Ranking the Attributes of Effective Disaster Responders and Leaders.

OBJECTIVE: To investigate the relative importance of 10 attributes identified in prior studies as essential for effective disaster medical responders and leaders. METHODS: Emergency and disaster medical response personnel (N=220) ranked 10 categories of disaster worker attributes in order of their importance in contributing to the effectiveness of disaster responders and leaders. RESULTS: Attributes of disaster medical leaders and responders were rank ordered, and the rankings differed for leaders and responders. For leaders, problem-solving/decision-making and communication skills were the highest ranked, whereas teamwork/interpersonal skills and calm/cool were the highest ranked for responders. CONCLUSIONS: The 10 previously identified attributes of effective disaster medical responders and leaders include personal characteristics and general skills in addition to knowledge of incident command and disaster medicine. The differences in rank orders of attributes for leaders and responders suggest that when applying these attributes in personnel recruitment, selection, and training, the proper emphasis and priority given to each attribute may vary by role. (Disaster Med Public Health Preparedness. 2019;13:700-703).

Qualitative Analysis of Surveyed Emergency Responders and the Identified Factors That Affect First Stage of Primary Triage Decision-Making of Mass Casualty Incidents.

INTRODUCTION: After all large-scale disasters multiple papers are published describing the shortcomings of the triage methods utilized. This paper uses medical provider input to help describe attributes and patient characteristics that impact triage decisions. METHODS: A survey distributed electronically to medical providers with and without disaster experience. Questions asked included what disaster experiences they had, and to rank six attributes in order of importance regarding triage. RESULTS: 403 unique completed surveys were analyzed. 92% practiced a structural triage approach with the rest reporting they used "gestalt".(gut feeling) Twelve per cent were identified as having placed patients in an expectant category during triage. Respiratory status, ability to speak, perfusion/pulse were all ranked in the top three. Gut feeling regardless of statistical analysis was fourth. Supplies were ranked in the top four when analyzed for those who had placed patients in the expectant category. CONCLUSION: Primary triage decisions in a mass casualty scenario are multifactorial and encompass patient mobility, life saving interventions, situational instincts, and logistics.

The evolution of PTSD criteria across editions of DSM.

BACKGROUND: The diagnosis of posttraumatic stress disorder (PTSD) has remained controversial from the time of its first inclusion in DSM-III. No reviews have fully documented the shifting PTSD definitions across editions of the criteria. This article chronicles the evolution of PTSD across editions of the DSM. METHODS: Diagnostic precursors to PTSD in DSM-I and DSM-II were briefly described, followed by systematic review of PTSD in subsequent editions of the DSM. Sections of the criteria and accompanying text were sorted into tables permitting visual comparisons across the editions. Research findings related to specific changes in the editions were provided from available research literature identified through specific PubMed searches using keywords relevant to each specific change. RESULTS: Fundamental topics of debate identified in this review are validity of the diagnosis, the trauma criterion, the role of symptoms in defining its psychopathology, differentiation from other disorders, and specifiers such as delayed onset. CONCLUSIONS: DSM-5 has corrected several major ambiguities and errors of the former editions that are fundamental to the construct of PTSD as a disorder that is defined conditionally in relation to exposure to trauma, but problems remain in DSM-5 trauma criteria, especially inconsistencies between exposure criteria and the definition of trauma. Discerning the critical distinctions required to understand PTSD depends on underlying clarity in terminology and precision in application of the diagnosis by academicians and clinicians. Trauma must be differentiated from other kinds of stressful events and conceptualized as an incident defined by physical injury rather than by emotional response.

Characteristics of Effective Disaster Responders and Leaders: A Survey of Disaster Medical Practitioners.

OBJECTIVE: To identify key attributes of effective disaster/mass casualty first responders and leaders, thereby informing the ongoing development of a capable disaster health workforce. METHODS: We surveyed emergency response practitioners attending a conference session, the EMS State of the Science: A Gathering of Eagles. We used open-ended questions to ask participants to describe key characteristics of successful disaster/mass casualty first responders and leaders. RESULTS: Of the 140 session attendees, 132 (94%) participated in the survey. All responses were categorized by using a previously developed framework. The most frequently mentioned characteristics were related to incident command/disaster knowledge, teamwork/interpersonal skills, performing one's role, and cognitive abilities. Other identified characteristics were related to communication skills, adaptability/flexibility, problem solving/decision-making, staying calm and cool under stress, personal character, and overall knowledge. CONCLUSIONS: The survey findings support our prior focus group conclusion that important characteristics of disaster responders and leaders are not limited to the knowledge and skills typically included in disaster training. Further research should examine the extent to which these characteristics are consistently associated with actual effective performance of disaster response personnel and determine how best to incorporate these attributes into competency models, processes, and tools for the development of an effective disaster response workforce. (Disaster Med Public Health Preparedness. 2016;page 1 of 4).

A Geospatial Analysis of Severe Firearm Injuries Compared to Other Injury Mechanisms: Event Characteristics, Location, Timing, and Outcomes.

OBJECTIVES: Relatively little is known about the context and location of firearm injury events. Using a prospective cohort of trauma patients, we describe and compare severe firearm injury events to other violent and nonviolent injury mechanisms regarding incident location, proximity to home, time of day, spatial clustering, and outcomes. METHODS: This was a secondary analysis of a prospective cohort of injured children and adults with hypotension or Glasgow Coma Scale score ≤ 8, injured by one of four primary injury mechanisms (firearm, stabbing, assault, and motor vehicle collision [MVC]) who were transported by emergency medical services to a Level I or II trauma center in 10 regions of the United States and Canada from January 1, 2010, through June 30, 2011. We used descriptive statistics and geospatial analyses to compare the injury groups, distance from home, outcomes, and spatial clustering. RESULTS: There were 2,079 persons available for analysis, including 506 (24.3%) firearm injuries, 297 (14.3%) stabbings, 339 (16.3%) assaults, and 950 (45.7%) MVCs. Firearm injuries resulted in the highest proportion of serious injuries (66.3%), early critical resources (75.3%), and in-hospital mortality (53.5%). Injury events occurring within 1 mile of a patient's home included 53.9% of stabbings, 49.2% of firearm events, 41.3% of assaults, and 20.0% of MVCs; the non-MVC events frequently occurred at home. While there was geospatial clustering, 94.4% of firearm events occurred outside of geographic clusters. CONCLUSIONS: Severe firearm events tend to occur within a patient's own neighborhood, often at home, and generally outside of geospatial clusters. Public health efforts should focus on the home in all types of neighborhoods to reduce firearm violence.

Needs Assessment of Hurricane Katrina Evacuees Residing Temporarily in Dallas.

This study assessed the psychosocial needs of Hurricane Katrina evacuees temporarily residing in Dallas, TX, after sheltering but prior to their permanent resettlement. Common trauma exposures were physical exposure to flood water, seeing corpses, witnessing death, and loss of family, friends, or home. Fewer than 10 % met symptom criteria for disaster-related posttraumatic stress disorder (PTSD). More than one-fourth met major depressive disorder (MDD) symptom criteria post-disaster but only 15 % had a new (incident) MDD episode after the disaster. Specific trauma exposures and some hurricane-related stressors contributed to risk for both Katrina-related PTSD symptom criteria and incident MDD, but other hurricane-related stressors were uniquely associated with incident MDD. Referral to mental health services was associated with meeting symptom criteria for PTSD and with incident MDD, but only about one-third of these individuals received a referral. Understanding the needs of disaster-exposed population requires assessing trauma exposures and identifying pre-disaster and post-disaster psychopathology.

Delivery of Mental Health Care in a Large Disaster Shelter.

Large numbers of evacuees arrived in Dallas, Texas, from Hurricanes Katrina and Rita just 3 weeks apart in 2005 and from Hurricanes Gustav and Ike just 3 weeks apart again in 2008. The Dallas community needed to locate, organize, and manage the response to provide shelter and health care with locally available resources. With each successive hurricane, disaster response leaders applied many lessons learned from prior operations to become more efficient and effective in the provision of services. Mental health services proved to be an essential component. From these experiences, a set of operating guidelines for large evacuee shelter mental health services in Dallas was developed, with involvement of key stakeholders. A generic description of the processes and procedures used in Dallas that highlights the important concepts, key considerations, and organizational steps was then created for potential adaptation by other communities.

Competencies for disaster mental health.

Competencies for disaster mental health are essential to domestic and international disaster response capabilities. Numerous consensus-based competency sets for disaster health workers exist, but no prior study identifies and discusses competency sets pertaining specifically to disaster mental health. Relevant competency sets were identified via MEDLINE, PsycINFO, EBSCO, and Google Scholar searches. Sixteen competency sets are discussed, some providing core competencies for all disaster responders and others for specific responder groups within particular professions or specialties. Competency sets specifically for disaster mental health professionals are lacking, with the exception of one set that focused only on cultural competence. The identified competency sets provide guidance for educators in developing disaster mental health curricula and for disaster health workers seeking education and training in disaster mental health. Valid, criterion-based competencies are required to guide selection and training of mental health professionals for the disaster mental health workforce. In developing these competencies, consideration should be given to the requirements of both domestic and international disaster response efforts.

The role of a radiology electronic notification system in the emergency department setting and its impact on patient care.

BACKGROUND: To determine the impact of a radiology electronic notification system (ENS) on emergency department (ED) patient care. MATERIALS AND METHODS: A retrospective review of de-identified patient data for a 2-year period (1 year prior to and 1 year following ENS implementation) was approved by the hospital's institutional review board. The effect of a radiology ENS on ED patient care was investigated by analyzing the intervals between completion of a chest radiograph and the times antibiotics were ordered/administered on patients presenting with symptoms of community acquired pneumonia (CAP). The square root transformation of the means was analyzed with an ANOVA model to determine statistical significance. RESULTS: During the 24-month study protocol, 1,341 patients who were evaluated in the ED met the study eligibility criteria. The least square estimates of the mean times from when the chest radiograph was completed to when antibiotics were ordered prior to and after the implementation of the ENS were 89 and 107 minutes, respectively (P < 0.01). The least square estimates of the mean times from when the chest radiograph was completed to when antibiotics were administered prior to and after the implementation of the ENS were 115 and 132 minutes, respectively (P = 0.02). CONCLUSION: The implementation of a radiology ENS does have advantages for the radiologist in streamlining the communication and documentation processes but may negatively impact time to treatment and thus patient care.

Enhancing the translation of disaster health competencies into practice.

OBJECTIVES: Disaster health workers currently have no common standard based on a shared set of competencies, learning objectives, and performance metrics with which to develop courses or training materials relevant to their learning audience. We examined how existing competency sets correlate within the 2012 pyramidal learning framework of competency sets in disaster medicine and public health criteria and describe how this exercise can guide curriculum developers. METHODS: We independently categorized 35 disaster health-related competency sets according to the 4 levels and criteria of the pyramidal learning framework of competency sets in disaster medicine and public health. RESULTS: Using the hierarchical learning framework of competency sets in disaster medicine and public health criteria as guidance, we classified with consistency only 10 of the 35 competency sets. CONCLUSIONS: The proposed series of minor modifications to the framework should allow for consistent classification of competency sets. Improved education and training of all health professionals is a necessary step to ensuring that health system responders are appropriately and adequately primed for their role in disasters. Revising the organizing framework should assist disaster health educators in selecting competencies appropriate to their learning audience and identify gaps in current education and training.

Core competencies for disaster medicine and public health.

Effective preparedness, response, and recovery from disasters require a well-planned, integrated effort with experienced professionals who can apply specialized knowledge and skills in critical situations. While some professionals are trained for this, others may lack the critical knowledge and experience needed to effectively perform under stressful disaster conditions. A set of clear, concise, and precise training standards that may be used to ensure workforce competency in such situations has been developed. The competency set has been defined by a broad and diverse set of leaders in the field and like-minded professionals through a series of Web-based surveys and expert working group meetings. The results may provide a useful starting point for delineating expected competency levels of health professionals in disaster medicine and public health.

Trauma exposure and posttraumatic stress disorder among employees of New York City companies affected by the September 11, 2001 attacks on the World Trade Center.

OBJECTIVE: Several studies have provided prevalence estimates of posttraumatic stress disorder (PTSD) related to the September 11, 2001 (9/11) attacks in broadly affected populations, although without sufficiently addressing qualifying exposures required for assessing PTSD and estimating its prevalence. A premise that people throughout the New York City area were exposed to the attacks on the World Trade Center (WTC) towers and are thus at risk for developing PTSD has important implications for both prevalence estimates and service provision. This premise has not, however, been tested with respect to DSM-IV-TR criteria for PTSD. This study examined associations between geographic distance from the 9/11 attacks on the WTC and reported 9/11 trauma exposures, and the role of specific trauma exposures in the development of PTSD. METHODS: Approximately 3 years after the attacks, 379 surviving employees (102 with direct exposures, including 65 in the towers, and 277 with varied exposures) recruited from 8 affected organizations were interviewed using the Diagnostic Interview Schedule/Disaster Supplement and reassessed at 6 years. The estimated closest geographic distance from the WTC towers during the attacks and specific disaster exposures were compared with the development of 9/11-related PTSD as defined by the Diagnostic and Statistical Manual, Fourth Edition, Text Revision. RESULTS: The direct exposure zone was largely concentrated within a radius of 0.1 mi and completely contained within 0.75 mi of the towers. PTSD symptom criteria at any time after the disaster were met by 35% of people directly exposed to danger, 20% of those exposed only through witnessed experiences, and 35% of those exposed only through a close associate's direct exposure. Outside these exposure groups, few possible sources of exposure were evident among the few who were symptomatic, most of whom had preexisting psychiatric illness. CONCLUSIONS: Exposures deserve careful consideration among widely affected populations after large terrorist attacks when conducting clinical assessments, estimating the magnitude of population PTSD burdens, and projecting needs for specific mental health interventions.

Attributes of effective disaster responders: focus group discussions with key emergency response leaders.

METHODS: An effective disaster response requires competent responders and leaders. The purpose of this study was to ask experts to identify attributes that distinguish effective from ineffective responders and leaders in a disaster. In this qualitative study, focus groups were held with jurisdictional medical directors for the 9-1-1 emergency medical services systems of the majority of the nation's largest cities. These sessions were recorded with audio equipment and later transcribed. RESULTS: The researchers identified themes within the transcriptions, created categories, and coded passages into these categories. Overall interrater reliability was excellent (κ = .8). The focus group transcripts yielded 138 codable passages. Ten categories were developed from analysis of the content: Incident Command System/Disaster Training/Experience, General Training/Experience, Teamwork/Interpersonal, Communication, Cognition, Problem Solving/Decision Making, Adaptable/Flexible, Calm/Cool, Character, and Performs Role. The contents of these categories included knowledge, skills, attitudes, behaviors, and personal characteristics. CONCLUSIONS: Experts in focus groups identified a variety of competencies for disaster responders and leaders. These competencies will require validation through further research that involves input from the disaster response community at large.

A consensus-based educational framework and competency set for the discipline of disaster medicine and public health preparedness.

BACKGROUND: Various organizations and universities have developed competencies for health professionals and other emergency responders. Little effort has been devoted to the integration of these competencies across health specialties and professions. The American Medical Association Center for Public Health Preparedness and Disaster Response convened an expert working group (EWG) to review extant competencies and achieve consensus on an educational framework and competency set from which educators could devise learning objectives and curricula tailored to fit the needs of all health professionals in a disaster. METHODS: The EWG conducted a systematic review of peer-reviewed and non-peer reviewed published literature. In addition, after-action reports from Hurricane Katrina and relevant publications recommended by EWG members and other subject matter experts were reviewed for congruencies and gaps. Consensus was ensured through a 3-stage Delphi process. RESULTS: The EWG process developed a new educational framework for disaster medicine and public health preparedness based on consensus identification of 7 core learning domains, 19 core competencies, and 73 specific competencies targeted at 3 broad health personnel categories. CONCLUSIONS: The competencies can be applied to a wide range of health professionals who are expected to perform at different levels (informed worker/student, practitioner, leader) according to experience, professional role, level of education, or job function. Although these competencies strongly reflect lessons learned following the health system response to Hurricane Katrina, it must be understood that preparedness is a process, and that these competencies must be reviewed continually and refined over time.

Use of computers and the Internet by residents in US family medicine programmes.

Computers, personal digital assistants (PDA), and the Internet are widely used as resources in medical education and clinical care. Educators who intend to incorporate these resources effectively into residency education programmes can benefit from understanding how residents currently use these tools, their skills, and their preferences. The researchers sent questionnaires to 306 US family medicine residency programmes for all of their residents to complete. Respondents were 1177 residents from 125 (41%) programmes. Access to a computer was reported by 95% of respondents. Of these, 97% of desktop and 89% of laptop computers could access the Internet. Residents accessed various educational and clinical resources. Half felt they had 'intermediate' skills at Web searches, 23% had 'some skills,' and 27% were 'quite skilled.' Those under 30 years of age reported higher skill levels. Those who experienced a Web-based curriculum in medical school reported higher search skills and greater success in finding clinical information. Respondents preferred to use technology to supplement the didactic sessions offered in resident teaching conferences. Favourable conditions exist in family medicine residency programmes to implement a blend of traditional and technology-based learning experiences. These conditions include residents' experience, skills, and preferences.

Tying it all together? A competency-based linkage model for family medicine.

Residency faculty in all specialties will be required by the Accreditation Council for Graduate Medical Education (ACGME) to fully implement competencies into residency programs by 2006. Understanding the new requirements is complicated by having several sets of guiding documents from different sources, including the general competencies of the ACGME, the Residency Review Committee for Family Practice requirements, the competencies developed by the Society of Teachers of Family Medicine, and the Recommended Curriculum Guidelines for Family Practice Residents by the American Academy of Family Physicians. A competency linkage model brings together the various guidelines and shows specifically how they are related. This model helps family practice residency faculty better understand the guiding expectations for their programs and develop more appropriate learning objectives and assessment methods.