A Socio-Health Approach to Improve Local Disaster Resilience and Contain Secondary Crises: A Case Study in an Agricultural Community Exposed to Bushfires in Australia.

Recent large-scale disasters have exposed the interconnected nature of modern societies, exacerbating the risk of cascading impacts. Examining elements of community health status, such as social determinants of health, their perceived health status, and how they relate to disaster resilience, can illuminate alternative actions for cost-effective disaster prevention and management. Moreover, agricultural communities are essential to food security and provide a working example of the importance of mitigation in escalation of crises. To that aim, this research examines perceptions of the relationship between disaster resilience and determinants of health, including health status. Participants also reported their views on perceived vulnerable groups in their community and proposed design characteristics of more effective community disaster plans.Here investigated are these elements in a small agricultural community of Western Australia previously exposed to bushfires. A questionnaire was used based on health elements from the Social Determinants of Health described by the World Health Organization (WHO) and compared this with quantitative data describing the community health status. A mixed methods approach combining qualitative (semi-structured interview) and quantitative (closed questions using a Likert scale) tools was undertaken with a small group of community members.It was found that community connection and social capital were perceived to provide knowledge and support that enhanced individual disaster risk awareness and preparedness and improved an individual's disaster resilience. Stress and social exclusion within a community were perceived to decrease an individual's resilience to disaster. Disaster resilience was reported to be a function of good physical and mental health. To achieve effective disaster planning, community partnership in the development, education, and testing of plans and robust communication were described as essential traits in community emergency plans.

Improving Disaster Data Systems to Inform Disaster Risk Reduction and Resilience Building in Australia: A Comparison of Databases.

OBJECTIVE: Disaster impact databases are important resources for informing research, policy, and decision making. Therefore, understanding the underpinning methodology of data collection used by the databases, how they differ, and quality indicators of the data recorded is essential in ensuring that their use as reference points is valid. METHODS: The Australian Disaster Resilience Knowledge Hub (AIDRKH) is an open-source platform supported by government to inform disaster management practice. A comparative descriptive review of the Disaster Mapper (hosted at AIDRKH) and the international Emergency Events Database (EM-DAT) was undertaken to identify differences in how Australian disasters are captured and measured. RESULTS: The results show substantial variation in identification and classification of disasters across hazard impacts and hazard types and a lack of data structure for the systematic reporting of contextual and impact variables. CONCLUSIONS: These differences may have implications for reporting, academic analysis, and thus knowledge management informing disaster prevention and response policy or plans. Consistency in reporting methods based on international classification standards is recommended to improve the validity and usefulness of this Australian database.

Triage in Complex, Coordinated Terrorist Attacks.

INTRODUCTION: Terror attacks have increased in frequency, and tactics utilized have evolved. This creates significant challenges for first responders providing life-saving medical care in their immediate aftermath. The use of coordinated and multi-site attack modalities exacerbates these challenges. The use of triage is not well-validated in mass-casualty settings, and in the setting of intentional mass violence, new and innovative approaches are needed. METHODS: Literature sourced from gray and peer-reviewed sources was used to perform a comparative analysis on the application of triage during the 2011 Oslo/Utoya Island (Norway), 2015 Paris (France), and 2015 San Bernardino (California USA) terrorist attacks. A thematic narrative identifies strengths and weaknesses of current triage systems in the setting of complex, coordinated terrorist attacks (CCTAs). DISCUSSION: Triage systems were either not utilized, not available, or adapted and improvised to the tactical setting. The complexity of working with large numbers of patients, sensory deprived environments, high physiological stress, and dynamic threat profiles created significant barriers to the implementation of triage systems designed around flow charts, physiological variables, and the use of tags. Issues were identified around patient movement and "tactical triage." CONCLUSION: Current triage tools are inadequate for use in insecure environments, such as the response to CCTAs. Further research and validation are required for novel approaches that simplify tactical triage and support its effective application. Simple solutions exist in tactical triage, patient movement, and tag use, and should be considered as part of an overall triage system.

Peer-Reviewed Validation of a Comprehensive Framework for Disaster Evaluation Typologies.

INTRODUCTION: The Comprehensive Framework for Disaster Evaluation Typologies, developed in 2017 (CFDET 2017), aims to unify and facilitate agreement regarding the identification, structure, and relationships between various evaluation typologies found in the disaster setting. A peer-reviewed validation process sought input from international experts in the fields of disaster medicine, disaster/emergency management, humanitarian/development, and evaluation. This paper discusses the validation process, its results, and outcomes.Research Problem:Previous frameworks, identified in the literature, lack validation and consistent terminology. To gain credibility and utility, this unique framework needed to be validated by international experts in the disaster setting. METHODS: A mixed methods approach was designed to validate the framework. An initial iterative process informed an online survey which used a combination of a five-point Likert scale and open-ended questions. Pre-determined consensus thresholds, informed by a targeted literature review, provided the validation criteria. RESULTS: A sample of 33 experts from 11 countries responded to the validation process. Quantitative measures largely supported the elements and relationships of the framework, and strongly supported its value and usefulness for supporting, promoting, and undertaking evaluations, as well as its usefulness for teaching evaluation in the disaster setting. Qualitative input suggested opportunities to strengthen and enhance the framework. There were limited responses to better understand the barriers and enablers of undertaking disaster evaluations. A potential for self-selection bias of respondents may be a limitation of this study. The attainment of high consensus thresholds, however, provides confidence in the validity of the results. CONCLUSION: For the first time, a framework of this nature has undergone a rigorous validation process by experts in three related disciplines at an international level. The modified framework, CFDET 2018, provides a unifying framework within which existing evaluation typologies can be structured. It gives evaluators confidence to choose an appropriate strategy for their particular evaluation in the disaster setting and facilitates consistency in reporting across the different phases of a disaster to better understand the process, outcomes, and impacts of the efficacy and efficiency of interventions. Future research could create a series of toolkits to support improved disaster evaluation processes and to evaluate the utility of the framework in the real-world setting.

Current and Emerging Disaster Risks Perceptions in Oceania: Key Stakeholders Recommendations for Disaster Management and Resilience Building.

Identification and profiling of current and emerging disaster risks is essential to inform effective disaster risk management practice. Without clear evidence, readiness to accept future threats is low, resulting in decreased ability to detect and anticipate these new threats. A consequential decreased strategic planning for mitigation, adaptation or response results in a lowered resilience capacity. This study aimed to investigate threats to the health and well-being of societies associated with disaster impact in Oceania. The study used a mixed methods approach to profile current and emerging disaster risks in selected countries of Oceania, including small and larger islands. Quantitative analysis of the International Disaster Database (EM-DAT) provided historical background on disaster impact in Oceania from 2000 to 2018. The profile of recorded events was analyzed to describe the current burden of disasters in the Oceania region. A total of 30 key informant interviews with practitioners, policy managers or academics in disaster management in the Oceania region provided first-hand insights into their perceptions of current and emerging threats, and identified opportunities to enhance disaster risk management practice and resilience in Oceania. Qualitative methods were used to analyze these key informant interviews. Using thematic analysis, we identified emerging disaster risk evidence from the data and explored new pathways to support decision-making on resilience building and disaster management. We characterized perceptions of the nature and type of contemporary and emerging disaster risk with potential impacts in Oceania. The study findings captured not only traditional and contemporary risks, such as climate change, but also less obvious ones, such as plastic pollution, rising inequality, uncontrolled urbanization, and food and water insecurity, which were perceived as contributors to current and/or future crises, or as crises themselves. The findings provided insights into how to improve disaster management more effectively, mainly through bottom-up approaches and education to increase risk-ownership and community action, enhanced political will, good governance practices and support of a people-centric approach.

Special Report: WADEM Climate Change Position Statement.

The World Association for Disaster and Emergency Medicine (WADEM; Madison, Wisconsin USA) is a multi-disciplinary professional association whose mission is the global improvement of prehospital and emergency health care, public health, and disaster health and preparedness. In April 2017, the biennial general meeting of the World Congress for Disaster and Emergency Medicine (WCDEM) endorsed the WADEM Climate Change Position Statement, which was subsequently published in Prehospital and Disaster Medicine in July 2017. This special report examines literature used and reviews the process of development of this Position Statement as a product of WADEM.Cuthbertson J, Archer F, Robertson A. Special report: WADEM climate change position statement. Prehosp Disaster Med. 2018;33(4):428-431.

Disaster Metrics: A Comprehensive Framework for Disaster Evaluation Typologies.

Introduction The frequency of disasters is increasing around the world with more people being at risk. There is a moral imperative to improve the way in which disaster evaluations are undertaken and reported with the aim of reducing preventable mortality and morbidity in future events. Disasters are complex events and undertaking disaster evaluations is a specialized area of study at an international level. Hypothesis/Problem While some frameworks have been developed to support consistent disaster research and evaluation, they lack validation, consistent terminology, and standards for reporting across the different phases of a disaster. There is yet to be an agreed, comprehensive framework to structure disaster evaluation typologies. The aim of this paper is to outline an evolving comprehensive framework for disaster evaluation typologies. It is anticipated that this new framework will facilitate an agreement on identifying, structuring, and relating the various evaluations found in the disaster setting with a view to better understand the process, outcomes, and impacts of the effectiveness and efficiency of interventions. METHODS: Research was undertaken in two phases: (1) a scoping literature review (peer-reviewed and "grey literature") was undertaken to identify current evaluation frameworks and typologies used in the disaster setting; and (2) a structure was developed that included the range of typologies identified in Phase One and suggests possible relationships in the disaster setting. RESULTS: No core, unifying framework to structure disaster evaluation and research was identified in the literature. The authors propose a "Comprehensive Framework for Disaster Evaluation Typologies" that identifies, structures, and suggests relationships for the various typologies detected. CONCLUSION: The proposed Comprehensive Framework for Disaster Evaluation Typologies outlines the different typologies of disaster evaluations that were identified in this study and brings them together into a single framework. This unique, unifying framework has relevance at an international level and is expected to benefit the disaster, humanitarian, and development sectors. The next step is to undertake a validation process that will include international leaders with experience in evaluation, in general, and disasters specifically. This work promotes an environment for constructive dialogue on evaluations in the disaster setting to strengthen the evidence base for interventions across the disaster spectrum. It remains a work in progress. Wong DF , Spencer C , Boyd L , Burkle FM Jr. , Archer F . Disaster metrics: a comprehensive framework for disaster evaluation typologies. Prehosp Disaster Med. 2017;32(5):501-514.

Defining disaster resilience: comparisons from key stakeholders involved in emergency management in Victoria, Australia.

Three years after the introduction of the National Strategy for Disaster Resilience there remains no unanimously adopted definition of disaster resilience within Australia's emergency management sector. The aim of this study is to determine what the concept means to key stakeholders in the emergency management sector in the Australian State of Victoria, and how these conceptualisations overlap and diverge. Via an online survey, 113 people were asked how they define disaster resilience in their work in the emergency management sector. A data mining software tool, Leximancer, was employed to uncover the relationships between the definitions provided. The findings show that stakeholders see resilience as an 'ability' that encompasses emergency management activities and personal responsibility. However, the findings also highlight some possible points of conflict between stakeholders. In addition, the paper outlines and discusses a number of potential consequences for the implementation and the success of the resilience-based approach in Australia.

A review of key national reports to describe the development of paramedic education in England (1966-2014).

INTRODUCTION: In the year 1966, important advances in mobile coronary care and trauma care in the UK and USA influenced globally the development of modern prehospital emergency services and paramedic education. In that year, to meet the evolving role of prehospital care in the UK, the 'Millar Report' specified a new syllabus for ambulance personnel in England. As the 50th anniversary of this report approaches, this paper reviews key national UK reports to describe the development of paramedic education in England over this period. METHODS: A hand search of documents available and a Google search identified documents in the public domain. MEDLINE and CINAHL Plus were searched for peer-reviewed publications. Thematic analysis was used to identify descriptive themes. RESULTS: Of the 83 reports and 431 articles screened, 33 documents met our inclusion criteria. We identified four historical periods in English paramedic education: development of paramedic education (1966-1996); paramedic role changes influencing education (1997-2004); paramedic education level changes and the emergency care practitioner (2005-2008); and paramedic education for the future (2010-2014). Our discussion of four descriptive themes: government authority and policy, influence of health professions, quality assurance and development of the paramedic profession includes comparisons with paramedic education in the USA and Australia. CONCLUSIONS: Political reform agendas and initiatives and advances in clinical medicine largely shaped paramedic roles and education in England. The degree to which the paramedic profession initiated education development is difficult to determine from the literature. Overall, a nationally coherent standard for paramedic education in England needed five decades to develop and mature.

An Historical Examination of the Development of Emergency Medical Services Education in the US through Key Reports (1966-2014).

INTRODUCTION: The Emergency Medical Services (EMS) approach to emergency prehospital care in the United States (US) has global influence. As the 50-year anniversary of modern US EMS approaches, there is value in examining US EMS education development over this period. This report describes US EMS education milestones and identifies themes that provide context to readers outside the US. METHOD: As US EMS education is described mainly in publications of federal US EMS agencies and associations, a Google search and hand searching of documents identified publications in the public domain. MEDLINE and CINAHL Plus were searched for peer reviewed publications. Documents were reviewed using both a chronological and thematic approach. RESULTS: Seventy-eight documents and 685 articles were screened, the full texts of 175 were reviewed, and 41 were selected for full review. Four historical periods in US EMS education became apparent: EMS education development (1966-1980); EMS education consolidation and review (1981-1989); EMS education reflection and change (1990-1999); and EMS education for the future (2000-2014). Four major themes emerged: legislative authority, physician direction, quality, and development of the profession. CONCLUSION: Documents produced through broad interprofessional consultations, with support from federal and US EMS authorities, reflect the catalysts for US EMS education development. The current model of US EMS education provides a structure to enhance educational quality into the future. Implementation evaluation of this model would be a valuable addition to the US EMS literature. The themes emerging from this review assist the understanding of the characteristics of US EMS education.

No fixed place of birth: unplanned BBAs in Victoria, Australia.

OBJECTIVES: the primary objective-to present data on the incidence of unplanned births before arrival (BBAs) in Victoria between 1991 and 2008. The secondary objective-to provide an extensive literature review highlighting the issues surrounding an unplanned BBA. SETTING: the incidence of BBAs in Victoria published in the relevant government reports. DESIGN: data were extracted from published government reports pertaining to perinatal statistics in Victoria-The Australian Institute of Health and Wellbeing and the Perinatal Data Collection Unit of Victoria. Data on place of birth for each year from both sources was identified and tabulated. Comparisons between the data sources were undertaken to provide a picture of the scope of out of hospital birth. FINDINGS: the incidence and absolute numbers of unplanned birth before arrival (BBA) to hospital in Victoria, are low compared to the total births. However, this number is comparable to unplanned BBAs in other developed countries with similar health systems. The incidence of unplanned BBAs has slowly but steadily doubled since 1991-2008. The two data sources almost mirror each other except for 1999 when there was an unexplained difference in the reported incidence in unplanned BBAs. Maternal and neonatal outcomes are disproportionally much poorer after unplanned BBAs than either planned home births or in hospital births. Various maternal factors can increase the risk of an unplanned BBA. KEY CONCLUSIONS: multiple approaches should be adopted to manage unplanned BBAs. Antenatal screening should be undertaken to identify the women most at risk. Strategies can be developed that will reduce poor neonatal and maternal outcomes, including education for women and their partners on immediate management of the newborn; ensuring paramedics have current knowledge on care during childbirth; and maternity and ambulance services should develop management plans for care of women having unplanned BBAs.

Paramedics and the effects of shift work on sleep: a literature review.

INTRODUCTION: This paper investigates the literature regarding the impact of shift work on prehospital emergency providers. While the issue of shift work has been thoroughly investigated in other health disciplines, this is not the case for the paramedic discipline, particularly in the Australian context. OBJECTIVE: To identify the literature available on prehospital providers regarding the effects of shift work on sleep. METHOD: Electronic databases used were the Cochrane Database of Systematic Reviews, Ovid MEDLINE, Proquest, AMED and CINAHL. The following MeSH terms and keywords with truncation were used in the search strategy: 'shift work'; 'sleep disorder'; 'sleep deprivation'; 'circadian rhythm'; 'fatigue'; 'occupational stress'. RESULTS: The electronic databases cited 226 articles, of which nine met the inclusion criteria with another three articles sourced from references in the retrieved papers. There is a lack of literature describing the effect of shift work on sleep in the prehospital arena, with only one paper exploring paramedics in the Australian setting. These findings suggest that further work is required to examine shift hours and workforce health and safety in the prehospital setting. CONCLUSIONS: Shift work can affect health and well-being on a variety of levels, both physiologically and psychologically, affecting aspects of work and personal life. Further research is warranted to prevent the issues of patient safety, work-related fatigue and the cumulative effects of shift work.

Fear, familiarity, and the perception of risk: a quantitative analysis of disaster-specific concerns of paramedics.

INTRODUCTION: Paramedics play an integral role in the response to and management of disasters and mass casualty events. Providing a core component of the front line response to disasters, paramedics potentially expose themselves to a variety of health and safety risks, including physical injury, death, communicable disease, and psychological effects. The health and safety risks to emergency service personnel were highlighted by the deaths of firefighters, paramedics, and police during the September 11, 2001, terrorist attacks, and the infection, illness, and deaths of paramedics and emergency health care staff during the severe acute respiratory syndrome outbreak in 2003. OBJECTIVE: Given that a willing and able prehospital workforce is a vital component of any successful response to a disaster situation, the present study explored paramedics' perception of risk and willingness to work, with a specific focus on identifying which type of disasters that paramedics associate with greater levels of fear, familiarity, and risk. METHODS: A total of 175 paramedics completed a survey ranking 40 disaster scenarios for levels of fear and familiarity. RESULTS: The results indicate that paramedics ranked nuclear and radiological events and outbreaks of new and highly infectious disasters highest for fear and unfamiliarity. This has implications for preparedness, education, and training.

Attitudes to living and working in pandemic conditions among emergency prehospital medical care personnel.

INTRODUCTION: Little is known about the risk perceptions and attitudes of healthcare personnel, especially of emergency prehospital medical care personnel, regarding the possibility of an outbreak or epidemic event. PROBLEM: This study was designed to investigate pre-event knowledge and attitudes of a national sample of the emergency prehospital medical care providers in relation to a potential human influenza pandemic, and to determine predictors of these attitudes. METHODS: Surveys were distributed to a random, cross-sectional sample of 20% of the Australian emergency prehospital medical care workforce (n = 2,929), stratified by the nine services operating in Australia, as well as by gender and location. The surveys included: (1) demographic information; (2) knowledge of influenza; and (3) attitudes and perceptions related to working during influenza pandemic conditions. Multiple logistic regression models were constructed to identify predictors of pandemic-related risk perceptions. RESULTS: Among the 725 Australian emergency prehospital medical care personnel who responded, 89% were very anxious about working during pandemic conditions, and 85% perceived a high personal risk associated with working in such conditions. In general, respondents demonstrated poor knowledge in relation to avian influenza, influenza generally, and infection transmission methods. Less than 5% of respondents perceived that they had adequate education/training about avian influenza. Logistic regression analyses indicate that, in managing the attitudes and risk perceptions of emergency prehospital medical care staff, particular attention should be directed toward the paid, male workforce (as opposed to volunteers), and on personnel whose relationship partners do not work in the health industry. CONCLUSIONS: These results highlight the potentially crucial role of education and training in pandemic preparedness. Organizations that provide emergency prehospital medical care must address this apparent lack of knowledge regarding infection transmission, and procedures for protection and decontamination. Careful management of the perceptions of emergency prehospital medical care personnel during a pandemic is likely to be critical in achieving an effective response to a widespread outbreak of infectious disease.

Anticipated behaviors of emergency prehospital medical care providers during an influenza pandemic.

INTRODUCTION: Emergency prehospital medical care providers are frontline health workers during emergencies. However, little is known about their attitudes, perceptions, and likely behaviors during emergency conditions. Understanding these attitudes and behaviors is crucial to mitigating the psychological and operational effects of biohazard events such as pandemic influenza, and will support the business continuity of essential prehospital services. PROBLEM: This study was designed to investigate the association between knowledge and attitudes regarding avian influenza on likely behavioral responses of Australian emergency prehospital medical care providers in pandemic conditions. METHODS: Using a reply-paid postal questionnaire, the knowledge and attitudes of a national, stratified, random sample of the Australian emergency prehospital medical care workforce in relation to pandemic influenza were investigated. In addition to knowledge and attitudes, there were five measures of anticipated behavior during pandemic conditions: (1) preparedness to wear personal protective equipment (PPE); (2) preparedness to change role; (3) willingness to work; and likely refusal to work with colleagues who were exposed to (4) known and (5) suspected influenza. Multiple logistic regression models were constructed to determine the independent predictors of each of the anticipated behaviors, while controlling for other relevant variables. RESULTS: Almost half (43%) of the 725 emergency prehospital medical care personnel who responded to the survey indicated that they would be unwilling to work during pandemic conditions; one-quarter indicated that they would not be prepared to work in PPE; and one-third would refuse to work with a colleague exposed to a known case of pandemic human influenza. Willingness to work during a pandemic (OR = 1.41; 95% CI = 1.0-1.9), and willingness to change roles (OR = 1.44; 95% CI = 1.04-2.0) significantly increased with adequate knowledge about infectious agents generally. Generally, refusal to work with exposed (OR = 0.48; 95% CI = 0.3-0.7) or potentially exposed (OR = 0.43; 95% CI = 0.3-0.6) colleagues significantly decreased with adequate knowledge about infectious agents. Confidence in the employer's capacity to respond appropriately to a pandemic significantly increased employee willingness to work (OR = 2.83; 95% CI = 1.9-4.1); willingness to change roles during a pandemic (OR = 1.52; 95% CI = 1.1-2.1); preparedness to wear PPE (OR = 1.68; 95% CI = 1.1-2.5); and significantly decreased the likelihood of refusing to work with colleagues exposed to (suspected) influenza (OR = 0.59; 95% CI = 0.4-0.9). CONCLUSIONS: These findings indicate that education and training alone will not adequately prepare the emergency prehospital medical workforce for a pandemic. It is crucial to address the concerns of ambulance personnel and the perceived concerns of their relationship with partners in order to maintain an effective prehospital emergency medical care service during pandemic conditions.

A national framework for disaster health education in Australia.

INTRODUCTION: Recent events have heightened awareness of disaster health issues and the need to prepare the health workforce to plan for and respond to major incidents. This has been reinforced at an international level by the World Association for Disaster and Emergency Medicine, which has proposed an international educational framework. OBJECTIVE: The aim of this paper is to outline the development of a national educational framework for disaster health in Australia. METHODS: The framework was developed on the basis of the literature and the previous experience of members of a National Collaborative for Disaster Health Education and Research. The Collaborative was brought together in a series of workshops and teleconferences, utilizing a modified Delphi technique to finalize the content at each level of the framework and to assign a value to the inclusion of that content at the various levels. FRAMEWORK: The framework identifies seven educational levels along with educational outcomes for each level. The framework also identifies the recommended contents at each level and assigns a rating of depth for each component. The framework is not intended as a detailed curriculum, but rather as a guide for educationalists to develop specific programs at each level. CONCLUSIONS: This educational framework will provide an infrastructure around which future educational programs in Disaster Health in Australia may be designed and delivered. It will permit improved articulation for students between the various levels and greater consistency between programs so that operational responders may have a consistent language and operational approach to the management of major events.

Can interdisciplinary clinical DVD simulations transform clinical fieldwork education for paramedic, occupational therapy, physiotherapy, and nursing students?

UNLABELLED: The aim of this study was to examine the usefulness of DVD simulations in a clinical teaching context, their impact on student learning, and their potential as a supplemental learning option for clinical placements/fieldwork education rotations that might assist in reducing the burden on the health care system. METHODS: Eleven clinical DVD simulations were developed by Monash University academic staff from four academic departments: nursing, occupational therapy, paramedics, and physiotherapy. Undergraduate students (n = 394) from these health science groups viewed the DVD simulations. Student perceptions and attitudes about the clinical relevance of the DVD simulations were assessed on a 7-point Likert-type scale standardized questionnaire (7 indicating the highest satisfaction score). Qualitative data were also collected from three focus groups that involved 24 students, assessing if and how the DVD simulations influenced the clinical fieldwork education placement learning experiences of the students. RESULTS: Overall, students' responses to the questionnaire indicated that they were satisfied with the DVD simulations with relation to attention (mean 4.25, SD 0.95), learning potential (mean 5.25, SD 1.16), clinical relevance to practice (mean 4.36, SD 0.60), and information-processing quality (mean 5.45, SD 0.23). Qualitative data supported the notions of interdisciplinary teamwork, clinical placements, clinical placement education, and DVD quality evaluation and feedback. CONCLUSION: Students viewed the simulations as being educationally, professionally, and clinically relevant. The cost benefit of using DVD simulations to replace or supplement components of clinical fieldwork education should be investigated further.

Lessons from the front lines: the prehospital experience of the 2009 novel H1N1 outbreak in Victoria, Australia.

The H1N1 (swine influenza) 2009 outbreak in Victoria, Australia, provided a unique opportunity to review the prehospital response to a public health emergency. As part of Ambulance Victoria's response to the outbreak, relevant emergency response plans and pandemic plans were instigated, focused efforts were aimed at encouraging the use of personal protective equipment (PPE), and additional questions were included in the call-taking script for telephone triage of emergency calls to identify potential cases of H1N1 from the point of call. As a result, paramedics were alerted to all potential cases of H1N1 influenza or any patient who met the current case definition before their arrival on the scene and were advised to use appropriate PPE. During the period of May 1 to July 2, Ambulance Victoria telephone triaged 1598 calls relating to H1N1 (1228 in metropolitan areas and 243 in rural areas) and managed 127 calls via a referral service that provides specific telephone triage for potential H1N1 influenza cases based on the national call-taking script. The referral service determines whether a patient requires an emergency ambulance or can be diverted to other resources such as flu clinics. Key lessons learned during the H1N1 outbreak include a focused need for continued education and communication regarding infection control and the appropriate use of PPE. Current guidelines regarding PPE use are adequate for use during an outbreak of infectious disease. Compliance with PPE needs to be addressed through the use of intra-agency communications and regular information updates early in the progress of the outbreak.