The assessment of hospital disaster preparedness and response performance is a way to find and remove possible gaps and weaknesses in hospital disaster management effectiveness. The aim of this pilot study was to test the association between the level of preparedness and the level of response performance during a full-scale hospital exercise.

This pilot study was conducted in a hospital during a full-scale exercise in the Piedmont region of Italy. The preparedness evaluation was conducted by a group of three experts, three days before the exercise, and the response evaluation was conducted during the exercise. The functional capacity module was used for preparedness evaluation, and the response performance of the “command and control” function of the hospital was evaluated by nine semiquantitative performance indicators.

The preparedness of the chosen hospital was 59%, while the response performance was evaluated as 70%. The hospital staff conducted Simple Triage and Rapid Transport (START) triage while they received 61 casualties, which was 90% correct for the yellow group and 100% correct for the green group.

This pilot study showed that it is possible to use standardized evaluations tools, to simultaneously assess the relationship between preparedness elements and response performance measures. An experimental study including a group of hospitals, also using more comprehensive evaluation tools, should be done to evaluate the correlation between the level of preparedness and the response performance of a hospital, and the impact of hospital disaster planning, on the outcome of disasters victims.

DjalaliA, CarenzoL, RagazzoniL, AzzarettoM, PetrinoR, Della CorteF, IngrassiaPL. Does Hospital Disaster Preparedness Predict Response Performance During a Full-scale Exercise? A Pilot Study. Prehosp Disaster Med. 2014;29(4):1-7.

Emergency Medical Services (EMS) professionals frequently care for patients experiencing acute pain. Analgesics are critical in patient comfort and satisfaction levels during the treatment of acute pain. The objective of this study was to assess the frequency of pain management in patients suffering a fall, the documented pain score, and the location of their injuries. It was hypothesized that the frequency of analgesia administration was low and would be associated with injury location.

This was a retrospective review of patients presenting with a complaint of an injury from a fall transported by a single municipal EMS system. Administration of analgesia was the primary outcome variable, with pain severity, injury location, age, gender, race, and distance of fall the independent variables of interest. Pain severity was assessed using a 0-10 scale. Injury location was defined as head/neck, extremities, back, and hip. Patients were deemed ineligible for analgesia, according to local protocol, if they reported chest or abdominal pain, or were hemodynamically unstable as determined by an assessment of pulse and blood pressure.

There were 1,200 patients who were classified as having injuries suffered from a fall, with 76 (6.3%) ineligible for analgesia. Ninety-two (8.2%) patients received analgesia, and they had a mean recorded pain score of 9.1 (95% CI, 8.7-9.5), which was higher than those who did not receive analgesia (5.8; 95% CI, 5.5-6.2). Analgesia administration was associated with injury location; patients experiencing an extremity injury (OR = 13.23; 95% CI, 5.58-31.36; P < .001) or hip injury (OR = 11.65; 95% CI, 4.64-29.24; P < .001) had increased odds of analgesia administration compared to those with head/neck injury. The odds of analgesia administration were decreased for black patients (OR = 0.19; 95% CI, 0.08-0.44; P < .001) when compared to white patients.

Analgesia administration was provided to 10% of eligible patients, and was associated with injury location. Of concern was the number of patients who suffered a fall and did not receive a documented pain score. The results from this study indicated a need for education relating to pain management in patients suffering a fall.

InfingerAE, StudnekJR. An Assessment of Pain Management Among Patients Presenting to Emergency Medical Services After Suffering a Fall. Prehosp Disaster Med. 2014;29(4):1-6.

Over the past decade, numerous groups of researchers have studied the willingness of health care personnel (HCP) to respond when a disaster threatens the health of a community. Not one of those studies reported that 100% of HCP were willing to work during a public-health event (PHE).

The objective of this study was to explore factors associated with the intent of HCP to respond to a future PHE.

The theory of planned behavior (TPB) framed this cross-sectional study. Data were obtained via a web-based survey from 305 HCP. Linear associations between the TPB-based predictor and outcome variables were examined using Pearson's correlations. Differences between two groups of HCP were calculated using independent t tests. A model-generating approach was used to develop and assess a series of TBP-based observed variable structural equation models for prediction of intent to respond to a future PHE and to explore moderating and mediating effects.

The beginning patterns of relationships identified by the correlation matrix and t tests were evident in the final structural equation model, even though the patterns of prediction differed from those posited by the theory. Outcome beliefs had both a significant, direct effect on intention and an indirect effect on intention that was mediated by perceived behavioral control. Control beliefs appeared to influence intention through perceived behavioral control, as posited by the TPB, and unexpectedly through subjective norm. Subjective norm not only mediated the relationship between control beliefs and intention, but also the relationship between referent beliefs and intention. Additionally, professional affiliation seemed to have a moderating effect on intention.

The intention to respond was influenced primarily by normative and control factors. The intent of nurses to respond to a future PHE was influenced most by the control factors, whereas the intent of other HCP was shaped more by the normative factors. Health care educators can bolster the normative and control factors through education by focusing on team building and knowledge related to accessing supplies and support needed to respond when a disaster occurs.

ConnorSB. Factors Associated with the Intention of Health Care Personnel to Respond to a Disaster. Prehosp Disaster Med. 2014;29(6):1-6.

During an earthquake, vulnerable populations, especially those with chronic conditions, are more susceptible to adverse, event-induced exacerbation of chronic conditions such as limited access to food and water, extreme weather temperatures, and injury. These circumstances merit special attention when health care facilities and organizations prepare for and respond to disasters.

This study explores the relationship between pre-earthquake burden of illness and postearthquake health-related and preparedness factors in the US. Data from a cohort of male veterans who were receiving care at the Sepulveda Veterans Affairs Medical Center (VAMC) in Los Angeles, California USA during the 1994 Northridge earthquake were analyzed.

Veterans with one or more chronic conditions were more likely to report pain lasting two or more days, severe mental/emotional stress for more than two weeks, broken/lost medical equipment, having difficulty refilling prescriptions, and being unable to get medical help following the quake compared to veterans without chronic conditions. In terms of personal emergency preparedness, however, there was no association between burden of illness and having enough food or water for at least 24 hours after the earthquake.

The relationship that exists between health care providers, including both individual providers and organizations like the US Department of Veterans Affairs (VA), and their vulnerable, chronically-ill patients affords providers the unique opportunity to deliver critical assistance that could make this vulnerable population better prepared to meet their postdisaster health-related needs. This can be accomplished through education about preparedness and the provision of easier access to medical supplies. Disaster plans for those who are burdened with chronic conditions should meet their social needs in addition to their psychological and physical needs.

Der-MartirosianC, RiopelleD, NaranjoD, YanoE, RubensteinL, DobalianA. Pre-earthquake Burden of Illness and Postearthquake Health and Preparedness in Veterans. Prehosp Disaster Med. 2014;29(3):1-7.

Education and training are key elements of disaster management. Despite national and international educational programs in disaster management, there is no standardized curriculum available to guide the European Union (EU) member states. European- based Disaster Training Curriculum (DITAC), a multiple university-based project financially supported by the EU, is charged with developing a holistic and highly-structured curriculum and courses for responders and crisis managers at a strategic and tactical level. The purpose of this study is to qualitatively assess the prevailing preferences and characteristics of disaster management educational and training initiatives (ETIs) at a postgraduate level that currently exist in the EU countries.

An Internet-based qualitative search was conducted in 2012 to identify and analyze the current training programs in disaster management. The course characteristics were evaluated for curriculum, teaching methods, modality of delivery, target groups, and funding.

The literature search identified 140 ETIs, the majority (78%) located in United Kingdom, France, and Germany. Master level degrees were the primary certificates granted to graduates. Face-to-face education was the most common teaching method (84%). Approximately 80% of the training initiatives offered multi- and cross-disciplinary disaster management content. A competency-based approach to curriculum content was present in 61% of the programs. Emergency responders at the tactical level were the main target group. Almost all programs were self-funded.

Although ETIs currently exist, they are not broadly available in all 27 EU countries. Also, the curricula do not cover all key elements of disaster management in a standardized and competency-based structure. This study has identified the need to develop a standardized competency-based educational and training program for all European countries that will ensure the practice and policies that meet both the standards of care and the broader expectations for professionalization of the disaster and crisis workforce.

IngrassiaPL, FolettiM, DjalaliA, ScaroneP, RagazzoniL, DellaCorte F, KaptanK, LupescuO, ArculeoC, von ArnimG, FriedlT, AshkenaziM, HeselmannD, HreckovskiB, Khorrram-ManeshA, KomadinaR, LechnerK, PatruC, BurkleFMJr., FisherP. Education and Training Initiatives for Crisis Management in the European Union: A Web-based Analysis of Available Programs. Prehosp Disaster Med. 2014;29(2):1-12.

Faith-based organizations represent a source of stability and are an established presence in a community. They frequently serve their community following disasters. They are not formally included or identified as a disaster resource; thus, there is an opportunity to increase the effectiveness with which faith-based organizations prepare for and respond to disasters.

This pilot study aimed to assess perceptions of the level of disaster preparedness and resiliency among faith-based organizations as a first step in understanding how to improve disaster preparedness and resiliency among these organizations and their communities.

Survey and semi-structured interviews were conducted with six faith-based organizations, one with a leader and one with a staff member. Frequency distributions of survey questions were obtained. Interviews were transcribed and thematic analysis was supported by analytical software, ATLAS. ti.

Results of the survey indicated strong social networks among congregation and community members. However, half of the members indicated that they did not socialize often with other races and other neighborhoods. Additionally, trust of other groups of people was generally low. Themes that emerged from qualitative analysis were: (1) perceived disaster preparedness and resiliency; (2) barriers to community preparedness and resiliency; (3) lessons learned from past disasters; (4) social services and networks; and (5) willingness to be prepared.

The results suggest that there is a need for interventions to improve disaster preparedness and resiliency among faith-based organizations.

MullerV, BurkeR, BergB, LinA, UppermanJ. A Mixed-methods Pilot Study of Disaster Preparedness and Resiliency Among Faith-based Organizations. Prehosp Disaster Med. 2014;29(2):1-7.

During disasters and complex emergencies, environmental conditions can adversely affect the performance of point-of-care (POC) testing. Knowledge of these conditions can help device developers and operators understand the significance of temperature and humidity limits necessary for use of POC devices. First responders will benefit from improved performance for on-site decision making.

To create dynamic temperature and humidity profiles that can be used to assess the environmental robustness of POC devices, reagents, and other resources (eg, drugs), and thereby, to improve preparedness.

Surface temperature and humidity data from the National Climatic Data Center (Asheville, North Carolina USA) was obtained, median hourly temperature and humidity were calculated, and then mathematically stretched profiles were created to include extreme highs and lows. Profiles were created for: (1) Banda Aceh, Indonesia at the time of the 2004 Tsunami; (2) New Orleans, Louisiana USA just before and after Hurricane Katrina made landfall in 2005; (3) Springfield, Massachusetts USA for an ambulance call during the month of January 2009; (4) Port-au-Prince, Haiti following the 2010 earthquake; (5) Sendai, Japan for the March 2011 earthquake and tsunami with comparison to the colder month of January 2011; (6) New York, New York USA after Hurricane Sandy made landfall in 2012; and (7) a 24-hour rescue from Hawaii USA to the Marshall Islands. Profiles were validated by randomly selecting 10 days and determining if (1) temperature and humidity points fell inside and (2) daily variations were encompassed. Mean kinetic temperatures (MKT) were also assessed for each profile.

Profiles accurately modeled conditions during emergency and disaster events and enclosed 100% of maximum and minimum temperature and humidity points. Daily variations also were represented well with 88.6% (62/70) of temperature readings and 71.1% (54/70) of relative humidity readings falling within diurnal patterns. Days not represented well primarily had continuously high humidity. Mean kinetic temperature was useful for severity ranking.

Simulating temperature and humidity conditions clearly reveals operational challenges encountered during disasters and emergencies. Understanding of environmental stresses and MKT leads to insights regarding operational robustness necessary for safe and accurate use of POC devices and reagents. Rescue personnel should understand these principles before performing POC testing in adverse environments.

FergusonWJ, LouieRF, TangCS, Paw UKT, KostGJ. Dynamic Temperature and Humidity Environmental Profiles: Impact for Future Emergency and Disaster Preparedness and Response. Prehosp Disaster Med. 2014;29(1):1-8.

The catastrophic Great East Japan Earthquake in 2011 created a crisis in a university-affiliated hospital by disrupting the water supply for 10 days. In response, this study was conducted to analyze water use and prioritize water consumption in each department of the hospital by applying a business impact analysis (BIA). Identifying the minimum amount of water necessary for continuing operations during a disaster was an additional goal.

Water is essential for many hospital operations and disaster-ready policies must be in place for the safety and continued care of patients.

A team of doctors, nurses, and office workers in the hospital devised a BIA questionnaire to examine all operations using water. The questionnaire included department name, operation name, suggested substitutes for water, and the estimated daily amount of water consumption. Operations were placed in one of three ranks (S, A, or B) depending on the impact on patients and the need for operational continuity. Recovery time objective (RTO), which is equivalent to the maximum tolerable period of disruption, was determined. Furthermore, the actual use of water and the efficiency of substitute methods, practiced during the water-disrupted periods, were verified in each operation.

There were 24 activities using water in eight departments, and the estimated water consumption in the hospital was 326 (SD = 17) m3 per day: 64 (SD = 3) m3 for S (20%), 167 (SD = 8) m3 for A (51%), and 95 (SD = 5) m3 for B operations (29%). During the disruption, the hospital had about 520 m3 of available water. When the RTO was set to four days, the amount of water available would have been 130 m3 per day. During the crisis, 81% of the substitute methods were used for the S and A operations.

This is the first study to identify and prioritize hospital operations necessary for the efficient continuation of medical treatment during suspension of the water supply by applying a BIA. Understanding the priority of operations and the minimum daily water requirement for each operation is important for a hospital in the event of an unexpected adverse situation, such as a major disaster.

SuginakaH, OkamotoK, HiranoY, FukumotoY, MorikawaM, OodeY, SumiY, InoueY, MatsudaS, TanakaH. Hospital Disaster Response Using Business Impact Analysis. Prehosp Disaster Med. 2014;29(5):1-8.

Although prehospital care is recognized as key in health systems development, it has been largely neglected in Haiti. The North East Department is one of the poorest areas of Haiti, and is a region where no data on out-of-hospital health care exists. This research assessed prehospital characteristics in the North East Department with the aim of providing baseline data to inform prehospital systems development.

In this observational study, data were collected from patients presenting at the Fort Liberté Hospital, the public regional referral health center in the North East Department. Data were accrued from April 2, 2012 through June 5, 2012. All patients accessing acute care at the hospital were eligible for enrollment. After obtaining consent, data on demographics, health needs, and prehospital information were gathered via a standardized questionnaire administered by hospital staff trained in study protocols.

Data were collected from 441 patient visits. The median age was 24 years, with 62% of the population being female. Medical complaints comprised 75% of visits, with fever and gastrointestinal complaints being the most common reasons for presentation. Traumatic injuries accounted for 25% of encounters, with an equal distribution of blunt and penetrating events. Extremity injuries were the most common traumatic subclassification. The majority of patients (67.2%) were transported by motorcycle taxi and paid transport fees. Trauma patients were more likely to be transported without charge (OR = 9.10; 95% CI, 2.19-37.76; P < .001). Medical patients were most commonly brought from home (78.5%) and trauma patients from a road/street setting (42.9%). Median time to presentation was 240 minutes (IQR = 120-500) and 65 minutes (IQR = 30-150) for medical and trauma complaints, respectively (P < .001). Eleven percent of patients reported receiving care prior to arrival. As compared with medical patients, trauma victims were less likely to have received prehospital care.

Assessing prehospital care in this low-income setting that lacks surveillance systems was feasible and required minimal resources. Motorcycle taxi drivers function as the primary emergency transport mechanism and may represent an access point for prehospital interventions in the North East Department of Haiti. Out-of-hospital care is nearly nonexistent in the region and its development has the potential to yield public health benefits.

AluisioAR, GoreR, DecomeI, De WulfA, BloemC. Prehospital Characteristics in the North East Department of Haiti: A Cross-sectional Study from a Low-income Setting Without Prehospital Systems. Prehosp Disaster Med. 2014;29(3):1-7.

Internationally there is an increasing amount of peer-reviewed literature pertaining to disaster nursing. The literature includes personal anecdotes, reflections, and accounts of single case studies. Furthermore, issues such as the willingness of nurses to assist in disasters, the role of nurses in disasters, leadership, competencies, and educational preparedness for nurses have been the focus of the literature.

The aim of this research was to determine the international research priorities for disaster nursing.

This research used a three-round Delphi technique. The first round used a face-to-face workshop to generate research statements with nursing members of the World Association for Disaster and Emergency Medicine (WADEM). The second and third rounds included the ranking of statements on a 5-point Likert scale with nursing members of WADEM and the World Society of Disaster Nursing (WSDN). Statements that achieved a mean of four or greater were considered a priority and progressed.

Participants were from multiple countries. Research statements were generated in the areas of: education, training, and curriculum; psychosocial; strategy, relationship, and networking; and clinical practice. Psychosocial aspects of disaster nursing ranked the highest, with five statements appearing in the top ten research areas, followed by statements relating to: education, training, and curriculum; clinical practice; and finally, strategy, relationship, and networking.

Future disaster nursing research should focus on the area of psychosocial aspects of disaster nursing, in particular, both the psychosocial needs of a disaster-affected community and the psychosocial wellbeing of nurses who assist in disaster health activities.

RanseJ, HuttonA, JeeawodyB, WilsonR. What Are the Research Needs for the Field of Disaster Nursing? An International Delphi Study. Prehosp Disaster Med. 2014;29(5):1-7.

Emergency Medical Services (EMS) routinely stage in a secure area in response to active shooter incidents until the scene is declared safe by law enforcement. Due to the time-sensitive nature of injuries at these incidents, some EMS systems have adopted response tactics utilizing law enforcement protection to expedite life-saving medical care.

Describe EMS provider perceptions of preparedness, adequacy of training, and general attitudes toward active shooter incident response after completing a tactical awareness training program.

An unmatched, anonymous, closed-format survey utilizing a five-point Likert scale was distributed to participating EMS providers before and after a focused training session on joint EMS/police active shooter rescue team response. Descriptive statistics were used to compare survey results. Secondary analysis of responses based on prior military or tactical medicine training was performed using a chi-squared analysis.

Two hundred fifty-six providers participated with 88% (225/256) pretraining and 88% (224/256) post-training surveys completed. Post-training, provider agreement that they felt adequately prepared to respond to an active shooter incident changed from 41% (92/225) to 89% (199/224), while agreement they felt adequately trained to provide medical care during an active shooter incident changed from 36% (82/225) to 87% (194/224). Post-training provider agreement that they should never enter a building with an active shooter changed from 73% (165/225) to 61% (137/224). Among the pretraining surveys, significantly more providers without prior military or tactical experience agreed they should never enter a building with an active shooter until the scene was declared safe (78% vs 50%, P = .002), while significantly more providers with prior experience felt both adequately trained to provide medical care in an active shooter environment (56% vs 31%, P = .007) and comfortable working jointly with law enforcement within a building if a shooter were still inside (76% vs 56%, P = .014). There was no difference in response to these questions in the post-training survey.

Attitudes and perceptions regarding EMS active shooter incident response appear to change among providers after participation in a focused active shooter response training program. Further studies are needed to determine if these changes are significant and whether early EMS response during an active shooter incident improves patient outcomes.

JonesJ, KueR, MitchellP, EblanG, DyerKS. Emergency Medical Services Response to Active Shooter Incidents: Provider Comfort Level and Attitudes Before and After Participation in a Focused Response Training Program. Prehosp Disaster Med. 2014;29(4):1-7.

Children are particularly vulnerable during disasters and mass-casualty incidents. Coordinated multi-hospital training exercises may help health care facilities prepare for pediatric disaster victims.

The purpose of this study was to use mixed methods to assess the disaster response of three hospitals, focusing on pediatric disaster victims.

A full-functional disaster exercise involving a simulated 7.8-magnitude earthquake was conducted at three Los Angeles (California USA) hospitals, one of which is a freestanding designated Level I Pediatric Trauma Center. Exercise participants provided quantitative and qualitative feedback regarding their perceptions of pediatric disaster response during the exercise in the form of surveys and interviews. Additionally, trained observers provided qualitative feedback and recommendations regarding aspects of emergency response during the exercise, including communication, equipment and supplies, pediatric safety, security, and training.

According to quantitative participant feedback, the disaster exercise enhanced respondents’ perceived preparedness to care for the pediatric population during a mass-casualty event. Further, qualitative feedback from exercise participants and observers revealed opportunities to improve multiple aspects of emergency response, such as communication, equipment availability, and physician participation. Additionally, participants and observers reported opportunities to improve safety and security of children, understanding of staff roles and responsibilities, and implementation of disaster triage exercises.

Consistent with previous investigations of pediatric disaster preparedness, evaluation of the exercise revealed several opportunities for all hospitals to improve their ability to respond to the needs of pediatric victims. Quantitative and qualitative feedback from both participants and observers was useful for comprehensively assessing the exercise's successes and obstacles. The present study has identified several opportunities to improve the current state of all hospitals’ pediatric disaster preparedness, through increased training on pediatric disaster triage methods and additional training on the safety and security of children. Regular assessment and evaluation of supplies, equipment, leadership assignments, and inter-hospital communication is also suggested to optimize the effectiveness and efficiency of response to pediatric victims in a disaster.

BurkeRV, KimTY, BachmanSL, IversonEI, BergBM. Using Mixed Methods to Assess Pediatric Disaster Preparedness in the Hospital Setting. Prehosp Disaster Med. 2014;29(6): 1-7.

The 2010 Haiti earthquake and Pakistan floods were similar in their massive human impact. Although the specific events were very different, the humanitarian response to disasters is supposed to achieve the same ends. This paper contrasts the disaster effects and aims to contrast the medium-term response.

In January 2011, similarly structured population-based surveys were carried out in the most affected areas using stratified cluster designs (80×20 in Pakistan and 60×20 in Haiti) with probability proportional to size sampling.

Displacement persisted in Haiti and Pakistan at 53% and 39% of households, respectively. In Pakistan, 95% of households reported damage to their homes and loss of income or livelihoods, and in Haiti, the rates were 93% and 85%, respectively. Frequency of displacement, and income or livelihood loss, were significantly higher in Pakistan, whereas disaster-related deaths or injuries were significantly more prevalent in Haiti.

Given the rise in disaster frequency and costs, and the volatility of humanitarian funding streams as a result of the recent global financial crisis, it is increasingly important to measure the impact of humanitarian response against the goal of a return to normalcy.

WeissWM, KirschTD, DoocyS, PerrinP. A Comparison of the Medium-term Impact and Recovery of the Pakistan Floods and the Haiti Earthquake: Objective and Subjective Measures. Prehosp Disaster Med. 2014;29(3):1-8.