Adverse event and error of unexpected life-threatening events within 24hours of ED admission.

OBJECTIVES: Errors and adverse events associated with unexpected life-threatening events including unplanned transfer to the intensive care unit (ICU) and unexpected death after emergency department (ED) hospitalization are not well characterized. We performed this study to investigate the role of unexpected life-threatening events as a trigger to capture errors and adverse events for ED patient safety. METHODS: This prospective observational study enrolled adult non-trauma patients with unexpected life-threatening events within 24h of general ward admission from the ED of a medical center in Taiwan. The period of study was one year (in 2013); the medical records of enrolled patients were reviewed to identify adverse events and errors. We measured the incidence rate of adverse events or errors. Preventability, type, and physical injury severity of adverse events were investigated. RESULTS: Of 33,224 adult non-trauma ward admissions from the ED, 100 admissions (0.3%) met the study criteria. Incidence rate was 2% and 15% for errors and adverse events, respectively. In admissions involving error, all were preventable and the error type was overlooked of severity. In admissions that involved adverse events, 93.3% were preventable. There were 20% of admissions that resulted in death and 60% developed with severe physical injury. The adverse event types were diagnosis issues (53.3%), management issues (40%), and medication adverse events (6.7%). CONCLUSIONS: Unexpected life-threatening events within 24h of admission from the ED could be a useful trigger tool to identify preventable adverse events with serious physical injury in ED.

Determining delayed admission to intensive care unit for mechanically ventilated patients in the emergency department.

INTRODUCTION: The adverse effects of delayed admission to the intensive care unit (ICU) have been recognized in previous studies. However, the definitions of delayed admission varies across studies. This study proposed a model to define "delayed admission", and explored the effect of ICU-waiting time on patients' outcome. METHODS: This retrospective cohort study included non-traumatic adult patients on mechanical ventilation in the emergency department (ED), from July 2009 to June 2010. The primary outcomes measures were 21-ventilator-day mortality and prolonged hospital stays (over 30 days). Models of Cox regression and logistic regression were used for multivariate analysis. The non-delayed ICU-waiting was defined as a period in which the time effect on mortality was not statistically significant in a Cox regression model. To identify a suitable cut-off point between "delayed" and "non-delayed", subsets from the overall data were made based on ICU-waiting time and the hazard ratio of ICU-waiting hour in each subset was iteratively calculated. The cut-off time was then used to evaluate the impact of delayed ICU admission on mortality and prolonged length of hospital stay. RESULTS: The final analysis included 1,242 patients. The time effect on mortality emerged after 4 hours, thus we deduced ICU-waiting time in ED > 4 hours as delayed. By logistic regression analysis, delayed ICU admission affected the outcomes of 21 ventilator-days mortality and prolonged hospital stay, with odds ratio of 1.41 (95% confidence interval, 1.05 to 1.89) and 1.56 (95% confidence interval, 1.07 to 2.27) respectively. CONCLUSIONS: For patients on mechanical ventilation at the ED, delayed ICU admission is associated with higher probability of mortality and additional resource expenditure. A benchmark waiting time of no more than 4 hours for ICU admission is recommended.

Analysis of closed malpractice medical claims against Taiwanese EDs: 2003 to 2012.

OBJECTIVES: The objective of the study is to examine the epidemiologic data of closed malpractice medical claims against emergency departments (EDs) in Taiwanese civil courts and to identify high-risk diseases. METHODS: We conducted a retrospective study and reviewed the verdicts from the national database of the Taiwan judicial system that pertained to EDs. Between 2003 and 2012, a total of 63 closed medical claims were included. RESULTS: Seven cases (11.1%) resulted in an indemnity payment, 55.6% of the cases were closed in the district court, but appeals were made to the supreme court in 12 cases (19.1%). The mean incident-to-litigation closure time was 57.7 ± 26.8 months. Of the cases with indemnity paid, 5 cases (71.4%) were deceased, and 2 cases (28.6%) were gravely injured. All cases with indemnity paid were determined to be negligent by a medical appraisal. The gravely injured patients had more indemnity paid than deceased patients ($299800 ± 37000 vs $68700 ± 29300). The most common medical conditions involved were infectious diseases (27.0%), central nervous system bleeding (15.9%), and trauma cases (12.7%). It was also found that 71.4% of the allegations forming the basis of the lawsuit were diagnosis related. CONCLUSIONS: Emergency physicians (EPs) in Taiwan have similar medico-legal risk as American EPs, with an annual risk of being sued of 0.63%. Almost 90% of EPs win their cases but spend 58 months in litigation, and the mean indemnity payment was $134738. Cases with indemnity paid were mostly categorized as having diagnosis errors, with the leading cause of error as failure to order an appropriate diagnostic test.

Evaluation of the effectiveness of peer pressure to change disposition decisions and patient throughput by emergency physician.

OBJECTIVES: The aim of this study was to develop a strategy for imposing peer pressure on emergency physicians to discharge patients and to evaluate patient throughput before and after intervention. METHODS: A before-and-after study was conducted in a medical center with more than 120 000 annual emergency department (ED) visits. All nontraumatic adult patients who presented to the ED between 7:30 and 11:30 am Wednesday to Sunday were reviewed. We created a "team norm" imposed peer-pressure effect by announcing the patient discharge rate of each emergency physician through monthly e-mail reminders. Emergency department length of stay (LOS) and 8-hour (the end of shift) and final disposition of patients before (June 1, 2011-September 30, 2011) and after (October 1, 2011-January 30, 2012) intervention were compared. RESULTS: Patients enrolled before and after intervention totaled 3305 and 2945. No differences existed for age, sex, or average number of patient visits per shift. The 8-hour discharge rate increased significantly for all patients (53.5% vs 48.2%, P < .001), particularly for triage level III patients (odds ratio, 1.3; 95% confidence interval, 1.09-1.38) after intervention and without corresponding differences in the final disposition (P = .165) or admission rate (33.7% vs 31.6%, P = .079). Patients with a final discharge disposition had a shorter LOS (median, 140.4 min vs 158.3 min; P < .001) after intervention. CONCLUSIONS: The intervention strategy used peer pressure to enhance patient flow and throughput. More patients were discharged at the end of shifts, particularly triage level III patients. The ED LOS for patients whose final disposition was discharge decreased significantly.

The influence of physician seniority on disparities of admit/discharge decision making for ED patients.

OBJECTIVES: Differences in disposition between emergency physicians (EPs) have been studied in select patient populations but not in general emergency department (ED) patients. After determining whether a difference existed in admit/discharge decision making of EPs for general ED patients, we focus our study in examining the influence of EP seniority on the decision to discharge ED patients. METHODS: In a 1-year retrospective study, we included a convenience sample of all 18 953 adult nontraumatic ED patients. We reviewed the admit/discharge dispositions at each shift made by 16 EPs. EPs were categorized by seniority to determine whether seniority influenced disposition. Three groups had 5, 4, and 7 EPs each, with >10 years, 5 to 9 years, and <5 years of working experience, respectively. RESULTS: Patient demographics, triage level, and number of patients per shift did not differ statistically between EPs and each group. The number of discharged patients per shift differed statistically between EPs (P < .001) and each group. The most senior EPs had the lowest discharge rates compared with EPs in intermediate and junior groups. They had lower discharge rates for patients at triage levels 1, 2, and 3 as well as for all patients. However, no difference in unscheduled ED revisit rates was found. CONCLUSIONS: EPs vary in their admit/discharge decision making for general ED patients. More importantly, the most senior EPs were found to have the lowest discharge rates compared with their junior colleagues.

Risk factors for complications after a foreign body is retained in the esophagus.

BACKGROUND: Foreign body (FB) ingestion is a common problem presenting to the emergency department (ED). The standard treatment, removal by endoscopy, is well established. However, some patients may refuse this invasive procedure due to their fear of an uncomfortable or painful experience. Obtaining hard evidence of potential complications of not having the FB removed by endoscopy would be helpful in convincing patients to have the procedure. OBJECTIVES: The aim of this study was to identify the risk factors for developing complications after FB ingestion. MATERIALS AND METHODS: The study was conducted over a period of 1 year (April 1, 2006 through March 31, 2007) at a referral medical center. Potential risk factors for developing complications (e.g., age, gender, type of FB, positive finding on radiography) were retrospectively evaluated in patients presenting with esophageal FBs and analyzed using chi-squared or Fisher's exact test and logistic regression. RESULTS: A total of 225 patients were included. Fish bones were found to be the most common FBs (73.4%). The most commonly affected site was the oropharynx (64.5%). The complication rate was 9.7%. Risk factors for complications after FB ingestion were: 1) time interval over 24 h between FB ingestion and presenting to the ED; 2) a positive radiographic finding; 3) age > 50 years. CONCLUSION: If a patient presents to the ED with at least one of the three risk factors identified, it is strongly suggested that the patient undergo endoscopy to remove the FB due to a higher risk for developing complications.

The Association of White Blood Cells and Air Pollutants-A Population-Based Study.

The links of air pollutants to health hazards have been revealed in literature and inflammation responses might play key roles in the processes of diseases. WBC count is one of the indexes of inflammation, however the l iterature reveals inconsistent opinions on the relationship between WBC counts and exposure to air pollutants. The goal of this population-based observational study was to examine the associations between multiple air pollutants and WBC counts. This study recruited community subjects from Kaohsiung city. WBC count, demographic and health hazard habit data were collected. Meanwhile, air pollutants data (SO2, NO2, CO, PM10, and O3) were also obtained. Both datasets were merged for statistical analysis. Single- and multiple-pollutants models were adopted for the analysis. A total of 10,140 adults (43.2% males; age range, 33~86 years old) were recruited. Effects of short-term ambient concentrations (within one week) of CO could increase counts of WBC, neutrophils, monocytes, and lymphocytes. However, SO2 could decrease counts of WBC, neutrophils, and monocytes. Gender, BMI, and smoking could also contribute to WBC count increases, though their effects are minor when compared to CO. Air pollutants, particularly SO2, NO2 and CO, may thus be related to alterations of WBC counts, and this would imply air pollution has an impact on human systematic inflammation.

The Association Pattern between Ambient Temperature Change and Leukocyte Counts.

Ambient temperature change is one of the risk factors of human health. Moreover, links between white blood cell counts (WBC) and diseases have been revealed in the literature. Still, we do not know of any association between ambient temperature change and WBC counts. The aim of our study is to investigate the relationship between ambient temperature change and WBC counts. We conducted this two-year population-based observational study in Kaohsiung city, recruiting voluntary community participants. Total WBC and differential counts, demographic data and health hazard habits were collected and matched with the meteorological data of air-quality monitoring stations with participants' study dates and addresses. Generalized additive models (GAM) with penalized smoothing spline functions were performed for the trend of temperature changes and WBC counts. There were 9278 participants (45.3% male, aged 54.3 ± 5.9 years-old) included in analysis. Compared with stable weather conditions, the WBC counts were statistically higher when the one-day lag temperature changed over 2 degrees Celsius, regardless of whether colder or hotter. We found a V-shaped pattern association between WBC counts and temperature changes in GAM. The ambient temperature change was associated with WBC counts, and might imply an impact on systematic inflammation response.

Barriers to surge capacity of an overcrowded emergency department for a serious foodborne disease outbreak.

OBJECTIVE: The purpose of this study was to investigate barriers to surge capacity of an overcrowded emergency department (ED) for a foodborne disease outbreak (FBDO) and to identify solutions to the problems. DESIGN: The emergency response of an overcrowded ED to a serious FBDO with histamine fish poisoning was reviewed. SETTING: The ED of a tertiary academic medical centre (study hospital) with 1600 acute beds in southern Taiwan. RESULTS: Among the 346 patients in the outbreak, 333 (96.2%) were transferred to the study hospital without prehospital management within about 2 h. The most common symptoms were dizziness (58.9%), nausea and vomiting (36.3%). 181 patients (54.4%) received intravenous fluid infusion and blood tests were ordered for 82 (24.6%). All patients were discharged except one who required admission. The prominent problems with surge capacity of the study hospital were shortage of spare space in the ED, lack of biological incident response plan, poor command system, inadequate knowledge and experience of medical personnel to manage the FBDO. CONCLUSIONS: Patients with FBDO could arrive at the hospital shortly after exposure without field triage and management. The incident command system and emergency operation plan of the study hospital did not address the clinical characteristics of the FBDO and the problem of ED overcrowding. Further planning and training of foodborne disease and surge capacity would be beneficial for hospital preparedness for an FBDO.

Comparing the Outcomes of Reporting and Trigger Tool Methods to Capture Adverse Events in the Emergency Department.

BACKGROUND: Little is known about which methods are best for detecting adverse events in the emergency department (ED). OBJECTIVES: This study compared the ability of trigger tool and reporting methods to capture adverse events in the ED and investigated the characteristics of the adverse events identified by each. METHODS: This 1-year prospective observational cohort study evaluated a monitoring system that combined 2 reporting methods and 5 trigger tool methods to capture adverse events in the ED of an academic medical center. Measurement outcomes included the number, type, and physical impact of the captured adverse events. RESULTS: Among 69,327 adult nontrauma ED visits, 285 adverse events were identified. Of these adverse events, 77.2% were identified using reporting methods, 26% using trigger tool methods, and 3.2% using both methods. Most patients (81.7%) incurred temporary, minor physical impacts. Of the adverse events that occurred, 86.7% were related to clinical performance. Compared with reporting methods, trigger tool methods had a lower positive predictive rate to identify adverse events (odds ratio [OR], 0.1; 95% confidence interval [CI], 0.09-0.16), a greater proportion of adverse events occurring during the preinterventation and postintervention phases (OR, 17.0; 95% CI, 8.48-34.16), and more cases of severe physical impact or death (OR, 5.4; 95% CI, 2.62-11.10). CONCLUSIONS: The reporting methods more effectively captured greater numbers of adverse events, whereas the adverse events captured by the trigger tool methods were more likely to be severe physical impacts. The combined use of the different methods had synergistic benefits for monitoring adverse events in the ED.

Delayed diagnosis of active pulmonary tuberculosis in emergency department.

BACKGROUND AND PURPOSE: Tuberculosis (TB) is a worldwide health challenge. Emergency department (ED) is the major public access to the health care system. Delayed diagnosis of active pulmonary TB was believed to precipitate mortality and morbidity. The study was designed to investigate clinical characteristics and factors in patients with delayed diagnosis of active TB in ED. METHODS: We used a retrospective chart review. PATIENTS: A total of 103 patients were enrolled between December 2003 and March 2006. RESULTS: Typical chest radiographic findings were noted in 79.8% of nondelayed TB group and 31.6% of delayed TB group (P < .001). Diagnosis of pneumonia was made at ED in 22.6% of nondelayed TB group and 68.4% of delayed TB group (P < .001). Length of initiation of TB treatment intervention was 0 days (0-1 days) and 9 days (6-16 days), respectively (P < .001). In-hospital mortality rate was 15.5% and 47.4%, respectively (P < .01). Age (odds ratio, 1.07; 95% confidence interval, 1.01-1.1) and intensive care unit admission (odds ratio, 5.01; 95% confidence interval, 1.18-21.3) were associated with lower in-hospital survival. Delayed ED diagnosis of TB was associated with mortality in results of univariate analysis (P = .002), but no statistical significance was noted in the final result of stepwise logistic regression analysis. CONCLUSION: Intensive care unit admission and age are associated with mortality. Awareness of varying features of pulmonary TB by physicians is important.

An Ultra-clean Multilayer Apparatus for Collecting Size Fractionated Marine Plankton and Suspended Particles.

The distributions of many trace elements in the ocean are strongly associated with the growth, death, and re-mineralization of marine plankton and those of suspended/sinking particles. Here, we present an all plastic (Polypropylene and Polycarbonate), multi-layer filtration system for collection of suspended particulate matter (SPM) at sea. This ultra-clean sampling device has been designed and developed specifically for trace element studies. Meticulous selection of all non-metallic materials and utilization of an in-line flow-through procedure minimizes any possible metal contamination during sampling. This system has been successfully tested and tweaked for determining trace metals (e.g., Fe, Al, Mn, Cd, Cu, Ni) on particles of varying size in coastal and open ocean waters. Results from the South China Sea at the South East Asia Time-Series (SEATS) station indicate that diurnal variations and spatial distribution of plankton in the euphotic zone can be easily resolved and recognized. Chemical analysis of size-fractionated particles in surface waters of the Taiwan Strait suggests that the larger particles (>153 µm) were mostly biologically derived, while the smaller particles (10 - 63 µm) were mostly composed of inorganic matter. Apart from Cd, the concentrations of metals (Fe, Al, Mn, Cu, Ni) decreased with increasing size.

Sinking fluxes of 210Pb and 210Po in the deep basin of the northern South China Sea.

Vertical fluxes of total mass (Fmass), particulate organic carbon (FPOC), particulate inorganic carbon (FPIC), 210Pb (FPb-210), and 210Po (FPo-210) were determined by sediment traps deployed at two depths, 2000 m and 3500 m, at SEATS (South East Asian Time-series Study, 116°00°E, 18°00°N) in the northern South China Sea during June 2008-June 2009. The Fmass ranges from 12.2 to 55.1 mg m-2 d-1 and from 89.3 to 250.8 mg m-2 d-1, at 2000 m and 3500 m, respectively, and shows seasonal and inter-annul variation. The temporal variation of FPOC, FPIC, and FPb-210 were in phase with the Fmass, which was coupled with the seasonal cycles of primary production in the euphotic layer. The FPb-210 ranges from 5 to 48 dpm m-2d-1 and from 38 to 105 dpm m-2d-1, at 2000 m and 3500 m, respectively. Contrasting with 210Pb, the FPo-210 shows poor correlation with Fmass. The FPo-210 ranges from 3 to 146 dpm m-2d-1 and from 50 to 309 dpm m-2d-1, at 2000 m and 3500 m, respectively. Episodic events of the settling of biological particles from the surface layer and the regeneration processes the deep layer control the 210Po removal in the water column of the South China Sea. Strong correlations of the flux and source ratio of 210Pb, (F/P)Pb-210, and the particulate carbon fluxes were found, which give relationships of FPOC (µg cm-2y-1) = 26.8 + 371.0 (F/P)Pb-210 and FPIC (µg cm-2y-1) = -1.4 + 533.1 (F/P)Pb-210.

Diagnostic value of the helical CT scan for traumatic aortic injury: correlation with mortality and early rupture.

To evaluate the value of helical computed tomography of the thorax (HCTT) as a definitive tool for diagnosing traumatic aortic injury, this study retrospectively examined 53 patients with blunt thoracic injuries and HCTT during a 5-year period. All CT scans were reviewed for direct signs of aortic injury and correlated with aortography or surgery. Correlations between clinical parameters, as well as combinations of direct signs and individual signs, and mortality were analyzed in all traumatic aortic injury (TAI) cases. Direct signs were seen on the HCTT in 25 cases and 22 had TAI. All false positive results came from the group with only a single direct sign depicted on HCTT. Among individual direct signs examined, intimal flap and luminal thrombus were the most specific (100%), whereas irregular aortic contour was the most sensitive (100%). A combination of > or = 3 direct signs (p = 0.006) and periaortic contrast material extravasation significantly correlated with early rupture and mortality (p = 0.002). In conclusion, intimal flap on HCTT is both the most specific and sensitive sign for TAI. TAI patients with > or = 3 direct signs, including periaortic contrast material extravasation, may not require aortography before immediate surgery.

Emergency medical preparedness and response to a Singapore airliner crash.

A Singapore airline crash in 2000 was the first documented mass casualty incident (MCI) caused by an aircraft disaster in Taiwan. This report reviews the emergency medical preparedness of the airport and examines its effects on the medical response during this incident. The anticipated benefits from the new MCI plan and prior medical preparedness were not achieved during this disaster. Poor compliance with the new MCI plan by the airport authority was noted. Victims were not triaged and did not receive adequate field medical care. Structural problems with the MCI plan were also noted. Site medical teams responding from hospitals could not function as the plan had been designed. This article discusses factors causing the poor compliance, various problems, and related issues in medical response to the incident. As learned from this experience, a properly and practically designed MCI plan, good compliance of responders, and a strong support system of responding agencies are the most important factors for successful emergency response to any MCI.

Acute myocarditis in dengue hemorrhagic fever: a case report and review of cardiac complications in dengue-affected patients.

We report a case of dengue hemorrhagic fever (DHF) complicated by acute myocarditis and review the literature. A 65-year-old woman experienced DHF due to dengue virus serotype 3, complicated with acute myocarditis and acute pulmonary edema. Clinically this masqueraded as acute myocardial infarction, with an electrocardiographically depressed ST segment in precordial leads and elevated serum cardiac-specific troponin I level. Under supportive management, the patient recovered 3 days later. A total of 18 pertinent articles involving 339 dengue-affected patients with cardiac complications were found by PubMed search. Clinical manifestations of cardiac complications varied considerably, from self-limiting tachy-brady arrhythmia to severe myocardial damage, leading to hypotension and pulmonary edema. Although rare, a fatal outcome was reported in some cases of dengue with cardiac complications. To avoid otherwise preventable morbidity and mortality, physicians should have a high index of suspicion for cardiac complications in patients with dengue illness and should manage this accordingly.

Comparison of the effects of oral hydration and intravenous fluid replacement in adult patients with non-shock dengue hemorrhagic fever in Taiwan.

The level of plasma leakage is mild to moderate in patients with non-shock dengue hemorrhagic fever (DHF grade I and grade II), and the necessity of intravenous fluid replacement for these patients remains controversial. We conducted an observational study in adult patients (>18 years) with non-shock DHF admitted to a medical centre in southern Taiwan comparing the effects of oral hydration [group 1 (n=19); age (mean+/-SD) 54.6+/-15.5 years] and intravenous fluid replacement, with a volume of >40ml/kg/day in the first 72h of hospitalization [group 2 (n=30); age 55.9+/-11.6 years]. No significant difference was found in demographics, clinical manifestations, and mean peak level of hematocrit between the two groups. Patients in group 2 had a significantly longer hospital stay compared to those in group 1 (P=0.007), and there was a trend suggesting patients in group 2 were prone to develop pleural effusion and/or pulmonary edema. No difference was found in daily mean pulse pressure, mean hematocrit level, and mean platelet count between the groups for the duration of the 7 days in hospital. All 49 patients survived. Our data suggest that oral hydration may be as effective as intravenous fluid replacement for adults with non-shock DHF and this warrants investigation in a larger series of patients.

The use of Charlson comorbidity index for patients revisiting the emergency department within 72 hours.

BACKGROUND: To validate the use of the Charlson Comorbidity Index (CCI) for predicting admission of patients revisiting the Emergency Department (ED) within 72 hours. METHODS: Non-trauma patients aged above 17 years old who revisited an urban ED within 72 hours during January of 2004 were included in this retrospective observational study. Demographic data, diagnosis, CCI, in-hospital mortality rate and length of hospital stay were reviewed, and comparisons were made between the patients who were admitted or discharged on their return visits. RESULTS: Of the 168 enrolled patients, 60 were admitted to a ward and 108 were discharged. Revisiting patients with high CCIs (> or = 2) had a higher admission rate (67.3% vs. 22.7%; p < 0.001) and an increased adjusted odds ratio of admission (odds ratio (OR) 2.06; 95% confidence interval (CI) 1.14-3.75) than low CCI patients. Admitted revisiting patients with high CCIs had poorer prognoses, longer hospital stays (11.79 +/- 8.92 days vs. 6.78 +/- 5.17 days; p < 0.05) and a higher in-hospital mortality rate (15.2% vs. 3.7%; p = 0.209). CONCLUSION: CCI was well correlated with the admission possibility of patients revisiting the ED within 72 hours. More clinical management and discharge strategies should target those revisiting patients who have more comorbidities.

Designation of a new training model of a local disaster medical system with tabletop exercises.

BACKGROUND: A new model of a local disaster medical system (LDMS) was proposed through the consensus method of expert panel meetings for county governments in Taiwan. This LDMS model adopts a local emergency medical response system (EMRS) for dealing with daily accidents as a basic structure by expanding its roles and functions. The objective of this study was to determine the feasibility of the new LDMS model by evaluating its initial phase response to simulated disasters using tabletop exercises. METHODS: Two tabletop exercises were held after the responders of the LDMS were trained according to the new model. Forty and 42 participants respectively joined the 2 tabletop exercises, which simulated an earthquake causing 400 casualties in 6 different locations in order to apply the new LDMS model. The outcome measurements of the tabletop exercises were the mean accuracy rate of victim triage and disposition, and medical interventions. RESULTS: About 92% of victims were correctly triaged, and 88% had a correct disposition. Moreover, around 86% of all victims received adequate medical interventions. All victims were dispatched to appropriate facilities or treatment areas within 45 min. CONCLUSION: The new EMRS-oriented model of this LDMS can respond quickly, efficiently, and adequately to the initial phase of a disaster during tabletop exercises. Further clinical investigations are required to prove the efficacy of the new LDMS model in real disasters or in full-scale drills.