Implementation of a nurse-led alternate care site for the management of the surge of patients with COVID-19 in an Italian emergency department.

BACKGROUND: To accommodate and separate the large numbers of patients going to hospital with COVID-19, many EDs had to create new pathways for patients. We describe the outcomes of patients treated in a nurse-led alternate care site (ACS) at our hospital. METHODS: This was a retrospective study of outcomes of patients managed at the ACS of 'San Bassiano' Hospital ED, Bassano del Grappa, Italy between 9 March and 16 April 2020. Self-presenting patients aged 5 years and older, suspected of having COVID-19, were initially diverted to the ACS. Patients with a National Early Warning Score ≥5 or with a desaturation ≥4% after the walking test were sent back to the main ED COVID-19 path for further evaluation and medical attention and were not further followed up. In the ACS, patients received a CXR, blood samples and a nasopharyngeal swab to test for SARS-CoV-2, and were sent home. An emergency physician reviewed the results later and called the patient back 5-6 hours later with instructions to return for medical evaluation of abnormal findings, or to seek their general practitioner's attention. Patients received a follow-up phone call 15 days later to learn of their course. RESULTS: A total of 487 patients were fully managed in the ACS and discharged home. Of the 392 (80.5%) patients with no abnormalities after the workup and instructed to stay at home, 29 reattended the ED in the next 15 days, and 13 were admitted. Among the 95 patients asked to return and receive medical attention, 20 were admitted and of those discharged, 3 reattended the ED within 15 days. At 15 days, no patient was deceased or received invasive ventilation; one admitted patient received non-invasive ventilation. CONCLUSIONS: A nurse-led ACS diverted a substantial proportion of patients from main ED resources without associated negative clinical outcomes.

Incidence of Lyme Disease Diagnosis in a Maryland Medicaid Population, 2004-2011.

The epidemiology of Lyme disease has been examined utilizing insurance claims from privately insured individuals; however, it is unknown whether reported patterns vary among the publicly insured. We examined trends in incidence rates of first Lyme disease diagnosis among 384,652 Maryland Medicaid recipients enrolled from July 2004 to June 2011. Age-, sex-, county-, season-, and year-specific incidence rates were calculated, and mixed-effects multiple logistic regression models were used to study the relationship between Lyme disease diagnosis and these variables. The incidence rate in our sample was 97.65 cases per 100,000 person-years (95% confidence interval (CI): 91.53, 104.06), and there was a 13% average annual increase in the odds of a Lyme disease diagnosis (odds ratio = 1.13, 95% CI: 1.09, 1.17; P < 0.001). Incidence rates for males and females were not significantly different, though males were significantly more likely to be diagnosed during high-season months (relative risk (RR) = 1.24, 95% CI: 1.06, 1.44) and less likely to be diagnosed during low-season months (RR = 0.63, 95% CI: 0.46, 0.87) than females. Additionally, adults were significantly more likely than children to be diagnosed during low-season months (RR = 1.59, 95% CI: 1.19, 2.12). While relatively rare in this study sample, Lyme disease diagnoses do occur in a Medicaid population in a Lyme-endemic state.

Living in Limbo: Contested Narratives of Patients With Chronic Symptoms Following Lyme Disease.

Persistent, subjective symptoms of unknown etiology following treatment for Lyme disease have been termed post- treatment Lyme disease syndrome or chronic Lyme disease (PTLDS/CLD). The objective of this study was to give primacy to the patient experience of this medically contested condition by eliciting patient illness narratives and identifying emergent issues through semistructured interviews conducted among 29 participants. We used thematic narrative analysis to identify three predominant themes: (a) Physical and social limitations lead to a "new normal" characterized by fundamental shifts of ways of being in the world, (b) disease-specific factors contribute to symptom and illness invisibility that affects social support in nuanced ways, and (c) pervasive medical uncertainty regarding PTLDS/CLD promotes an increased sense of personal responsibility for care. Similar to other contested or medically unexplained syndromes, our findings suggest that the social sequelae of PTLDS/CLD can be equally protracted as the physical effects of this illness.

A Pilot Study in the Use of the Delphi Method to Document Conference Proceedings: Comparison of the Rate of Consensus Among Attending and Nonattending Participants.

OBJECTIVE: While many medical practitioners value the interactive nature of in-person conferences, results of these interactions are often poorly documented. The objective of this study was to pilot the Delphi method for developing consensus following a national conference and to compare the results between experts who did and did not attend. METHODS: A 3-round Delphi included experts attending the 2023 Society of Disaster Medicine and Health Preparedness Annual Meeting and experts who were members of the society but did not attend. Conference speakers provided statements related to their presentations. Experts rated the statements on a 1-7 scale for agreement using STAT59 software (STAT59 Services Ltd, Edmonton, Alberta, Canada). Consensus was defined as a standard deviation of ≤ 1.0. RESULTS: Seventy-five statements were rated by 27 experts who attended and 10 who did not: 2634 ratings in total. There was no difference in the number of statements reaching consensus in the attending group (26/75) versus that of the nonattending group (27/75) (P = 0.89). However, which statements reached consensus differed between the groups. CONCLUSION: The Delphi method is a viable method to document consensus from a conference. Advantages include the ability to involve large groups of experts, statistical measurement of the degree of consensus, and prioritization of the results.

Pager Explosion in Beirut: An Unprecedented Event.

On September 17, 2024, at 15:30 local time, thousands of pagers used by members of a specific party group detonated across Lebanon. As a result of the explosions, 2800 were wounded and 12 lost their lives. Almost two-thirds of the injuries were in the face, eyes, or hands. The Lebanese American University Medical Center received 38 injured and admitted 36 patients, 13 of them to the Intensive care unit. A total of 33 patients needed surgeries. All medical and nursing staff were deployed. The health care workers faced major challenges that night: the severity of the injuries and the unprecedented types of injuries with the same pattern, and the urgent need for ophthalmology and orthopedics within the hospital and across the country. Learning from the Pager Explosion, each hospital should perform assessments of their disaster response plan, develop trainings, and conduct regular exercises in preparation for future disasters.

What If Nice Terrorist Attack Would Have Happened in Milan? Drawing a Disaster Plan for Mass Casualty Incidents Involving the Pediatric Population.

Terrorist attacks involving children raised concern regarding the preparedness to treat pediatric trauma patients during mass casualty incidents (MCIs). The purpose of this project was to assess the resources available in Milan to respond to MCIs as the 2016 Bastille Day attack in Nice. Literature and guidelines were reviewed and minimal standard requirements of care of pediatric trauma patients in MCIs were identified. The hospitals that took part in the study were asked to answer a survey regarding their resource availability. An overall surge capability of 40-44 pediatric trauma patients was identified, distributed based on age and severity, hospital resources, and expertise. The findings showed that adult and pediatric hospitals should work in synergy with pediatric trauma centers, or offer an alternative if there is none, and should be included in disaster plans for MCIs. Simulations exercises need to be carried out to evaluate and validate the results.

Criteria for Deployment of the United States National Guard to Domestic Sudden-Onset Natural Disasters: A Scoping Review.

INTRODUCTION: This study is a scoping review to identify literature pertinent to the question: "What are the criteria for deployment of the United States National Guard (USNG) to domestic sudden-onset natural disasters (SODs)?" As this question relies on factors across many disciplines-legal, medical, technical, cultural-and as there is no foundational body of academic literature or unified governmental or USNG policy addressing this question, a scoping review was designed to identify the body of literature on which further research and policy decisions surrounding this question may be based. MATERIALS AND METHODS: On January 23, 2023 a modified PRISMA-ScR search was performed using an online search engine of the following databases: Academic Search Premier, Google Scholar, JSTOR, PubMed, Web of Science, and WorldCat. The inclusion criteria included the involvement of the USNG response to U.S. domestic SOD. Non-SOD results were excluded. Results from all years and of any type of literature were considered and were limited to the English language. First, titles and abstracts were screened by 2 independent reviewers. Then, a full-text review was performed by 2 independent reviewers. Finally, data were extracted from included texts by 2 independent reviewers. A third reviewer resolved any discrepancies at each stage. This study did not require approval of an institutional review board. RESULTS: Out of the 886 results identified by the original search, after the complete review process, 34 sources were relevant to the research question. Fifteen criteria for the deployment of the USNG to SODs were identified. Overwhelmed local responders, utility failure, the need for the provision of security, and the need for logistical coordination were the most commonly identified criteria. Hurricanes were the most common SOD addressed in the included literature, and most results were event reports. CONCLUSIONS: This modified PRISMA-ScR identified a foundation on which elected officials, USNG leadership, and the larger disaster response community may develop policies and disaster response plans to optimize available resources through the activation of the USNG when responding to SODs.

Severe Acute Respiratory Syndrome Coronavirus 2 and Medical Evacuation in Lombardy: Lessons Learned from an Unprecedented Pandemic.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerging infectious disease pandemic developed in Lombardy (northern Italy) during the last week of February 2020 with a progressive increase of patients presenting with serious clinical findings. Despite the efforts of the Central Italian Government, regional resources were rapidly at capacity. The solution was to plan the medical evacuation (MEDEVAC) of 119 critically ill patients (median age 61 years) to in-patient intensive care units in other Italian regions (77) and Germany (42). Once surviving patients were deemed suitable, the repatriation process concluded the assignment. The aim of this report is to underline the importance of a rapid organization and coordination process between different nodes of an effective national and international network during an emerging infectious disease outbreak and draw lessons learned from similar published reports.

Education, training and technological innovation, key components of the ESTES-NIGHTINGALE project cooperation for Mass Casualty Incident preparedness in Europe.

Disasters induced by extreme weather events and terrorism-related activities, causing mass casualty incidents (MCIs) in Europe, are expected to increase in the upcoming years. This challenging scenario demands a high level of readiness and coordinated multi-disciplinary response to reduce morbidity and mortality. The European Society of Trauma and Emergency Surgery (ESTES) is one of the 23 partners of the European-funded project Novel Integrated Toolkit for Enhanced Pre-Hospital Life Support and Triage in Challenging and Large Emergencies (NIGHTINGALE), whose primary objective is to promote the exchange in experiences and define the best practices among first responders. Additionally, the project promotes multi-disciplinary and multi-institutional efforts to achieve technological innovation that will enhance preparedness in MCI management. This manuscript aims to describe the challenges of MCI triage, the education and training programs for MCI response in Europe, and the technological innovation that may aid optimal response. These three elements were discussed by ESTES Disaster and Military Surgery Section members during the German Society for Trauma Surgery session at the ECTES 2022 in Oslo "TDSC® and beyond: ideas and concepts for education and training in Terror Preparedness", additionally the manuscript describes the first steps of the cooperation between ESTES and the rest of the NIGHTINGALE consortium.

The Challenge of Mass Casualty Incident Response Simulation Exercise Design and Creation: A Modified Delphi Study.

BACKGROUND: A Mass Casualty Incident response (MCI) full scale exercise (FSEx) assures MCI first responder (FR) competencies. Simulation and serious gaming platforms (Simulation) have been considered to achieve and maintain FR competencies. The translational science (TS) T0 question was asked: how can FRs achieve similar MCI competencies as a FSEx through the use of MCI simulation exercises? METHODS: T1 stage (Scoping Review): PRISMA-ScR was conducted to develop statements for the T2 stage modified Delphi (mD) study. 1320 reference titles and abstracts were reviewed with 215 full articles progressing for full review leading to 97 undergoing data extraction.T2 stage (mD study): Selected experts were presented with 27 statements derived from T1 data with instruction to rank each statement on a 7-point linear numeric scale, where 1 = disagree and 7 = agree. Consensus amongst experts was defined as a standard deviation ≤ 1.0. RESULTS: After 3 mD rounds, 19 statements attained consensus and 8 did not attain consensus. CONCLUSIONS: MCI simulation exercises can be developed to achieve similar competencies as FSEx by incorporating the 19 statements that attained consensus through the TS stages of a scoping review (T1) and mD study (T2), and continuing to T3 implementation, and then T4 evaluation stages.

Advancing the scientific study of prehospital mass casualty response through a Translational Science process: the T1 scoping literature review stage.

PURPOSE: The European Union Horizon 2020 research and innovation funding program awarded the NIGHTINGALE grant to develop a toolkit to support first responders engaged in prehospital (PH) mass casualty incident (MCI) response. To reach the projects' objectives, the NIGHTINGALE consortium used a Translational Science (TS) process. The present work is the first TS stage (T1) aimed to extract data relevant for the subsequent modified Delphi study (T2) statements. METHODS: The authors were divided into three work groups (WGs) MCI Triage, PH Life Support and Damage Control (PHLSDC), and PH Processes (PHP). Each WG conducted simultaneous literature searches following the PRISMA extension for scoping reviews. Relevant data were extracted from the included articles and indexed using pre-identified PH MCI response themes and subthemes. RESULTS: The initial search yielded 925 total references to be considered for title and abstract review (MCI Triage 311, PHLSDC 329, PHP 285), then 483 articles for full reference review (MCI Triage 111, PHLSDC 216, PHP 156), and finally 152 articles for the database extraction process (MCI Triage 27, PHLSDC 37, PHP 88). Most frequent subthemes and novel concepts have been identified as a basis for the elaboration of draft statements for the T2 modified Delphi study. CONCLUSION: The three simultaneous scoping reviews allowed the extraction of relevant PH MCI subthemes and novel concepts that will enable the NIGHTINGALE consortium to create scientifically anchored statements in the T2 modified Delphi study.

Sudden-Onset Disaster Mass-Casualty Incident Response: A Modified Delphi Study on Triage, Prehospital Life Support, and Processes.

The application and provision of prehospital care in disasters and mass-casualty incident response in Europe is currently being explored for opportunities to improve practice. The objective of this translational science study was to align common principles of approach and action and to identify how technology can assist and enhance response. To achieve this objective, the application of a modified Delphi methodology study based on statements derived from key findings of a scoping review was undertaken. This resulted in 18 triage, eight life support and damage control interventions, and 23 process consensus statements. These findings will be utilized in the development of evidence-based prehospital mass-casualty incident response tools and guidelines.

Beirut Explosion: Challenge of Hospital Emergency Preparedness.

On August 4, 2020, a major explosion took place in Beirut, the capital of Lebanon. Some hospitals in Beirut were destroyed and became nonfunctional, and others were overwhelmed with casualties, with 8643 casualties admitted to emergency departments on that night. The Lebanese American University Medical Center-Rizk Hospital, 2.8 km away from the blast, received an unexpected number of casualties. While a disaster plan was conceived earlier, this hospital's emergency department faced many challenges on that night, and major flaws in their preparedness plan were seen.

Facilitators and Barriers for Effective Staff Work in Swedish National Governmental Crisis Response to the COVID-19 Pandemic.

OBJECTIVES: The coronavirus disease (COVID-19) crisis response in Sweden was managed foremost by a collaboration of several national agencies. Normally, their strategical and operational collaboration is limited, but the pandemic required new and unfamiliar collaborations. This study aimed to clarify the facilitators and barriers of perceived effective staff work within and between 4 national agencies. METHODS: A qualitative study of 10 participants with leading roles within the 4 national agencies' crisis organization was conducted via snowball sampling. The participant interviews were conducted between August and November 2020 and analyzed using content analysis. RESULTS: Four categories emerged from the analysis: individual characteristics, intra-agency organization, interorganizational collaboration, and governmental directives. Subcategories crystallized from the data were analyzed and divided into factors for facilitating or to function as barriers for effective staff work. CONCLUSION: Individual factors such as attitude and approach were important for perceived effective staff work as well as clear mandates and structure of the organization. Barriers for perceived effective staff work include lack of network, the complexity of the mission and organizational structures, as well as lack of preparations and unclear mandates. Although flexibility and adaptability are necessary, they cannot always be planned, but can be incorporated indirectly by selecting suitable individuals and optimizing organizational planning.

Prehospital Response Time of the Emergency Medical Service during Mass Casualty Incidents and the Effect of Triage: A Retrospective Study.

OBJECTIVE: Prehospital time affects survival in trauma patients. Mass casualty incidents (MCIs) are overwhelming events where medical care exceeds available resources. This study aimed at evaluating the prehospital time during MCIs and investigating the effect of triage. METHODS: A retrospective analysis was performed using Florida's Event Medical Services Tracking and Reporting System database. All patients involved in MCIs during 2018 were accessed, and prehospital time intervals were evaluated and compared to that of non-MCIs. The effect of MCI triage and field triage (Field Triage Criteria) on prehospital time was evaluated. RESULTS: In 2018, it was estimated that 2236 unique MCIs occurred in Florida, with a crude incidence of 10.1-10.9/100000 people. 2180 EMS units arrived at the hospital for patient disposition with a median alarm-to-hospital time of 43.74 minutes, significantly longer than non-MCIs (39.15 min; P < 0.001). MCI triage and field triage were both associated with shorter alarm-to-hospital time (39.37 min and 37.55 min, respectively). CONCLUSIONS: MCIs resulted in longer prehospital time intervals than non-MCIs. This finding suggests that additional efforts are needed to reduce the prehospital time for MCI patients. MCI triage and field triage were both associated with shorter alarm-to-hospital times. Widespread use may improve prehospital MCI care.

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.

Impact of Point-of-Care Ultrasound on Secondary Triage: A Pilot Study.

OBJECTIVES: In mass casualty scenarios, patients with apparent hemodynamic and respiratory stability might have occult life-threatening injuries. These patients could benefit from more accurate triage methods. This study assessed the impact of point-of-care ultrasound on the accuracy of secondary triage conducted at an advanced medical post to enhance the detection of patients who, despite their apparent clinically stable condition, could benefit from earlier evacuation to definitive care or immediate life-saving treatment. METHODS: A mass casualty simulated event consisting of a bomb blast in a remote area was conducted with 10 simulated casualties classified as YELLOW at the primary triage scene; patients were evaluated by 4 physicians at an advanced medical post. Three patients had, respectively, hemoperitoneum, pneumothorax, and hemothorax. Only 2 physicians had sonographic information. RESULTS: All 4 physicians were able to suspect hemoperitoneum as a possible critical condition to be managed first, but only physicians with additional sonographic information accurately detected pneumothorax and hemothorax, thus deciding to immediately evacuate or treat.

Applying the Haddon Matrix to Frontline Care Preparedness and Response in Asymmetric Warfare.

INTRODUCTION: Asymmetric warfare and the reaction to its threats have implications in the way far-forward medical assistance is provided in such settings. Investments in far-forward emergency resuscitation and stabilization can contribute to saving lives and increase the resilience of health systems. Thus, it is proposed to extend the use of the Haddon Matrix to determine a set of strategies to better understand and prioritize activities to prepare for and set-up frontline care in the form of Trauma Stabilization Points (TSPs). METHODS: An expert consensus methodology was used to achieve the research aim. A small subject matter experts' group was convened to create and validate the content of the Haddon Matrix. RESULTS: The result of the expert group consultations presented an overview of TSP Preparedness and Operational Readiness activities within a Haddon Matrix framework. Main strategies to be adopted within the cycle from pre- to post-event had been identified and presented considering the identified opportunities in the context of the possibility of implementation. Of particular importance was the revision of a curriculum that fits the civilian medical system and facilitates its adaptation to the context and available resources. CONCLUSION: The new framework to enhance frontline care preparedness and response using the Haddon Matrix facilitated the identification of a set of strategies to support frontline health care workers in a more efficient manner. Since the existing approach and tools are insufficient for modern warfare, additional research is needed.

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

BACKGROUND: 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. This becomes particularly evident during the on-going coronavirus disease 2019 (COVID-19) pandemic. More resilient resource allocation strategies, that is, 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 sudden onset disaster 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 disaster, 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. It becomes particularly relevant when considering the risk of indirect damage of emergencies, where all the available resources are shifted from the care of the ordinary to the "disaster" patients, like during the on-going COVID-19 pandemic. 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.

The Ethical Triage and Management Guidelines of the Entrapped and Mangled Extremity in Resource Scarce Environments: A Systematic Literature Review.

OBJECTIVE: A systematic literature review (SLR) was performed to elucidate the current triage and treatment of an entrapped or mangled extremity in resource scarce environments (RSEs). METHODS: A lead researcher followed the search strategy following inclusion and exclusion criteria. A first reviewer (FR) was randomly assigned sources. One of the 2 lead researchers was the second reviewer (SR). Each determined the level of evidence (LOE) and quality of evidence (QE) from each source. Any differing opinions between the FR and SR were discussed between them, and if differing opinions remained, then a third reviewer (the other lead researcher) discussed the article until a consensus was reached. The final opinion of each article was entered for analysis. RESULTS: Fifty-eight (58) articles were entered into the final study. There was 1 study determined to be LOE 1, 29 LOE 2, and 28 LOE 3, with 15 determined to achieve QE 1, 37 QE 2, and 6 QE 3. CONCLUSION: This SLR showed that there is a lack of studies producing strong evidence to support the triage and treatment of the mangled extremity in RSE. Therefore, a Delphi process is suggested to adapt and modify current civilian and military triage and treatment guidelines to the RSE.