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Disaster Medicine (DM) is the clinical specialty whose expertise includes the care and management of patients and populations outside conventional care protocols. While traditional standards of care assume the availability of adequate resources, DM practitioners operate in situations where resources are not adequate, necessitating a modification in practice. While prior academic efforts have succeeded in developing a list of core disaster competencies for emergency medicine residency programs, international fellowships, and affiliated health care providers, no official standardized curriculum or consensus has yet been published to date for DM fellowship programs based in the United States.
The objective of this work is to define the core curriculum for DM physician fellowships in the United States, drawing consensus among existing DM fellowship directors.
A panel of DM experts was created from the members of the Council of Disaster Medicine Fellowship Directors. This council is an independent group of DM fellowship directors in the United States that have met annually at the American College of Emergency Physicians (ACEP)’s Scientific Assembly for the last eight years with meeting support from the Disaster Preparedness and Response Committee. Using a modified Delphi technique, the panel members revised and expanded on the existing Society of Academic Emergency Medicine (SAEM) DM fellowship curriculum, with the final draft being ratified by an anonymous vote. Multiple publications were reviewed during the process to ensure all potential topics were identified.
The results of this effort produced the foundational curriculum, the 2023 Model Core Content of Disaster Medicine.
Members from the Council of Disaster Medicine Fellowship Directors have developed the 2023 Model Core Content for Disaster Medicine in the United States. This living document defines the foundational curriculum for DM fellowships, providing the basis of a standardized experience, contributing to the development of a board-certified subspecialty, and informing fellowship directors and DM practitioners of content and topics that may appear on future certification examinations.
An effective hospital response to mass casualty incidents (MCIs) requires rapid mobilization of personnel capable of caring for critically ill trauma patients and availability of resuscitation resources.
Hospitals facing an MCI wrestle with the challenge of immediately adjusting their overextended clinical operations to resuscitate a large number of rapidly arriving patients without compromising the care of existing patients.
Hospitalists are well positioned to add significant value by off-loading the emergency department (ED) given their broad clinical expertise. We describe our institution’s protocol to generate immediate and sustained surge capacity by integrating our hospitalist service into MCI response.
Our protocol details the safe and rapid transfer of care of existing ED patients to hospitalist teams to make ED staff and space available to care for incoming MCI patients.
In response to the 2014–2016 West Africa Ebola virus disease (EVD) epidemic, the Centers for Disease Control and Prevention (CDC) designated 56 US hospitals as Ebola treatment centers (ETCs) with high-level isolation capabilities. We sought to determine the ongoing sustainability of ETCs and to identify how ETC capabilities have affected hospital, local, and regional coronavirus disease 2019 (COVID-19) readiness and response.
An electronic survey included both qualitative and quantitative questions and was structured into 2 sections: operational sustainability and role in the COVID-19 response.
Setting and participants:
The survey was distributed to site representatives from the 56 originally designated ETCs, and 37 (66%) responded.
Data were coded and analyzed using descriptive statistics.
Of the 37 responding ETCs, 33 (89%) reported that they were still operating, and 4 had decommissioned. ETCs that maintain high-level isolation capabilities incurred a mean of $234,367 in expenses per year. All but 1 ETC reported that existing capabilities (eg, trained staff, infrastructure) before COVID-19 positively affected their hospital, local, and regional COVID-19 readiness and response (eg, ETC trained staff, donated supplies, and shared developed protocols).
Existing high-level isolation capabilities and expertise developed following the 2014–2016 EVD epidemic were leveraged by ETCs to assist hospital-wide readiness for COVID-19 and to support responses by other local and regional hospitals However, ETCs face continued challenges in sustaining those capabilities for high-consequence infectious diseases.
Emergency preparedness programs have evolved over the last several decades as communities have responded to natural, intentional, and accidental disasters. This evolution has resulted in a comprehensive all-hazards approach centered around 4 fundamental phases spanning the entire disaster life cycle: mitigation, preparedness, response, and recovery. Increasing frequency of outbreaks and epidemics of emerging and reemerging infectious diseases in the last decade has emphasized the significance of healthcare emergency preparedness programs, but the coronavirus disease 2019 (COVID-19) pandemic has tested healthcare facilities’ emergency plans and exposed vulnerabilities in healthcare emergency preparedness on a scale unexperienced in recent history. We review the 4 phases of emergency management and explore the lessons to be learned from recent events in enhancing health systems capabilities and capacities to mitigate, prepare for, respond to, and recover from biological threats or events, whether it be a pandemic or a single case of an unknown infectious disease. A recurring cycle of assessing, planning, training, exercising, and revising is vital to maintaining healthcare system preparedness, even in absence of an immediate, high probability threat. Healthcare epidemiologists and infection preventionists must play a pivotal role in incorporating lessons learned from the pandemic into emergency preparedness programs and building more robust preparedness plans.
The Hospital Surge Preparedness and Response Index is an all-hazards template developed by a group of emergency management and disaster medicine experts from the United States. The objective of the Hospital Surge Preparedness and Response Index is to improve planning by linking action items to institutional triggers across the surge capacity continuum. This responder tool is a non-exhaustive, high-level template: administrators should tailor these elements to their individual institutional protocols and constraints for optimal efficiency. The Hospital Surge Preparedness and Response Index can be used to provide administrators with a snapshot of their facility’s current service capacity in order to promote efficiency and situational awareness both internally and among regional partners.
Before coronavirus disease 2019 (COVID-19), few hospitals had fully tested emergency surge plans. Uncertainty in the timing and degree of surge complicates planning efforts, putting hospitals at risk of being overwhelmed. Many lack access to hospital-specific, data-driven projections of future patient demand to guide operational planning. Our hospital experienced one of the largest surges in New England. We developed statistical models to project hospitalizations during the first wave of the pandemic. We describe how we used these models to meet key planning objectives. To build the models successfully, we emphasize the criticality of having a team that combines data scientists with frontline operational and clinical leadership. While modeling was a cornerstone of our response, models currently available to most hospitals are built outside of their institution and are difficult to translate to their environment for operational planning. Creating data-driven, hospital-specific, and operationally relevant surge targets and activation triggers should be a major objective of all health systems.
The early phase of the coronavirus disease 2019 (COVID-19) pandemic and ongoing efforts for mitigation underscore the importance of universal travel and symptom screening. We analyzed adherence to documentation of travel and symptom screening through a travel navigator tool with clinical decision support to identify patients at risk for Middle East Respiratory Syndrome.
Although hospital emergency preparedness efforts have been recognized as important, there has been growing pressure on cost containment, as well as consolidation within the US health care system. There is little data looking at what health care emergency preparedness functions have been, could be, or should be centrally coordinated at a system level.
We developed a questionnaire for academic health systems and asked about program funding, resources provided, governance, and activities. The questionnaire also queried managers’ opinions regarding the appropriate role for the system-level resources in emergency response, as well as about what is most helpful at the system-level supporting preparedness.
Fifty-two of 97 systems (54%) responded. The most frequently occurring system-wide activities included: creating trainings or exercise templates (75%), promoting preparedness for employees in the system (75%), providing access to specific subject matter experts (73%), and developing specific plans for individual member entities within their system (73%). The top resources provided included a common mass notification system (71%), arranging for centralized contracts for goods and services (71%), and providing subject matter expertise (69%).
Currently, there is wide variation in the resources, capabilities, and programs used to support and coordinate system-level emergency preparedness among academic health systems. (Disaster Med Public Health Preparedness. 2018;12:574–577)
Great demands have been placed on disaster medicine educators. There is a need to develop innovative methods to educate Emergency Physicians in the ever-expanding body of disaster medicine knowledge. The authors sought to demonstrate that video-based learning (VBL) could be a promising alternative to traditional learning methods for teaching disaster medicine core competencies.
The objective was to compare VBL to traditional lecture (TL) for instructing Emergency Medicine residents in the American College of Emergency Physicians (ACEP; Irving, Texas USA) disaster medicine core competencies of patient triage and decontamination.
A randomized, controlled pilot study compared two methods of instruction for mass triage, decontamination, and personal protective equipment (PPE). Emergency Medicine resident learning was measured with a knowledge quiz, a Likert scale measuring comfort, and a practical exercise. An independent samples t-test compared the scoring of the VBL with the TL group.
Twenty-six residents were randomized to VBL (n=13) or TL (n=13). Knowledge score improvement following video (14.9%) versus lecture (14.1%) did not differ significantly between the groups (P=.74). Comfort score improvement also did not differ (P=.64) between video (18.3%) and lecture groups (15.8%). In the practical skills assessment, the VBL group outperformed the TL group overall (70.4% vs 55.5%; P<.0001), with significantly better performance in donning PPE and decontamination. Although not part of the original study design, a three-month post-hoc analysis was performed. When comparing the pre-intervention and three-month post-hoc performances, there were no significant differences in knowledge increases between VBL versus TL (P=.41) or in comfort (P=.39).
Video modules can be as effective as TL when utilized to train Emergency Medicine residents in the ACEP disaster medicine core competencies of patient triage and decontamination.
CurtisHA, TrangK, ChasonKW, BiddingerPD. Video-Based Learning vs Traditional Lecture for Instructing Emergency Medicine Residents in Disaster Medicine Principles of Mass Triage, Decontamination, and Personal Protective Equipment. Prehosp Disaster Med. 2018;33(1):7–12.
To describe current Ebola treatment center (ETC) locations, their capacity to care for Ebola virus disease patients, and infection control infrastructure features.
A 19-question survey was distributed electronically in April 2015. Responses were collected via email by June 2015 and analyzed in an electronic spreadsheet.
The survey was sent to and completed by site representatives of each ETC.
The survey was sent to all 55 ETCs; 47 (85%) responded.
Of the 47 responding ETCs, there are 84 isolation beds available for adults and 91 for children; of these pediatric beds, 35 (38%) are in children’s hospitals. In total, the simultaneous capacity of the 47 reporting ETCs is 121 beds. On the basis of the current US census, there are 0.38 beds per million population. Most ETCs have negative pressure isolation rooms, anterooms, and a process for category A waste sterilization, although only 11 facilities (23%) have the capability to sterilize infectious waste on site.
Facilities developed ETCs on the basis of Centers for Disease Control and Prevention guidance, but specific capabilities are not mandated at this present time. Owing to the complex and costly nature of Ebola virus disease treatment and variability in capabilities from facility to facility, in conjunction with the lack of regulations, nationwide capacity in specialized facilities is limited. Further assessments should determine whether ETCs can adapt to safely manage other highly infectious disease threats.
Infect. Control Hosp. Epidemiol. 2016;37(3):313–318
Exercises that simulate emergency scenarios are accepted widely as an essential component of a robust Emergency Preparedness program. Unfortunately, the variability in the quality of the exercises conducted, and the lack of standardized processes to measure performance, has limited the value of exercises in measuring preparedness.
In order to help health organizations improve the quality and standardization of the performance data they collect during simulated emergencies, a model online exercise evaluation toolkit was developed using performance measures tested in over 60 Emergency Preparedness exercises. The exercise evaluation toolkit contains three major components: (1) a database of measures that can be used to assess performance during an emergency response exercise; (2) a standardized data collection tool (form); and (3) a program that populates the data collection tool with the measures that have been selected by the user from the database. The evaluation toolkit was pilot tested from January through September 2014 in collaboration with 14 partnering organizations representing 10 public health agencies and four health care agencies from eight states across the US. Exercise planners from the partnering organizations were asked to use the toolkit for their exercise evaluation process and were interviewed to provide feedback on the use of the toolkit, the generated evaluation tool, and the usefulness of the data being gathered for the development of the exercise after-action report.
Ninety-three percent (93%) of exercise planners reported that they found the online database of performance measures appropriate for the creation of exercise evaluation forms, and they stated that they would use it again for future exercises. Seventy-two percent (72%) liked the exercise evaluation form that was generated from the toolkit, and 93% reported that the data collected by the use of the evaluation form were useful in gauging their organization’s performance during the exercise. Seventy-nine percent (79%) of exercise planners preferred the evaluation form generated by the toolkit to other forms of evaluations.
Results of this project show that users found the newly developed toolkit to be user friendly and more relevant to measurement of specific public health and health care capabilities than other tools currently available. The developed toolkit may contribute to the further advancement of developing a valid approach to exercise performance measurement.
AgboolaF, BernardD, SavoiaE, BiddingerPD. Development of an Online Toolkit for Measuring Performance in Health Emergency Response Exercises. Prehosp Disaster Med. 2015;30(5):503–508.
The unprecedented Ebola Virus Disease (EVD) outbreak in West Africa, with its first cases documented in March 2014, has claimed the lives of thousands of people, and it has devastated the health care infrastructure and workforce in affected countries. Throughout this outbreak, there has been a critical lack of health care workers (HCW), including physicians, nurses, and other essential non-clinical staff, who have been needed, in most of the affected countries, to support the medical response to EVD, to attend to the health care needs of the population overall, and to be trained effectively in infection protection and control. This lack of sufficient and qualified HCW is due in large part to three factors: 1) limited HCW staff prior to the outbreak, 2) disproportionate illness and death among HCWs caused by EVD directly, and 3) valid concerns about personal safety among international HCWs who are considering responding to the affected areas. These guidelines are meant to inform institutions who deploy professional HCWs. (Disaster Med Public Health Preparedness. 2015;9:586–590)
Although widespread support favors prospective planning for altered standards of care during mass casualty events, the literature includes few, if any, accounts of groups that have formally addressed the overarching policy considerations at the state level. We describe the planning process undertaken by public health officials in the Commonwealth of Massachusetts, along with community and academic partners, to explore the issues surrounding altered standards of care in the event of pandemic influenza. Throughout 2006, the Massachusetts Department of Public Health and the Harvard School of Public Health Center for Public Health Preparedness jointly convened a working group comprising ethicists, lawyers, clinicians, and local and state public health officials to consider issues such as allocation of antiviral medications, prioritization of critical care, and state seizure of private assets. Community stakeholders were also engaged in the process through facilitated discussion of case scenarios focused on these and other issues. The objective of this initiative was to establish a framework and some fundamental principles that would subsequently guide the process of establishing specific altered standards of care protocols. The group collectively identified 4 goals and 7 principles to guide the equitable allocation of limited resources and establishment of altered standards of care protocols. Reviewing and analyzing this process to date may serve as a resource for other states. (Disaster Med Public Health Preparedness. 2009;3(Suppl 2):S132–S140)
Objective: Legal preparedness is a critical component of comprehensive public health preparedness for public health emergencies. The scope of this study was to assess the usefulness of combining didactic sessions with a tabletop exercise as educational tools in legal preparedness, to assess the impact of the exercise on the participants’ level of confidence about the legal preparedness of a public health system, and to identify legal issue areas in need of further improvement.
Methods: The exercise scenario and the pre- and postexercise evaluation were designed to assess knowledge gained and level of confidence in declaration of emergencies, isolation and quarantine, restrictions (including curfew) on the movement of people, closure of public places, and mass prophylaxis, and to identify legal preparedness areas most in need of further improvement at the system level. Fisher exact test and paired t test were performed to compare pre- and postexercise results.
Results: Our analysis shows that a combination of didactic teaching and experiential learning through a tabletop exercise regarding legal preparedness for infectious disease emergencies can be effective in both imparting perceived knowledge to participants and gathering information about sufficiency of authorities and existence of gaps.
Conclusions: The exercise provided a valuable forum to judge the adequacy of legal authorities, policies, and procedures for dealing with pandemic influenza at the state and local levels in Massachusetts. In general, participants were more confident about the availability and sufficiency of legal authorities than they were about policies and procedures for implementing them. Participants were also more likely to report the need for improvement in authorities, policies, and procedures in the private sector and at the local level than at the state level. (Disaster Med Public Health Preparedness. 2009;3:104–110)
The objective of disaster preparedness is to ensure that appropriate systems, procedures, and resources are in place to provide prompt, effective assistance to disaster victims, thus facilitating relief measures and rehabilitation of services. Disaster preparedness efforts include the identification of possible health scenarios based on the probability of hazards and vulnerability of the population as a basis for creating a disaster plan. Exercises that simulate emergency response, involving the health and other sectors, have been suggested as useful tools to test the plans on a regular basis and measure preparedness efforts; the absence of actual testing is likely to negate even the best of abstract plans.
Exercises and after action reports (AARs) are used to document preparedness activities. However, to date, limited analysis has been performed on what makes an exercise an effective tool to assess public health emergency preparedness (PHEP), and how AARs can be developed and used to support PHEP improvement efforts. The scope of this project was to achieve consensus on: (1) what makes an exercise an effective tool to assess PHEP; and (2) what makes an AAR an effective tool to guide PHEP improvement efforts.
Sixty-one PHEP experts were convened by the use of Nominal Group Techniques to achieve consensus on a series of characteristics that exercises should have when designed to assess PHEP and on the recommendations for developing high-quality AARs.
The panelists achieved consensus on a list of recommendations to improve the use of exercises and AARs in PHEP improvement efforts. Such recommendations ranged from the characteristics of the exercise audience to the evaluation methodology being used and the characteristics of the produced AAR such as its structure and content.
The characteristics of the exercise audience, scenario and scope are among the most important attributes to the effectiveness of an exercise conducted for PHEP evaluation purposes. The evaluation instruments used to gather observations need an appropriate matching between exercise objectives and the response capabilities tested during the exercise, to build the base for the production of a good AAR. Improvements in the design and creation of exercises and AARs could facilitate better reporting and measurement of preparedness outcomes.
SavoiaE, PrestonJ, BiddingerPD. A Consensus Process on the Use of Exercises and After Action Reports to Assess and Improve Public Health Emergency Preparedness and Response. Prehosp Disaster Med. 2013;28(3):1-4.