Impact of COVID-19 pandemic on the care of severe burns in Japan: Repeated survey of specialized burn care facilities.

BACKGROUND: The spread of coronavirus disease 2019 (COVID-19), which began in 2020, has had a major impact on healthcare systems. The spread of COVID-19 has been reported to have affected the readiness to treat patients with burns worldwide. However, the existing reports have evaluated burn care status within a limited time period during the pandemic, and no report clarifies the change in the impact of infection status on burn care from the beginning of the pandemic to the present. METHODS: Japanese Society for Burn Injuries-accredited burn care facilities were surveyed using questionnaires on April 9-23, 2020; June 23-July 6, 2020; July 9-21, 2021; and January 21-31, 2022. Differences between groups were evaluated using Friedman's test or Bonferroni's multiple comparison test, as appropriate. RESULTS: From the 103 facilities included in the study, we received 85, 55, 56, and 58 responses in the first, second, third, and fourth surveys, respectively. We could continuously observe 34 facilities. The rate of acceptance of patients with severe burns improved significantly over time (P < 0.05). However, in the second and third surveys, there was an increase in the number of respondents who did not accept patients with burns irrespective of COVID-19 status. CONCLUSIONS: The number of facilities treating patients with burns who have COVID-19 is increasing; however, COVID-19 care may negatively impact routine burn care. It is necessary to continuously examine medical resource allocation through methods such as information sharing by academic societies.

Restoration of clean water supply and toilet hygiene reduces infectious diseases in post-disaster evacuation shelters: A multicenter observational study.

After a massive disaster, many residents in affected areas are forced to temporarily stay in evacuation shelters. The exact impact of the state of resource supply and infrastructure in evacuation shelters on the health status of evacuees has not been sufficiently studied. Two weeks after the 2011 Great East Japan Earthquake (GEJE), comprehensive surveillance related to the health status and hygiene level was performed for all evacuation shelters (328 shelters with 46,480 evacuees at the peak) in one of the most devastating medical zones after the tsunami hit the area (Ishinomaki City). The joint relief team regularly visited all evacuation shelters across the area to assess the situation of resource supply levels, infrastructural damage, rapid need of resources, and the health status of the evacuees. In this cross-sectional observational study, we evaluated the relationship between the resource supply levels and health status among evacuees in two time periods (days 14-19 and 20-25). Among the evaluated vital resources, clean tap water supply was among the most disrupted by the disaster, and was not fully restored in most shelters during the assessment period. The cross-sectional relationship between resource supplies and morbidity was inconsistent between the two assessment periods, reflecting the multifactorial nature of health status in evacuation shelters. The clean tap water supply level at the first assessment showed a strong negative correlation with the subsequent prevalence of respiratory or gastrointestinal infectious conditions at the second assessment. Restorations in the clean tap water supply and toilet hygiene correlated each other, and both correlated with a decrease in the prevalence of gastrointestinal infectious conditions. In conclusion, disrupted clean tap water supply and inadequate toilet hygiene after a massive disaster would jointly harm the health status of those in shelters. Prompt assessments using quick visual assessment and restorations of these key resources have validity with suppressed environmental health risks among evacuees.

Quick sequential organ failure assessment versus systemic inflammatory response syndrome criteria for emergency department patients with suspected infection.

Previous studies have shown inconsistent prognostic accuracy for mortality with both quick sequential organ failure assessment (qSOFA) and the systemic inflammatory response syndrome (SIRS) criteria. We aimed to validate the accuracy of qSOFA and the SIRS criteria for predicting in-hospital mortality in patients with suspected infection in the emergency department. A prospective study was conducted including participants with suspected infection who were hospitalised or died in 34 emergency departments in Japan. Prognostic accuracy of qSOFA and SIRS criteria for in-hospital mortality was assessed by the area under the receiver operating characteristic (AUROC) curve. Of the 1060 participants, 402 (37.9%) and 915 (86.3%) had qSOFA ≥ 2 and SIRS criteria ≥ 2 (given thresholds), respectively, and there were 157 (14.8%) in-hospital deaths. Greater accuracy for in-hospital mortality was shown with qSOFA than with the SIRS criteria (AUROC: 0.64 versus 0.52, difference + 0.13, 95% CI [+ 0.07, + 0.18]). Sensitivity and specificity for predicting in-hospital mortality at the given thresholds were 0.55 and 0.65 based on qSOFA and 0.88 and 0.14 based on SIRS criteria, respectively. To predict in-hospital mortality in patients visiting to the emergency department with suspected infection, qSOFA was demonstrated to be modestly more accurate than the SIRS criteria albeit insufficiently sensitive.Clinical Trial Registration: The study was pre-registered in the University Hospital Medical Information Network Clinical Trials Registry (UMIN000027258).

Investigation of Japan Disaster Medical Assistance Team response guidelines assuming catastrophic damage from a Nankai Trough earthquake.

Aim: Transporting critically ill patients outside of disaster-affected areas for treatment is an important activity of Japan Disaster Medical Assistance Teams (DMATs). We investigated whether this activity is possible after possible catastrophic damage from a Nankai Trough earthquake. Methods: Japan was divided into three areas based on the level of predicted damage (definitely, possibly, and non-affected areas). A survey of DMATs and the locations of emergency base hospitals and intensive care units (ICUs) in each area was carried out, and the ability to support disaster areas was investigated. Next, a survey of wide-area medical transport by Self-Defense Force aircraft and the medical transport abilities of helicopter ambulances was carried out. The numbers of ICU beds in each area were compared, and the capacity to accept patients was investigated. Finally, subjects for further study were examined. Results: The number of DMATs that could be sent from non-affected areas was insufficient. The number of patients that can be transported by Self-Defense Force aircraft and helicopter ambulance during the first 3 days was determined to be 1,443. The number of patients that can be accepted by ICUs in non-affected areas was insufficient. A system needs to be developed to provide medical treatment for critically ill patients within disaster areas during the acute phase. This will require DMAT operational reforms and the creation of logistics systems such as the supply of resources for earthquake-reinforced hospitals. Conclusion: In addition to patient transport, systems to provide medical care inside disaster-affected areas are needed.

Development of Mass-casualty Life Support-CBRNE (MCLS-CBRNE) in Japan.

This report outlines the need for the development of an advanced course in mass-casualty life support (MCLS) and introduces the course content. The current problems with education on disasters involving chemical agents, biological agents, radiation/nuclear attacks, or explosives (CBRNE) in Japan are presented. This newly developed "MCLS-CBRNE" program was created by a Ministry of Health, Labour, and Welfare (Tokyo, Japan) research group based on these circumstances. Modifications were then made after a trial course. Training opportunities for relevant organizations to learn how to act at a CBRNE disaster site currently are lacking. The developed course covers initial responses at a disaster site. This one-day training course comprises lectures, three tabletop simulations, and practical exercises in pre-decontamination triage and post-decontamination triage. With regard to field exercises conducted to date, related organizations have experienced difficulties in understanding each other and adapting their approaches. Tabletop simulations provide an opportunity for participants to learn how organizations working on-site, including fire, police, and medical personnel, act with differing goals and guiding principles. This course appears useful as a means for relevant organizations to understand the importance of developing common guidelines. The MCLS-CBRNE training is proposed to support CBRNE disaster control measures during future events. Anan H , Otomo Y , Kondo H , Homma M , Koido Y , Morino K , Oshiro K , Harikae K , Akasaka O . Development of mass-casualty life support-CBRNE (MCLS-CBRNE) in Japan. Prehosp Disaster Med. 2016;31(5):547-550.

Development and Verification of a Mobile Shelter Assessment System "Rapid Assessment System of Evacuation Center Condition Featuring Gonryo and Miyagi (RASECC-GM)" for Major Disasters.

UNLABELLED: Introduction There were 5,385 deceased and 710 missing in the Ishinomaki medical zone following the Great East Japan Earthquake that occurred in Japan on March 11, 2011. The Ishinomaki Zone Joint Relief Team (IZJRT) was formed to unify the relief teams of all organizations joining in support of the Ishinomaki area. The IZJRT expanded relief activity as they continued to manually collect and analyze assessments of essential information for maintaining health in all 328 shelters using a paper-type survey. However, the IZJRT spent an enormous amount of time and effort entering and analyzing these data because the work was vastly complex. Therefore, an assessment system must be developed that can tabulate shelter assessment data correctly and efficiently. The objective of this report was to describe the development and verification of a system to rapidly assess evacuation centers in preparation for the next major disaster. Report Based on experiences with the complex work during the disaster, software called the "Rapid Assessment System of Evacuation Center Condition featuring Gonryo and Miyagi" (RASECC-GM) was developed to enter, tabulate, and manage the shelter assessment data. Further, a verification test was conducted during a large-scale Self-Defense Force (SDF) training exercise to confirm its feasibility, usability, and accuracy. The RASECC-GM comprises three screens: (1) the "Data Entry screen," allowing for quick entry on tablet devices of 19 assessment items, including shelter administrator, living and sanitary conditions, and a tally of the injured and sick; (2) the "Relief Team/Shelter Management screen," for registering information on relief teams and shelters; and (3) the "Data Tabulation screen," which allows tabulation of the data entered for each shelter, as well as viewing and sorting from a disaster headquarters' computer. During the verification test, data of mock shelters entered online were tabulated quickly and accurately on a mock disaster headquarters' computer. Likewise, data entered offline also were tabulated quickly on the mock disaster headquarters' computer when the tablet device was moved into an online environment. CONCLUSIONS: The RASECC-GM, a system for rapidly assessing the condition of evacuation centers, was developed. Tests verify that users of the system would be able to easily, quickly, and accurately assess vast quantities of data from multiple shelters in a major disaster and immediately manage the inputted data at the disaster headquarters. Ishii T , Nakayama M , Abe M , Takayama S , Kamei T , Abe Y , Yamadera J , Amito K , Morino K . Development and verification of a mobile shelter assessment system "Rapid Assessment System of Evacuation Center Condition featuring Gonryo and Miyagi (RASECC-GM)" for major disasters. Prehosp Disaster Med. 2016;31(5):539-546.

Access Control for Mobile Assessment Systems Using ID.

The assessment of shelters during disaster is critical to ensure the health of evacuees and prevent pandemic. In the Ishinomaki area, one of the areas most damaged by the Great East Japan Earthquake, the highly organized assessment helped to successfully manage a total of 328 shelters with a total of 46,480 evacuees. The input and analysis of vast amounts of data was tedious work for staff members. However, a web-based assessment system that utilized mobile devices was thought to decrease workload and standardize the evaluation form. The necessary access of information should be controlled in order to maintain individuals' privacy. We successfully developed an access control system using IDs. By utilizing a unique numerical ID, users can access the input form or assessment table. This avoids unnecessary queries to the server, resulting in a quick response and easy availability, even with poor internet connection.

Experience from the Great East Japan Earthquake response as the basis for revising the Japanese Disaster Medical Assistance Team (DMAT) training program.

OBJECTIVE: The objective of this study was to draft a new Japanese Disaster Medical Assistance Team (DMAT) training program based on the responses to the Great East Japan Earthquake. METHODS: Working group members of the Japan DMAT Investigative Commission, Ministry of Health, Labour and Welfare, reviewed reports and academic papers on DMAT activities after the disaster and identified items in the current Japanese DMAT training program that should be changed. A new program was proposed that incorporates these changes. RESULTS: New topics that were identified to be added to the DMAT training program were hospital evacuation, preparations to receive DMATs at damaged hospitals, coordination when DMAT activities are prolonged, and safety management and communication when on board small helicopters. The use of wide-area transport was reviewed and changes were made to cover selection of various transport means including helicopter ambulances. Content related to confined space medicine was removed. The time spent on emergency medical information system (EMIS) practical training was increased. Redundant or similar content was combined and reorganized, and a revised DMAT training program that did not increase the overall training time was designed. CONCLUSION: The revised DMAT training program will provide practical training better suited to the present circumstances in Japan.

Streamlining of medical relief to areas affected by the Great East Japan earthquake with the "area-based/line-linking support system".

INTRODUCTION: When disasters that affect a wide area occur, external medical relief teams play a critical role in the affected areas by helping to alleviate the burden caused by surging numbers of individuals requiring health care. Despite this, no system has been established for managing deployed medical relief teams during the subacute phase following a disaster. After the Great East Japan Earthquake and tsunami, the Ishinomaki Medical Zone was the most severely-affected area. Approximately 6,000 people died or were missing, and the immediate evacuation of approximately 120,000 people to roughly 320 shelters was required. As many as 59 medical teams came to participate in relief activities. Daily coordination of activities and deployment locations became a significant burden to headquarters. The Area-based/Line-linking Support System (Area-Line System) was thus devised to resolve these issues for medical relief and coordinating activities. METHODS: A retrospective analysis was performed to examine the effectiveness of the medical relief provided to evacuees using the Area-Line System with regards to the activities of the medical relief teams and the coordinating headquarters. The following were compared before and after establishment of the Area-Line System: (1) time required at the coordinating headquarters to collect and tabulate medical records from shelters visited; (2) time required at headquarters to determine deployment locations and activities of all medical relief teams; and (3) inter-area variation in number of patients per team. RESULTS: The time required to collect and tabulate medical records was reduced from approximately 300 to 70 minutes/day. The number of teams at headquarters required to sort through data was reduced from 60 to 14. The time required to determine deployment locations and activities of the medical relief teams was reduced from approximately 150 hours/month to approximately 40 hours/month. Immediately prior to establishment of the Area-Line System, the variation of the number of patients per team was highest. Variation among regions did not increase after establishment of the system. CONCLUSION: This descriptive analysis indicated that implementation of the Area-Line System, a systematic approach for long-term disaster medical relief across a wide area, can increase the efficiency of relief provision to disaster-stricken areas.

Time to initiation of treatment with polymyxin B cartridge hemoperfusion in septic shock patients.

BACKGROUND: We investigated whether early initiation of hemoperfusion with a polymyxin B cartridge (PMX) after the diagnosis of septic shock could improve the clinical outcome. METHODS: A prospective, open-labeled, multicenter cohort study was performed at intensive care units in Japan. 41 patients received PMX within 6 h after the diagnosis of septic shock (early group) and 51 patients were treated after 6 h (late group). RESULTS: The early group had a significantly shorter duration of ventilator support and also had a lower catecholamine requirement. PMX was effective for improvement of hypotension, hypoperfusion, the sequential organ failure assessment score, and pulmonary oxygenation regardless of the timing of its initiation. The 28-day mortality rate did not differ between the two groups. CONCLUSIONS: Early initiation of PMX shortened the duration of ventilator support and also reduced the catecholamine requirement, so early treatment of septic shock should achieve a better outcome.

Establishing disaster medical assistance teams in Japan.

INTRODUCTION: The large number casualties caused by the 1995 Great Hanshin and Awaji Earthquake created a massive demand for medical care. However, as area hospitals also were damaged by the earthquake, they were unable to perform their usual functions. Therefore, the care capacity was reduced greatly. Thus, the needs to: (1) transport a large number of injured and ill people out of the disaster-affected area; and (2) dispatch medical teams to perform such wide-area transfers were clear. The need for trained medical teams to provide medical assistance also was made clear after the Niigata-ken Chuetsu Earthquake in 2004. Therefore, the Japanese government decided to establish Disaster Medical Assistance Teams (DMATs), as "mobile, trained medical teams that rapidly can be deployed during the acute phase of a sudden-onset disaster". Disaster Medical Assistance Teams have been established in much of Japan. The provision of emergency relief and medical care and the enhancement and promotion of DMATs for wide-area deployments during disasters were incorporated formally in the Basic Plan for Disaster Prevention in its July 2005 amendment. RESULTS: The essential points pertaining to DMATs were summarized as a set of guidelines for DMAT deployment. These were based on the results of research funded by a Health and Labour Sciences research grant from the, Labour and Welfare (MHLW) of the Ministry of Health. The guidelines define the basic procedures for DMAT activities-for example: (1) the activities are to be based on agreements concluded between prefectures and medical institutions during non-emergency times; and (2) deployment is based on requests from disaster-affected prefectures and the basic roles of prefectures and the MHLW. The guidelines also detail DMAT activities at the disaster scene of the, support from medical institutions, and transportation assistance including "wide-area" medical transport activities, such as medical treatment in staging care units and the implementation of medical treatment onboard aircraft. CONCLUSIONS: Japan's DMATs are small-scale units that are designed to be suitable for responding to the demands of acute emergencies. Further issues to be examined in relation to DMATs include expanding their application to all prefectures, and systems to facilitate continuous education and training.

A case report of the effect of plasma exchange on reactive hemophagocytic syndrome associated with toxic shock syndrome.

We report here the case of a patient suffering from hemophagocytic syndrome (HPS) associated with toxic shock syndrome (TSS). A 50-year-old man was admitted because of fever, watery diarrhea and shortness of breath. Clinical analysis revealed systemic cyanosis, sunburn-like erythema and septic shock. Staphylococcus aureus was identified from both blood and sputum culture and the serum enterotoxin A antibody test was positive, suggesting that this was a case of TSS. Though the respiratory and hemodynamic status improved by the mechanical ventilation, fluid resuscitation with catecholamine and antibiotic therapy, the platelet count decreased rapidly. Bone marrow aspiration revealed a large quantity of hemophagocytosis by macrophages. This reactive HPS was treated not with immunosuppressive drugs but with therapeutic plasma exchange in order to prevent worsening of S. aureus infection. After plasma exchange, the circulating macrophage colony-stimulating factor (M-CSF) level was reduced and the platelet count increased rapidly. Bacteria associated HPS remains a difficult diagnosis with high mortality and there is a crucial question of whether this should be treated with immunosuppressive drugs. The patient's clinical course would suggest that the therapeutic plasma exchange should be considered as a therapeutic tool for the bacteria associated HPS instead of immunosuppressive drugs.