Developing Equitable Primary Health Care in Conflict-Affected Settings: Expert Perspectives From the Frontlines.

Health systems are frequently among the casualties of conflict. Within these settings, increased knowledge is needed on how to rebuild and strengthen health infrastructure resilience, such as primary health care (PHC) systems, in context-specific ways that promote health equity. Therefore, this study aimed to explore perspectives of experts with experience working on frontlines of social crises to contribute to understandings of pathways toward equitable PHC in conflict-affected settings. Semistructured qualitative interviews with 18 expert participants were completed. Through engaging elements of grounded theory situational analysis, three themes emerged iteratively, including (a) Building Blocks, (b) Intermediating Factors, and (c) a Roadmap. These emergent themes contribute to conceptual frameworks explaining key contextually specific priorities, challenges, and facilitating factors for developing resilient health infrastructures under social crises. Findings inform policy and practical guidelines that address complexities of conflict conditions and underscore the importance of PHC development toward promoting health as a human right.

Hospital preparedness and response in CBRN emergencies: TIER assessment tool.

INTRODUCTION: Chemical, biological, radiological, and nuclear (CBRN) emergencies need particular hospital preparedness and resources availability. Also, specific skills and capabilities are required for efficient response to these types of events. The aim of this study was to develop an assessment tool to evaluate hospital preparedness and response performance with respect to CBRN emergencies. METHODS: An evaluation tool was developed using the Delphi technique. A panel of experts from 10 countries, both European and non-European, with more than 5 years of experience in research or practice in CBRN emergency management was involved in this study. The study was run online, and the experts were asked to evaluate a list of items on hospital preparedness and response in CBRN emergencies. A threshold of 85% agreement level was defined as the consensus of experts in this study. RESULTS: The first-round questionnaire was answered by 13 experts. Consensus on the preparedness section was reached for all 29 items during the first round and one item was also added by the experts. Consensus on the response performance indicators were reached in 51 out of the 59 items, during the first round, and eight items were modified and then approved in the second round by the experts. CONCLUSION: Hospitals need a specific level of preparedness to enable an effective response to CBRN emergencies. The assessment tool, developed through experts' consensus in this study, provides a standardized method for the evaluation of hospital preparedness and response performance with respect to CBRN emergencies. The feasibility and reliability of this assessment tool could be evaluated before and during simulated exercises in a standardized manner.

TIER competency-based training course for the first receivers of CBRN casualties: a European perspective.

INTRODUCTION: Education and training are key elements of health system preparedness vis-à-vis chemical, biological, radiological and nuclear (CBRN) emergencies. Medical respondents need sufficient knowledge and skills to manage the human impact of CBRN events. OBJECTIVE: The current study was designed to determine which competencies are needed by hospital staff when responding to CBRN emergencies, define educational needs to develop these competencies, and implement a suitable delivery method. METHODS: This study was carried out from September 2014 to February 2015, using a three-step modified Delphi method. On the basis of international experiences, publications, and experts' consensus, core competencies for hospital staff - as CBRN casualty receivers - were determined, and training curricula and delivery methods were defined. RESULTS: The course consists of 10 domains. These are as follows: threat identification; health effects of CBRN agents; planning; hospital incident command system; information management; safety, personal protective equipment and decontamination; medical management; essential resources; psychological support; and ethical considerations. Expected competencies for each domain were defined. A blended approach was chosen. CONCLUSION: By identifying a set of core competencies, this study aimed to provide the specific knowledge and skills required by medical staff to respond to CRBN emergencies. A blended approach may be a suitable delivery method, allowing medical staff to attend the same training sessions despite different time zones and locations. The study output provides a CBRN training scheme that may be adapted and used at the European Union level.

Assessment of disaster preparedness among emergency departments in Italian hospitals: a cautious warning for disaster risk reduction and management capacity.

STUDY HYPOTHESIS: Since the 1990s, Italian hospitals are required to comply with emergency disaster plans known as Emergency Plan for Massive Influx of Casualties. While various studies reveal that hospitals overall suffer from an insufficient preparedness level, the aim of this study was to better determine the preparedness level of Emergency Departments of Italian hospitals by assessing the knowledge-base of emergency physicians regarding basic disaster planning and procedures. METHODS: A prospective observational study utilized a convenience sample of Italian Emergency Departments identified from the Italian Ministry of Health website. Anonymous telephone interviews were conducted of medical consultants in charge at the time in the respective Emergency Departments, and were structured in 3 parts: (1) general data and demographics, (2) the current disaster plan and (3) protocols and actions of the disaster plan. RESULTS: Eighty-five Emergency Departments met inclusion criteria, and 69 (81 %) agreed to undergo the interview. Only 45 % of participants declared to know what an Emergency Plan for Massive Influx of Casualties is, 41 % believed to know who has the authority to activate the plan, 38 % knew who is in charge of intra-hospital operations. In Part 3 physicians revealed a worrisome inconsistency in critical content knowledge of their answers. CONCLUSIONS: Results demonstrate a poor knowledge-base of basic hospital disaster planning concepts by Italian Emergency Department physicians-on-duty. These findings should alert authorities to enhance staff disaster preparedness education, training and follow-up to ensure that these plans are known to all who have responsibility for disaster risk reduction and management capacity.

Evaluation of a new community-based curriculum in disaster medicine for undergraduates.

BACKGROUND: Nowadays, many medical schools include training in disaster medicine in undergraduate studies. This study evaluated the efficacy of a disaster medicine curriculum recently designed for Saudi Arabian medical students. METHODS: Participants were 15 male and 14 female students in their fourth, fifth or sixth year at Jazan University Medical School, Saudi Arabia. The course was held at the Research Center in Emergency and Disaster Medicine and Computer Sciences Applied to the Medical Practice in Novara, Italy. RESULTS: The overall mean score on a test given before the course was 41.0 % and it increased to 67.7 % on the post-test (Wilcoxon test for paired samples: z = 4.71, p < 0.0001). There were no significant differences between the mean scores of males and females, or between students in their fourth, fifth or sixth year of medical school. CONCLUSIONS: These results show that this curriculum is effective for teaching disaster medicine to undergraduate medical students. Adoption of this course would help to increase the human resources available for dealing with disaster situations.

Education in Disaster Management: What Do We Offer and What Do We Need? Proposing a New Global Program.

OBJECTIVE: Although there is a significant willingness to respond to disasters, a review of post-event reports following incidents shows troubling repeated patterns with poorly integrated response activities and response managers inadequately trained for the requirements of disasters. This calls for a new overall approach in disaster management. METHODS: An in-depth review of the education and training opportunities available to responders and disaster managers has been undertaken, as well as an extensive review of the educational competencies and their parent domains identified by subject matter experts as necessary for competent performance. RESULTS: Seven domains of competency and competencies that should be mastered by disaster mangers were identified. This set of domains and individual competencies was utilized to define a new and evolving curriculum. In order to evaluate and assess the mastery of each competency, objectives were more widely defined as activities under specific topics, as the measurable elements of the curriculum, for each managerial level. CONCLUSIONS: This program enables interagency cooperation and collaboration and could be used to increase and improve decision-makers' understanding of disaster managers' capabilities; at the strategic/tactical level to promote the knowledge and capability of the disaster managers themselves; and as continuing education or further career development for disaster managers at the operational level. (Disaster Med Public Health Preparedness. 2016;10:854-873).

Hospital Disaster Preparedness in Italy: a preliminary study utilizing the World Health Organization Hospital Emergency Response Evaluation Toolkit.

BACKGROUND: Natural and human-initiated disasters are occurring with greater devastating consequences and increased frequency. During these events, hospitals have the burden to care for acutely ill and injured patients. The aim of this study was to evaluate the level of disaster preparedness of Italian hospitals. METHODS: Site visits were conducted from January, 2014 to December, 2014. The hospital emergency response checklist, developed by the WHO, was used as an evaluation toolkit. It consists of 92 items classified as 9 key components, such as command and control, triage, and critical services. The status of each component was determined by consensus of 3 independent evaluators. RESULTS: The study selected 15 hospitals from different areas in Italy. Out of the 15 hospitals, 12 were considered to be at insufficients level of preparedness, only 3 were considered to have an effective level of preparedness. The average preparedness of all components were lower than the optimal level suggested by the WHO checklist. CONCLUSIONS: The study revealed that a large majority of Italian hospitals evaluated are not well prepared to manage potential disasters. Also, all important elements of hospital preparedness, such as the command system, surge capacity, and safety, were insufficiently implemented. Nationwide standards, guidelines and procedures are required to improve hospital disaster preparedness in Italy.

Tools and Checklists Used for the Evaluation of Hospital Disaster Preparedness: A Systematic Review.

Hospitals need to be fully operative during disasters. It is therefore essential to be able to evaluate hospital preparedness. However, there is no consensus of a standardized, comprehensive and reliable tool with which to measure hospital preparedness. The aim of the current study was to perform a systematic review of evaluation tools for hospital disaster preparedness. A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The key words "crisis," "disaster," "disaster medicine," "emergency," "mass casualty," "hospital preparedness," "hospital readiness," "hospital assessment," "hospital evaluation," "hospital appraisal," "planning," "checklist," and "medical facility" were used in combination with the Boolean operators "OR" and "AND." PubMed (National Library of Medicine, Bethesda, MD), ISI Web of Science (Thomson Reuters, New York, NY), and Scopus (Elsevier, New York, NY) were searched. A total of 51,809 publications were screened. The following themes were required for relevance: logistics, planning, human resources, triage, communication, command and control, structural and nonstructural preparedness, training, evacuation, recovery after disaster, coordination, transportation, surge capacity, and safety. The results from 15 publications are presented. Fifteen articles fulfilled the criteria of relevance and considered at least 1 of the 14 predetermined themes. None of the evaluated checklists and tools included all dimensions required for an appropriate hospital preparedness evaluation. The results of the current systematic review could be used as a basis for designing an evaluation tool for hospital disaster preparedness. (Disaster Med Public Health Preparedness. 2016;page 1 of 8).

Evaluation of Disaster Preparedness Based on Simulation Exercises: A Comparison of Two Models.

OBJECTIVE: The objective of this study was to highlight 2 models, the Hospital Incident Command System (HICS) and the Disaster Management Indicator model (DiMI), for evaluating the in-hospital management of a disaster situation through simulation exercises. METHODS: Two disaster exercises, A and B, with similar scenarios were performed. Both exercises were evaluated with regard to actions, processes, and structures. After the exercises, the results were calculated and compared. RESULTS: In exercise A the HICS model indicated that 32% of the required positions for the immediate phase were taken under consideration with an average performance of 70%. For exercise B, the corresponding scores were 42% and 68%, respectively. According to the DiMI model, the results for exercise A were a score of 68% for management processes and 63% for management structure (staff skills). In B the results were 77% and 86%, respectively. CONCLUSIONS: Both models demonstrated acceptable results in relation to previous studies. More research in this area is needed to validate which of these methods best evaluates disaster preparedness based on simulation exercises or whether the methods are complementary and should therefore be used together. (Disaster Med Public Health Preparedness. 2016;10:544-548).

Postgraduate Education in Disaster Health and Medicine.

INTRODUCTION: Education is key to effective disaster management. This study reviews several postgraduate educational programs in disaster medicine. METHODS: This cross-sectional study was conducted in two stages between October 2011 and February 2012. An online search was completed, followed by a web-based survey to collect information on key aspects of the identified programs. RESULTS: Thirty-four programs were identified worldwide. Public health was the main focus in 84% of these. E-learning was the preferred mode of instruction in 25% of cases. Most programs were accredited either nationally or internationally. Tuitions fees were the main source of funding. CONCLUSION: There is a dearth of postgraduate training programs in disaster health and medicine. This applies especially to Asia, which is also the most vulnerable area. Educational provision must be strengthened in Asia and in low- and middle-income countries to enhance capacity building in the health management of disasters.

Virtual Disaster Simulation: Lesson Learned from an International Collaboration That Can Be Leveraged for Disaster Education in Iran.

Disaster education needs innovative educational methods to be more effective compared to traditional approaches. This can be done by using virtual simulation method. This article presents an experience about using virtual simulation methods to teach health professional on disaster medicine in Iran. The workshop on the "Application of New Technologies in Disaster Management Simulation" was held in Tehran in January 2015. It was co-organized by the Disaster and Emergency Health Academy of Tehran University of Medical Sciences and Emergency and the Research Center in Disaster Medicine and Computer Science applied to Medicine (CRIMEDIM), Università del Piemonte Orientale. Different simulators were used by the participants, who were from the health system and other relevant fields, both inside and outside Iran. As a result of the workshop, all the concerned stakeholders are called on to support this new initiative of incorporating virtual training and exercise simulation in the field of disaster medicine, so that its professionals are endowed with field-based and practical skills in Iran and elsewhere. Virtual simulation technology is recommended to be used in education of disaster management. This requires capacity building of instructors, and provision of technologies. International collaboration can facilitate this process.

Proposal for a community-based disaster management curriculum for medical school undergraduates in Saudi Arabia.

OBJECTIVES: Health professional preparedness is a key element of disaster response; overall there is a need for increased disaster medicine training worldwide. The objective of this study was to design and develop a curriculum in community-based disaster medicine for Saudi Arabian medical undergraduates. METHODS: A structured five-step approach was used to develop a curriculum. Expert stakeholders from the Saudi Arabian and international disaster medicine communities were surveyed to determine objectives and content. Learning strategies were carefully considered to maximize participation and retention. Particular attention was paid to equipping learners with the teaching skills required to promote disaster preparedness in their local communities. CURRICULUM DESIGN: The course consists of 2 weeks of classroom activities followed by 8 weeks of e-learning structured within five domains of disaster medicine. The curriculum introduces core principles in emergency medicine, public health, and disaster management. Simulations, experiential activities, case studies, and role-playing activities are all used to promote higher levels of cognitive engagement. Special content addresses the adult-learning process, and students design their own community-based seminars in disaster preparedness. CONCLUSIONS: The curriculum is designed to promote learning in disaster medicine. Given the paucity of disaster medicine educators in the region, student graduates of this program would be able to improve disaster preparedness in Saudi Arabia by launching their own community-based disaster preparedness initiatives. The program could also be adapted for use throughout the Middle East.

Core Competencies in Disaster Management and Humanitarian Assistance: A Systematic Review.

Disaster response demands a large workforce covering diverse professional sectors. Throughout this article, we illustrate the results of a systematic review of peer-reviewed studies to identify existing competency sets for disaster management and humanitarian assistance that would serve as guidance for the development of a common disaster curriculum. A systematic review of English-language articles was performed on PubMed, Google Scholar, Scopus, ERIC, and Cochrane Library. Studies were included if reporting competency domains, abilities, knowledge, skills, or attitudes for professionals involved disaster relief or humanitarian assistance. Exclusion criteria included abstracts, citations, case studies, and studies not dealing with disasters or humanitarian assistance. Thirty-eight papers were analyzed. Target audience was defined in all articles. Five references (13%) reported cross-sectorial competencies. Most of the articles (81.6%) were specific to health care. Eighteen (47%) papers included competencies for at least 2 different disciplines and 18 (47%) for different professional groups. Nursing was the most widely represented cadre. Eighteen papers (47%) defined competency domains and 36 (94%) reported list of competencies. Nineteen articles (50%) adopted consensus-building to define competencies, and 12 (31%) included competencies adapted to different professional responsibility levels. This systematic review revealed that the largest number of papers were mainly focused on the health care sector and presented a lack of agreement on the terminology used for competency-based definition.

Impact of the 2011 Revolution on Hospital Disaster Preparedness in Yemen.

OBJECTIVE: Hospitals are expected to serve the medical needs of casualties in the face of a disaster or other crisis, including man-made conflicts. The aim of this study was to evaluate the impact of the 2011 Yemeni revolution on hospital disaster preparedness in the capital city of Sana'a. METHODS: The study was conducted in September 2011 and 2013. For evaluation purposes, the hospital emergency response checklist published by the World Health Organization (WHO) was used. Additional information was also obtained to determine what steps were being taken by hospital authorities to improve hospital preparedness. RESULTS: The study selected 11 hospitals. At the time of the first evaluation, 7 hospitals were rated "unacceptable" for level of preparedness and 4 were rated "insufficient," receiving a WHO checklist rating of 10 to 98. At the second evaluation, 5 hospitals were rated "unacceptable," 3 "insufficient," and 1 "effective," receiving a rating of 9 to 134. CONCLUSIONS: Unfortunately, this study shows that between 2011 and 2013, no significant progress was made in hospital disaster preparedness in Sana'a. In a disaster-prone country like Yemen, the current situation calls for drastic improvement. Health system authorities must take responsibility for issuing strategic plans as well as standards, guidelines, and procedures to improve hospital disaster preparedness.

The hospital incident command system: modified model for hospitals in iran.

INTRODUCTION: Effectiveness of hospital management of disasters requires a well-defined and rehearsed system. The Hospital Incident Command System (HICS), as a standardized method for command and control, was established in Iranian hospitals, but it has performed fairly during disaster exercises. This paper describes the process for, and modifications to HICS undertaken to optimize disaster management in hospitals in Iran. METHODS: In 2013, a group of 11 subject matter experts participated in an expert consensus modified Delphi to develop modifications to the 2006 version of HICS. RESULTS: The following changes were recommended by the expert panel and subsequently implemented: 1) A Quality Control Officer was added to the Command group; 2) Security was defined as a new section; 3) Infrastructure and Business Continuity Branches were moved from the Operations Section to the Logistics and the Administration Sections, respectively; and 4) the Planning Section was merged within the Finance/Administration Section. CONCLUSION: An expert consensus group developed a modified HICS that is more feasible to implement given the managerial organization of hospitals in Iran. This new model may enhance hospital performance in managing disasters. Additional studies are needed to test the feasibility and efficacy of the modified HICS in Iran, both during simulations and actual disasters. This process may be a useful model for other countries desiring to improve disaster incident management systems for their hospitals.

Education in Disaster Management and Emergencies: Defining a New European Course.

OBJECTIVE: Unremitting natural disasters, deliberate threats, pandemics, and humanitarian suffering resulting from conflict situations necessitate swift and effective response paradigms. The European Union's (EU) increasing visibility as a disaster response enterprise suggests the need not only for financial contribution but also for instituting a coherent disaster response approach and management structure. The DITAC (Disaster Training Curriculum) project identified deficiencies in current responder training approaches and analyzed the characteristics and content required for a new, standardized European course in disaster management and emergencies. METHODS: Over 35 experts from within and outside the EU representing various organizations and specialties involved in disaster management composed the DITAC Consortium. These experts were also organized into 5 specifically tasked working groups. Extensive literature reviews were conducted to identify requirements and deficiencies and to craft a new training concept based on research trends and lessons learned. A pilot course and program dissemination plan was also developed. RESULTS: The lack of standardization was repeatedly highlighted as a serious deficiency in current disaster training methods, along with gaps in the command, control, and communication levels. A blended and competency-based teaching approach using exercises combined with lectures was recommended to improve intercultural and interdisciplinary integration. CONCLUSION: The goal of a European disaster management course should be to standardize and enhance intercultural and inter-agency performance across the disaster management cycle. A set of minimal standards and evaluation metrics can be achieved through consensus, education, and training in different units. The core of the training initiative will be a unit that presents a realistic situation "scenario-based training."

Professionalization of anesthesiologists and critical care specialists in humanitarian action: a nationwide poll among italian residents.

BACKGROUND: Over the last decades, humanitarian crises have seen a sharp upward trend. Regrettably, physicians involved in humanitarian action have often demonstrated incomplete preparation for these compelling events which have proved to be quite different from their daily work. Responders to these crises have included an unpredictable mix of beginner-level, mid-level, and expert-level providers. The quality of care has varied considerably. The international humanitarian community, in responding to international calls for improved accountability, transparency, coordination, and a registry of professionalized international responders, has recently launched a call for further professionalization within the humanitarian assistance sector, especially among academic-affiliated education and training programs. As anesthetists have been involved traditionally in medical relief operations, and recent disasters have seen a massive engagement of young physicians, the authors conducted, as a first step, a poll among residents in Anesthesia and Critical Care Medicine in Italy to evaluate their interest in participating in competency-based humanitarian assistance education and in training incorporated early in residencies. METHODS: The Directors of all the 39 accredited anesthesia/critical care training programs in Italy were contacted and asked to submit a questionnaire to their residents regarding the objectives of the poll study. After acceptance to participate, residents were enrolled and asked to complete a web-based poll. RESULTS: A total of 29 (74%) of the initial training programs participated in the poll. Out of the 1,362 questionnaires mailed to residents, 924 (68%) were fully completed and returned. Only 63(6.8%) of the respondents voiced prior participation in humanitarian missions, but up to 690 (74.7%) stated they were interested in participating in future humanitarian deployments during their residency that carried over into their professional careers. Countrywide, 896 (97%) favored prior preparation for residents before participating in humanitarian missions, while the need for a specific, formal, professionalization process of the entire humanitarian aid sector was supported by 889 (96.2%). CONCLUSIONS: In Italy, the majority of anesthesia/critical care residents, through a formal poll study, affirmed interest in participating in humanitarian assistance missions and believe that further professionalization within the humanitarian aid sector is required. These results have implications for residency training programs worldwide.

Does Hospital Disaster Preparedness Predict Response Performance During a Full-scale Exercise? A Pilot Study.

INTRODUCTION: The assessment of hospital disaster preparedness and response performance is a way to find and remove possible gaps and weaknesses in hospital disaster management effectiveness. The aim of this pilot study was to test the association between the level of preparedness and the level of response performance during a full-scale hospital exercise. METHOD: This pilot study was conducted in a hospital during a full-scale exercise in the Piedmont region of Italy. The preparedness evaluation was conducted by a group of three experts, three days before the exercise, and the response evaluation was conducted during the exercise. The functional capacity module was used for preparedness evaluation, and the response performance of the "command and control" function of the hospital was evaluated by nine semiquantitative performance indicators. RESULTS: The preparedness of the chosen hospital was 59%, while the response performance was evaluated as 70%. The hospital staff conducted Simple Triage and Rapid Transport (START) triage while they received 61 casualties, which was 90% correct for the yellow group and 100% correct for the green group. CONCLUSION: This pilot study showed that it is possible to use standardized evaluations tools, to simultaneously assess the relationship between preparedness elements and response performance measures. An experimental study including a group of hospitals, also using more comprehensive evaluation tools, should be done to evaluate the correlation between the level of preparedness and the response performance of a hospital, and the impact of hospital disaster planning, on the outcome of disasters victims.