Evaluation of US Federal Guidelines (Primary Response Incident Scene Management [PRISM]) for Mass Decontamination of Casualties During the Initial Operational Response to a Chemical Incident

Study objective The aim of this study was to evaluate the clinical and operational effectiveness of US federal government guidance (Primary Response Incident Scene Management [PRISM]) for the initial response phase to chemical incidents. Methods The study was performed as a large-scale exercise (Operation DOWNPOUR). Volunteers were dosed with a chemical warfare agent simulant to quantify the efficacy of different iterations of dry, ladder pipe system, or technical decontamination. Results The most effective process was a triple combination of dry, ladder pipe system, and technical decontamination, which attained an average decontamination efficiency of approximately 100% on exposed hair and skin sites. Both wet decontamination processes (ladder pipe system and technical decontamination, alone or in combination with dry decontamination) were also effective (decontamination efficiency >96%). In compliant individuals, dry decontamination was effective (decontamination efficiency approximately 99%), but noncompliance (tentatively attributed to suboptimal communication) resulted in significantly reduced efficacy (decontamination efficiency approximately 70%). At-risk volunteers (because of chronic illness, disability, or language barrier) were 3 to 8 times slower than ambulatory casualties in undergoing dry and ladder pipe system decontamination, a consequence of which may be a reduction in the overall rate at which casualties can be processed. Conclusion The PRISM incident response protocols are fit for purpose for ambulatory casualties. However, a more effective communication strategy is required for first responders (particularly when guiding dry decontamination). There is a clear need to develop more appropriate decontamination procedures for at-risk casualties.Peer reviewedFinal Published versio

Challenge Patient Dispatching in Mass Casualty Incidents

Efficient management of mass casualty incidents is complex, since regular emergency medical services struc-tures have to be switched to a temporary “disaster mode” involving additional operational and tactical struc-tures. Most of the relevant decisions have to be taken on-site in a provisional and chaotic environment. Data gathering about affected persons is one side of the coin; the other side is on-site patient dispatching requiring information exchange with the regular emergency call center and destination hospitals. In this paper we extend a previous conference contribution about the research project e-Triage to the aspect of patient data and on-site patient dispatching. Our considerations reflect the situation in Germany, which deserves from our point of view substantial harmonization

Online Optimisation of Casualty Processing in Major Incident Response

Recent emergency response operations to Mass Casualty Incidents (MCIs) have been criticised for a lack of coordination, implying that there is clear potential for response operations to be improved and for corresponding benefits in terms of the health and well-being of those affected by such incidents. In this thesis, the use of mathematical modelling, and in particular optimisation, is considered as a means with which to help improve the coordination of MCI response. Upon reviewing the nature of decision making in MCIs and other disaster response operations in practice, this work demonstrates through an in-depth review of the available academic literature that an important problem has yet to be modelled and solved using an optimisation methodology. This thesis involves the development of such a model, identifying an appropriate task scheduling formulation of the decision problem and a number of objective functions corresponding to the goals of the MCI response decision makers. Efficient solution methodologies are developed to allow for solutions to the model, and therefore to the MCI response operation, to be found in a timely manner. Following on from the development of the optimisation model, the dynamic and uncertain nature of the MCI response environment is considered in detail. Highlighting the lack of relevant research considering this important aspect of the problem, the optimisation model is extended to allow for its use in real-time. In order to allow for the utility of the model to be thoroughly examined, a complementary simulation is developed and an interface allowing for its communication with the optimisation model specified. Extensive computational experiments are reported, demonstrating both the danger of developing and applying optimisation models under a set of unrealistic assumptions, and the potential for the model developed in this work to deliver improvements in MCI response operations

Optimizing emergency preparedness and resource utilization in mass-casualty incidents

This paper presents a response model for the aftermath of a Mass-Casualty Incident (MCI) that can be used to provide operational guidance for regional emergency planning as well as to evaluate strategic preparedness plans. A mixed integer programming (MIP) formulation is proposed for the combined ambulance dispatching, patient-to-hospital assignment, and treatment ordering problem. T he goal is to allocate effectively the limited resources during the response so as to improve patient outcomes, while the objectives are to minimize the overall response time and the total flow time required to treat all patients, in a hierarchical fashion. The model is solved via exact and MIP-based heuristic solution methods. The applicability of the model and the performance of the new methods are challenged on realistic MCI scenarios. We consider the hypothetical case of a terror attack at the New York Stock Exchange in Lower Manhattan with up to 150 trauma patients. We quantify the impact of capacity-based bottlenecks for both ambulances and available hospital beds. We also explore the trade-off between accessing remote hospitals for demand smoothing versus reduced ambulance transportation times

Review of current practices in recording road traffic incident data: with specific reference to spatial analysis and road policing policy

Road safety involves three major components: the road system, the human factor and the vehicle element. These three elements are inter-linked through geo-referenced traffic events and provide the basis for road safety analyses and attempts to reduce the number of road traffic incidents and improve road safety. Although numbers of deaths and serious injuries are back to approximately the 1950s levels when there were many fewer vehicles on the road, there are still over 100 fatalities or serious injuries every day, and this is a considerable waste of human capital. It is widely acknowledged that the location perspective is the most suitable methodology by which to analyse different traffic events, where by in this paper, I will concentrating on the relationship between road traffic incidents and traffic policing. Other methods include studying road and vehicle engineering and these will be discussed later. It is worth noting here that there is some division within the literature concerning the definitions of ‘accident’ and ‘incident’. In this paper I will use ‘incident’ because it is important to acknowledge a vast majority of ‘road accidents’ are in fact crimes. However I will use the term ‘accident’ where it is referred to in the literature or relevant reports. It is important to mention here that a road traffic accident can be defined as ‘the product of an unwelcome interaction between two or more moving objects, or a fixed and moving object’ (Whitelegg 1986). Road safety and road incident reduction relates to many other fields of activity including education, driver training, publicity campaigns, police enforcement, road traffic policing, the court system, the National Health Service and Vehicle engineering. Although the subject of using GIS to analyse road traffic incidents has not received much academic attention, it lies in the field of crime mapping which is becoming increasingly important. It is clear that studies have been attempted to analyse road traffic incidents using GIS are increasingly sophisticated in terms of hypotheses and statistical technique (for example see Austin, Tight and Kirby 1997). However it is also clear that there is considerable blurring of boundaries and the analysis of road accidents sits uncomfortably in crime mapping. This is due to four main reasons: - Road traffic incidents are associated with road engineering, which is concerned with generic solutions while road traffic analysis is about sensitivity to particular contexts. - Not all road traffic incidents are crimes - It is not just the police who have an interest in reducing road traffic incidents, other partners include local authorities, hospitals and vehicle manufacturers - The management of road traffic incidents is not just confined to the police GIS has been used for over thirty years however it has only been recently been used in the field of transportation. The field of transportation has come to embrace Geographical Information Systems as a keytechnology to support its research and operational need. The acronym GIS-T is often employed to refer to the application and adaptation of GIS to research, planning and management in transportation. GIS-T covers a broad arena of disciplines of which road traffic incident detection is just one theme. Others include in vehicle navigation systems. Initially it was only used to ask simple accident enquiries such as depicting the relative incidence of accidents in wet weather or when there is no street lighting, or to flag high absolute or relative incidences of accidents (see Anderson 2002). Recently however there has been increased acknowledgement that there is a requirement to go beyond these simple questions and to extend the analyses. It has been widely claimed by academics and the police alike that knowing where road accidents occur must lead to better road policing, in order to ensure that road policing becomes better integrated with other policing activities. This paper will be used to explore issues surrounding the analysis of road traffic accidents and how GIS analysts, police and policy makers can achieve a better understanding of road traffic incidents and how to reduce them. For the purpose of this study I will be trying to achieve a broader overview of the aspects concerning road accident analysis with a strong emphasis on data quality and accuracy with concern to GIS analysis. Data quality and accuracy are seen as playing a pivotal role in the road traffic management agenda because they assist the police and Local Authorities as to the specific location whereby management can be undertaken. Part one will consider the introduction to road incidents and their relationship with geography and spatial analysis and how this were initially applied to locating ‘hotspots’ and the more recent theory of ‘accident migration’. Part two will address current data issues of the UK collection procedure. This section will pay particular reference to geo-referencing and the implication of data quality on the procedure of analysing road incidents using GIS. Part three addresses issues surrounding the spatial analysis of road traffic incidents, including some techniques such as spatial autocorrelation, time-space geography and the modifiable area unit problem. Finally part four looks at the role of effective road traffic policing and how this can be achieved due to better understanding of the theory and issues arising from analysing road traffic incidents. It will also look at the diffusion and use of GIS within the police and local authorities

Evaluation of medical response in disaster preparedness : with special reference to full-scale exercises

Background: Disaster exercises and simulations serves as teaching and training tool for improving medical response in disaster preparedness. Rapid and effective medical response in major incidents is known as a “key phase” to optimise resources, and this requires that management systems have an “all hazards” approach. Decision-making at all levels of management is based on available information and involves allocation of medical resources and triage decisions. Aim: The overall aim of this thesis was to increase our knowledge of the impact of quantitative evaluation of medical response on disaster preparedness. The specific aims were: to increase the ability to learn from full-scale exercises by applying quality indicators at two levels of command and control (I, II); to identify key indicators essential for initial disaster medical response registration (III); to explore ambulance staff attitudes towards practising triage tagging (IV); and to increase our knowledge of the applicability of a technical support system and its potential to provide real-time, overall situation awareness available to those overseeing the medical management of the operation. Methods: Study I, II and V were observational studies based on data collections from full-scale exercises. Templates with measurable performance indicators for evaluation of command and control were used in Study I and II and the same performance indicators combined with outcome indicators was also included in Study II. A consensus method, the Delphi technique, with 30 experts was used in Study III. Study IV used mixed methods, a pre-and post web survey answered by ambulance nurses and physicians (n=57 respectively 57) before and after a time limited strategy with triage tags and three focus groups interviews comprising 21 ambulance nurses and emergency medical technicians. Study V used major two incidents simulations to test the applicability of Radio Frequency Identification (RFID tags) technology and compare it with traditionally paper-based triage tags (n= 20 respectively 20). The quantitative data were analysed using descriptive statistics, and content analysis was used for the qualitative data. Results: The evaluation model exposed several problems occurring in the initial decision-making process that were repeatedly observed (I, II). These results in study II also demonstrated to have a major impact on patient outcome.Out of 17 severely injured patients five respectively seven were at risk for preventable death. A total of 97 statements were generated, of these 77 statements reached experts consensus, and 20 did not (III). Ambulance staffs believe in the usefulness of standardised triage methods, but the sparse application of triage tags at the scene indicates that the tags are not used frequently. Infrequent use in daily practice prevents participants from feeling confident with the triage tool (IV).The Radio Frequency Identification system improved situational awareness in disaster management. Triage information was available at least one hour earlier compared to a paper-based triage system (V). Conclusions: The presented evaluation model can be used in an objective, systematic and reproducible way to evaluate complex medical responses, which is a prerequisite for quality assurance, identification of problems, and the development of disaster preparedness

Prioritizing Patients: Stochastic Dynamic Programming for Surgery Scheduling and Mass Casualty Incident Triage

The research presented in this dissertation contributes to the growing literature on applications of operations research models to problems in healthcare through the development and analysis of mathematical models for two fundamental problems facing nearly all hospitals: the single-day surgery scheduling problem and planning for triage in the event of a mass casualty incident. Both of these problems can be understood as sequential decision-making processes aimed at prioritizing between different classes of patients under significant uncertainty and are modeled using stochastic dynamic programming. Our study of the single-day surgery scheduling problem represents the first model to capture the sequential nature of the operating room (OR) manager's decisions during the transition between the generality of cyclical block schedules (which allocate OR time to surgical specialties) and the specificity of schedules for a particular day (which assign individual patients to specific ORs). A case study of the scheduling system at the University of Maryland Medical Center highlights the importance of the decision to release unused blocks of OR time and use them to schedule cases from the surgical request queue (RQ). Our results indicate that high quality block release and RQ decisions can be made using threshold-based policies that preserve a specific amount of OR time for late-arriving demand from the specialties on the block schedule. The development of mass casualty incident (MCI) response plans has become a priority for hospitals, and especially emergency departments and trauma centers, in recent years. Central to all MCI response plans is the triage process, which sorts casualties into different categories in order to facilitate the identification and prioritization of those who should receive immediate treatment. Our research relates MCI triage to the problem of scheduling impatient jobs in a clearing system and extends earlier research by incorporating the important trauma principle that patients' long-term (post-treatment) survival probabilities deteriorate the longer they wait for treatment. Our results indicate that the consideration of deteriorating survival probabilities during MCI triage decisions, in addition to previously studied patient characteristics and overall patient volume, increases the total number of expected survivors

A concept for major incident triage: full-scaled simulation feasibility study

<p>Abstract</p> <p>Background</p> <p>Efficient management of major incidents involves triage, treatment and transport. In the absence of a standardised interdisciplinary major incident management approach, the Norwegian Air Ambulance Foundation developed Interdisciplinary Emergency Service Cooperation Course (TAS). The TAS-program was established in 1998 and by 2009, approximately 15 500 emergency service professionals have participated in one of more than 500 no-cost courses. The TAS-triage concept is based on the established triage Sieve and Paediatric Triage Tape models but modified with slap-wrap reflective triage tags and paediatric triage stretchers. We evaluated the feasibility and accuracy of the TAS-triage concept in full-scale simulated major incidents.</p> <p>Methods</p> <p>The learners participated in two standardised bus crash simulations: without and with competence of TAS-triage and access to TAS-triage equipment. The instructors calculated triage accuracy and measured time consumption while the learners participated in a self-reported before-after study. Each question was scored on a 7-point Likert scale with points labelled "Did not work" (1) through "Worked excellent" (7).</p> <p>Results</p> <p>Among the 93 (85%) participating emergency service professionals, 48% confirmed the existence of a major incident triage system in their service, whereas 27% had access to triage tags. The simulations without TAS-triage resulted in a mean over- and undertriage of 12%. When TAS-Triage was used, no mistriage was found. The average time from "scene secured to all patients triaged" was 22 minutes (range 15-32) without TAS-triage vs. 10 minutes (range 5-21) with TAS-triage. The participants replied to "How did interdisciplinary cooperation of triage work?" with mean 4,9 (95% CI 4,7-5,2) before the course vs. mean 5,8 (95% CI 5,6-6,0) after the course, p < 0,001.</p> <p>Conclusions</p> <p>Our modified triage Sieve tool is feasible, time-efficient and accurate in allocating priority during simulated bus accidents and may serve as a candidate for a future national standard for major incident triage.</p

Mass Casualty Decontamination in the United States : An Online Survey of Current Practice

Final publication is available from Mary Ann Liebert, Inc., publishers https://doi.org/10.1089/hs.2016.0047.Mass casualty decontamination is a public health intervention that would be employed by emergency responders following a chemical, biological, or radiological incident. The decontamination of large numbers of casualties is currently most often performed with water to remove contaminants from the skin surface. An online survey was conducted to explore US fire departments' decontamination practices and their preparedness for responding to incidents involving mass casualty decontamination. Survey respondents were asked to provide details of various aspects of their decontamination procedures, including expected response times to reach casualties, disrobing procedures, approaches to decontamination, characteristics of the decontamination showering process, provision for special populations, and any actions taken following decontamination. The aim of the survey was to identify any differences in the way in which decontamination guidance is implemented across US states. Results revealed that, in line with current guidance, many US fire departments routinely use the "ladder-pipe system" for conducting rapid, gross decontamination of casualties. The survey revealed significant variability in ladder-pipe construction, such as the position and number of fire hoses used. There was also variability in decontamination characteristics, such as water temperature and water pressure, detergent use, and shower duration. The results presented here provide important insights into the ways in which implementation of decontamination guidance can vary between US states. These inconsistencies are thought to reflect established perceived best practices and local adaptation of response plans to address practical and logistical constraints. These outcomes highlight the need for evidence-based national guidelines for conducting mass casualty decontamination.Peer reviewedFinal Accepted Versio