Assessing Hospital Adaptive Resource Allocation Strategies in Responding to Mass Casualty Incidents.

OBJECTIVES: Hospitals are expected to operate at a high-performance level even under exceptional conditions of peak demand and resource disruptions. This understanding is not mature yet, and there are wide areas of possible improvement. In particular, the fast mobilization and reconfiguration of resources frequently result into the severe disruption of elective activities, worsening the quality of care. More resilient resource allocation strategies, ie, which adapt to the dynamics of the prevailing circumstance, are needed to maximize the effectiveness of health-care delivery. In this study, a simulation approach was adopted to assess and compare different hospital's adaptive resource allocation strategies in responding to a mass casualty incident (MCI). METHODS: A specific set of performance metrics was developed to take into consideration multiple objectives and priorities and holistically assess the effectiveness of health-care delivery when coping with an MCI event. Discrete event simulation (DES) and system dynamics (SD) were used to model the key hospital processes and the MCI plan. RESULTS: In the daytime scenario, during the recovery phase of the emergency, a gradual disengagement of resources from the emergency department (ED) to restart ordinary activities in operating rooms and wards, returned the best performance. In the night scenario, the absorption capacity of the ED was evaluated by identifying the current bottleneck and assessment of the benefit of different resource mobilization strategies. CONCLUSIONS: The present study offers a robust approach, effective strategies, and new insights to design more resilient plans to cope with MCIs. Future research is needed to widen the scope of the analysis and take into consideration additional resilience capacities, such as operational coordination mechanisms, among multiple hospitals in the same geographic area.

Evaluation of Interaction Between Emergency Medical System and Hospital Network During a Train Derailment in Milano.

On January 25, 2018 a 5-car train derailed in Pioltello, 10 kilometers North-East of Milano City. A standardized post-hoc form was distributed to the hospitals involved in the management of the victims and allowed for an evaluation of the response to the incident.The management of the incident by EMS (Emergency Medical System) was effective in terms of organization of the scene and distribution of the patients, although the time for the first severe patient to reach the closest appropriate hospital was very long (2 hours). This can be partially explained by the extrication time.None of the alerted hospitals exceeded their capacity, as patients were distributed carefully among the hospitals. The overall outcome was quite satisfactory; no deaths were reported except for those on scene. Some responding hospitals reported that there was an over-activation based on the services ultimately needed. However this is common in MCIs, as an over-activation is preferable to an under-estimation. To address this concern, as more data are available, activation should be scaled down based on a plan established prior to it; this mechanism of scaling down seems to have failed in this event.It is of note that the highest performing hospitals underwent recently to an educational program on MCI management.

Hospital preparedness for mass gathering events and mass casualty incidents in Matera, Italy, European Capital of Culture 2019.

INTRODUCTION: Mass Casualty Incidents (MCI) may occur during Mass Gathering Events (MGE). A failure to prepare and train the health care system for potential MCI, can cause chaos and delays in the response, leading to an increased morbidity and mortality. Education and training of staff are crucial for preparedness. In Italy, hospital Emergency Plans for Massive Influx of Injured (in Italian designated with the acronym PEMAF) are mandatory since the '90's. However, when available, they are usually poorly known by the staff, rarely reviewed and validated. In 2014, Matera, a city in Southern Italy, was designated as the European Capital of Culture for 2019. As a result, we took this opportunity to revise the "Madonna delle Grazie" PEMAF and to start a program for increasing the awareness of the plan among the medical staff and provide specific training for MCI management. MATERIAL & METHODS: The PEMAF was reviewed through simulations that involved the entire staff. A partnership with the International Association for Medical Response to Major Incidents & Disasters (MRMI) led to the support of experts and to the organization of residential courses based on the MAss Casualty SIMulation tool (MACSIM®). In total, six residential educational events of MACSIM-PEMAF were organized. Individual capacity was tested before and after the education through self-administered semi-quantitative questionnaires. RESULTS: All the available resources were mapped and the functional areas identified. Alert, coordination and command sequences were defined. The communication network was improved. Documentation and registration systems were developed. Standard operational procedures (action cards) were created for the key positions. The knowledge and capacity to function in active roles during a MCI was improved among the participants in the educational program. CONCLUSIONS: MGE are great opportunities for the development of the hosting community but also represent an increased risk of MCI. Preparedness is mandatory for health care systems. The educational format MACSIM-PEMAF seems to be adequate to review and improve the existing plans and transfer specific skills to attendants.

Stranger Months: How SARS-CoV-2, Fear of Contagion, and Lockdown Measures Impacted Attendance and Clinical Activity During February and March 2020 at an Urban Emergency Department in Milan.

OBJECTIVES: An unprecedented wave of patients with acute respiratory failure due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease 2019 (COVID-19) hit emergency departments (EDs) in Lombardy, starting in the second half of February 2020. This study describes the direct and indirect impacts of the SARS-CoV-2 outbreak on an urban major-hospital ED. METHODS: Data regarding all patients diagnosed with COVID-19 presenting from February 1 to March 31, 2020, were prospectively collected, while data regarding non-COVID patients presenting within the same period in 2019 were retrospectively retrieved. RESULTS: ED attendance dropped by 37% in 2020. Two-thirds of this reduction occurred early after the identification of the first autochthonous COVID-19 case in Lombardy, before lockdown measures were enforced. Hospital admissions of non-COVID patients fell by 26%. During the peak of COVID-19 attendance, the ED faced an extraordinary increase in: patients needing oxygen (+239%) or noninvasive ventilation (+725%), transfers to the intensive care unit (+57%), and in-hospital mortality (+309%), compared with the same period in 2019. CONCLUSIONS: The COVID-19 outbreak determined an unprecedented upsurge in respiratory failure cases and mortality. Fear of contagion triggered a spontaneous, marked reduction of ED attendance, and, presumably, some as yet unknown quantity of missed or delayed diagnoses for conditions other than COVID-19.