Emergency Department Disaster Research Articles

Nonfatal Injuries Sustained in Mass Shootings in the US, 2012-2019: Injury Diagnosis Matrix, Incident Context, and Public Health Considerations.

The epidemic of gun violence in the United States (US) is exacerbated by frequent mass shootings. In 2021, there were 698 mass shootings in the US, resulting in 705 deaths and 2,830 injuries. This is a companion paper to a publication in JAMA Network Open, in which the nonfatal outcomes of victims of mass shootings have been only partially described. We gathered clinical and logistic information from 31 hospitals in the US about 403 survivors of 13 mass shootings, each event involving greater than 10 injuries, from 2012-19. Local champions in emergency medicine and trauma surgery provided clinical data from electronic health records within 24 hours of a mass shooting. We organized descriptive statistics of individual-level diagnoses recorded in medical records using International Classification of Diseases codes, according to the Barell Injury Diagnosis Matrix (BIDM), a standardized tool that classifies 12 types of injuries within 36 body regions. Of the 403 patients who were evaluated at a hospital, 364 sustained physical injuries-252 by gunshot wound (GSW) and 112 by non-ballistic trauma-and 39 were uninjured. Fifty patients had 75 psychiatric diagnoses. Nearly 10% of victims came to the hospital for symptoms triggered by, but not directly related to, the shooting, or for exacerbations of underlying conditions. There were 362 gunshot wounds recorded in the Barell Matrix (1.44 per patient). The Emergency Severity Index (ESI) distribution was skewed toward higher acuity than typical for an emergency department (ED), with 15.1% ESI 1 and 17.6% ESI 2 patients. Semi-automatic firearms were used in 100% of these civilian public mass shootings, with 50 total weapons for 13 shootings (Route 91 Harvest Festival, Las Vegas. 24). Assailant motivations were reported to be associated with hate crimes in 23.1%. Survivors of mass shootings have substantial morbidity and characteristic injury distribution, but 37% of victims had no GSW. Law enforcement, emergency medical systems, and hospital and ED disaster planners can use this information for injury mitigation and public policy planning. The BIDM is useful to organize data regarding gun violence injuries. We call for additional research funding to prevent and mitigate interpersonal firearm injuries, and for the National Violent Death Reporting System to expand tracking of injuries, their sequelae, complications, and societal costs.

Epidemiology of mass casualty incidents in a tertiary care trauma center in eastern India: A retrospective observational study.

OBJECTIVES:Disasters and mass casualty incidents (MCIs) that cause substantial mortality and morbidity have been increasing worldwide. The emergency department (ED) services manage MCIs by optimizing triage and providing health care with required resources. The present study attempted to describe the epidemiological characteristics and outcomes of MCIs presenting to the ED.METHODS:The present retrospective observational study was conducted at the ED of a tertiary care hospital on patients of MCI for 4 years from 2017 to 2021. The data were extracted from the ED disaster records and other paper-based patient records. Information on patient demography, date and time of arrival, mode of transport, method of arrival (direct or referral), type and mechanism of MCI, ED management, and outcome were recorded. Statistical analysis was performed using R, version 4.1.0.RESULTS:Analysis of 21 MCIs was conducted. Road traffic accidents (RTAs) were the predominant cause of MCIs. The majority of MCI victims, except for those of blast injuries, were men. The victims in medical emergencies were significantly younger than those in other MCI groups (P < 0.001). The majority of patients were brought to ED through ambulance services (n = 120 [47.1%]), followed by private vehicles (n = 112 [44.2%]). Most of the MCI victims (n = 143 [56.2%]) were brought to the ED during evening hours (4 pm–8 pm). The majority of victims belonged to the “Red” triage category (n = 110 [43.3%]). The injury severity score was significantly higher (P = 0.014) in the disaster group than in other trauma MCI groups (20 vs. 17). Autorickshaw occupants were the most common victims of mass casualty RTAs (n = 38 [40%]). Suturing (n = 97 [50%]) and dressing (n = 167 [88%]) were the most common ED procedures required by the victims of trauma MCIs. Of the total, 167 (66%) patients were discharged from the ED, 47 (19%) patients were admitted to wards, 13 (5%) patients were admitted to intensive care units, and 24 (9%) patients got referred to other centers. In addition, two patients died in the ED during treatment, whereas one patient was brought dead.CONCLUSIONS:RTAs dominate the MCIs and are affecting the young producative male population. The present study exhibited the severity of the cases in MCIs and their impact in the health-care setting, therefore signifying the importance of standardized MCI management protocols.

Experience of pharmacy involvement in a disaster simulation exercise within a pediatric hospital emergency department: A pilot project.

In this descriptive report, we describe a unique trial of pharmacist participation in a multidisciplinary pediatric emergency department disaster simulation exercise. With the number of disasters increasing worldwide, the role of pharmacists in disaster response is of particular interest to the profession. This observational study describes pharmacist participation in a disaster simulation exercise. An evaluation tool was developed to assess participants' performance in the following domains: communication, pharmacotherapy, problem solving/decision making, and teamwork/organization. The observers used a rating scale of "concise/prompt," "needs improvement," or "not done" to evaluate performance on each objective. The participants' self-perceived knowledge of disaster response was assessed with pre- and postsimulation surveys using Likert scales. Five simulation exercises were held from June to October 2019, with 2 pharmacists participating in each simulation. Within the problem solving/decision making and communication domains, pharmacists were concise/prompt 66% of the time, while they were concise/prompt for 88.8% and 92.5% of tasks in the teamwork/organization and pharmacotherapy domains, respectively. Surveys of self-perceived knowledge revealed that while only 10% of pharmacists felt "moderately prepared" prior to the simulation exercise, 80% of pharmacists felt moderately prepared to care for patients during a disaster event after the simulation exercise. This report describes a unique approach of including emergency department-trained pharmacists in disaster simulation exercises to enhance their professional development, improve team dynamics in a mass casualty scenario, and increase their own reported level of preparedness to effectively manage a surge in critically ill pediatric patients.

Medical students as disaster volunteers: A strategy for improving emergency department surge response in times of crisis.

Disasters resulting in mass casualty incidents can rapidly overwhelm the Emergency Department (ED). To address critical manpower needs in the ED’s disaster response, medical student involvement has been advocated. Duke-National University of Singapore Medical School is in proximity to Singapore General Hospital and represents an untapped manpower resource. With appropriate training and integration into ED disaster workflows, medical students can be leveraged upon as qualified manpower. This review provides a snapshot of the conceptualization and setting up of the Disaster Volunteer Corps – a programme where medical students were recruited to receive regular training and assessment from emergency physicians on disaster response principles to fulfil specific roles during a crisis, while working as part of a team under supervision. We discuss overall strategy and benefits to stakeholders, emphasizing the close symbiotic relationship between academia and healthcare services.

Disaster Olympics: Paediatric emergency department disaster preparedness gamification.

Disaster Olympics: Paediatric emergency department disaster preparedness gamification.

Developing a Context Appropriate Emergency Department Disaster Preparedness Protocol in Black Lion Hospital, Addis Ababa, Ethiopia

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Ready or not: Does household preparedness prevent absenteeism among emergency department staff during a disaster?

During major disasters, hospitals experience varied levels of absenteeism among healthcare workers (HCWs) in the immediate response period. Loss of critical hospital personnel, including Emergency Department (ED) staff, during this time can negatively impact a facility's ability to effectively treat large numbers of ill and injured patients. Prior studies have examined factors contributing to HCW ability and willingness to report for duty during a disaster. The purpose of this study was to determine if the degree of readiness of ED personnel, as measured by household preparedness, is associated with predicted likelihood of reporting for duty. Additionally, the authors sought to elucidate other factors associated with absenteeism among ED staff during a disaster. ED staff of five hospitals participated in this survey-based study, answering questions regarding demographic information, past disaster experience, household disaster preparedness (using a novel,15-point scale), and likelihood of reporting to work during various categories of disaster. The primary outcome was personal predicted likelihood of reporting for duty following a disaster. A total of 399 subjects participated in the study. ED staffs were most likely to report for duty in the setting of an earthquake (95 percent) or other natural disaster, followed by an epidemic (90 percent) and were less likely to report for work during a biological, chemical, or a nuclear event (63 percent). Degree of household preparedness was determined to have no association with an ED HCW's predicted likelihood of reporting for duty. Factors associated with predicted absenteeism varied based on type of disaster and included having dependents in the home, female gender, past disaster relief experience, having a spouse or domestic partner, and not owning pets. Having dependents in the home was associated with predicted absenteeism for all disaster types (OR 0.30-0.66). However, when stratified by gender, the presence of dependents at home was only a significantly associated with predicted absenteeism among women as opposed to men (OR 0.07-0.59 versus OR 0.41-1.02). Personal household preparedness, while an admirable goal, appears to have no effect on predicted absenteeism among ED staff following a disaster. Having responsibilities for dependents is the most consistent factor associated with predicted absenteeism among female staff. Hospital and ED disaster planners should consider focusing preparedness efforts less toward household preparedness for staff and instead concentrate on addressing dependent care needs in addition to professional preparedness.

Simulation of a Hospital Disaster Plan: A Virtual, Live Exercise

Currently, there is no widely available method to evaluate an emergency department disaster plan. Creation of a standardized patient database and the use of a virtual, live exercise may lead to a standardized and reproducible method that can be used to evaluate a disaster plan. A virtual, live exercise was designed with the primary objective of evaluating a hospital's emergency department disaster plan. Education and training of participants was a secondary goal. A database (disastermed.ca) of histories, physical examination findings, and laboratory results for 136 simulated patients was created using information derived from actual patient encounters. The patient database was used to perform a virtual, live exercise using a training version of the emergency department's information system software. Several solutions to increase patient flow were demonstrated during the exercise. Conducting the exercise helped identify several faults in the hospital disaster plan, including outlining the important rate-limiting step. In addition, a significant degree of under-triage was demonstrated. Estimates of multiple markers of patient flow were identified and compared to Canadian guidelines. Most participants reported that the exercise was a valuable learning experience. A virtual, live exercise using the disastermed.ca patient database was an inexpensive method to evaluate the emergency department disaster plan. This included discovery of new approaches to managing patients, delineating the rate-limiting steps, and evaluating triage accuracy. Use of the patient timestamps has potential as a standardized international benchmark of hospital disaster plan efficacy. Participant satisfaction was high.

Emergency department disaster preparedness: Identifying the barriers

Study objectives: Recent world events have highlighted the necessity of emergency departments (ED) being prepared to respond to disasters. The Metropolitan Medical Response System is one form of targeted funding aimed at improving regional preparedness and disaster response. Significant progress has been made at the systems level, but it is unclear what impact these initiates have had on front-line ED providers. There is a perception among providers that they are not prepared, especially for nuclear, biological, or chemical (NBC) agents. We attempted to identify some of the factors that hinder ED provider preparedness. Methods: A 23-question survey was given to physicians, nurses, and administrators (safety officer/disaster team manager) at Level I and II trauma centers in St. Louis, Missouri. Respondents were asked to complete the survey according to their clinical experience. The survey tried to gauge the degree to which a number of factors (eg, personnel, training, funding) affect the provider's ED in being able to handle a mass casualty incident (MCI) using a 5-point Likert scale ("not a reason" to "critical reason"). Results: One hundred seventy surveys were returned (77 nurses, 65 physicians, 6 administrators, 22 who did not identify their position). Only a few ED providers (13%) agreed with the statement, "You can't plan for them, disasters just happen." About half (55%) of respondents thought that the events of September 11, 2001, spurred hospitals to make significant improvements in their level of disaster preparedness. Most providers are familiar with their hospital's disaster plan (59%) and believe that drills improve readiness (69%). Lack of commitment (13%) and financial support (15%) by the hospitals does not appear to be a hindrance to disaster preparedness. Few identified the lack of a disaster planning group (16%) or ED provider staff participation within that group (23%) as a major hurdle. Most providers thought that ED staff are familiar with existing MCI protocols (physicians 65%, nurses 60%), but non-ED staff were not (physicians 69%, nurses and technicians 67%). Respondents are split (56%) over whether the presence of rotating resident physicians affected ED preparedness. Most providers (68%) thought that physicians were knowledgeable about NBC issues; however, they were more ambivalent about nursing and ED technician staff knowledge (57%) of these agents. EDs do not appear to be lacking in terms of NBC reference material or basic supplies. Half of providers (49%) believed that they lacked specialized protective gear, and even more (60%) perceive the lack of familiarity with equipment and decontaminating techniques as a major issue. Most ED providers think that there are sufficient MCI drills but identified the lack of dedicated time for instruction and participation (61%) as a concern. Although the ED is often the first part of a hospital to be affected by a disaster, other clinical and ancillary services are inevitably involved in the response plan. Many ED providers think that lack of involvement by other services (clinical and ancillary) limits their overall ability to respond (45% to 47%). Conclusion: Many barriers exist that limit ED providers disaster preparedness. Internal ED issues include lack of specialized equipment and training in NBC events. External to the ED, providers are concerned about insufficient knowledge about MCI and lack of involvement by other hospital departments. Although funding and hospital commitment are minor issues, providing dedicated time for education appears to be the greatest barrier we must overcome.

Emergency department disaster preparedness: Are Regional efforts reaching local front lines?

Study objectives: Since the attacks of September 11, 2001, there has been heightened awareness for the possibility of a mass casualty incident (MCI). The Metropolitan Medical Response Systems (MMRS) are one form of targeted funding aimed at improving regional preparedness and response. Although significant progress has been made at the system level during the past 2 years, it is unclear whether these initiatives have filtered down to front-line providers. We choose to assess the impact of MMRS initiatives on emergency department (ED) provider familiarity with and perceptions about disaster preparedness. Methods: A 3-part survey with 30 questions was given to physicians, nurses, and administrators (safety officer/disaster team manager) at Level I and II trauma centers in St Louis, Missouri. Respondents were asked to complete the survey according to their clinical experience. They were asked about disaster preparedness and drills and their institution's ability to handle a number of specific scenarios. Answers were either dichotomous or used a 5-point Likert scale (entirely false to entirely true or unprepared to very prepared). Results: One hundred seventy surveys were returned (50%). Participants included 77 nurses, 65 physicians, 6 administrators, and 22 who did not identify their position. Thirty-eight percent of respondents work in Level I hospitals and 31% in pediatric hospitals. The majority (84%) were aware that their hospital had a disaster or MCI committee. Most (78%) were aware of the existence of the St. Louis MMRS to which their hospitals belong. Fewer (53%) were aware of the mutual aid agreement (signed by all 41 area hospitals 2 years ago) indicating that hospitals will support one another during a disaster (including the sharing of equipment, supplies, and personnel). Of respondents, 43% affirmed that disaster preparedness was part of their employee orientation. Most noted that periodic disaster drills occurred, and 58% said they were familiar with their facility's plan and would be able to carry out their individual portion of it. Although the September 11, 2001, attacks have caused facilities to improve their level of disaster preparedness, less than half of providers thought that the disaster drills being held provided effective training to handle an MCI (41%). However, most believed that holding drills will improve readiness (69%). The vast majority (81%) did not have a working understanding about how MMRS operations would affect their institutions during a disaster. Most ED providers surveyed felt prepared to handle limited local disasters outside the hospital, such as a 4-car highway accident (74%) or food poisoning at a local restaurant (67%). If there were more than 25 patients of mixed acuity, such as tornado hitting nursing home (53%) or protest march (57%), most thought that hospitals would not be able to handle the influx. Most did not feel prepared to handle incidents involving the hospital, such as a fire in central supply (61%) or an earthquake damaging a portion of the building (50%). Despite the attention paid to bioterrorism recently, respondents felt least prepared to handle situations involving nuclear, biological, or chemical agents. Only 22% said they are prepared to deal with an anthrax scare at a local mall with 200 potential victims, and only 35% could handle a tanker derailment with leaking chlorine gas. However, the problem is not only overwhelming numbers of patients; less than 35% of providers felt ready to care for a single smallpox-infected patient. Conclusion: Many ED providers are aware of the heightened concern about disaster preparedness. However, our ability to respond effectively remains limited. Despite more than 2 years of intense work at the regional systems level, most providers, although familiar with MMRS, do not understand its role or likely impact on their institutions during a disaster, such as providing pharmacy caches, sharing supplies between local hospitals, and improving interhospital communication. Staff members are familiar with hospital disaster plans. Although most providers think that disaster drills can improve readiness, they disagree about the effectiveness of current drills to prepare them to handle an MCI.

An emergency department response to severe acute respiratory syndrome: A prototype response to bioterrorism

Study objective On March 13, 2003, Singapore physicians were alerted about an outbreak of atypical pneumonia that became known as severe acute respiratory syndrome (SARS). I describe the application of an emergency department (ED) disaster response plan to manage the SARS outbreak. Methods The ED implemented protection for staff, patients, and facility; infection control measures; and disaster-response workflow changes. The Ministry of Health, Singapore, centralized SARS cases in the hospital, and the ED became the national screening center. A screening questionnaire and a set of admission criteria were applied after assessment of clinical features and chest radiograph findings. Results For the duration of the outbreak that ended on May 31, 2003, the ED screened 11,461 persons for SARS, of whom 1,386 (12.9%) were admitted to rule out SARS and 235 (17%) were confirmed to have SARS. Among 10,075 persons discharged from the ED, there were 28 reattending patients who were admitted and diagnosed with SARS, giving an undertriage rate of 0.3% (95% confidence interval [CI] 0.1% to 0.4%). The sensitivity of an ED admission for SARS was 89.4% (95% CI 85.6% to 93.1%), and specificity was 89.7% (95% CI 89.2% to 90.3%). The positive predictive value was 17% (95% CI 15.7% to 18.4%), and the negative predictive value was 99.7% (95% CI 99.6% to 99.8%). No patient contracted SARS as a result of an ED visit. After full implementation of protective measures, 1 ED nurse with undiagnosed diabetes mellitus was treated for suspected SARS. Conclusion Although the SARS outbreak was not a bioterrorism event, the ED disaster response was applicable in the outbreak's management. The use of a screening questionnaire and admission criteria enabled the ED to screen, treat, and safely discharge the majority of the patients.

Development of a Quantitative Assessment Score for Analyzing Emergency Department Disaster Preparedness

Development of a Quantitative Assessment Score for Analyzing Emergency Department Disaster Preparedness

Emergency Department Organisation for Disasters: A Review of Emergency Department Disaster Plans in Public Hospitals of Singapore

Disaster management plans of emergency departments (EDs) in four major public hospitals were reviewed. A comparison was made between these plans, and they were analyzed to gain an understanding of the differing objectives and doctrines behind the practices. These were summarized into five major management concepts, which are considered to be critical to the success of a disaster plan: 1) staff mobilization systems (cascading vs batch mobilization); 2) staff deployment systems; 3) team organization (surgeons vs residents); 4) area management (the role of the area manager); 5) casualty volume management (accommodation vs expansion vs extension concepts). The concepts derived should serve as a useful guide to the development of an ED disaster plan and potentially influence how new ED facilities could be planned.