Conclusions
The survivors' physical and psychological conditions have improved compared to 1st year results. However most of the survivors still had some health problems in their health.
Every year, the City of Zurich hosts the “Street Parade”. This is one of the biggest European “techno parade” dance parties attracting way over a half a million mostly young people who party on a 2 km route along the lakeside of the City. Many of these guests drink alcohol and some eventually consume other drugs (e.g., GHB, Ecstasy, LSD). Combinations of these drugs may affect conscience eventually leading to a critical medical condition. Until recently the emergency-posts at the scene, as well as the emergency rooms of the local hospitals have been “flooded” with such patients, leading to obvious logistical problems.
Discussion of Intervention
Over the last years the Ambulance Service of the City of Zurich utilized an unused shelter close to the event scene, where these “intoxicated” mostly young patients were medically supervised and taken care of. The shelter has room for 108 patients. Every patient is first triaged; if a patient suffers from something else than just “intoxication” (e.g., cuts from broken glass) he is sent directly to the hospital for adequate treatment. The patients are then numbered, if needed showered, and receive a bed where they are regularly assessed for pulse, oxygen saturation, blood pressure and GCS by professional personnel. In parallel, if their clothes are dirty, they are washed and dried so the patient will have something clean to dress at the moment of dismissal. The average time of the patients in this shelter is 3 hours 7 minute and the charge is 600 CHF (approx 620 USD). This system has been so helpful for the hospitals, they now supply medical personnel for no cost.
Conclusion
This system of triage and separate medical supervision of “simply” intoxicated patients has been successful in the management of a large number these kind of patients.
Tsunamis are infrequent but devastating natural disasters. Loss of life, livelihood, and property contribute psychological stresses to an affected population, resulting in new psychiatric illness.
Objective
To describe post-disaster hospital, Department of Human Services (DHS), and Department of Education (DOE) methods of mental health resource dissemination, and their effectiveness.
Methods
A retrospective review of after-action reports, psychiatric clinic charts, and key-informant interviews over a 4 month period was employed. Descriptive statistics were used to evaluate data.
Results
The September 29, 2009 tsunami claimed 33 American Samoan lives. Hospital Family Assistance Center counselors aided families in the identification of 12 corpses, 9 missing persons, and providing psychiatric referral. Fifty-four hospital staff suffered loss. (Loss of: transportation, n = 13; utilities, n = 15; homes/shelter, n = 2). Coupled with the stresses of providing post-event medical care, the hospital staff was at high risk for psychiatric sequelae. Debriefing sessions for hospital staff were poorly attended due to conflicting work responsibilities, and an unfamiliar discussion format. DHS assembled four teams, each composed of one psychiatrist/psychologist leader and 6 crisis counselors. DOE school counselors utilized DHS mental health teams to screen all school aged children. The hospital psychiatry clinic remained the definitive referral destination. Federal mitigation grants provided funding for two psychiatrists, and two psychologists (including pediatric specialists) to augment hospital mental health capacity. Screening statistics and prevalence of psychiatric disease are further reported. Six month post-event rates of persistent psychiatric disease reflect that reported in recent literature (1-2%).
Conclusion
Hospital critical incident stress management requires culturally acceptable counseling methods and administrative support. Family assistance counselors are key players in identifying the needs of families of the deceased. Student counseling services and collaborative mental health teams provide a novel approach to the dissemination of mental health services within a community.
Each year a report is prepared for the World Economic Forum on global risks. It outlines the issues most likely to impact on society, and makes recommendations on actions required. The 2010 report concludes that global risks are becoming more volatile, uncertain, complex and ambiguous; and it comments on the increased number of high-impact, hard to predict ‘black swan’ events over the past decade. Indeed, recent disasters such as the Haiti earthquake which killed over 250,000 people, the eruption of Mount Eyjafjallajökull in Iceland, the rapid onset of the 2008/09 global financial crisis, and terrorist attacks around the world have all contributed to a heightened awareness of personal risk and vulnerability. In less than a decade the term resilience has evolved from the disciplines of materials science and environmental studies to become a concept used enthusiastically by policy makers, practitioners and academics. The concept is attractive as it suggests an ability of something or someone to cope in the face of adversity – to recover and return to normality after confronting an abnormal, alarming and often unexpected threat. It is used alongside security to understand how governments, local authorities, the emergency services and health agencies can best address the threats from natural disasters, health pandemics, malicious attacks on a country's critical infrastructure, and other major disruptive events. The paper discusses the meaning and utility of the concept of resilience. It traces the origins of the term through to its current use in addressing contemporary threats facing individuals, communities, organisations and nations. It identifies and describes a number of characteristics which are common to the concept of resilience in its many contexts and manifestations. In conclusion, the paper supports a review of the language and thinking of emergency and disaster management, and promotes the emerging concept of disaster resilience.
The frequency of catastrophic events has increased considerably in recent times. As a result, impacts of such catastrophes have multiplied exponentially. It is the responsibility of the government to revive and reconstruct the communities and economies affected by disasters. Domestic institutions should be resilient enough to absorb the shocks and mitigate the impacts. Too often, damage assessments rely on quantification in terms of monetary valuations of damage. This approach has created various distortions in valuation. Damage evaluation in developed countries is higher because of the monetary value of infrastructure and housing. On the contrary, in a poor, informal settlement, the value of the damage is less, but the impact is huge from a human development perspective. The government follows a standard procedure for items and means of assistance for initiating post-disaster recovery and response. All affected families are entitled to compensation based on the damage done to life and property, irrespective of socio-economic conditions. All items are listed beforehand, with their monetary values ascertained respectively. This paper examines Leh (Ladakh, India), which was struck by heavy flash flood in the month August 2010. It explores the methodology adopted for damage assessment in 42 affected villages of Leh. This case study demonstrates the inherent drawbacks of the standard procedure and methodology in assessing post-disaster damage and needs assessments, and analyzes the role of community participation in household and community damage assessment. The paper presents recommendations for a flexible and accommodating approach for conducting damage assessments on a contextual basis.
A four-story building collapse in east Delhi, India in November 2010 claimed 66 lives and left 130 injured. It is considered one of the worst such disasters in Delhi. This disaster included massive rescue operations to pull out those trapped under the debris. The nodal hospital, which did not have a well-defined hospital disaster management plan, managed the disaster extremely well. The success indicators included a SMART triage, autopsy and tagging/labeling dead bodies, public notification system, effective hospital networking for patient transfer and getting injured family members together, excellent media management, important dignitaries' management, important decision-making processes, and commendable teamwork. The critical aspects of management proved as a key indicator for the successful management. The paper discusses the details of the case study and analyzes each indicator in greater focus. The lessons learned are critically evaluated.
A multidisciplinary approach with Geographical information systems, Public health and Social science inputs was adopted to survey the fatal and non-fatal traffic crash events in the New Mumbai municipality region in Western India to identify the risky zones on the arterial highways.
Methods
A Standardized questionnaire was used to collect event data about the time, date, day of the week, location, type of injury, and vehicle type involved in the accidents, from the police station records. The data for the time period of January 2009 to July 2010 was merged into ESRI's ArcGIS software as attribute data. All the crash sites were georeferenced into the base map (with the major road networks of the region) by using a GPS receiver.
Results
Analysis was done for Hot spot identification along the major highways, number of accidents, number of fatalities and injured, case-fatality ratio and number of accidents with only financial loss. Further, the role of environmental, geographical, sociological and constructional factors was highlighted on the locations of the RTC. These roadway factors, weather, population density, road conditions, profile of the injured and healthcare access was studied. Majority of RTCs occurred during normal weather and road conditions, during daylight and on dry roads. All the analyses and interpretations were done within the ArcGIS software environment and classifying RTCs according to the attributes on the Geodatabase gave significant results.
Conclusion
Spatial analysis using GIS for Road Traffic Accidents to identify hot spots to identify high risk zones in the region enables policy makers to design injury prevention strategies for RTCs. In India, further GIS-based research is needed for planning access to emergency health care, to determine environmental-related causes, developing Injury registries and design population-based educational interventions in a developing country setting.
Inappropriate distribution of casualties in mass casualty incidents (MCIs) may result in patient overload in primary medical facilities.
Objective
The aim of this study was to review the consequences of evacuating casualties from a bus accident to a single rural hospital and lessons learned regarding policy of casualty evacuation.
Methods
Hospital medical records of all casualties from primary and tertiary hospitals were independently reviewed by two senior trauma surgeons. In addition four senior trauma surgeons reviewed the impact of treatment provided in the primary hospital on patient outcomes.
Results
31 survivors from the accident were transferred to the closest local hospital; 4 died en route to the hospital or within 30 minutes of arrival. 27 casualties were air evacuated from the local hospital within 2.5 to 6.15 hours to level I and II hospitals. Under-triage of 15% and over-triage of 7% were noted. 4 casualties did not receive treatment at the local hospital that might have improved their condition.
Discussion
Over and under-triage might have been due to minimal trauma related experience of primary hospital personnel. Evacuation of casualties from an MCI to a limited capacity hospital may overwhelm the facility and affect its ability to provide appropriate medical care.
Conclusions
In MCIs occurring in rural areas, only immediate unstable casualties should be transferred to the closest primary hospital. On-site Advanced Life Support (ALS) should be administered to non-severe casualties until they can be evacuated directly to tertiary care hospitals. First responders must be trained to provide ALS to non-severe casualties until evacuation resources are available.
Disasters refer to collective stress situations that happen or at least manifest themselves suddenly in a particular geographic area, involve some degree of loss, interfere with the ongoing social life of the community, and are subject to human management (Gist and Lubin, 1989). The World Disaster Report (2001) has reported that about 211 million people are affected by natural disasters every year and the poorest are becoming more exposed to disaster risks and disasters set back the development process by decades. The Tsunami imposed a huge burden on the community not only physically but also in terms of psychological trauma inflicted on them. Asia remained the most affected continent. Nine of the top 10 countries with the highest number of disaster-related deaths were in Asia. Women play an integral part in the functioning of societies, with established roles and rules. Enerson (1998) in her review of twenty years of disaster studies reports study findings that show that women are progressively vulnerable. The vulnerability of women stems due to the pre existing social epi- centres. Vulnerable woman-headed households generally consist of women with severely handicapped husbands and young children, handicapped women, widows, and young single women. The widows have to bear and go through the grief of the loss of their spouse. They have the burden of increased responsibility towards their surviving children, aged parents/ in laws and other family members. The current study focus on understanding the impact of widowhood in the after math of the disaster.
In Singapore, the H1N1 outbreak lasted 108 days. The study emergency department (ED) was designated as Singapore's H1N1 screening centre for the borders and the country's primary care centers. Our aim was to determine the psychological morbidity among ED physicians, nurses, administrative and ancillary staff during the H1N1 outbreak.
Methods
We conducted a survey on all ED healthcare worker (n = 305) using the 12-item General Health Questionnaire (GHQ-12). The bimodal scoring of GHQ-12 was dichotomised into non-cases (score 0 – 2) and potential cases (score ≥ 3). Participation was strictly voluntary.
Results
The overall response rate was 273 (89.5%). Most respondents were females (73.3%); the mean age was 33 (SD 10.6) years. The mean GHQ score was found to be 1.9 (SD 2.7) with no gender-related differences. A comparison of the dichotomised GHQ-12 scores, found psychological morbidity to be more common in administrative staff (40%) and physicians (38.1%) than ancillary (24.2%) and nurses (19%) (p = 0.011). The average prevalence of psychological morbidity among ED staff was 25.3%. When we considered the 12 items of the GHQ separately and analyzed them by occupational group, we found physicians scoring the worst on item 6 - “Could not overcome difficulties” - than nurses, administrative and ancillary staff (p < 0.001). Physicians and administrative staff alike felt constantly under strain and were unable to concentrate compared to nurses and ancillary staff (p = 0.001).
Conclusion
Healthcare workers in an emergency setting unlike those in the rest of the hospital, face a wide range of risks on the job and this has a substantial effect on their mental well-being and job satisfaction.
Golden time of thrombolysis therapy in acute ischemic stroke is only three hours. Emergency medical services transport and hospital prenotification were not been strengthened in Taiwan.
Aims
In order to elevate the medical quality of acute ischemic stroke, we developed a Quality Control Circle (QCC) focused on a comprehensive thrombolysis service for patients with acute ischemic stroke administered pre-hospital and in an emergency department.
Methods
QCC activities contained early recognition of acute stroke by EMT, hospital prenotification, early emergency management, activate the stroke team, shorten the time to CT scan and report, and early thromobolytic therapy. There were three policy groups via quality method analysis which these methods aimed to improve the efficiency and quality of management process focused on acute ischemic stroke.
Results
Group 1: After the implementation of QCC, the number of times of pre-hospital notification was six in Mar. 2010, achieve the expected standard. Group 2: Responses were received from 160 people for the pretest and 145 people for the posttest. In the pretest and posttest analysis, significant improvement in the attitudes of the physician group (p < 0.001) and general behavior (p < 0.001) were disclosed. The case-based educational module of acute stroke was better than the traditional oral lecture especially in the nursing group (p < 0.001). Group 3: The rate of administering thrombolytic therapy/total ischemic stroke increased from 3.1% to 10.5 % (from Mar to Apr, 2010) after running the organized service. These activities reached the goal of expected standard (5%). All above groups were set up into standardization. The thrombolytic rate in effect maintainence was still around 5% eight months later.
Conclusion
Setting up and running a organized thrombolysis service for patients with acute ischemic stroke prehospital and in the emergency department can be a good method to increase the rate of administration of thrombolytic therapy.
Cooperation between veterinary and public health authorities in Bosnia and Herzegovina and their respective field services has historically been weak and inefficient. As is the case in many countries, animal health and public health fall under separate ministries with animal health the responsibility of the ministry of agriculture and public health the ministry of health. This model has promoted interagency competition for funding for disease surveillance and control. It has also resulted in poor information exchange, lack of efficient utilization of diagnostic resources, and poor harmonization of policies. Political decentralization, established in Bosnia after the Dayton peace agreement, resulted in the lack of a national-level responsibility for animal or public health. This was instead placed at mid-governmental levels. A state (national) veterinary office was created in 2000, but there still remains no national public health agency. The H5N1 Avian Influenza (AI) outbreak which began in Southeast Asia in 2003 and reached Europe in 2005 raised concerns about Bosnia and Herzegovina's (BiH) preparedness to combat pandemic disease. Accordingly, the state (national) veterinary service of Bosnia and Herzegovina (BiH) conducted exercises which resulted in increased monitoring of wild and domestic bird populations and the drafting and adoption of a contingency plan (CP) for AI. The activities prescribed by the CP were implemented in February 2006 when the H5N1 virus was diagnosed in wild swans. However, no cooperation was established with public health authorities during this incident, further underscoring the need for a one health approach to disease control activities. Adoption of the One Health concept is challenging, and there is no simple plan that can be applied across all cultures. To prevent it from simply existing as an idealistic theory, some revision is needed and practical guidelines must be developed. The authors will include suggestions as to how this might be achieved.