The 2005 Gulf Coast hurricane season was one of the most costly and deadly in US history. Hurricane Rita stressed hospitals and led to multiple, simultaneous evacuations. This study systematically identified community factors associated with patient movement out of seven hospitals evacuated during Hurricane Rita.

This study represents the second of two systematic, observational, and retrospective investigations of seven acute care hospitals that reported off-site evacuations due to Hurricane Rita. Participants from each hospital included decision makers that comprised the Incident Management Team (IMT). Investigators applied a standardized interview process designed to assess evacuation factors related to external situational awareness of community activities during facility evacuation due to hurricanes. The measured outcomes were responses to 95 questions within six sections of the survey instrument.

Investigators identified two factors that significantly impacted hospital IMT decision making: (1) incident characteristics affecting a facility's internal resources and challenges; and (2) incident characteristics affecting a facility's external evacuation activities. This article summarizes the latter and reports the following critical decision making points: (1) Emergency Operations Plans (EOP) were activated an average of 85 hours (3 days, 13 hours) prior to Hurricane Rita's landfall; (2) the decision to evacuate the hospital was made an average of 30 hours (1 day, 6 hours) from activation of the EOP; and (3) the implementation of the evacuation process took an average of 22 hours. Coordination of patient evacuations was most complicated by transportation deficits (the most significant of the 11 identified problem areas) and a lack of situational awareness of community response activities. All evacuation activities and subsequent evacuation times were negatively impacted by an overall lack of understanding on the part of hospital staff and the IMT regarding how to identify and coordinate with community resources.

Hospital evacuation requires coordinated processes and resources, including situational awareness that reflects the condition of the community as a result of the incident. Successful hospital evacuation decision making is influenced by community-wide situational awareness and transportation deficits. Planning with the community to create realistic EOPs that accurately reflect available resources and protocols is critical to informing hospital decision making during a crisis. Knowledge of these factors could improve decision making and evacuation practices, potentially reducing evacuation times in future hurricanes.

DowneyEL, AndressK, SchultzCH. External Factors Impacting Hospital Evacuations Caused by Hurricane Rita: The Role of Situational Awareness. Prehosp Disaster Med. 2013;28(3):1-8.

Tropical cyclone (TC) Yasi, thought to be the largest and most severe cyclone to cross the Queensland coast since 1918, made landfall on the southern tropical coast near Mission Beach and continued to track westward across Northern Queensland on February 3, 2011. The warning and response model (WRM) suggests that situational factors, personal characteristics, and social contextual variables influence the degree of threat perceived and protective actions taken.

The aim of this study was to examine preparation for this impending natural disaster by residents of the affected regions, and to identify the residents’ resource losses and symptoms of psychological distress following TC Yasi.

A cross-sectional survey was conducted 6-12 months after the cyclone using an adapted tool designed to measure preparedness, loss and psychosocial distress. Four hundred and thirty-three responses were received. Statistical analysis was conducted using Statistical Package for the Social Sciences (SPSS). Categorical characteristics were described using sample size and percentages.

Almost all respondents perceived the cyclone warning as serious or very serious, and more than a third started preparing for the cyclone at least three days before it reached landfall. Overall, 115 (26.7%) respondents reported moderate and 59 (13.7%) reported major property damage; 72 (17.1%) reported a moderate and 49 (11.6%) reported a major change in their feeling of whether they have control over their life; 55 (13.1%) reported a major change in their motivation of getting things done; and 33 (7.9%) reported a major change in their perception of feeling valuable to others. Overall, 142 (34.1%) documented at least one of five symptoms of acute distress.

The findings document the experiences of Australians who have lived through tropical cyclone Yasi. The results support the WRM theory which proposes that people with previous experience take threatened disasters seriously.

UsherK, BuettnerP, WestC, MillisJ, WoodsC, MasonM, BoonH, Chamberlain-SalaunJ. Preparedness for and Impact of Tropical Cyclone Yasi in North Queensland, Australia. Prehosp Disaster Med. 2013;28(3):1-7.

Electronic medical records (EMRs) are considered superior in documentation of care for medical practice. Current disaster medical response involves paper tracking systems and radio communication for mass-casualty incidents (MCIs). These systems are prone to errors, may be compromised by local conditions, and are labor intensive. Communication infrastructure may be impacted, overwhelmed by call volume, or destroyed by the disaster, making self-contained and secure EMR response a critical capability.

As the prehospital disaster EMR allows for more robust content including protected health information (PHI), security measures must be instituted to safeguard these data. The Wireless Internet Information System for medicAl Response in Disasters (WIISARD) Research Group developed a handheld, linked, wireless EMR system utilizing current technology platforms. Smart phones connected to radio frequency identification (RFID) readers may be utilized to efficiently track casualties resulting from the incident. Medical information may be transmitted on an encrypted network to fellow prehospital team members, medical dispatch, and receiving medical centers. This system has been field tested in a number of exercises with excellent results, and future iterations will incorporate robust security measures.

A secure prehospital triage EMR improves documentation quality during disaster drills.

DeMersG, KahnC, JohanssonP, BuonoC, ChiparaO, GriswoldW, ChanT. Secure Scalable Disaster Electronic Medical Record and Tracking System. Prehosp Disaster Med. 2013;28(5):1-4.

Very little is known on the impact of recurrent disasters on mental health.

The present study examines the immediate impact of a recurrent flood on mental health and functioning among an affected population in the rural district of Bahraich, Uttar Pradesh, India, compared with a population in the same region that is not affected by floods.

The study compared 318 affected respondents with 308 individuals who were not affected by floods. Symptoms of anxiety and depression were assessed by the Hopkins Symptom Checklist-25 (HSCL-25). Psychological and physical functioning was assessed by using the Short Form-12 (SF-12).

The affected group showed large to very large differences with the comparison group on symptoms of anxiety (D = .92) and depression (D = 1.22). The affected group scored significantly lower on psychological and physical functioning than the comparison group (respectively D = .33 and D = .80). However, hierarchical linear regressions showed no significant relationship between mental health and the domains of functioning in the affected group, whereas mental health and the domains of functioning were significantly related in the comparison group.

This study found a large negative impact of the recurrent floods on mental health outcomes and psychological and physical functioning. However, in a context with recurrent floods, disaster mental health status is not a relevant predictor of functioning. The findings suggest that the observed mental health status and impaired functioning in this context are also outcomes of another mechanism: Both outcomes are likely to be related to the erosion of the social and environmental and material context. As such, the findings refer to a need to implement psychosocial context-oriented interventions to address the erosion of the context rather than specific mental health interventions.

WindTR, JoshiPC, KleberRJ, KomproeIH. The Impact of Recurrent Disasters on Mental Health: A Study on Seasonal Floods in Northern India. Prehosp Disaster Med. 2013;28(3):1-7.

Successful oxygenation and ventilation can mean the difference between life and death in the prehospital setting. While airway challenges can be numerous within the confines of the emergency department, there are many additional confounding difficulties in the prehospital setting, which include limited access to equipment, poor lighting, extreme environments, limited personnel to assist, no immediate backup, and limited rescue airway options. The concept of an easy, reliable, and rapidly deployable alternative rescue airway device is critical, especially when considering the addition of rapid sequence intubation protocols in the prehospital setting.

The primary objective of this study was to ascertain whether paramedics can be trained to deploy this alternative airway device with an acceptable success rate in a simulated critical care airway scenario. The secondary objective was to determine whether the previously-trained paramedics were able to retain their ability to deploy the device successfully at one year.

This was a prospective, observational, single-group, descriptive cohort, educational trial. Forty paramedics were trained in the use of the Intubating Laryngeal Mask Airway (I-LMA) in a simulation medicine curriculum culminating in a simulated critical care difficult airway scenario requiring urgent oxygenation and ventilation after failed traditional endotracheal intubation. An emergency medicine physician proctor determined successful airway management. Repeat testing was then performed at approximately one year out, challenging the medics to intubate a mannequin using the I-LMA during an unrelated training session.

Of the 40 paramedics who underwent complete simulation training, 39 were able to intubate and ventilate the simulated difficult airway using the I-LMA during the critical care scenario. This yields a success rate of 97.5% (95% CI, 87.1%-99.4%). At approximately one year out, 35 out of 35 medics were able to intubate the mannequin using the I-LMA, resulting in a success rate of 100% (95% CI, 91.4%-100%).

In this study, paramedics were able to deploy the I-LMA with a high degree of success in a simulated difficult airway, with a high degree of skill retention at one year out.

ByarsD, LoB, YatesJ. Evaluation of Paramedic Utilization of the Intubating Laryngeal Mask Airway in High-Fidelity Simulated Critical Care Scenarios. Prehosp Disaster Med.2013;28(6):1-2.

Since 2001, a Japanese national project has developed a helicopter emergency medical service (HEMS) system (“doctor-helicopter”) and a central Disaster Medical Assistance Team (DMAT) composed of mobile and trained medical teams for rapid deployment during the response phase of a disaster.

In Japan, the DMAT Research Group has focused on command and control of doctor-helicopters in future disasters. The objective of this study was to investigate the effectiveness of such planning, as well as the problems encountered in deploying the doctor-helicopter fleet with DMAT members following the March 11, 2011 Great East Japan Earthquake.

This study was undertaken to examine the effectiveness of aeromedical disaster relief activities following the Great East Japan Earthquake and to evaluate the assembly and operations of 15 doctor-helicopter teams dispatched for patient evacuation with medical support.

Fifteen DMATs from across Japan were deployed from March 11th through March 13th to work out of two doctor-helicopter base hospitals. The dispatch center at each base hospital directed its own doctor-helicopter fleet under the command of DMAT headquarters to transport seriously injured or ill patients out of hospitals located in the disaster area. Disaster Medical Assistance Teams transported 149 patients using the doctor-helicopters during the first five days after the earthquake. The experiences and problems encountered point to the need for DMATs to maintain direct control over 1) communication between DMAT headquarters and dispatch centers; 2) information management concerning patient transportation; and 3) operation of the doctor-helicopter fleet during relief activities. As there is no rule of prioritization for doctor-helicopters to refuel ahead of other rotorcraft, many doctor-helicopters had to wait in line to refuel.

The “doctor-helicopter fleet” concept was vital to Japan's disaster medical assistance and rescue activities. The smooth and immediate dispatch of the doctor-helicopter fleet must occur under the direct control of the DMAT, independent from local government authority. Such a command and control system for dispatching the doctor-helicopter fleet is strongly recommended, and collaboration with local government authorities concerning refueling priority should be addressed.

MatsumotoH, MotomuraT, HaraY, MasudaY, MashikoK, YokotaH, KoidoY. Lessons Learned from the Aeromedical Disaster Relief Activities Following the Great East Japan Earthquake. Prehosp Disaster Med. 2013;28(2):1-4.

The emergency telephone number 9-1-1 serves as a lifeline to the public during emergencies, and first responders rely on information gathered by 9-1-1 telecommunicators who speak with callers. Timely, accurate information from the telecommunicators is essential for providing appropriate care on scene. Language barriers can hamper these efforts and result in less efficient information exchange. Although 9-1-1 telecommunicators may access over-the-phone interpreter (OPI) services to facilitate communication, managing three-way communication during an emergency is challenging.

There is little published on the relationship between limited English proficient (LEP) callers and 9-1-1 police telecommunicators, and the role of OPI services during these calls. Further, little is known about effective strategies to manage such calls.

In King County, Washington, 9-1-1 police telecommunicators were surveyed about their experiences handling LEP calls and managing three-way communication with OPI services. The survey contained 13 multiple-choice and three open-response questions addressing communication strategies, challenges with LEP callers, and three-way communication with OPI services. Goodman-Kruskal Gamma and chi-square tests were conducted with OPI use as the dependent variable. Additional analyses were conducted using stress levels as the dependent variable.

Of 123 respondents, 69 (56.5%) 9-1-1 telecommunicators reported utilizing OPI services at least 75% of the time when receiving a call from an LEP caller. Further, 35 (28.7%) of these telecommunicators reported calls with LEP individuals as more stressful than calls with fluent English speakers. Dispatcher stress level during LEP calls compared with stress during calls with fluent English speakers was positively associated with use of OPI services (P < .01). Further, stress level was also positively associated with telecommunicator difficulties in assessing the situation with respect to officer safety (P < .01). Sixty-three (58.3%) of the telecommunicators described difficulties assessing the situation to determine the appropriate response as the biggest challenge with LEP callers. Additionally, 62 (53%) identified knowing their location in English as information LEP callers need to know prior to calling 9-1-1.

These results highlight intervention opportunities for both 9-1-1 telecommunicators and LEP communities. Together, interventions such as working with LEP communities to educate them on best communication practices during 9-1-1 calls, and with 9-1-1 telecommunicators to help them manage three-way communication and reduce stress associated with concern for officer safety may improve emergency communication during 9-1-1 calls.

CarrollLN, CalhounRE, SubidoCC, PainterIS, MeischkeHW. Serving Limited English Proficient Callers: A Survey of 9-1-1 Police Telecommunicators. Prehosp Disaster Med. 2013;28(3):1-6.

Severe sepsis and septic shock are common, expensive and often fatal medical problems. The care of the critically sick and injured often begins in the prehospital setting; there is limited data available related to predictors and interventions specific to sepsis in the prehospital arena. The objective of this study was to assess the predictive effect of physiologic elements commonly reported in the out-of-hospital setting in the outcomes of patients transported with sepsis.

This was a cross-sectional descriptive study. Data from the years 2004-2006 were collected. Adult cases (≥18 years of age) transported by Emergency Medical Services to a major academic center with the diagnosis of sepsis as defined by ICD-9-CM diagnostic codes were included. Descriptive statistics and standard deviations were used to present group characteristics. Chi-square was used for statistical significance and odds ratio (OR) to assess strength of association. Statistical significance was set at the .05 level. Physiologic variables studied included mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR) and shock index (SI).

Sixty-three (63) patients were included. Outcome variables included a mean hospital length of stay (HLOS) of 13.75 days (SD = 9.97), mean ventilator days of 4.93 (SD = 7.87), in-hospital mortality of 22 out of 63 (34.9%), and mean intensive care unit length-of-stay (ICU-LOS) of 7.02 days (SD = 7.98). Although SI and RR were found to predict intensive care unit (ICU) admissions, [OR 5.96 (CI, 1.49-25.78; P = .003) and OR 4.81 (CI, 1.16-21.01; P = .0116), respectively] none of the studied variables were found to predict mortality (MAP <65 mmHg: P = .39; HR >90: P = .60; RR >20 P = .11; SI >0.7 P = .35).

This study demonstrated that the out-of-hospital shock index and respiratory rate have high predictability for ICU admission. Further studies should include the development of an out-of-hospital sepsis score.

BaezAA, HanudelP, WilcoxSR. The Prehospital Sepsis Project: Out-of-Hospital Physiologic Predictors of Sepsis Outcomes. Prehosp Disaster Med. 2013;28(6):1-4.