An Analysis of After Action Reports From Texas Hurricanes in 2005 and 2017.

OBJECTIVE: To review and analyze After Action Reports from jurisdictions in Texas following Hurricanes Katrina and Rita in 2005 and Hurricane Harvey in 2017 in order to assess the utility of AARs as a quality improvement measurement tool. METHODS: The authors searched the Homeland Security Digital Library, the Assistant Secretary for Preparedness and Response Technical Resources, Assistance Center, and Information Exchange, and Google Scholar for any AARs that covered the response phase of at least one of the 3 hurricanes, mentioned the state of Texas, and suggested solutions to problems. The authors applied public health emergency management (PHEM) domains, as outlined by Rose et al, to frame the AAR analysis. AARs were coded by 2 reviewers independently, with a third acting as adjudicator. As an example, the problem statements in 2005 and 2017 AARs from 1 statewide agency were compared. RESULTS: Sixteen AARs met the inclusion criteria. There were 500 identified problem-solution sets mapped to a PHEM domain. The content was unevenly distributed, with most issues coming under PHEM 2: Policies, Plans, Procedures, and Partnerships at 45.2% in the 2005 hurricanes and 39.9% in 2017. AARs lacked consistent format and were often prepared by the response agencies themselves. Five consistent issues were raised in 2005 and again in 2017. These were volunteer management and credential verification, donations management, information sharing, appropriately identifying those requiring a medical needs shelter, and inadequate transportation to support evacuation. CONCLUSION: Because of the lack of objective data, inconsistent format, unevenly distributed content, and lack of adherence to any framework, AARs are fraught with shortcomings as a tool for PHEM. Inclusion of more objective reporting measures is urgently needed.

Tackling causes and costs of ED presentation for American football injuries: a population-level study.

BACKGROUND: American tackle football is the most popular high-energy impact sport in the United States, with approximately 9 million participants competing annually. Previous epidemiologic studies of football-related injuries have generally focused on specific geographic areas or pediatric age groups. Our study sought to examine patient characteristics and outcomes, including hospital charges, among athletes presenting for emergency department (ED) treatment of football-related injury across all age groups in a large nationally representative data set. METHODS: Patients presenting for ED treatment of injuries sustained playing American tackle football (identified using International Classification of Diseases, Ninth Revision, Clinical Modification code E007.0) from 2010 to 2011 were studied in the Nationwide Emergency Department Sample. Patient-specific injuries were identified using the primary International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code and categorized by type and anatomical region. Standard descriptive methods examined patient demographics, diagnosis categories, and ED and inpatient outcomes and charges. RESULTS: During the study period 397363 football players presented for ED treatment, 95.8% of whom were male. Sprains/strains (25.6%), limb fractures (20.7%), and head injuries (including traumatic brain injury; 17.5%) represented the most presenting injuries. Overall, 97.9% of patients underwent routine ED discharge with 1.1% admitted directly and fewer than 11 patients in the 2-year study period dying prior to discharge. The proportion of admitted patients who required surgical interventions was 15.7%, of which 89.9% were orthopedic, 4.7% neurologic, and 2.6% abdominal. Among individuals admitted to inpatient care, mean hospital length of stay was 2.4days (95% confidence interval, 2.2-2.6) and 95.6% underwent routine discharge home. The mean total charge for all patients was $1941 (95% confidence interval, $1890-$1992) with substantial injury type-specific variability. Overall, at the US population, estimated total charges of $771299862 were incurred over the 2-year period. CONCLUSION: In this nationally representative sample, most ED-treated injuries associated with football were not acutely life threatening and very few required major therapeutic intervention. This study provides a cross-sectional overview of ED presentation for acute football-related injury across age groups at the population level in recent years. Longitudinal studies may be warranted to examine associations between the patterns of injury observed in this study and long-term outcomes among American tackle football players.

An Electronic Emergency Triage System to Improve Patient Distribution by Critical Outcomes.

BACKGROUND: Patient triage is necessary to manage excessive patient volumes and identify those with critical conditions. The most common triage system used today, Emergency Severity Index (ESI), focuses on resources utilized and critical outcomes. OBJECTIVE: This study derives and validates a computer-based electronic triage system (ETS) to improve patient acuity distribution based on serious patient outcomes. METHODS: This cross-sectional study of 25,198 (97 million weighted) adult emergency department visits from the 2009 National Hospital Ambulatory Medical Care Survey. The ETS distributes patients by using a composite outcome based on the estimated probability of mortality, intensive care unit admission, or transfer to operating room or catheterization suite. We compared the ETS with the ESI based on the differentiation of patients, outcomes, inpatient hospitalization, and resource utilization. RESULTS: Of the patients included, 3.3% had the composite outcome and 14% were admitted, and 2.52 resources/patient were used. Of the 90% triaged to low-acuity levels, ETS distributed patients evenly (Level 3: 30%; Level 4: 30%, and Level 5: 29%) compared to ESI (46%, 34%, and 7%, respectively). The ETS better-identified patients with the composite outcome present in 40% of ETS Level 1 vs. 17% for ESI and the ETS area under the receiver operating characteristic curve (AUC) was 0.83 vs. ESI 0.73. Similar results were found for hospital admission (ETS AUC = 0.83 vs. ESI AUC = 0.72). The ETS demonstrated slight improvements in discriminating patient resource utilization. CONCLUSIONS: The ETS is a triage system based on the frequency of critical outcomes that demonstrate improved differentiation of patients compared to the current standard ESI.

Measuring impact: a cross-sectional multi-stage cluster survey to assess the attainment of durable solutions in post-tsunami Aceh, Indonesia.

BACKGROUND: There exists little agreement on the choice of indicators to be used to assess the impact of humanitarian assistance. The 2004 Indian Ocean tsunami led to significant mortality and displacement in Aceh Province, Indonesia, as well as a nearly unprecedented humanitarian response. Six years after the disaster we conducted an impact assessment of humanitarian services rendered in Aceh using a comprehensive set of rights-based indicators and sought to determine modifiable predictors of improved outcomes in disaster-affected households. METHODS: A sample of 597 returned and non-returned households in Banda Aceh and Meulaboh was selected using a multistage stratified cluster survey design. We employed principle components analysis and the Framework on Durable Solutions for Internally Displaced Persons to develop a comprehensive and rights-based approach to humanitarian impact measurement using multivariate regression models. RESULTS: The attainment of durable solutions was equivalent in both returned households 100.1 [CI] 97.63-102.5) and households that integrated elsewhere (99.37 [CI] 95.43-103.3, P = 0.781). Standard of living as well as education and health facility satisfaction increased significantly whereas monthly income decreased after the tsunami, from 2585241 IDR ([CI] 2357202-2813279 IDR) to 2038963 ([CI] 1786627-2291298 IDR, P < 0.001). Shelter (P = 0.007) and legal assistance (P < 0.001) were both significantly associated with positive durable solutions outcomes, whereas prolonged displacement duration was significantly associated with poorer outcomes (P < 0.001). Livelihood assistance received after one year was associated with higher odds of increasing or maintaining pre-tsunami income levels (OR = 3.02, P = 0.008), whereas livelihood assistance received within one year was associated with lower odds of attaining pre-tsunami income (OR = 0.52, P = 0.010). CONCLUSIONS: We find that after adjusting for pre-tsunami conditions and tsunami-related damages, the impact of sectoral responses can be assessed. The duration of displacement was the strongest negative predictive factor for the attainment of durable solutions, suggesting that measures to reduce displacement time may be effective in mitigating the long-term effects of disaster on households. The durable solutions framework is a novel and effective impact measurement tool and can be used to identify factors amenable to intervention and inform future disaster recovery efforts.

A comparison of the medium-term impact and recovery of the Pakistan floods and the Haiti earthquake: objective and subjective measures.

INTRODUCTION: The 2010 Haiti earthquake and Pakistan floods were similar in their massive human impact. Although the specific events were very different, the humanitarian response to disasters is supposed to achieve the same ends. This paper contrasts the disaster effects and aims to contrast the medium-term response. METHODS: In January 2011, similarly structured population-based surveys were carried out in the most affected areas using stratified cluster designs (80×20 in Pakistan and 60×20 in Haiti) with probability proportional to size sampling. RESULTS: Displacement persisted in Haiti and Pakistan at 53% and 39% of households, respectively. In Pakistan, 95% of households reported damage to their homes and loss of income or livelihoods, and in Haiti, the rates were 93% and 85%, respectively. Frequency of displacement, and income or livelihood loss, were significantly higher in Pakistan, whereas disaster-related deaths or injuries were significantly more prevalent in Haiti. CONCLUSION: Given the rise in disaster frequency and costs, and the volatility of humanitarian funding streams as a result of the recent global financial crisis, it is increasingly important to measure the impact of humanitarian response against the goal of a return to normalcy.

Mortality following the Haitian earthquake of 2010: a stratified cluster survey.

INTRODUCTION: Research that seeks to better understand vulnerability to earthquakes and risk factors associated with mortality in low resource settings is critical to earthquake preparedness and response efforts. This study aims to characterize mortality and associated risk factors in the 2010 Haitian earthquake. METHODS: In January 2011, a survey of the earthquake affected Haitian population was conducted in metropolitan Port-au-Prince. A stratified 60x20 cluster design (n = 1200 households) was used with 30 clusters sampled in both camp and neighborhood locations. Households were surveyed regarding earthquake impact, current living conditions, and unmet needs. RESULTS: Mortality was estimated at 24 deaths (confidence interval [CI]: 20-28) per 1,000 in the sample population. Using two approaches, extrapolation of the survey mortality rate to the exposed population yielded mortality estimates ranging from a low of 49,033 to a high of 86,555. No significant difference in mortality was observed by sex (p = .786); however, age was significant with adults age 50+ years facing increased mortality risk. Odds of death were not significantly higher in camps, with 27 deaths per 1,000 (CI: 22-34), compared to neighborhoods, where the death rate was 19 per 1,000 (CI: 15-25; p = 0.080). Crowding and residence in a multistory building were also associated with increased risk of death. CONCLUSIONS: Haiti earthquake mortality estimates are widely varied, though epidemiologic surveys conducted to date suggest lower levels of mortality than officially reported figures. Strategies to mitigate future mortality burden in future earthquakes should consider improvements to the built environment that are feasible in urban resource-poor settings.

Household economic and food security after the 2010 Pakistan floods.

BACKGROUND: The 2010 floods inundated one-fifth of Pakistan and affected more than 20 million people. OBJECTIVE: To characterize the impact of the floods and subsequent humanitarian response on household economy and food security. METHODS: A cross-sectional 80 x 20 cluster survey (n = 1,569 households) was conducted using probability proportional to size sampling in the four most flood-affected provinces 6 months after the floods. Analysis included both descriptive statistics and regression models, with receipt of food aid (in the first month), dietary quality, and household income at 6 months postflood as outcomes. RESULTS: Need for food aid was nearly ubiquitous (98.9%); however, only half of the study population ever received food aid. Displacement was not a significant predictor of food aid receipt (OR, 1.28; 95% CI, 0.83 to 1.98); however urban location (OR, 2.78; 95% CI, 2.00 to 3.86) and damage to the home (OR, 2.73; 95% CI, 1.34 to 5.60) were significantly associated. Some of the hardest-hit groups, including both farmers and day laborers, were significantly less likely to receive food aid (p < .05). Additionally, receipt of food aid was not necessarily associated with improved household economy or food security; although households in internally displaced people (IDP) camps were more likely to receive food aid (OR, 2.78; 95% CI, 2.00 to 3.86), they were less likely to report same or improved dietary quality (OR, 0.63; 95% CI, 0.46 to 0.88) or income status (OR, 0.55; 95% CI, 0.35 to 0.86). CONCLUSIONS: Food aid coverage following the 2010 floods was relatively low, and many of the most affected populations were less likely to receive aid, suggesting that targeting should be improved in future responses.

Satisfaction with the humanitarian response to the 2010 Pakistan floods: a call for increased accountability to beneficiaries.

OBJECTIVE: Ascertain recipients' level of satisfaction with humanitarian response efforts. DESIGN: A multi-stage, 80×20 cluster sample randomized survey (1800 households) with probability proportional to size of households affected by the 2010 Indus river floods in Pakistan. The floods affected over 18 million households and led to more than 8 billion USD in response dollars. RESULTS: Less than 20% of respondents reported being satisfied with response, though a small increase in satisfaction levels was observed over the three time periods of interest. Within the first month, receipt of hygiene items, food and household items was most strongly predictive of overall satisfaction. At 6 months, positive receipt of medicines was also highly predictive of satisfaction. The proportion of households reporting unmet needs remained elevated throughout the 6-month period following the floods and varied from 50% to 80%. Needs were best met between 1 and 3 months postflood, when response was at its peak. Unmet needs were the greatest at 6 months, when response was being phased down. CONCLUSIONS: Access-limiting issues were rarely captured during routine monitoring and evaluation efforts and seem to be a significant predictor in dissatisfaction with relief efforts, at least in the case of Pakistan, another argument in favor of independent, population-based surveys of this kind. There is also need to better identify and serve those not residing in camps. Direct surveys of the affected population can be used operationally to assess ongoing needs, more appropriately redirect humanitarian resources, and ultimately, judge the overall quality of a humanitarian response.

Use of Information Technology Systems for Regional Health Care Information-Sharing and Coordination During Large-Scale Medical Surge Events.

Medical surge events require effective coordination between multiple partners. Unfortunately, the information technology (IT) systems currently used for information-sharing by emergency responders and managers in the United States are insufficient to coordinate with health care providers, particularly during large-scale regional incidents. The numerous innovations adopted for the COVID-19 response and continuing advances in IT systems for emergency management and health care information-sharing suggest a more promising future. This article describes: (1) several IT systems and data platforms currently used for information-sharing, operational coordination, patient tracking, and resource-sharing between emergency management and health care providers at the regional level in the US; and (2) barriers and opportunities for using these systems and platforms to improve regional health care information-sharing and coordination during a large-scale medical surge event. The article concludes with a statement about the need for a comprehensive landscape analysis of the component systems in this IT ecosystem.

A Multisite Investigation of Areas for Improvement in COVID-19 Surge Capacity Management.

The congressionally authorized National Disaster Medical System Pilot Program was created in December 2019 to strengthen the medical surge capability, capacity, and interoperability of affiliated healthcare facilities in 5 regions across the United States. The COVID-19 pandemic provided an unprecedented opportunity to learn how participating healthcare facilities handled medical surge events during an active public health emergency. We applied a modified version of the Barbisch and Koenig 4-S framework (staff, stuff, space, systems) to analyze COVID-19 surge management practices implemented by healthcare stakeholders at 5 pilot sites. In total, 32 notable practices were identified to increase surge capacity during the COVID-19 pandemic that have potential applications for other healthcare facilities. We found that systems was the most prevalent domain of surge capacity among the identified practices. Systems and staff were discussed across all 5 pilot sites and were the 2 domains co-occurring most often within each surge management practice. These results can inform strategies for scaling up and optimizing medical surge capability, capacity, and interoperability of healthcare facilities nationwide. This study also specifies areas of surge capacity worthy of strategic focus in the pilot's planning and implementation efforts while more broadly informing the US healthcare system's response to future large-scale, medical surge events.

Mass Shootings in America: Consensus Recommendations for Healthcare Response.

BACKGROUND: In 2021, 702 people died in mass shooting incidents (MSIs) in the US. To define the best healthcare response to MSIs, the Uniformed Services University's National Center for Disaster Medicine and Public Health hosted a consensus conference of emergency medical services (EMS) clinicians, emergency medicine (EM) physicians, and surgeons who provided medical response to six of the nation's largest recent mass shootings. STUDY DESIGN: The study consisted of a 3-round modified Delphi process. A planning committee selected 6 MSI sites with the following criteria: the MSI occurred in 2016 or later, and must have resulted in at least 15 people killed and injured. The MSI sites were Orlando, FL, Las Vegas, NV, Sutherland Springs, TX, Parkland, FL, El Paso, TX, and Dayton, OH. Fifteen clinicians participated in the conference. All participants had EMS, EM, or surgery expertise and responded to 1 of the 6 MSIs. The first round consisted of a 2-part survey. The second and third rounds consisted of site-specific presentations followed by specialty-specific discussion groups to generate consensus recommendations. RESULTS: The 3 specialty-specific groups created 8 consensus recommendations in common. These 8 recommendations addressed readiness training, public education, triage, communication, patient tracking, medical records, family reunification, and mental health services for responders. There were an additional 11 recommendations created in common between 2 subgroups, either EMS and EM (2), EM and surgery (7), or EMS and surgery (2). CONCLUSIONS: There are multiple common recommendations identified by EMS, EM, and surgery clinicians who responded to recent MSIs. Clinicians, emergency planners, and others involved in preparing and executing a response to a future mass shooting event may benefit from considering these consensus lessons learned.

Validation of Opportunities to Strengthen the National Disaster Medical System: The Military-Civilian NDMS Interoperability Study Quantitative Step.

The National Disaster Medical System (NDMS) Pilot Program was authorized by Congress to improve the interoperability, capabilities, and capacity of the NDMS. To develop a roadmap for planning and research, the mixed methods Military-Civilian NDMS Interoperability Study (MCNIS) was conducted in 2020-2021. The initial qualitative phase of the study identified critical themes for improvement: (1) coordination, collaboration, and communication; (2) funding and incentives to increase private sector preparedness; (3) staffing capacity and competencies; (4) clinical and support surge capacity; (5) training, education, and exercises between federal and private sector partners; and (6) metrics, benchmarks, and modeling to track NDMS performance. These qualitative findings were subsequently refined, validated, and prioritized through a quantitative survey. Expert respondents ranked 64 statements based on weaknesses and opportunities identified during the qualitative phase. Data were collected using Likert scales, and multivariate proportions and confidence intervals were estimated to compare and prioritize each statement's level of support. Pairwise tests were conducted for each item-to-item pair to determine statistically significant differences. The survey results corroborated the earlier qualitative findings, with all weaknesses and opportunities ranked as important by a majority of respondents. Survey results also pointed to specific priorities for interventions within the 6 previously identified themes. As with the qualitative study, the survey found that the most common weaknesses and opportunities were related to coordination, collaboration, and communication, especially regarding information technology and planning at the federal and regional levels. These priority interventions are now being developed, implemented, and validated at 5 pilot partner sites.

Requirements for independent community-based quality assessment and accountability practices in humanitarian assistance and disaster relief activities.

During responses to disasters, the credibility of humanitarian agencies can be threatened by perceptions of poor quality of the responses. Many initiatives have been introduced over the last two decades to help address these issues and enhance the overall quality of humanitarian response, often with limited success. There remain important gaps and deficiencies in quality assurance efforts, including potential conflicts of interest. While many definitions for quality exist, a common component is that meeting the needs of the "beneficiary" or "client" is the ultimate determinant of quality. This paper examines the current status of assessment and accountability practices in the humanitarian response community, identifies gaps, and recommends timely, concise, and population-based assessments to elicit the perspective of quality performance and accountability to the affected populations. Direct and independent surveys of the disaster-affected population will help to redirect ongoing aid efforts, and generate more effective and comparable methods for assessing the quality of humanitarian practices and assistance activities.

Reexamining Health-Care Coalitions in Light of COVID-19.

The national response to the coronavirus disease 2019 (COVID-19) pandemic has highlighted critical weaknesses in domestic health care and public health emergency preparedness, despite nearly 2 decades of federal funding for multiple programs designed to encourage cross-cutting collaboration in emergency response. Health-care coalitions (HCCs), which are funded through the Hospital Preparedness Program, were first piloted in 2007 and have been continuously funded nationwide since 2012 to support broad collaborations across public health, emergency management, emergency medical services, and the emergency response arms of the health-care system within a geographical area. This commentary provides a SWOT (strengths, weaknesses, opportunities, and threats) analysis to summarize the strengths, weaknesses, opportunities, and threats related to the current HCC model against the backdrop of COVID-19. We close with concrete recommendations for better leveraging the HCC model for improved health-care system readiness. These include better evaluating the role of HCCs and their members (including the responsibility of the HCC to better communicate and align with other sectors), reconsidering the existing framework for HCC administration, increasing incentives for meaningful community participation in HCC preparedness, and supporting next-generation development of health-care preparedness systems for future pandemics.

The National Disaster Medical System and military combat readiness: A scoping review.

ABSTRACT: A scoping review was conducted to describe the history of the National Disaster Medical System (NDMS) in the context of US military medical preparedness for a large-scale overseas military conflict. National Disaster Medical System civilian hospitals would serve as backups to military treatment facilities if both US Department of Defense and US Department of Veterans Affairs hospitals reached capacity during such a conflict. Systematic searches were used to identify published works discussing the NDMS in the scientific and gray literature. Results were limited to publicly available unclassified English language works from 1978 to January 2022; no other restrictions were placed on the types of published works. Full-text reviews were conducted on identified works (except student papers and dissertations) to determine the extent to which they addressed NDMS definitive care. Data charting was performed on a final set of papers to assess how these works addressed NDMS definitive care. The search identified 54 works published between 1984 and 2022. More than half of the publications were simple descriptions of the NDMS (n = 30 [56%]), and most were published in academic or professional journals (n = 38 [70%]). Only nine constituted original research. There were recurrent criticisms of and recommendations for improving the definitive care component of the NDMS. The lack of published literature on NDMS definitive care supports the assertion that the present-day NDMS may lack the capacity and military-civilian interoperability necessary to manage the casualties resulting from a large-scale overseas military conflict.