[The disaster task force medical officer as a pivotal decision maker in the superordinate pandemic hospital capacity management : A field report covering the initial COVID-19 surge in a Bavarian district]. / Der Ärztliche Leiter Führungsgruppe Katastrophenschutz als zentrale Entscheidungsinstanz bei der Steuerung regionaler Krankenhauskapazitäten in der Pandemie : Ein Erfahrungsbericht zur ersten Welle der COVID-19-Pandemie in einem bayerischen Regierungsbezirk.

BACKGROUND AND OBJECTIVE: During the initial phase of the COVID-19 pandemic the government of the state of Bavaria, Germany, declared a state of emergency for its entire territory for the first time in history. Some areas in eastern Bavaria were among the most severely affected communities in Germany, prompting authorities and hospitals to build up capacities for a surge of COVID-19 patients. In some areas, intensive care unit (ICU) capacities were heavily engaged, which occasionally made a redistribution of patients necessary. MATERIAL AND METHODS: For managing COVID-19-related hospital capacities and patient allocation, crisis management squads in Bavaria were expanded by disaster task force medical officers ("Ärztlicher Leiter Führungsgruppe Katastrophenschutz" [MO]) with substantial executive authority. The authors report their experiences as MO concerning the superordinate patient allocation management in the district of Upper Palatinate (Oberpfalz) in eastern Bavaria. RESULTS: By abandoning routine patient care and building up additional ICU resources, surge capacity for the treatment of COVID-19 patients was generated in hospitals. In parts of the Oberpfalz, ICU capacities were almost entirely occupied by patients with corona virus infections, making reallocation to other hospitals within the district and beyond necessary. The MO managed patient pathways in an escalating manner by defining local (within the region of responsibility of a single MO), regional (within the district), and cross-regional (over district borders) reallocation lanes, as needed. When regional or cross-regional reallocation lanes had to be established, an additional management level located at the district government was involved. Within the determined reallocation lanes, emitting and receiving hospitals mutually agreed on any patient transfer without explicitly involving the MO, thereby maintaining the established interhospital routine transfer procedures. The number of patients and available treatment resources at each hospital were monitored with the help of a web-based treatment capacity registry. If indicated, reallocation lanes were dynamically revised according to the present situation. To oppose further virus spreading in nursing homes, the state government prohibited patient allocation to these facilities, which led to considerably longer hospital length of stay of convalescent elderly and/or dependent patients. In parallel to the flattening of the COVID-19 incidence curve, routine hospital patient care could be re-established in a stepwise manner. CONCLUSION: Patient allocation during the state of emergency by the MO sought to keep up routine interhospital reallocation procedures as much as possible, thereby reducing management time and effort. Occasionally, difficulties were observed during patient allocations crossing district borders, if other MO followed different management principles. The nursing home blockade and conflicting financial interests of hospitals posed challenges to the work of the disaster task force medical officers.

[Management of COVID-19 mass casualty incidents in nursing and retirement homes]. / Managementstrategie für den Massenanfall von Erkrankten/Infizierten in Alten- und Pflegeheimen im Kontext der COVID-19-Pandemie.

BACKGROUND: During the coronavirus disease 2019 (COVID-19) pandemic, outbreaks in inpatient care facilities, which grow into a large-scale emergency scenario, are frequently observed. A standardized procedure analogous to algorithms for mass casualty incidents (MCI) is lacking. METHODS: Based on a case report and the literature, the authors present a management strategy for infectious MCI during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic and distinguish it from traumatic MCI deployment tactics. RESULTS: This management strategy can be divided into three phases, beginning with the acute emergency response including triage, stabilization of critical patients, and transport of patients requiring hospitalization. Phase 2 involves securing the facility's operational readiness, or housing residents elsewhere in case staff are infected or quarantined to a relevant degree. Phase 3 marks the return to regular operations. DISCUSSION: Phase 1 is based on usual MCI principles, phase 2 on hospital crisis management. Avoiding evacuation of residents to relieve hospitals is an important operational objective. The lack of mission and training experience with such situations, the limited applicability of established triage algorithms, and the need to coordinate a large number of participants pose challenges. CONCLUSION: This strategic model offers a practical, holistic approach to the management of infectious mass casualty scenarios in nursing facilities.

Primary mass casualty incident triage: evidence for the benefit of yearly brief re-training from a simulation study.

BACKGROUND: Triage is a mainstay of early mass casualty incident (MCI) management. Standardized triage protocols aim at providing valid and reproducible results and, thus, improve triage quality. To date, there is little data supporting the extent and content of training and re-training on using such triage protocols within the Emergency Medical Services (EMS). The study objective was to assess the decline in triage skills indicating a minimum time interval for re-training. In addition, the effect of a one-hour repeating lesson on triage quality was analyzed. METHODS: A dummy based trial on primary MCI triage with yearly follow-up after initial training using the ASAV algorithm (Amberg-Schwandorf Algorithm for Primary Triage) was undertaken. Triage was assessed concerning accuracy, sensitivity, specificity, over-triage, under-triage, time requirement, and a comprehensive performance measure. A subgroup analysis of professional paramedics was made. RESULTS: Nine hundred ninety triage procedures performed by 51 providers were analyzed. At 1 year after initial training, triage accuracy and overall performance dropped significantly. Professional paramedic's rate of correctly assigned triage categories deteriorated from 84 to 71%, and the overall performance score decreased from 95 to 90 points (maximum = 100). The observed decline in triage performance at 1 year after education made it necessary to conduct re-training. A brief didactic lecture of 45 min duration increased accuracy to 88% and the overall performance measure to 97. CONCLUSIONS: To improve disaster preparedness, triage skills should be refreshed yearly by a brief re-education of all EMS providers.

Apoptosis as a cellular predictor for histopathologic response to neoadjuvant radiochemotherapy in patients with rectal cancer.

BACKGROUND: Tumor shrinkage by preoperative radiochemotherapy (RCT) can markedly improve surgery in locally advanced (T4) rectal cancer with clear resection margins and may enable sphincter preservation in low-lying tumors. However, tumor response varies considerably, even among tumors treated according to the same protocol. If one is able to identify patients with highly radio-responsive tumors at the time of diagnosis, a selective and individualized policy of preoperative RCT might be pursued. METHODS: The apoptotic index (AI), Ki-67, p53, and bcl-2 were evaluated by immunohistochemistry on pretreatment biopsies from 44 patients treated uniformly according to a prospective neoadjuvant RCT protocol (CAO/AIO/ARO-94). Treatment response was assessed histopathologically in the resected surgical specimen, using a five-point grading system. Expression of each marker was correlated with tumor response and relapse-free survival after curative surgery. RESULTS: Tumors with complete (n = 3) or good (n = 28) response to RCT showed significantly higher pretreatment levels of apoptosis (mean AI: 2.06%) than tumors with moderate (n = 7), minimal (n = 5), or no regression (n = 1) from RCT (AI: 1.44%, p = 0.003). The AI was significantly related to Ki-67 (p = 0.05), but not to p53 and bcl-2 status. Tumor regression and AI best predicted relapse-free survival after combined modality treatment and curative surgery. CONCLUSION: Spontaneous apoptosis in rectal cancer may serve as an important predictor of tumor regression from RCT in rectal cancer and as a significant prognosticator of relapse-free survival. Thus, this molecular marker may finally help to tailor therapy with regard to (neo-) adjuvant treatment of rectal cancer.

Evaluation of a novel algorithm for primary mass casualty triage by paramedics in a physician manned EMS system: a dummy based trial.

BACKGROUND: The Amberg-Schwandorf Algorithm for Primary Triage (ASAV) is a novel primary triage concept specifically for physician manned emergency medical services (EMS) systems. In this study, we determined the diagnostic reliability and the time requirements of ASAV triage. METHODS: Seven hundred eighty triage runs performed by 76 trained EMS providers of varying professional qualification were included into the study. Patients were simulated using human dummies with written vital signs sheets. Triage results were compared to a standard solution, which was developed in a modified Delphi procedure. Test performance parameters (e.g. sensitivity, specificity, likelihood ratios (LR), under-triage, and over-triage) were calculated. Time measurements comprised the complete triage and tagging process and included the time span for walking to the subsequent patient. Results were compared to those published for mSTaRT. Additionally, a subgroup analysis was performed for employment status (career/volunteer), team qualification, and previous triage training. RESULTS: For red patients, ASAV sensitivity was 87%, specificity 91%, positive LR 9.7, negative LR 0.139, over-triage 6%, and under-triage 10%. There were no significant differences related to mSTaRT. Per patient, ASAV triage required a mean of 35.4 sec (75th percentile 46 sec, 90th percentile 58 sec). Volunteers needed slightly more time to perform triage than EMS professionals. Previous mSTaRT training of the provider reduced under-triage significantly. There were significant differences in time requirements for triage depending on the expected triage category. CONCLUSIONS: The ASAV is a specific concept for primary triage in physician governed EMS systems. It may detect red patients reliably. The test performance criteria are comparable to that of mSTaRT, whereas ASAV triage might be accomplished slightly faster. From the data, there was no evidence for a clinically significant reliability difference between typical staffing of mobile intensive care units, patient transport ambulances, or disaster response volunteers. Up to now, there is no clinical validation of either triage concept. Therefore, reality based evaluation studies are needed.