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Introduction: In the prehospital setting, optimal endotracheal tube (ETT) depth may be approximated using the patient's sex or height, and assessed by auscultation. Even when using these methods, the ETTs still may be placed at inappropriate depths.
Problem: This study assessed the inter-rater reliability and accuracy of manual cuff palpation (ballottement) at excluding an improperly placed ETT depth in adult patients.
Methods: This is a prospective, observational, pilot study in a convenience sample of adults recently intubated in the prehospital, medical floor, intensive care unit, or emergency department settings of an urban, teaching hospital. Two physician participants separately performed ballottement on each intubated subject and rated the ballottement as none, weak, or strong prior to assessment of appropriate depth using a chest radiograph (CXR). Results were compared for simple agreement and compared to the CXR to estimate accuracy.
Results: Of 163 patients, 27 (17%) had an inappropriate ETT depth. Physician assessments of ballottement agreed in 79% of patients (95% CI = 72-85%). Chest radiograph assessment found the ETT in the “strong” ballottement group properly placed in 93%, as compared to 77% in the “weak”, and 42% in the “none” groups. Combining “weak” and “strong” ballottement, the sensitivity was 96% (95% CI = 93–100%), specificity was 26% (95% CI = 9–43%), and accuracy was 85% (95% CI = 79–90%).
Conclusions: Manual cuff palpation is a simple and reproducible technique that is sensitive, but nonspecific, in identifying intubations of appropriate depth.
The Impact of Event Scale Revised (IES-R) has been used in various epidemiological studies to assess the prevalence of post-traumatic stress disorder (PTSD). Previous studies using the IES-R Japanese version to assess the mental health of firefighters were based on the premise that firefighters had experienced a traumatic event(s) as a matter of course. However, use of the IES-R-J does not indicate whether or not a traumatic event was experienced. The purpose of this study is to clarify the differences between: (1) IES-R-J high and low score groups; and (2) those who report symptoms similar to those of PTSD with and without having been being exposed to a traumatic event.
Methods:
Questionnaire packets distributed to all 157 workers in a Japanese fire station included the IES-R, the Japan Brief Job Stress Questionnaire, a questionnaire regarding traumatic event experiences, and demographic questions. Participants who scored ≥25 points on the IES-R-J scale were defined as the PTSD high risk (HR) group; those with scores <25 points as the PTSD low risk (LR) group.
Results:
One hundred thirty-one of the 157 subjects (83.4%) responded to the questionnaire; three were excluded from the analysis because of missing data. The mean total IES-R-J score was 14.9 ±15.2. Twenty-eight subjects scored in the PTSD HR group (≥25); 100 scored in the LR group (<25). A total of 54 (42.2%) participants had experienced a traumatic event; 57.8% had not. In the HR group, 14 subjects had experienced a traumatic event and 14 had not. Participants who had experienced a traumatic event reported a higher incidence of intrusion/re-experience symptoms than did those who had not experienced a traumatic event. The level of social support significantly affected the risk for PTSD.
Firefighters who scored ≥25 on the IES-R-J and, thus, considered to be at high risk for the development of PTSD, were less confident about their health, experienced more job stressors and had less social support than did those whose IES-R-J scores were <25. Having experienced a traumatic event was reported by only 42% of all the participants and by only 50% of those in the high risk PTSD group.
Conclusions:
Although the IES-R is an easily-administered tool useful in epidemiological studies evaluating psychological stress, it is recommended that the questionnaire be amended to include a question regarding the existence of a threatened experience or event and to analyze the data using positive and negative predictive value methodology.
Background: In April 2004, the US Army Medical Department approved the use of the Army Knowledge Online (AKO) electronic e-mail system as a teleconsultation service for remote teledermatology consultations from healthcare providers in Iraq, Kuwait, and Afghanistan to medical subspecialists in the United States. The success of the system has resulted in expansion of the telemedicine program to include 11 additional clinical specialty services: (1) burn-trauma; (2) cardiology; (3) dermatology; (4) infectious disease; (5) nephrology; (6) ophthalmology; (7) pediatric intensive care; (8) preventive and occupational medicine; (9) neurology; (10) rheumatology; and (11) toxicology. The goal of the program is to provide a mechanism for enhanced diagnosis of remote cases resulting in a better evacuation system (i.e., only evacuation of appropriate cases). The service provides a standard practice for managing acute and emergent care requests between remote medical providers in austere environments and rear-based specialists in a timely and consistent manner.
Methods: Consults are generated using the AKO e-mail system routed through a contact group composed of volunteer, on-call consults. The project manager receives and monitors all teleconsultations to ensure Health Insurance Portability and Accountability Act compliance and consultant's recommendations are transmitted within a 24-hour mandated time period. A subspecialty “clinical champion” is responsible for recruiting consultants to answer teleconsultations and developing a call schedule for each specialty. Subspecialties may have individual consultants on call for specific days (e.g., dermatology and toxicology) or place entire groups on-call for a designated period of time (e.g., ophthalmology).
Results: As of May 2007, 2,337 consults were performed during 36 months, with an average reply time of five hours from receipt of the teleconsultation until a recommendation was sent to the referring physician. Most consultations have been for dermatology (66%), followed by infectious disease (10%). A total of 51 known evacuations were prevented from use of the program, while 63 known evacuations have resulted following receipt of the consultants' recommendation. A total of 313 teleconsultations also have been performed for non-US patients.
Conclusions: The teleconsultation program has proven to be a valuable resource for physicians deployed in austere and remote locations. Furthermore, use of such a system for physicians in austere environments may prevent unnecessary evacuations or result in appropriate evacuations for patients who initially may have been “underdiagnosed.”
With limited available hospital beds in most urban areas, there are very few options when trying to relocate patients already within the hospital to make room for incoming patients from a mass-casualty incident (MCI) or epidemic (a patient surge). This study investigates the possibility and process for utilizing shuttered (closed or former) hospitals to accept medically stable, ambulatory patients transferred from a tertiary medical facility.
Methods:
Two recently closed, acute care hospitals were evaluated critically to determine if they could be made ready to accept inpatients within 3–7 days of a MCI. This surge facility ideally would be able to support 200–300 patients/beds. Two generic scenarios were used for planning: (1) a patient surge (including one caused by conventional war or terrorism, weapons of mass destruction, or a disaster caused by natural hazards) requiring transfer of ambulatory, medically-stable inpatients to another facility in an effort to increase capacity at existing hospitals; and (2) a bio-event or epidemic where a shuttered hospital could be used as an isolation facility.
Results:
Both recently closed hospitals had significant, but different challenges to reopening, although with careful planning and resource allocation it would be possible to reopen them within 3–7 days. Planning was the most conclusive recommendation. It does not appear possible to reopen shuttered hospitals with major structural deterioration or a complete lack of current mission (i.e., no current utilities). Staffing would represent the most challenging issue as a surge facility would represent an incremental additional need for existing and scarce human resources.
Conclusions:
With careful planning, a shuttered hospital could be reopened and ready to accept patients within 3–7 days of a MCI or epidemic.
Hospital surge capacity is a crucial part of community disaster preparedness planning, which focuses on the requirements for additional beds, equipment, personnel, and special capabilities.The scope and urgency of these requirements must be balanced with a practical approach addressing cost and space concerns. Renewed concerns for infectious disease threats, particularly from a potential avian flu pandemic perspective, have emphasized the need to be prepared for a prolonged surge that could last six to eight weeks.
Null Hypothesis:
The surge capacity that realistically would be generated by the cumulative Greater Dayton Area Hospital Association (GDAHA) plan is sufficient to meet the demands of an avian influenza pandemic as predicted by the [US] Centers for Disease Control and Prevention (CDC) models.
Methods:
Using a standardized data form, surge response plans for each hospital in the GDAHA were assessed.The cumulative results were compared to the demand projected for an avian influenza pandemic using the CDC's FluAid and FluSurge models.
Results:
The cumulative GDAHA capacity is sufficient to meet the projected demand for bed space, intensive care unit beds, ventilators, morgue space, and initial personal protective equipment (PPE) use. There is a shortage of negative pressure rooms, some basic equipment, and neuraminidase inhibitors. Many facilities lack a complete set of written surge policies, including screening plans to segregate contaminated patients and staff prior to entering the hospital. Few hospitals have agreements with nursing homes or home healthcare agencies to provide care for patients discharged in order to clear surge beds. If some of the assumptions in the CDC's models are changed to match the morbidity and mortality rates reported from the 1918 pandemic, the surge capacity of GDAHA facilities would not meet the projected demand.
Conclusions:
The GDAHA hospitals should test their regional distributors' ability to resupply PPE for multiple facilities simultaneously. Facilities should retrofit current air exchange systems to increase the number of potential negative pressure rooms and include such designs in all future construction. Neuraminidase inhibitor supplies should be increased to provide treatment for healthcare workers exposed in the course of their duties. Each hospital should have a complete set of policies to address the special considerations for a prolonged surge. Additional capacity is required to meet the predicted demands of a threat similar to the 1918 pandemic.
Earthquakes present a major threat to mankind. Increasing knowledge about geophysical interactions, progressing architectural technology, and improved disaster management algorithms have rendered modern populations less susceptible to earthquakes. Nevertheless, the mass casualties resulting from earthquakes in Great Kanto (Japan), Ancash (Peru), Tangshan (China), Guatemala, Armenia, and Izmit (Turkey) or the recent earthquakes in Bhuj (India), Bam (Iran), Sumatra (Indonesia) and Kashmir (Pakistan) indicate the devastating effect earthquakes can have on both individual and population health. Appropriate preparation and implementation of crisis management algorithms are of utmost importance to ensure a large-scale medical-aid response is readily available following a devastating event. In particular, efficient triage is vital to optimize the use of limited medical resources and to effectively mobilize these resources so as to maximize patient salvage. However, the main priorities of disaster rescue teams are the rescue and provision of emergency care for physical trauma. Furthermore, the establishment of transport evacuation corridors, a feature often neglected, is essential in order to provide the casualties with a chance for survival. The optimal management of victims under such settings is discussed, addressing injuries of the body and psyche by means of simple diagnostic and therapeutic procedures globally applicable and available.
Global warming has been hotly debated over the last two decades among scientists, economists, legal experts, philosophers, and politicians. Yet, the medical and public health communities are relative newcomers to understanding this global threat to humanity. As we celebrate Earth Day on 22 April 2008, there is an opportunity to educate physicians and other healthcare providers involved in mitigating, preparing for, responding to, and recovering from disasters about the medical and health implications of global warming.
Foreign field hospitals (FFHs) may provide care for the injured and substitute for destroyed hospitals in the aftermath of sudden-onset disasters.
Problem:
In the aftermath of sudden-onset disasters, FFHs have been focused on providing emergency trauma care for the initial 48 hours following the sudden-onset disasters, while they tend to be operational much later. In addition, many have remained operational even later. The aim of this study was to assess the timing, activities, and capacities of the FFHs deployed after four recent sudden-onset disasters, and also to assess their adherence to the essential criteria for FFH deployment of the World Health Organization (WHO).
Methods:
Secondary information on the sudden-onset disasters in Bam, Iran in 2003, Haiti in 2004, Aceh, Indonesia in 2004, and Kashmir, Pakistan in 2005, including the number of FFHs deployed, their date of arrival, country of origin, length of stay, activities, and costs was retrieved by searching the Internet.Additional information was collected on-site in Iran, Indonesia, and Pakistan through direct observation and key informant interviews.
Results:
Basic information was found for 43 FFHs in the four disasters. The first FFH was operational on Day 3 in Bam and Kashmir, and on Day 8 in Aceh. The first FFHs were all from the militaries of neighboring countries. The daily cost of a bed was estimated to be US$2,000. The bed occupancy rate generally was <50%. None of the 43 FFHs met the first WHO/Pan-American Health Organization (PAHO) essential requirement if the aim is to provide emergency trauma care, while 15% followed the essential requirement if follow-up trauma and medical care is the aim of deployment.
Discussion:
A striking finding was the lack of detailed information on FFH activities. None of the 43 FFHs arrived early enough to provide emergency medical trauma care. The deployment of FFHs following sudden-onset disasters should be better adapted to the main needs and the context and more oriented toward substituting for pre-existing hospitals, rather than on providing immediate trauma care.
Terrorism is a global public health burden. South Americans have been victims of terrorism for many decades.While the causes vary, the results are the same: death, disability, and suffering.The objective of this study was to perform a comprehensive, epidemiological, descriptive study of terrorist incidents in South America.
Methods:
This is a cross-sectional, descriptive study. Data from January 1971 to July 2006 was selected using the RAND Terrorism Chronology 1968–1997 and RAND®-Memorial Institute for Prevention of Terrorism (MIPT) Terrorism Incident database (1998–Present). Statistical significance was set at 0.05.
Results:
The database reported a total of 2,997 incidents in South American countries that resulted in 3,435 victims with injuries (1.15 per incident) and 1,973 fatalities (0.66 per incident). The overall case fatality ratio (CFR) was 35.8%. Colombia had the majority of incidents with 57.9% (1,734 of 2,997), followed by Peru with 363 (12.1%), and Argentina with 267 (8.9%). The highest individual CFR occurred in Paraguay (83.3%), and the lowest in Chile with 4.8%. Of the total injuries and deaths, Colombia had 66.1% (2,269 of 2,997) of all injuries and 75.2% (1,443 out of 1,920) of all deaths. Living in the country of Colombia was associated with a 16 times greater likelihood of becoming a victim of terrorist violence [odds ratio (OR) 16.15; 95% CI 13.45 to 19.40; p <0.0001].The predominant method of choice for terrorist incidents was the use of conventional explosives with 2,543 of 2,883 incidents (88.2%).
Conclusions:
Terrorist incidents in South America have accounted for nearly 2,000 deaths, with conventional explosive devices as the predominant method of choice. Understanding the nature of terrorist attacks and the medical consequences assist emergency preparedness and disaster management officials in allocating resources and preparing for potential future events.
The objective of this preliminary study was to evaluate the perceptions of internationally deployed Disaster Medical Assistance Team (DMAT) personnel regarding the psychosocial support needs of these teams.
Methods:
The DMAT questionnaire was sent to 34 members of Australian medical teams involved in deployments to the 2004 Southeast Asian tsunami and the 2006 Java earthquake. Twenty personnel (59%) completed this survey, which reviewed key deployment stressors, specific support strategies, and the support needs of team members, their families, and team leaders. A key aspect of the survey was to determine whether the perceived psychosocial needs would be supported best within with existing provisions and structures, or if they would be enhanced by further provisions, including the deployment of mental health specialists.
Results:
There was strong support for brief reviews of stress management strategies as part of the pre-deployment briefing, and access to written stress management information for both team members and their families. However, more comprehensive provisions, including pre-deployment, stressmanagement training programs for personnel and intra-deployment family support programs, received lower levels of support. The availability of mental health-related training for the team leader role and access to consultation with mental health specialists was supported, but this did not extend to the actual deployment of mental health specialists.
Conclusions:
In this preliminary study, clear trends toward the maintenance of current mental health support provisions and the role of the DMAT leader were evident. A follow-up study will examine the relationship between teamleader, psychosocial support strategies and team functioning.
Surge capacity is defined as a healthcare system's ability to rapidly expand beyond normal services to meet the increased demand for appropriate space, qualified personnel, medical care, and public health in the event of bioterrorism, disaster, or other large-scale, public health emergencies. There are many individuals and agencies, including policy makers, planners, administrators, and staff at the federal, state, and local level, involved in the process of planning for and executing policy in respect to a surge in the medical requirements of a population. They are responsible to ensure there is sufficient surge capacity within their own jurisdiction.
Problem:
The [US] federal government has required New York State to create a system of hospital bed surge capacity that provides for 500 adult and pediatric patients per 1 million population, which has been estimated to be an increase of 15–20% in bed availability. In response, the New York City Department of Health and Mental Hygiene (NYC DOH) has requested that area hospitals take an inventory of available beds and set a goal to provide for a 20% surge capacity to be available during a mass-casualty event or other conditions calling for increased inpatient bed availability.
Methods:
In 2003, under the auspices of the NYC DOH, the New York Institute of All Hazard Preparedness (NYIHP) was formed from four unaffiliated, healthcare facilities in Central Brooklyn to address this and other goals.
Results:
The NYIHP hospitals have developed a surge capacity plan to provide necessary space and utilities. As these plans have been applied, a bed surge capacity of approximately 25% was identified and created for Central Brooklyn to provide for the increased demand on the medical care system that may accompany a disaster. Through the process of developing an integrated plan that would engage a public health incident, the facilities of NYIHP demonstrate that a model of cooperation may be applied to an inherently fractioned medical system.
Hospital medical incident monitoring improves preventable morbidity and mortality rates. Error management systems have been adopted widely in this setting. Data relating to incident monitoring in the prehospital setting is limited.
Problem:
Implementation of an incident monitoring process in a prehospital setting.
Methods:
This is a prospective, descriptive study of the pilot phase of the implementation of an incident monitoring process in a regional prehospital setting, with a focus on trauma care. Paramedics and emergency department staff submitted anonymous incident reports, and a chart review was performed on patients who met major trauma criteria. Selected trauma cases were analyzed by a structured interview/debriefing process to elucidate undocumented incidents.A project committee coded and logged all incidents and developed recommendations.
Results:
Of 4,429 ambulance responses, 41 cases were analyzed.Twenty-four (58.5%; 95% CI = 49.7–67.4%) were reported anonymously, and the rest were major trauma patients. A total of 77 incidents were identified (mean per case = 1.8; CI = 1.03–2.57). Anonymous cases revealed 26 incidents (mean = 1.1; CI = 0.98–1.22); eight trauma debriefings revealed 38 incidents (mean = 4.8; CI = 0.91–8.69) and nine trauma chart reviews revealed 13 incidents (mean = 1.6; CI = 1.04–2.16). A total of 56 of 77 (72.7%; CI = 65.5–80.0%) incidents related to system inadequacies, and 15 (57.7%; CI = 46.7–68.6%) anonymously reported incidents related to resource problems. A total of 35 of 77 (45.5%; CI = 40.4–50.5%) incidents had minimal or no impact on the patients' outcomes. Thirty-four of 77 (44.2%; CI = 39.3–49.1%) incidents were considered mitigated by circumstance. Incident monitoring led to generalized feedback in most cases (65 of 77; 84.4%; CI = 77.6–91.3%); in three cases (3.9%; CI = 3.7–4.1%), specific education occurred; two cases were reported to an external body (2.6%; CI = 2.5–2.7%); three cases resulted in remedial action (3.9%; CI = 3.7–4.1%); four for trend/further observation and analysis responses (5.2%; CI = 4.9–5.5%).
Conclusions:
The pilot project demonstrates successful implementation of an incident monitoring system within a regional, prehospital environment. The combination of incident detecting techniques has a high yield with potential to capture different error types.The large proportion of incidents in the “near miss” category allows analysis of incidents without patient harm. The majority of incidents were system related and many were mitigated by circumstance. The model used is appropriate for ongoing incident monitoring in this setting.
Inadequately controlled chronic diseases may present a threat to life and well-being during the emergency response phase of disasters. Chronic disease exacerbations (CDE) account for one of the largest patient populations during disasters, and patients are at increased risk for adverse outcomes.
Objective:
The objective of this study was to assess the burden of chronic renal failure, diabetes, and cardiovascular disease during disasters due to natural hazards, identify impediments to care, and propose solutions to improve the disaster preparation and management of CDE.
Methods:
A thorough search of the PubMed, Ovid, and Medline databases was performed. Dr. Miller's personal international experiences treating CDE after disasters due to natural hazards, such as the 2005 Kashmir earthquake, are included.
Discussion:
Chronic disease exacerbations comprise a sizable disease burden during disasters related to natural hazards. Surveys estimate that 25–40% of those living in the regions affected by hurricanes Katrina and Rita lived with at least one chronic disease. Chronic illness accounted for 33% of visits, peaking 10 days after hurricane landfall. The international nephrology community has responded to dialysis needs by forming a well-organized and effective organization called the Renal Disaster Relief Task Force (RDRTF). The response to the needs of diabetic and cardiac patients has been less vigorous.
Patients must be familiar with emergency diet and renal fluid restriction plans, possible modification of dialysis schedules and methods, and rescue treatments such as the administration of kayexalate. Facilities may consider investing in water-independent extracorporeal dialysis techniques as a rescue treatment. In addition to patient databases and medical alert identification, diabetics should maintain an emergency medical kit. Diabetic patients must be taught and practice the carbohydrate counting technique. In addition to improved planning, responding agencies and organizations must bring adequate supplies and medications to care for diabetic, cardiac, and renal patients during relief efforts.
Conclusions:
By recognizing and addressing impediments to the care of chronic disease exacerbations after natural disasters, the quality, delivery, and effectiveness of the care provided to diabetic patients during relief efforts can be improved.
In recent years, attention has been given to disaster preparedness for first responders and first receivers (hospitals). One such focus involves the decontamination of individuals who have fallen victim to a chemical agent from an attack or an accident involving hazardous materials. Children often are overlooked in disaster planning. Children are vulnerable and have specific medical and psychological requirements. There is a need to develop specific protocols to address pediatric patients who require decontamination at the entrance of hospital emergency departments. Currently, there are no published resources that meet this need. An expert panel convened by the New York City Department of Health and Mental Hygiene developed policies and procedures for the decontamination of pediatric patients.The panel was comprised of experts from a variety of medical and psychosocial areas.Using an iterative process, the panel created guidelines that were approved by the stakeholders and are presented in this paper.These guidelines must be utilized, studied, and modified to increase the likelihood that they will work during an emergency situation.
Patients who have been contaminated by chemical compounds present a number of difficulties to emergency departments, in particular, the risk of secondary contamination of healthcare staff and facilities. The Department of Health in the United Kingdom has provided equipment to decontaminate chemically contaminated casualties who present at emergency departments. The capacity of this equipment is limited, and although both the ambulance and fire services have equipment to cope with mass casualties at the scene of a chemical incident, there is still the possibility that acute hospitals will be overwhelmed by large numbers of self-presenting patients. The risks and potential consequences of this gap in resilience are discussed and a number of possible practical solutions are proposed.
The purpose of this study was to examine how agencies in South Carolina that provide in-home health care and personal care services help older and/or disabled clients to prepare for disasters.The study also examines how agencies safeguard clients' records, train staff, and how they could improve their preparedness.
Methods:
The relevant research and practice literature was reviewed. Nine public officials responsible for preparedness for in-home health care and personal care services in South Carolina were interviewed. A telephone survey instrument was developed that was based on these interviews and the literature review. Administrators from 16 agencies that provide in-home personal care to 2,147 clients, and five agencies that provide in-home health care to 2,180 clients, were interviewed. Grounded theory analysis identified major themes in the resulting qualitative data; thematic analysis organized the content.
Results:
Federal regulations require preparedness for agencies providing inhome health care (“home health”). No analogous regulations were found for in-home personal care. The degree of preparedness varied substantially among personal care agencies. Most personal care agencies were categorized as “less” prepared or “moderately” prepared. The findings for agencies in both categories generally suggest lack of preparedness in: (1) identifying clients at high risk and assisting them in planning; (2) providing written materials and/or recommendations; (3) protecting records; (4) educating staff and clients; and (5) coordinating disaster planning and response across agencies. Home health agencies were better prepared than were personal care agencies.
However, some home health administrators commented that they were unsure how well their plans would work during a disaster, given a lack of training. The majority of home health agency administrators spoke of a need for better coordination and/or more preparedness training.
Conclusions:
Agencies providing personal care and home health services would benefit from developing stronger linkages with their local preparedness systems. The findings support incorporating disaster planning in the certification requirements for home health agencies, and developing additional educational resources for administrators and staff of personal care agencies and their clients.