Students Experience Mass Casualty Nursing From the Patient Perspective in a Simulated Mass Casualty Exercise.

ABSTRACT: Life-saving response to mass casualty incidents (MCIs) requires education and training. Participation in an MCI full-scale exercise provided nursing students with a rare opportunity to experience a simulated disaster from the patient perspective to better understand the unique issues involved in mass casualty response. This innovative teaching approach enabled students to undergo triage and decontamination as victims of a chemical MCI and participate in a research study. We describe student feedback on this learning experience and the implications of incorporating a full-scale MCI for providing a patient perspective into nursing curricula.

Designing and executing a functional exercise to test a novel informatics tool for mass casualty triage.

OBJECTIVE: The testing of informatics tools designed for use during mass casualty incidents presents a unique problem as there is no readily available population of victims or identical exposure setting. The purpose of this article is to describe the process of designing, planning, and executing a functional exercise to accomplish the research objective of validating an informatics tool specifically designed to identify and triage victims of irritant gas syndrome agents. MATERIALS AND METHODS: During a 3-year time frame, the research team and partners developed the Emergency Department Informatics Computational Tool and planned a functional exercise to test it using medical records data from 298 patients seen in 1 emergency department following a chlorine gas exposure in 2005. RESULTS: The research team learned valuable lessons throughout the planning process that will assist future researchers with developing a functional exercise to test informatics tools. Key considerations for a functional exercise include contributors, venue, and information technology needs (ie, hardware, software, and data collection methods). DISCUSSION: Due to the nature of mass casualty incidents, testing informatics tools and technology for these incidents is challenging. Previous studies have shown a functional exercise as a viable option to test informatics tools developed for use during mass casualty incidents. CONCLUSION: Utilizing a functional exercise to test new mass casualty management technology and informatics tools involves a painstaking and complex planning process; however, it does allow researchers to address issues inherent in studying informatics tools for mas casualty incidents.

Mobile Decision Support Tool for Emergency Departments and Mass Casualty Incidents (EDIT): Initial Study.

BACKGROUND: Chemical exposures pose a significant threat to life. A rapid assessment by first responders and emergency nurses is required to reduce death and disability. Currently, no informatics tools exist to process victims of chemical exposures efficiently. The surge of patients into a hospital emergency department during a mass casualty incident creates additional stress on an already overburdened system, potentially placing patients at risk and challenging staff to process patients for appropriate care and treatment efficacy. Traditional emergency department triage models are oversimplified during highly stressed mass casualty incident scenarios in which there is little margin for error. Emerging mobile technology could alleviate the burden placed on nurses by allowing the freedom to move about the emergency department and stay connected to a decision support system. OBJECTIVE: This study aims to present and evaluate a new mobile tool for assisting emergency department personnel in patient management and triage during a chemical mass casualty incident. METHODS: Over 500 volunteer nurses, students, and first responders were recruited for a study involving a simulated chemical mass casualty incident. During the exercise, a mobile application was used to collect patient data through a kiosk system. Nurses also received tablets where they could review patient information and choose recommendations from a decision support system. Data collected was analyzed on the efficiency of the app to obtain patient data and on nurse agreement with the decision support system. RESULTS: Of the 296 participants, 96.3% (288/296) of the patients completed the kiosk system with an average time of 3 minutes, 22 seconds. Average time to complete the entire triage process was 5 minutes, 34 seconds. Analysis of the data also showed strong agreement among nurses regarding the app's decision support system. Overall, nurses agreed with the system 91.6% (262/286) of the time when it came to choose an exposure level and 84.3% (241/286) of the time when selecting an action. CONCLUSIONS: The app reliably demonstrated the ability to collect patient data through a self-service kiosk system thus reducing the burden on hospital resources. Also, the mobile technology allowed nurses the freedom to triage patients on the go while staying connected to a decision support system in which they felt would give reliable recommendations.

Validation of a novel irritant gas syndrome triage algorithm.

OBJECTIVE: Our objective was to validate a novel irritant gas syndrome agent (IGSA) triage algorithm for use in an emergency department (ED). We assessed efficiency, accuracy, and precision of our IGSA triage algorithm based on signs/symptoms of actual patients. DESIGN: After characterizing the signs/symptoms of an actual IGSA exposure event, we developed and validated the IGSA triage algorithm using a simulated computer exercise to compare the IGSA triage algorithm to the preferred hospital triage algorithm, the Emergency Severity Index (ESI). SETTING: This study was a simulated computer exercise using surveys developed in Research Electronic Data Capture software. Nurse volunteers simulated triaging 298 patients. PARTICIPANTS: Patient data included 146 patients treated during the disaster as well as 152 unexposed patients. Twenty-six nurse volunteers were assigned to triage the patients using one of the algorithms in the simulated computer exercise. MAIN OUTCOME MEASURE(S): The precision of the IGSA triage algorithm was 0.82 (confidence interval [CI] 0.78-0.85) and ESI 0.73 (CI 0.69-0.77). Weighted κ for ESI and IGSA accuracy for exposed patients was 0.32 (95% CI 0.26-0.37) and 0.81 (95% CI 0.77-0.85), respectively. RESULTS: The IGSA triage algorithm was more accurate and precise than the ESI algorithm for triaging patients exposed to an irritant gas. CONCLUSIONS: This study validates the IGSA triage algorithm as the basis for the development of a prototype software application to quickly identify victims of a chemical disaster and triage patients efficiently and accurately with the potential to dramatically improve the processing of patients in EDs.

Data Capture and Analysis of Signs and Symptoms in a Chemically Exposed Population.

This manuscript provides a practical case study to demonstrate data collection from paper-based medical records so that the occurrence of specific signs/symptoms indicative of a chemical exposure can be studied.

National nursing science priorities: Creating a shared vision.

BACKGROUND: Nursing science is essential to advance population health through contributions at all phases of scientific inquiry. Multiple scientific initiatives important to nursing science overlap in aims and population focus. PURPOSE: This article focused on providing the American Academy of Nursing and nurse scientists in the Unites States with a blueprint of nursing science priorities to inform a shared vision for future collaborations, areas of scientific inquiry, and resource allocation. METHODS: The Science Committee convened four times and using Delphi methods identified priorities with empirical evidence and expert opinion for prioritization, state of the science, expert interest, and potential target stakeholders. DISCUSSION: Nursing science priorities for 2017 were categorized into four themes including: (a) precision science, (b) big data and data analytics, (c) determinants of health, and (d) global health. CONCLUSION: Nurse scientists can generate new knowledge in priority areas that advances the health of the world's populations.

Validating Signs and Symptoms From An Actual Mass Casualty Incident to Characterize An Irritant Gas Syndrome Agent (IGSA) Exposure: A First Step in The Development of a Novel IGSA Triage Algorithm.

CONTRIBUTION TO EMERGENCY NURSING PRACTICE: • Chemical exposures daily pose a significant threat to life. Rapid assessment by first responders/emergency nurses is required to reduce death and disability. Currently, no informatics tools for Irritant Gas Syndrome Agents (IGSA) exposures exist to process victims efficiently, continuously monitor for latent signs/symptoms, or make triage recommendations. • This study uses actual patient data from a chemical incident to characterize and validate signs/symptoms of an IGSA Syndrome. Validating signs/symptoms is the first step in developing new emergency department informatics tools with the potential to revolutionize the process by which emergency nurses manage triage victims of chemical incidents. ABSTRACTINTRODUCTION: Chemical exposures can pose a significant threat to life. Rapid assessment by first responders/emergency nurses is required to reduce death and disability. Currently, no informatics tools for irritant gas syndrome agents (IGSA) exposures exist to process victims efficiently, continuously monitor for latent signs/symptoms, or make triage recommendations. This study describes the first step in developing ED informatics tools for chemical incidents: validation of signs/symptoms that characterize an IGSA syndrome. METHODS: Data abstracted from 146 patients treated for chlorine exposure in one emergency department during a 2005 train derailment and 152 patients not exposed to chlorine (a comparison group) were mapped to 93 possible signs/symptoms within 2 tools (WISER and CHEMM-IST) designed to assist emergency responders/emergency nurses with managing hazardous material exposures. Inferential statistics (χ2/Fisher's exact test) and diagnostics tests were used to examine mapped signs/symptoms of persons who were and were not exposed to chlorine. RESULTS: Three clusters of signs/symptoms are statistically associated with an IGSA syndrome (P < .01): respiratory (shortness of breath, wheezing, coughing, and choking); chest discomfort (tightness, pain, and burning), and eye, nose and/or throat (pain, irritation, and burning). The syndrome requires the presence of signs/symptoms from at least 2 of these clusters. The latency period must also be considered for exposed/potentially exposed persons. DISCUSSION: This study uses actual patient data from a chemical incident to characterize and validate signs/symptoms of an IGSA syndrome. Validating signs/symptoms is the first step in developing new ED informatics tools with the potential to revolutionize the process by which emergency nurses manage triage victims of chemical incidents.

Diabetic Peripheral Neuropathy: The Learning Curve.

Living with diabetes mellitus and its complications can be challenging, but treatment by a specialized wound care staff adept in treating diabetic foot ulcers and educating patients about care can ensure favorable outcomes.

A validation study of 5 triage systems using data from the 2005 Graniteville, South Carolina, chlorine spill.

INTRODUCTION: Lack of outcomes-based research results in uncertainty about the effectiveness of any of the current triage systems in determining priority of care during actual chemical disasters. The purpose of this study was to determine whether the level of injury severity extrapolated from 5 triage systems correlated with actual injury severity outcomes of victims exposed to a chlorine disaster. METHODS: Using secondary data analysis, data for 631 victims were merged, de-identified, and analyzed. Using logic models from the triage systems, the actual injury severity was compared with the extrapolated injury severity classifications. RESULTS: Analysis showed weak to modest correlations between the extrapolated injury severity triage outcome classifications and the actual injury severity outcomes (Spearman correlation range 0.38 to 0.71, P < .0001). There was slight to fair agreement between the extrapolated injury severity triage outcome classifications and the actual injury severity outcomes (weighted κ = - 0.23 to 0.42). DISCUSSION: The extrapolated injury severity triage outcome categories from the 5 triage systems did not agree with the actual injury severity categories. Oxygen saturation measured by pulse oximetry provides early indications and is very predictive of outcome severity in incidents involving irritant chemical exposures such as chlorine, and should be a part of a mass casualty protocol for any irritant chemical incident. Additional research is needed to identify the most sensitive clinical measures for triaging victims of toxic inhalation disasters.

A review of the literature on the validity of mass casualty triage systems with a focus on chemical exposures.

INTRODUCTION: Mass casualty incidents (MCIs) include natural (eg, earthquake) or human (eg, terrorism or technical) events. They produce an imbalance between medical needs and resources necessitating the use of triage strategies. Triage of casualties must be performed accurately and efficiently if providers are to do the greatest good for the greatest number. There is limited research on the validation of triage system efficacy in determining the priority of care for victims of MCI, particularly those involving chemicals. OBJECTIVE: To review the literature on the validation of current triage systems to assign on-site treatment status codes to victims of mass casualties, particularly those involving chemicals, using actual patient outcomes. METHODS: The focus of this article is a systematic review of the literature to describe the influences of MCIs, particularly those involving chemicals, on current triage systems related to the on-site assignment of treatment status codes to a victim and the validation of the assigned code using actual patient outcomes. RESULTS: There is extensive literature published on triage systems used for MCI but only four articles used actual outcome data to validate mass casualty triage outcomes including three for chemical events. Currently, the amount and type of data collected are not consistent or standardized and definitions are not universal. CONCLUSIONS: Current literature does not provide needed evidence on the validity of triage systems for MCI in particular those involving chemicals. Well designed studies are needed to validate the reliability, sensitivity, and specificity of triage systems used for MCI including those involving chemicals.

Engaging a chemical disaster community: lessons from Graniteville.

Community engagement remains a primary objective of public health practice. While this approach has been adopted with success in response to many community health issues, it is rarely adopted in chemical disaster response. Empirical research suggests that management of chemical disasters focuses on the emergency response with almost no community engagement for long-term recovery. Graniteville, an unincorporated and medically underserved community in South Carolina was the site of one of the largest chlorine exposures by a general US population. Following the immediate response, we sought community participation and partnered with community stakeholders and representatives in order to address community-identified health and environmental concerns. Subsequently, we engaged the community through regular town hall meetings, harnessing community capacity, forming coalitions with existing local assets like churches, schools, health centers, and businesses, and hosting community-wide events like health picnics and screenings. Information obtained from these events through discussions, interviews, and surveys facilitated focused public health service which eventually transitioned to community-driven public health research. Specific outcomes of the community engagement efforts and steps taken to ensure sustainability of these efforts and outcomes will be discussed.

Social networking policies in nursing education.

Social networking use has increased exponentially in the past few years. A literature review related to social networking and nursing revealed a research gap between nursing practice and education. Although there was information available on the appropriate use of social networking sites, there was limited research on the use of social networking policies within nursing education. The purpose of this study was to identify current use of social media by faculty and students and a need for policies within nursing education at one institution. A survey was developed and administered to nursing students (n = 273) and nursing faculty (n = 33). Inferential statistics included χ², Fisher exact test, t test, and General Linear Model. Cronbach's α was used to assess internal consistency of social media scales. The χ² result indicates that there were associations with the group and several social media items. t Test results indicate significant differences between student and faculty for average of policies are good (P = .0127), policies and discipline (P = .0315), and policy at the study school (P = .0013). General Linear Model analyses revealed significant differences for "friend" a patient with a bond, unprofessional posts, policy, and nursing with class level. Results showed that students and faculty supported the development of a social networking policy.

Gleaning data from disaster: a hospital-based data mining method to study all-hazard triage after a chemical disaster.

OBJECTIVE: To describe the methods of evaluating currently available triage models for their efficacy in appropriately triaging the surge of patients after an all-hazards disaster. DESIGN: A method was developed for evaluating currently available triage models using extracted data from medical records of the victims from the Graniteville chlorine disaster. SETTING: On January 6, 2005, a freight train carrying three tanker cars of liquid chlorine was inadvertently switched onto an industrial spur in central Graniteville, SC. The train then crashed into a parked locomotive and derailed. This caused one of the chlorine tankers to rupture and immediately release ~60 tons of chlorine. Chlorine gas infiltrated the town with a population of 7,000. PARTICIPANTS: This research focuses on the victims who received emergency care in South Carolina. RESULTS: With our data mapping and decision tree logic, the authors were successful in using the available extracted clinical data to estimate triage categories for use in our study. CONCLUSIONS: The methodology outlined in this article shows the potential use of well-designed secondary analysis methods to improve mass casualty research. The steps are reliable and repeatable and can easily be extended or applied to other disaster datasets.

Use of a computer-mediated Delphi process to validate a mass casualty conceptual model.

Since the original work on the Delphi technique, multiple versions have been developed and used in research and industry; however, very little empirical research has been conducted that evaluates the efficacy of using online computer, Internet, and e-mail applications to facilitate a Delphi method that can be used to validate theoretical models. The purpose of this research was to develop computer, Internet, and e-mail applications to facilitate a modified Delphi technique through which experts provide validation for a proposed conceptual model that describes the information needs for a mass-casualty continuum of care. Extant literature and existing theoretical models provided the basis for model development. Two rounds of the Delphi process were needed to satisfy the criteria for consensus and/or stability related to the constructs, relationships, and indicators in the model. The majority of experts rated the online processes favorably (mean of 6.1 on a seven-point scale). Using online Internet and computer applications to facilitate a modified Delphi process offers much promise for future research involving model building or validation. The online Delphi process provided an effective methodology for identifying and describing the complex series of events and contextual factors that influence the way we respond to disasters.

The role of the Medical Reserve Corps in nursing education.

Graduates of baccalaureate nursing programs are expected to demonstrate basic competency in responding to emergencies, including those related to emergency preparedness and disaster response. Faculty find it challenging to provide learning experiences that enable students to use appropriate assessment, clinical judgment, and decision making skills during disaster, mass casualty, and other emergency situations. This article describes a partnership between a school of nursing and a university health service to form a Medical Reserve Corps. The partnership resulted in unique and diverse learning experiences for nursing students in collaboration with volunteers from other professional disciplines and laypeople. The Medical Reserve Corps provides opportunities for students to experience emergency preparedness and disaster responses firsthand and to develop competencies required for generalist nursing practice.

Development and validation of a mass casualty conceptual model.

PURPOSE: To develop and validate a conceptual model that provides a framework for the development and evaluation of information systems for mass casualty events. DESIGN: The model was designed based on extant literature and existing theoretical models. A purposeful sample of 18 experts validated the model. Open-ended questions, as well as a 7-point Likert scale, were used to measure expert consensus on the importance of each construct and its relationship in the model and the usefulness of the model to future research. METHODS: Computer-mediated applications were used to facilitate a modified Delphi technique through which a panel of experts provided validation for the conceptual model. Rounds of questions continued until consensus was reached, as measured by an interquartile range (no more than 1 scale point for each item); stability (change in the distribution of responses less than 15% between rounds); and percent agreement (70% or greater) for indicator questions. FINDINGS: Two rounds of the Delphi process were needed to satisfy the criteria for consensus or stability related to the constructs, relationships, and indicators in the model. The panel reached consensus or sufficient stability to retain all 10 constructs, 9 relationships, and 39 of 44 indicators. Experts viewed the model as useful (mean of 5.3 on a 7-point scale). CONCLUSIONS: Validation of the model provides the first step in understanding the context in which mass casualty events take place and identifying variables that impact outcomes of care. CLINICAL RELEVANCE: This study provides a foundation for understanding the complexity of mass casualty care, the roles that nurses play in mass casualty events, and factors that must be considered in designing and evaluating information-communication systems to support effective triage under these conditions.

Conceptual model for a mass casualty continuum of care.

This research proposes a comprehensive Information Conceptual Model for a Mass Casualty Continuum of Care. The conceptual model lays out the key relationships among entities/factors in mass casualty events needed to provide real-time visibility of data that track patients, personnel, resources and potential hazards to improve responders situational awareness. Validation of the model is being done using Delphi techniques that establish consensus among a panel of experts.