Healthcare workers' willingness to respond following a disaster: a novel statistical approach toward data analysis.

BACKGROUND: The willingness of healthcare workers (HCW) to respond is an important factor in the health system's response capacity during emergencies. Although much research has been devoted to exploring this issue, the statistical methods employed have been predominantly traditional and have not enabled in-depth analysis focused on absenteeism-prone employees during emergencies. The present study employs an innovative statistical approach for modeling HCWs' willingness to respond (WTR) following an earthquake. METHODS: A validated questionnaire measuring knowledge, perceptions, and attitudes toward an earthquake scenario was distributed among Israeli HCWs in a hospital setting. Two regression models were employed for data analysis - a traditional linear model, and a quantile regression model that makes it possible to examine associations between explanatory variables across different levels of a dependent variable. A supplementary analysis was performed for selected variables using broken line spline regression. RESULTS: Females under the age of forty, and nurses were the most absenteeism-prone sub-groups of employees (showed low WTR) in earthquake events. Professional commitment to care and perception of efficacy were the most powerful predictors associated with WTR across all quantiles. Both marital status (married) and concern for family wellbeing, designated as statistically significant in the linear model, were found to be statistically significant in only one of the WTR quantiles (the former in Q10 and the latter in Q50). Gender and number of children, which were not significantly associated with WTR in the linear model, were found to be statistically significant in the 25th quantile of WTR. CONCLUSIONS: This study contributes to both methodological and practical aspects. Quantile regression provides a more comprehensive view of associations between variables than is afforded by linear regression alone. Adopting an advanced statistical approach in WTR modeling can facilitate effective implementation of research findings in the field.

Telecommunications in Israeli field hospitals deployed to three crisis zones.

A field hospital overseas requires various types of communication equipment. This study presents the communications equipment used by three Israeli field hospital delegations to earthquake sites at Adapazari, Turkey, in 1999, Port-au-Prince, Haiti, in 2010 and Minamisanriku, Japan, in 2011. The delegations to Turkey and Haiti were relatively large (105-230 personnel) and were on the site early (three to four days after each event). The 55-person delegation to Japan arrived later and was established as an outpatient community hospital. Standard military VHF radios were the only effective tool up to 5 km, until cellular coverage was regained (1-2 weeks after each event). International communication was good. While short-wave communication (telephone and Internet) was used in Turkey, a direct satellite channel was set up in Haiti. In Japan, BGAN Inmarsat provided efficient Wi-Fi for all needs. Motorola walkie talkies were not efficient beyond the immediate vicinity. This paper recommends continued use of military-specification equipment alongside newer modalities, particularly in situations where infrastructure is damaged.

Impact of pandemic flu training on ability of medical personnel to recognize an index case of avian influenza.

BACKGROUND: This study investigated the relationship between training programmes for pandemic flu and level of knowledge of health-care professionals with performance in an avian flu exercise. METHODS: Training programmes of all general hospitals in Israel for managing a pandemic influenza were evaluated. Spearman's ρ correlation was used to analyse the relationship between training scores and level of knowledge of medical personnel with performance in an avian flu exercise. Hospital preparedness levels were evaluated at two time points and Wilcoxon signed-rank test was used to determine if overall preparedness scores improved over time. RESULTS: Evaluation of training programmes for pandemic influenza showed high to very high scores in most hospitals (mean 85, SD 22). Significant correlations between training and performance in the exercise were noted for: implementation of training programmes 0.91, P = 0.000; designating personnel for training 0.87, P = 0.000; content of training 0.61, P = 0.001; and training materials 0.36, P = 0.05. Overall reliability of the evaluation scores was 0.82 and reliability for two of the sub-scales was: implementation of the programme 0.78; and designating personnel for training 0.37. No significant correlation was found between level of knowledge and performance in the exercise. DISCUSSION: Training programmes for hospital personnel for pandemic flu have a significant role in improving performance in case of pandemic flu. The key component of the training programme appears to be the implementation of the programme. Use of knowledge tests should be further investigated, as they do not appear to correlate with the level of emergency preparedness for pandemic influenza.

Resilience emotions and acute stress reactions in the population of Dimona and the general population of Israel two days after the first suicide bombing attack in Dimona.

BACKGROUND: On 4 February 2008, two terrorists armed with suicide bombs arrived atthe open market in the southern Israeli city of Dimona. One detonated his bomb at approximately 10:30 a.m. causing multiple casualties. Short-term emotional effects and acute stress reactions usually appear among survivors after such incidents. OBJECTIVES: To compare the differences in emotions and in disturbances of daily life activities that emerge a couple of days following such an event and to identify patterns of stress development among resilient and low-resilient members of the population in Dimona and in the general population of Israel. METHODS: A telephone survey of two randomly selected representative samples of adults (428 Israeli residents and 250 Dimona residents) was conducted 2 days afterthe event. RESULTS: A higher prevalence of stress and fear and a lower prevalence of joy were reported among the population of Dimona compared to the general population in Israel (P < 0.05). Differences were also recorded when the population of Dimona was categorized by its personal degree of resilience (P < 0.05). A higher prevalence of disturbances in daily life activities and changes in leisure activity was found in the low-resilient population in Dimona (P < 0.01). CONCLUSIONS: This study demonstrates that following a public terror event, self-reported low-resilient subjects have a higher prevalence of disturbances in daily life activities, as well as adverse emotional responses. These differences must be addressed by the relevant social service agencies for immediate public intervention.

Coexistent pyoderma gangrenosum and tibialis anterior myositis as presenting manifestations of Crohn's disease: case report and review of the literature.

Crohn's disease (CD) is a well defined inflammatory bowel disease. Patients primarily present with abdominal pain and diarrhea, however, extra-intestinal manifestations due to musculoskeletal and cutaneous involvement are seen in a varying range of patients. In this communication we describe a young woman who presented with a severe inflammatory illness that consequently developed into pyoderma gangrenosum, anterior tibialis myositis and arthritis that were all antecedent to the intestinal involvement. The patient favorably responded to infliximab with concomitant azathioprine therapy.

The relationship between demographic/educational parameters and perceptions, knowledge and earthquake mitigation in Israel.

Perceptions, knowledge and mitigation are factors that might play a role in preventing injury and loss of life during a major earthquake.(2) Little is known about the relationships between different demographic and educational parameters and these factors. A national representative sample of 495 adults was investigated in order to determine the relationship between demographic and educational parameters in terms of the perceived threat, perceived coping, knowledge and mitigation of earthquakes in Israel. Compared to females, males perceived the threat of earthquakes to be lower (t = 3.183, p = 0.002), manifested higher levels of perceived coping (t = 2.55, p = 0.011), and had higher levels of earthquake related knowledge (t = 2.047, p = 0.041). We conclude that there are gender differences in perceptions and knowledge regarding earthquakes.

The effect of different educational interventions on schoolchildren's knowledge of earthquake protective behaviour in Israel.

Knowledge of appropriate behaviour during an earthquake is crucial for prevention of injury and loss of life. The Israeli Home Front Command conducts a yearly earthquake education programme in all Israeli schools, using three types of educational interventions: lectures, drills and a combination of the two. The aim of this study was to evaluate the effectiveness of these interventions in providing students with knowledge. We distributed a questionnaire to 2,648 children from the 5th and 6th grades in 120 schools nationwide. Knowledge scores for both 5th and 6th grades were increased, regardless of type of intervention, compared to the non-exposure group. A combined intervention of lectures and drills resulted in the highest knowledge scores. Our findings suggest that for the age group studied a combination of lectures and drills will likely prepare students best for how to behave in the event of an earthquake.

Preparedness for anthrax attack: the effect of knowledge on the willingness to treat patients.

Little is known about the factors that may impact on the willingness of physicians and nurses to treat patients during a bioterrorism attack. This survey was conducted among 76 randomly selected nurses and physicians in the emergency rooms of three public hospitals in order to analyse the relationship between knowledge, profession and the willingness to treat anthrax. The study finds that the willingness of physicians and nurses to come to work is 50% greater among the group with the highest knowledge about anthrax (P < 0.0001). Within that group, the willingness to treat patients suspected of being infected with anthrax was 37% greater (P < 0.0001) and the willingness to treat patients diagnosed with anthrax was 28% greater (P = 0.004) than in the other groups. These results imply that enhancement of knowledge among health care workers may improve their willingness to come to work and treat patients infected with anthrax during a bioterrorism attack.

Differences in the sources of information and acquaintance with instructions between Dimona and the general population after a suicide bomber event.

A telephone survey among two randomly selected, representative samples of adults was conducted two days after a suicide bomber event in Dimona, Israel. Television, radio, Internet, and newspapers were more common sources of information in the general population, whereas friends, family, and the local authorities were the more common sources of information in Dimona. Higher acquaintance with police instructions and higher knowledge of the exact location of the event were found in the population of Dimona. Authorities must pay attention to this phenomenon and use the correct sources of information in each area in order to achieve better exposure of the target population to the police instructions after a terrorist event.

The effectiveness of an educational intervention on clinicians' knowledge of pandemic influenza.

BACKGROUND: The growing numbers of H1N1 "swine influenza" cases should prompt national health systems to achieve dual preparedness: preparedness of clinicians to recognize and treat cases of human H1N1 flu, and national preparedness for an influenza pandemic. This is similar to recent contingency planning for an avian flu pandemic. OBJECTIVES: To evaluate hospital personnel's knowledge on avian flu (zoonotic, sporadic, pandemic), comparing among nurses, residents and faculty, and between those who attended lectures or other educational modalities targeted at avian flu and those who did not. METHODS: A 14 item multiple choice questionnaire was designed to test crucial points concerning preparedness for human avian flu. The directors of 26 general hospitals were instructed by the Ministry of Health to improve knowledge of and preparedness for different avian flu scenarios, and to expect an official inspection. As part of this inspection, we distributed the questionnaires to nurses, residents and senior physicians. RESULTS: Altogether, 589 questionnaires were collected from the 26 hospitals. Examinees who participated in training modules (course, lecture or any training provided by the hospital) did somewhat better (scoring 78 points out of 100) than those who did not attend the training (70 points) (P < 0.05). Differences in nurses' knowledge were even more striking: 66 points for the non-attendants compared to 79 for nurses who attended the lecture (P < 0.05). Residents had significantly lower scores compared to nurses or senior physicians: 70 compared to 77 and 78 respectively (P (0.05)). CONCLUSIONS: The knowledge of hospital clinicians regarding avian flu is moderate, but can be augmented by hospital-based educational efforts aimed at physicians and particularly nurses. Improving attendance rates at lectures and targeting residents will likely yield better results.

The endless differential diagnosis of acute obstructive renal failure: unusual challenges for the sharp-sighted clinician.

Obstruction of urine outflow can result from mechanical blockade as well as from functional defects. In adults, urinary tract obstruction is due mainly to acquired defects, such as pelvic tumors, calculi, and urethral stricture. In childhood it is mostly due to congenital malformations. In this article we present two rare cases of acute obstructive renal failure that presented with hydronephrosis. These cases underline the wide range of causes that may lead to this clinical feature.

[The treatment of anxiety and acute stress reaction (ASR) in civilian casualties in community stress centers (CSC) in the 2nd Lebanon War].

INTRODUCTION: The treatment of anxiety and acute stress reaction (ASR) in civilian casualties exposed to continuous missile attacks during Lebanon War II is described in this study. Casualties were treated in community stress centers (CSC) erected ad-hoc, as a result of cooperation between the Mental Health Section of the Home Front Command of the Israel Defense Forces (IDF), the Mental Health Services of the Ministry of Health (MOH) and the Emergency and Disaster Management Division of the MOH. RESULTS: A total of 536 casualties were admitted to the centers. Eighteen were evacuated to the zone hospitals due to physical problems. The remaining casualties were released within 2-4 hours of intensive intervention according to the protocol. Symptoms of casualties ranged from anxiety (and ASR)--90%; fear (mainly agoraphobia)--7%; adaptation--2%; sleep disturbances--1%. Mental health intervention included counseling talk--80%; ventilation--9%; relaxation--3%; non-verbaL intervention--3%; fulfillment of basic needs--1% and evacuation to hospitals--3%. We discovered that anxiety and ASR were the most prevalent syndromes among those casualties as a result of the missile attacks on the civil population. RECOMMENDATIONS: The CSCs succeeded in providing adequate response and treatment for the majority of the casualties, thus putting off the need to evacuate those casualties to the ERs. Thereby, evacuation resources were saved and the ER load was reduced. The authors recommend that preparedness of the population under missile attacks, as well as other disaster scenarios, which resulted in a high rate of mental casualties, will be focused in the activation of CSCs in the format which has been described in this article.

Advanced rescue techniques: lessons learned from the collapse of a building in Nairobi, Kenya.

This paper examines the collapse of a five-storey building in Nairobi, Kenya, on 23 January 2006. It draws on reports from local authorities and on debriefings by Israel's Home Front Command (HFC), including information on injury distribution, rescue techniques, and the mode of operation. Most of the 117 people found under the structure were evacuated on the first day to a public hospital, which was overwhelmed by the incident. HFC forces arrived 23 hours after the disaster. At that stage, two people were still buried under the building and special techniques (tunnelling and scalping) were required to secure their evacuation. The two people quickly recovered after a short stay in hospital. Local technology is the preferred option during such events because time is crucial. International cooperation is required when this technology is not available. All of the hospitals in the disaster area, including private facilities, should participate in treating casualties.

DISAST-CIR: Disastrous incidents systematic analysis through components, interactions and results: application to a large-scale train accident.

Disasters or hazardous incidents, either natural or man-made, continue to increase in frequency and affect more and more citizens of the world community. Many of these are published in the medical literature, each being a "case report" of a single event. In clinical medicine, a common nomenclature and uniform reporting of data enables the collection of similar cases to series studies, with clinical conclusions being drawn. Such a platform is lacking in the field of disaster medicine, impairing the ability to learn from past experiences. In the Medical Department of the Israeli Home Front Command, we coordinate the operation of various medical units and forces in a wide array of events. By doing so, we collect and analyze the relevant data related to disaster management, various components of the medical response, interactions between different components, and the ensuing results. We developed a systematic method of analyzing and describing disaster management issues in various events-DISAST-CIR-Disastrous Incidents Systematic AnalysiS Through Components, Interactions, Results. In this article, we describe this method by presenting the components, interactions, and results of a large-scale train accident that resulted in 270 casualties, 35 of whom were evacuated by helicopters from the accident site. Casualties were distributed among 10 different hospitals. The death toll was 7 people, 5 of whom died at the scene and 2 who died in hospitals. We recommend this method as a standard for scientific reporting of hazardous incidents. Accumulation of data, reported in a similar standardized fashion, would enable comparison and reporting of series, improving our understanding regarding the optimal medical response to various events.

Relationship between standards of procedures for pandemic flu and level of hospital performance in simulated drills.

STUDY OBJECTIVE: Standard operating procedures are the basis of a consistent response to varied threats. The aim of this study is to investigate the relationship between the quality of standard operating procedures developed by hospitals for the management of a pandemic influenza outbreak and the level of performance in a H5N1 flu drill. METHODS: Standard operating procedures developed by all general hospitals in Israel for the management of pandemic influenza were evaluated with a tool developed for this purpose. The hospital standard operating procedure score was then compared with the score obtained by the hospital in a simulated drill. RESULTS: Cronbach's alpha was used to determine the reliability of the standard operating procedure evaluation scores and the scores obtained on the drill. Reliability of both scores was high (>0.70). Hospital standard operating procedure scores were found to be moderately related to the scores obtained on the simulated drill. An important relationship was found between performance on the drill and the following components of the standard operating procedure: protection of staff and patients, staffing coordination and control, and infrastructure maintenance and minimizing overload. Hospital characteristics were not found to be important in determining either the hospital standard operating procedure score or performance on the simulated drill. CONCLUSION: A reasonably strong relationship was found between quality of the standard operating procedures developed by hospitals to deal with a pandemic influenza and performance on a pandemic drill. Components of the standard operating procedure that dealt with areas that were relatively unfamiliar to staff or topics that were perceived by personnel as posing a risk to their well-being were found to be more important. The quality of the standard operating procedures was found to be important in relation to performance in a pandemic flu drill; therefore, we suggest investing effort in developing standard operating procedures that are comprehensive and cover relatively new domains in detail.

Differences in sources of information used by the population between the affected area and the general population during the first phase of a bird flu outbreak.

INTRODUCTION: In March 2006, a few cases of bird flu were discovered in approximately 10 rural settlements in Israel. As a result, approximately one million birds were destroyed within a three kilometer radius of the settlements. The Israeli population was instructed to take preventive measures against the spread of the infection. OBJECTIVES: The objective of this study was to compare the frequency of use of different sources of information by the population in the affected area with the general population during the first phase of a bird flu outbreak in Israel. METHODS: A telephone survey among two randomly selected, representative samples of adults was conducted. One sample involved 500 adult Israeli residents; the other sample involved 103 adult residents from the affected area during the first phase of the outbreak. The use of different sources of information by the population concerning the disease was assessed. The differences in these parameters between the affected area and the nationwide population were analyzed using a chi-square and t-test analysis. A p-value of < 0.05 was considered statistically significant. RESULTS: Television was a significantly more common source of information in Israel as a whole (p < 0.05), whereas friends (p < 0.05) and local authorities (p < 0.05) were significantly more common sources of information in the affected area. CONCLUSIONS: The frequency of use of the sources of information by the population during the early phase of a bird flu outbreak is different in the affected area compared with the general population in the same country. Authorities must pay attention to this phenomenon and use the correct sources of information in each area in order to achieve better exposure of the population to the recommended behaviors during an outbreak.

Standards in collaborative international disaster drills: a case study of two international search and rescue drills.

INTRODUCTION: During the last few decades, various global disasters have rendered nations helpless (such as Thailand's tsunami and earthquakes in Turkey, Pakistan, Iran, and India). A lack of knowledge and resources make it difficult to address such disasters. Preparedness for a national disaster is expensive, and in most cases, unachievable even for modern countries. International collaboration might be useful for coping with large-scale disasters. Preparedness for international collaboration includes drills. Two such drills held by the Israeli Home Front Command and other military and civilian bodies with the nations of Greece and Turkey are described in this article. METHODS: The data were gathered from formal debriefings of the Israeli teams collaborating in two separate drills with Greek and Turkish teams. RESULTS: Preparations began four months before the drills were conducted and included three meetings between Israeli and foreign officials. The Israeli and foreign officials agreed upon the drill layout, logistics, communications, residence, real-time medicine, hardware, and equipment. The drills took place in Greece and Turkey and lasted four days. The first day included meetings between the teams and logistics preparations. The second and third days were devoted to exercises. The drills included evacuating casualties from a demolition zone and treating typical injuries such as crush syndrome. Every day ended with a formal debriefing by the teams' commanders. The fourth day included a ceremony and transportation back home. Members in both teams felt the drills improved their skills and had an important impact on creating common language that would enhance cooperation during a real disaster. CONCLUSIONS: A key factor in the management of large-scale disasters is coordination between countries. International drills are important to create common language within similar regulations.

Population evacuations in industrial accidents: a review of the literature about four major events.

This article reviews the literature describing four chemical and nuclear accidents and the lessons learned from each regarding the evacuation of civilian populations. Evacuation may save lives however, if poorly orchestrated, it may cause serious problems. For example, an inaccurate assessment of danger may lead to the evacuation of the same population twice, as the area requiring evacuation becomes larger than originally expected. Evacuation programs should focus on the vulnerable components of the populations, such as the elderly, children, and the disabled, and also should include plans for the care of pets and other animals. Training programs for civilians living near industrial centers and other high-risk areas should be considered. Finally, pre-event planning and preparation can improve the evacuation process and prevent panic behavior, and thus result in fewer casualties.

Lessons learned from chlorine intoxications in swimming pools: the challenge of pediatric mass toxicological events.

INTRODUCTION: The classical doctrine of mass toxicological events provides general guidelines for the management of a wide range of "chemical" events. The guidelines include provisions for the: (1) protection of medical staff with personal protective equipment; (2) simple triage of casualties; (3) airway protection and early intubation; (4) undressing and decontamination at the hospital gates; and (5) medical treatment with antidotes, as necessary. A number of toxicological incidents in Israel during the summer of 2005 involved chlorine exposure in swimming pools. In the largest event, 40 children were affected. This study analyzes its medical management, in view of the Israeli Guidelines for Mass Toxicological Events. METHODS: Data were collected from debriefings by the Israeli Home Front Command, emergency medical services (EMS), participating hospitals, and hospital chart reviews. The timetable of the event, the number and severity of casualties evacuated to each hospital, and the major medical and logistical problems encountered were analyzed according to the recently described methodology of Disastrous Incident Systematic Analysis Through-Components, Interactions, Results (DISAST-CIR). RESULTS: The first ambulance arrived on-scene seven minutes after the first call. Emergency medical services personnel provided supplemental oxygen to the victims at the scene and en route when required. Forty casualties were evacuated to four nearby hospitals. Emergency medical services classified 26 patients as mildly injured, 13 as mild-moderate, and one as moderate, suffering from pulmonary edema. Most children received bronchodilators and steroids in the emergency room; 20 were hospitalized. All were treated in pediatric emergency rooms. None of the hospitals deployed their decontamination sites. CONCLUSIONS: Event management differed from the standard Israeli toxicological doctrine. It involved EMS triage of casualties to a number of medical centers, treatment in pediatric emergency departments, lack of use of protective gear, and omission of decontamination prior to emergency department entrance. Guidelines for mass toxicological events must be tailored to unique scenarios, such as chlorine intoxications at swimming pools, and for specific patient populations, such as children. All adult emergency departments always should be prepared and equipped for taking care of pediatric patients.

Primary triage, evacuation priorities, and rapid primary distribution between adjacent hospitals--lessons learned from a suicide bomber attack in downtown Tel-Aviv.

INTRODUCTION: Terrorist attacks have occurred in Tel-Aviv that have caused mass-casualties. The objective of this study was to draw lessons from the medical response to an event that occurred on 19 January 2006, near the central bus station, Tel-Aviv, Israel. The lessons pertain to the management of primary triage, evacuation priorities, and rapid primary distribution between adjacent hospitals and the operational mode of the participating hospitals during the event. METHODS: Data were collected in formal debriefings both during and after the event. Data were analyzed to learn about medical response components, interactions, and main outcomes. The event is described according to Disastrous Incidents Systematic AnalysiS Through-Components, Interactions and Results (DISAST-CIR) methodology. RESULTS: A total of 38 wounded were evacuated from the scene, including one severely injured, two moderately injured, and 35 mildly injured. The severe casualty was the first to be evacuated 14 minutes after the explosion. All of the casualties were evacuated from the scene within 29 minutes. Patients were distributed between three adjacent hospitals including one non-Level-1 Trauma Center that received mild casualties. Twenty were evacuated to the nearby, Level-1 Sourasky Medical Center, including the only severely injured patient. Nine mildly injured patients were evacuated to the Sheba Medical Center and nine to Wolfson Hospital, a non-Level-1 Trauma Center hospital. All the receiving hospitals were operated according to the mass-casualty incident doctrine. CONCLUSIONS: When a mass-casualty incident occurs in the vicinity of more than one hospital, primary triage, evacuation priority decision-making, and rapid distribution of casualties between all of the adjacent hospitals enables efficient and effective containment of the event.