Development and Psychometric Properties of Decision-Making Scale for Emergency Hospital Evacuation in Disasters.

BACKGROUND: The evidence shows that the need for emergency evacuation in hospitals has arisen. Designing an emergency evacuation decision making tool increases the confidence of hospital managers in the decision made. Therefore, this study was aimed at the development, and the psychometric properties, of the decision-making scale for emergency hospital evacuation in disasters. METHODS: This study was done in 2 phases of qualitative study and literature review and designing and psychometric properties of the instrument. After development of the primary item pool, the psychometric properties of the questionnaire were evaluated. In this regard, face and content validity, internal consistency (Alpha's Cronbach), reliability (ICC), and stability were assessed. RESULTS: In the validity stage of the instrument, 4 items were removed. Also, 4 items were modified and 2 items were merged. The number of items was thus decreased to 64. After CVI calculation, 5 items were removed, 4 items were modified, and 2 items were merged. As a result of this, the number of items decreased to 58 items. The scale has good reliability and stability. CONCLUSION: It seems that the instrument could be useful in decision-making for emergency hospital evacuation in disasters.

Applications of Technology to Record Locomotion Measurements in Dairy Cows: A Systematic Review.

Lameness within the dairy industry is a concern because of its associated costs and welfare implications. Visual locomotion scoring has been commonly used for assessing cows' locomotion quality, but it can have low reliability and is relatively subjective compared to automated methods of assessing locomotion. Kinematic, kinetic, and accelerometric technologies can provide a greater number of more detailed outcome measurements than visual scoring. The objective of this systematic review was to determine outcome measurements, and the relationships between them, that have been recorded using kinematic, kinetic, and accelerometric technologies, as well as other approaches to evaluating cow locomotion. Following PRISMA guidelines, two databases were searched for studies published from January 2000 to June 2022. Thirty-seven articles were retained after undergoing a screening process involving a title and abstract evaluation, followed by a full-text assessment. Locomotion measurements recorded using these technologies often overlapped, but inconsistencies in the types of technology, the arrangement of equipment, the terminology, and the measurement-recording approaches made it difficult to compare locomotion measurements across studies. Additional research would contribute to a better understanding of how factors regarding the health, environment, and management of dairy cows affect aspects of locomotion, as recorded through the detailed, objective outcome measurements provided by these technologies.

Technology applications in bovine gait analysis: A scoping review.

Quantitative bovine gait analysis using technology has evolved significantly over the last two decades. However, subjective methods of gait assessment using visual locomotion scoring remain the primary on-farm and experimental approach. The objective of this review is to map research trends in quantitative bovine gait analysis and to explore the technologies that have been utilized to measure biomechanical parameters of gait. A scoping literature review was conducted according to PRISMA guidelines. A search algorithm based on PICO framework generated three components-bovine, gait, and technology-to address our objectives. Three online databases were searched for original work published from January 2000 to June 2020. A two-step screening process was then conducted, starting with the review of article titles and abstracts based on inclusion criteria. A remaining 125 articles then underwent a full-text assessment, resulting in 82 final articles. Thematic analysis of research aims resulted in four major themes among the studies: gait/claw biomechanics, lameness detection, intervention/comparison, and system development. Of the 4 themes, lameness detection (55% of studies) was the most common reason for technology use. Within the literature identified three main technologies were used: force and pressure platforms (FPP), vision-based systems (VB), and accelerometers. FPP were the first and most popular technologies to evaluate bovine gait and were used in 58.5% of studies. They include force platforms, pressure mapping systems, and weight distribution platforms. The second most applied technology was VB (34.1% of studies), which predominately consists of video analysis and image processing systems. Accelerometers, another technological method to measure gait characteristics, were used in 14.6% of studies. In sum, the strong demand for automatic lameness detection influenced the path of development for quantitative gait analysis technologies. Among emergent technologies, deep learning and wearable sensors (e.g., accelerometers) appear to be the most promising options. However, although progress has been made, more research is needed to develop more accurate, practical, and user-friendly technologies.

Climate adaptive hospital: A systematic review of determinants and actions.

Introduction: Climate change is among the most renowned concerns of the current century, endangering the lives of millions of people worldwide. To comply with the United Nations Climate Change Conference (COP21), hospitals should be on track to reduce greenhouse gas emissions. Although hospitals contribute to climate change by emitting greenhouse gases, they are also affected by the health consequences of climate change. Despite all the guidance provided, hospitals need more radical measures to confront climate change. The current study was carried out to examine the components of hospitals' adaptation to climate change and to review measures to confront climate change in hospitals. Method: This systematic review was designed and carried out in 2020. The required information was collected from international electronic databases including Scopus, PubMed, Web of Science, EMBASE, and Google Scholar. Moreover, Iranian datasets such as Scientific Database (SID), Irandoc, Magiran, and IranMedex were reviewed. No restriction was considered in the methodology of the study. For the relevant thesis, the ProQuest database was also explored. The related sources were examined and the Snowball method was applied to find additional related studies. The research team also reviewed other accessible electronic resources, such as international guidelines and academic websites. The checklist of the Joanna Briggs Institute (JBI, 2017) was employed in order to evaluate the quality of the included papers. The studies published until June1, 2020, were included in the study. Results: Of 11,680 published documents in the initial search, the full-texts of 140 were read after evaluating the titles and abstracts, of which 114 were excluded due to lack of sufficient information related to countermeasures in hospitals. Finally, the full-texts of 26 studies were reviewed to extract the required components. Two strategies were found, including climate change mitigation and climate change adaptation, with 13 components including water, wastewater, energy, waste, green buildings, food, transportation, green purchasing policy, medicines, chemicals and toxins, technology, sustainable care models, and leadership in hospitals were identified as affecting these measures and strategies. Conclusion: Considering the significance of climate change and strategies to confront it as one of the current challenges and priorities in the world, it is necessary to develop a framework and model to reduce the effects of climate change and adapt to climate changes in hospitals and other health centers. The identification and classification of the measures and components, influencing hospital adaptability and solutions for reducing the climate change impacts could be the first stage in developing this strategy. This is because it is impossible to create this framework without identifying these factors and their mutual impacts at the first. In the present study, through a systematic review using a comprehensive approach, the related components were explored and divided into two categories, including measures to reduce the effects and measures to adapt to climate change. The results of this study can be useful in developing a comprehensive action model to reduce greenhouse gas emissions and adapt hospitals to climate change.

Astragalus hamosus Acts as an Insulin Sensitizer in the Treatment of Polycystic Ovary Syndrome Rat Models by Affecting IRS1 Expression.

BACKGROUND: Polycystic ovary syndrome (PCOS) is the most common endocrine abnormality among women of reproductive age. Insulin resistance is known as the hallmark of PCOS that leads to hyperinsulinemia and type 2 diabetes in PCOS patients. OBJECTIVE: This study aimed to evaluate the expression pattern of IRS1 as a candidate gene in insulin resistance development in the PCOS rat models. METHODS: In this study, estradiol valerate was used for PCOS induction. Then, all of the rats were divided into five experimental groups and treated with Astragalus hamosus extract. Ethanol was used for extraction by Soxhlet, and extracts were analyzed by GC-MS. Ovarian morphology was analyzed using histological experiments. Finally, the expression of IRS1 and hormonal titration of testosterone and insulin were evaluated using qRT-PCR and ELISA assays, respectively. RESULTS: Induction of PCOS led to an increase in body weight, which decreased after treatment with the extract. Histological assessment declared an increased number of corpora lutea in treated groups and reduced cystic follicles compared to the PCOS group. Astragalus hamosus extract-treated groups exhibited decreased levels of insulin and testosterone compared to the PCOS group. qRT-PCR results showed an increase in the expression levels of IRS1 in the treated groups compared to the PCOS group. CONCLUSION: This study indicated the impact of Astragalus hamosus extract on PCOS by clarifying the increased levels of IRS1 expression in the treated groups compared to the PCOS group.

Fair prioritization of casualties in disaster triage: a qualitative study.

BACKGROUND: Disasters may result in mass casualties and an imbalance between health care demands and supplies. This imbalance necessitates the prioritization of the victims based on the severity of their condition. Contributing factors and their effect on decision-making is a challenging issue in disaster triage. The present study seeks to address criteria for ethical decision-making in the prioritization of patients in disaster triage. METHODS: This conventional content analysis study was conducted in 2017. Subjects were selected from among Iranian experts using purposeful and snowball sampling methods. Data were collected using semi-structured interviews and were analyzed by the content analysis. RESULTS: Efficient and effective triage and priority-oriented triage were the main categories. These categories summarized a number of medical and nonmedical factors that should be considered in the prioritization of the victims in disaster triage. CONCLUSION: A combination of measures should be considered to maximize the benefits of the prioritization of causalities in disasters. None of these measures alone would suffice to explain all aspects of ethical decision-making in disaster triage. Further investigations are needed to elaborate on these criteria in decision-making.

Perceptions on principle of priority setting in disaster triage: A Q-method study.

INTRODUCTION: An ethical plan is required to make decisions regarding setting the priority for assisting injured patients through triage. The aim of this study was to explore the measures used to sort patients for ethical decision-making in disaster triage. METHOD: The participants were 54 clinicians and non-clinicians among the Iranian experts. Q-statements were selected from a literature review and face-to-face interviews. Data were analyzed by principal components factor analysis (PCA), Varimax, and hand-rotation techniques. RESULTS: Distinct perspectives included: Saving patients with greater medical needs, survivability of patients and the community, providing effective treatment based on available capacity, maximizing health gain, supporting the human generation and productive and independent lives. Approximately 61% of the variance in decision is explained by these factors. CONCLUSION: A combination of saving more people and more positive outcomes has been accepted to make an ethical decision in triage. Public engagement needs to reach a more acceptable view of patients' prioritizing factors in a scarce-resource situation.

The efficacy of intravenous lidocaine and its side effects in comparison with intravenous morphine sulfate in patients admitted to the ED with right upper abdominal pain suspected of biliary colic.

BACKGROUND: Intravenous (IV) Lidocaine can be used as analgesic in acute pain management in the emergency department (ED). OBJECTIVE: Efficacy of IV Lidocaine in comparison with IV morphine in acute pain management in the ED. METHOD: This is a double-blind randomized clinical trial on adult (18-64 year) patients with right upper abdominal pain suspected of biliary colic who needed pain management. Participants randomly received IV lidocaine (5 cc = 100 mg) or morphine sulfate (5 cc = 5 mg). In both groups, patients' pain scores were recorded and assessed by Numeric Rating Scale (NRS) at baseline, 10, 20, 30, 45, 60 and 120 min after drug administration. Adverse side effects of lidocaine and morphine sulfate and changes in vital signs were also recorded and compared. RESULTS: A total number of 104 patients were enrolled in the study, including 49 men and 55 women. IV lidocaine reduced pain in less time in comparison with morphine sulfate. Mean (±SD) basic pain score was 8.23 (±1.76) in the lidocaine group and 8.73 (±0.96) in the morphine group. Patients' mean (±SD) pain score in both groups had no significant difference during the study except that of NRS2 (10 min after drug administration), which was 5.05 (±2.69) in lidocaine group compared with 6.39 (±2.06) in the morphine group and NRS4 (30 min after drug administration), which was significantly lower (P-value = 0.01) in the morphine group [3.84(±1.73) vs 4.41(±2.82)]. Only 9 patients had adverse effects in either group. CONCLUSION: The findings of this study suggest that IV lidocaine can be a good choice in pain management in biliary colic and can reduce pain in less time than morphine sulfate (in 10 min) without adding significant side effects; however, our primary outcome was the comparison of these two drugs after 60 min of drug administration in pain reduction which showed no significant difference between two groups.

The assessment of ice pack effect in pain reduction during digital nerve block: A randomized clinical study.

OBJECTIVES: Digital nerve block is a painful procedure. Several methods have been proposed to decrease the injection pain. Applying an ice pack is a pertinent choice due to its effectiveness on pain reduction, convenience, and low costs. In this study, the degree of injection pain reduction was assessed after applying an ice pack to the site of anesthetic injection. METHODS: One hundred participants with traumatic finger injury were assessed. Digital nerve block was performed in fifty patients in the intervention group after 6 min of ice application. In the control group, this procedure was done without ice. The primary outcome was the difference between the needle stick and infiltration pain scores with and without ice pack. The secondary outcome the patient satisfaction score. The protocol of this study was approved by the Institutional Review Board, and it is registered in the Iranian Registry of Clinical Trials. RESULTS: The pain score was assessed using a Numeric Rating Scale. Both the needle skin and infiltration pain scores were statistically significantly lower in the intervention group (P < 0.001). The mean and median needle stick pain scores were 1.5 and 1.0 in the intervention group and 6.8 and 7.0 in the control group, respectively. Moreover, the mean and median infiltration pain scores were 2.7 and 2.0 in the intervention group and 8.5 and 9.0 in the control group, respectively. Patient satisfaction score was significantly higher in the intervention group. CONCLUSIONS: Ice pack is inexpensive, readily available, and is easy to apply. We recommend this method to reduce the injection pain before digital nerve block in the emergency department.

Factors Affecting the Effectiveness of Hospital Incident Command System; Findings from a Systematic Review.

OBJECTIVE: To examine all aspects affecting the functioning of the system and the most important factors in its assessment through a systematic review during 1990 to 2017. METHODS: This systematic review of the current literature study was conducted during July 2017, and all articles, books, guidelines, manuals and dissertations pertaining to the Incident Command System were analyzed. A total of articles and relevant documents were identified and finally these articles, which we found, were analyzed based on the specified indicators. RESULTS: In this research 992 articles and relevant documents were identified and eventually, 48 articles were included and analyzed. The results were categorized into 6 main groups including 65 subgroups and 221 variables: features of hospital incident command system (14 subgroups and 53 variables), strengths of the system (15 subgroups and 70 variables), weaknesses of the system (10 subgroups and 15 variables), factors influencing the system's performance improvement (12 subgroups and 42 variables), factors that reduce the effectiveness of system include 11 subgroups (10 internal factors and 1 external factor) and 22 variables and important factors in assessing system performance (2 sub-groups and 19 variables). CONCLUSION: According to the results, Evaluating the effectiveness of a hospital accident command system (HICS) in a valid method can improve the efficiency of this system. In this appraisal, hospital managers and health decision-makers should consider principles, characteristics, strengths and weakness of it.

Prioritized Criteria for Casualty Distribution following Trauma-related Mass Incidents; a Modified Delphi Study.

INTRODUCTION: In the aftermath of mass casualty incidents (MCIs), many decisions need to be made in a fast and influential manner in a high pressure environment to distribute the limited resources among the numerous demands. This study was planned to rank the criteria influencing distribution of casualties following trauma-related MCI. METHODS: This study utilized a modified Delphi methodology, concentrating on extracted criteria attained from preceding systematic literature reviews. The 114 extracted criteria were classified into eight sections including space, staff, equipment, system and structures, triage, treatment, transport, and uncategorized criteria and were imported into an online survey tool. In the first round, experts were asked to rank each criterion on a five-point Likert scale. The second round incorporated feedbacks from the first round, stating percent and median scores from the panel as a whole. Experts were then called upon to reassess their initial opinions regarding uncertain remarks from the first round, and once again prioritize the presented criteria. RESULTS: Fifty-seven criteria were regarded as relevant to the following sections: space: 70% (7/10); staff: 44% (4/9); system / structure: 80% (4/5); equipment: 39.1% (9/23); treatment; 66.7% (6/9); triage: 73.7% (14/19); transport: 38.7% (12/31) and other sections: 12.5% (1/8). The first round achieved nearly 98% (n=48) response rate. Of the 114 criteria given to the experts, 68 (almost 60%) were approved. The highest percentage of approval belonged to the system and structures sections (4/5=80%). The response rate for the second round was about 86% (n=42). A consensus could be reached about nearly 84% (57) of the 68 criteria presented to experts. CONCLUSION: "Casualty Level of Triage on the Scene" and "Number of Available Ambulances" were the two criteria that obtained the highest level of consensus. On the other hand, "gender of casualty", "Number of Non-Medical staff in each Hospital" and "Desire to transport family members together" got lowest level of consensus. This sorted list could be used as a catalogue for developing a decision support system or tool for distribution of victims following mass casualty incidents.

Emergency numbers accessibility for disabled peoples': Case of the Islamic Republic of Iran.

INTRODUCTION: An emergency is a serious, unexpected situation which may lead to injury, loss of life and damage to property and often needs urgent interventions. Emergency calls can bring urgent life-saving intervention in such situations. Although access to emergency lines for all persons of a society is one of the effectiveness indexes of this critical service, in most countries, these lines are not accessible for disabled people. CASE PRESENTATION: This study examined the issue of emergency number accessibility for disabled people in the I.R. of Iran. Two persons who had been poisoned by carbon monoxide died because their deaf-mute father could not communicate with the Emergency Medical Service Center (EMSC). This led to the Emergency Medical Service Management Center (EMSMC), in collaboration with Iranian Society of Deaf People Family (ISDPF), developing a system that is a combination of short message system (SMS) and location-based information (LBI) to facilitate the communication of such disabled persons with EMSMCs. The system did not receive any emergency message until this report is provided. CONCLUSION: Because emergency call service has not been available for disabled people in Iran until now, emergency service organizations should take a proactive approach in developing a reliable and easy to use a method with the current technologies. These organizations should also provide information about the installed systems for end-users.

Does intramuscular ondansetron have an effect on intramuscular ketamine-associated vomiting in children? A prospective, randomized, double blind, controlled study.

OBJECTIVE: This study was conducted to determine the effect of intramuscular ondansetron on ketamine-associated vomiting in children undergoing procedural sedation. METHODS: This randomized, double-blind, placebo-controlled, parallel-group clinical trial was conducted at the emergency departments of two university-affiliated tertiary care hospitals. Eligible participants included all 6-month to 16-year-old children who received IM ketamine for PSA in the ED. A convenience sampling approach was used and a block randomization method was applied (blocks of four) using a computer-generated random sequence. Patients received ketamine 4 mg/kg or ketamine 4 mg/kg plus ondansetron 0.1 mg/kg intramuscularly. All findings including the occurrence of vomiting and its frequency were then recorded in the data collection sheets. RESULTS: Of 56 patients who received ondansetron plus ketamin, 7 (12.5%) and 1 (1.8%) experienced vomiting during recovery and before discharge and Of 65 patients in the control group, 14 (21.5%) and 6 (9.2%) experienced vomiting during recovery and before discharge, respectively. The observed differences in the rates of vomiting during recovery and at discharge were statistically significant between the two groups (P-value of 0.03 and <0.001, respectively). CONCLUSION: Intramuscular ondansetron is effective in controlling ketamine-associated vomiting.

Developing a Checklist for Cardiopulmonary Resuscitation (CPR) Quality Control in Emergency Department; a Qualitative Study.

INTRODUCTION: Monitoring the quality of cardiopulmonary resuscitation (CPR) could help in achieving favorable outcomes, decreasing mortality, and preventing post-CPR neurologic sequels. This study aimed to generate a user-friendly checklist for CPR quality control in emergency department (ED). METHOD: A qualitative study was performed between January and December 2018. In the first step, two emergency medicine specialists searched currently available databases and extracted the factors related to CPR quality. Afterward, two sessions of focus group discussions were held. The participants included four emergency medicine specialists, two ED managers, one anesthesiologist, and one cardiologist. Subsequently, 20 medical specialists, consisting of 10 emergency medicine specialists, six anesthesiologists, and four cardiologists, were invited to a Delphi panel in order to rate the extracted items from the prior group discussions. RESULTS: During the two rounds of focus group discussions, 38 items related to the quality of CPR were identified. A Delphi panel evaluated the items; 31 items with at least 75% agreement were selected. These 31 items were included in the final checklist and after a pilot study and adjustment of its content they were sorted in 10 categories as follows: 1. chest compression, 2. airway, 3. bag-mask ventilation, 4. cardiac monitoring, 5. defibrillation, 6. intravenous (IV) drug delivery, 7. Medications, 8. Advanced airway, 9. CPR sequence, and 10. Reversible causes. CONCLUSION: Our study provides a checklist for monitoring the quality of CPR in ED, but it is still necessary to include other factors related to the ED environment on this checklist.

Ethical prioritization of patients during disaster triage: A systematic review of current evidence.

INTRODUCTION: Triage is a dynamic and complex decision-making process in order to determine priority of access to medical care in a disaster situation. The elements which should govern an ethical decision-making in prioritizing of victims have been debated for a long time. This paper aims to identify ethical principles guiding patient prioritization during disaster triage. METHOD: Electronic databases were searched via structured search strategy from 1990 until July 2017. The studies investigating patients' prioritization in disaster situation were eligible for inclusion. All types of articles and guidelines were included. RESULT: Of 7167 titles identified in the search, 35 studies were included. The important factors identified in patient prioritization were grouped into two categories: medical measures (medical need, likelihood of benefit and survivability) and Nonmedical measures (saving the most lives, youngest first, preserving function of society, protecting vulnerable groups, required resources and unbiased selection). Demographic characteristics, health status of patients, social value of patient, and unbiased selection are discriminatory factors in disaster triage. CONCLUSION: Various factors have been introduced to consider ethical patient prioritization in disaster triage. Providers' engagement, public education, and ongoing training are required to reach a fair decision.

Comparison between intravenous morphine versus fentanyl in acute pain relief in drug abusers with acute limb traumatic injury.

BACKGROUND: Rapid and effective pain relief in acute traumatic limb injuries (ATLI) is one of the most important roles of emergency physicians. In these situations, opioid addiction is an important concern because of the dependency on opioids. The study aims to compare the effectiveness of intravenous (IV) fentanyl versus morphine in reducing pain in patients with opioid addiction who suffered from ATLI. METHODS: In this double-blind randomized clinical trial, 307 patients with ATLI, who presented to the emergency department (ED) from February 2016 to April 2016, were randomly divided into two groups. One group (152 patients) received 0.1 mg/kg IV morphine. The other group (155 patients) received 1 mcg/kg IV fentanyl. Patients' demographic data, pain score at specific intervals, vital signs, side effects, satisfaction and the need for rescue analgesia were recorded. RESULTS: Eight patients in the morphine group and five patients in the fentanyl group were excluded. Pain score in the fentanyl group had a significant decrease at 5-minute follow-up (P value=0.00). However, at 10, 30, and 60-minute follow-ups no significant differences were observed between the two groups in terms of pain score reduction. The rescue analgesia was required in 12 (7.7%) patients in the fentanyl group and in 48 (31.6%) patients in the morphine group (P value=0.00). No significant difference was observed regarding side effects, vital signs and patients' satisfaction between the two groups. CONCLUSION: Fentanyl might be an effective and safe drug in opioid addicts suffering from ATLI.

Intranasal ketamine reduces pain of digital nerve block; a double blind randomized clinical trial.

BACKGROUND: Low dose ketamine can be used as analgesic in acute pain management in the emergency department (ED). OBJECTIVE: Efficacy of IN ketamine in acute pain management in the ED. METHOD: This is a double blind randomized clinical trial on patients older than 15 years who needed digital nerve block (DNB). Participants randomly received IN Ketamine (1 ml = 50 mg) or placebo (normal saline, 1 ml) 5 min before DNB. In both groups, patients' pain score was recorded by visual analogue score (VAS) at baseline, after DNB and 45 min after completion of DNB. Adverse effects of ketamine and changes in vital signs were also recorded and compared with placebo group. RESULTS: A total number of 100 patients were enrolled in the study with the median (IQR) age of 36.5 (26) years, including 65 men and 35 women. IN ketamine resulted in less pain compared to placebo after performing DNB and 45 min after the procedure. Median (IQR) basic VAS score was 50 (15) in ketamine group, and 49 (27) in control group. Median (IQR) block pain VAS score was 28.5 (19) in ketamine group and 47.5 (31) in control group. Median (IQR) procedural pain VAS score was 21.5 (16) in ketamine group and 43.5 (29) in control group. Only 7 patients had adverse effects in either group. CONCLUSION: The findings of this study suggest that IN ketamine can be effective in reducing pain in patients with acute pain, without adding significant side effects.

A systematic literature review of criteria and models for casualty distribution in trauma related mass casualty incidents.

INTRODUCTION: Mass casualty incidents impose a large burden on the emergency medical systems, hospitals and community infrastructures. The pre-hospital and hospital capacities are usually bear the burden of casualties large numbers. One of the challenging issues in mass casualty incidents is the distribution of casualties among the suitable health care facilities. OBJECTIVE: To review models and criteria affecting the distribution of casualties during the trauma-related mass causality incidents. MATERIALS AND METHODS: A systematic literature search in the scientific databases which included: PubMed, Scopus and Web of Science was conducted. Relevant literature which was published before August 2017 was searched. Neither the publication date nor language limitations were considered in the literature search. All the trauma-related mass casualty incidents are included in this study. Two independent reviewers conducted the data extraction and quality assessment of the documents was considered using a checklist developed by the researchers. RESULTS: Literature search yielded 4540 documents of which 493 were duplicated and removed. After reviewing the titles and abstracts of the remaining documents (4047), only 73 documents were considered relevant. Finally, the inclusion and exclusion criteria were applied and only 30 documents were considered for data extraction and quality assessment. The study found 491 criteria to be affecting the distribution of casualties following trauma-related mass casualty incidents. These are categorized as pre-hospital (triage, treatment and transport); hospital (space, staff, stuff, system / structure); incidents' characteristics and others. The criteria which were extracted from the models are termed as "model extracted" while the other labeled as "author suggested". CONCLUSION: To the best of our knowledge, this is the first systematic literature review on criteria affecting distribution of casualties following trauma-related mass casualty incidents based on the pre-hospital and hospital capacities. SYSTEMATIC REVIEW REGISTRATION NUMBER: This review was registered in international prospective register of systematic reviews (PROSPERO) with registration number CRD42016049115.

Specialist Physicians' Attitude towards Emergency Medicine; a Semi-Structured Qualitative Study.

INTRODUCTION: The present study is a survey to assess the pros and cons of emergency medicine (EM) from the viewpoint of the scholars from other medicine disciplines to improve the efficiency of EM in the healthcare system. METHODS: This is a semi-structured qualitative study. Face-to-face interviews with various physicians with different specialties were performed to gather information on their viewpoints. Study population was selected mainly based on their history of collaboration with emergency medicine specialists in several educational hospitals in Tehran, Iran. All interviews were recorded and then transcribed to paper. Data were mainly categorized and reported into four themes: 1) general aspects of emergency medicine, goals and policies 2) Management of emergency department 3) Educational aspects 4) therapeutic aspects. RESULTS: 22 specialist physicians with the mean age of 47.3±7.6 years were studied (77.3% male). The average of their work experience as a specialist was 13.6±7.5 years. From the viewpoint of other experts, the establishment of EM and training of EM specialists is accompanied with relative disadvantages and advantages regarding goals and policies, patient management, therapeutic interventions and student education in the emergency department. Initiating resuscitation and maintaining hemodynamic stability and appropriate triage of the patients can add to the benefits of EM by preventing unreasonable hospitalization, and reducing the workload and difficulty of the work of other professionals working in the hospital. CONCLUSIONS: Based on the results of the current study, it seems that most Iranian specialist physicians have a positive attitude towards emergency medicine and think that emergency medicine could have beneficial effects for the health system and hospital management system.