Adherence to protective measures among healthcare workers in the UK: a cross-sectional study.

BACKGROUND: Healthcare workers (HCWs) are frontline responders to emergency infectious disease outbreaks such as COVID-19. To avoid the rapid spread of disease, adherence to protective measures is paramount. We investigated rates of correct use of personal protective equipment (PPE), hand hygiene and physical distancing in UK HCWs who had been to their workplace at the start of the COVID-19 pandemic and factors associated with adherence. METHODS: We used an online cross-sectional survey of 1035 UK healthcare professionals (data collected 12-16 June 2020). We excluded those who had not been to their workplace in the previous 6 weeks, leaving us with a sample size of 831. Respondents were asked about their use of PPE, hand hygiene and physical distancing in the workplace. Frequency of uptake was reported descriptively; adjusted logistic regressions were used to separately investigate factors associated with adherence to use of PPE, maintaining good hand hygiene and physical distancing from colleagues. RESULTS: Adherence to personal protective measures was suboptimal (PPE use: 80.0%, 95% CI 77.3 to 82.8; hand hygiene: 67.8%, 95% CI 64.6 to 71.0; coming into close contact with colleagues: 74.7%, 95% CI 71.7 to 77.7). Adherence to PPE use was associated with having received training about health and safety in the workplace for COVID-19, greater perceived social pressure to adopt the behaviour and availability of PPE. Non-adherence was associated with fatalism about COVID-19 and greater perceived difficulty of adopting protective measures. Workplace design using markings to facilitate distancing was associated with adherence to physical distancing. CONCLUSIONS: Uptake of personal protective behaviours among UK HCWs at the start of the pandemic was variable. Factors associated with adherence provide insight into ways to support HCWs to adopt personal protective behaviours, such as ensuring that adequate PPE is available and designing workplaces to facilitate physical distancing.

Compression asphyxia and other clinicopathological findings from the Hillsborough Stadium disaster.

Ninety-six people died following a crowd crush at the Hillsborough Football Stadium, Sheffield, UK in 1989. The cause of death in nearly all cases was compression asphyxia. The clinical and pathological features of deaths encountered in crowds are discussed with a particular focus on the Hillsborough disaster.

Preparation for the next major incident: are we ready? Comparing major trauma centres and other hospitals.

OBJECTIVES: A major incident is any emergency requiring special arrangements by the emergency services. All hospitals are required by law to keep a major incident plan (MIP) detailing the response to such events. In 2006 and 2019, we assessed the preparedness and knowledge of key individuals in hospitals across England and found a substantial gap in responding to the MIP. In this report, we compare responses from doctors at major trauma centres (MTCs) and other hospitals (non-MTCs). METHODS: We identified trusts in England that received over 30 000 patients through the ED in the fourth quarter of 2016/2017. We contacted the on-call anaesthetic, emergency, general surgery and trauma and orthopaedic registrar at each location and asked three questions assessing their confidence in using their hospital's MIP: (1) Have you read your hospital's MIP? (2) Do you know where you can access your hospital's MIP guidelines? (3) Do you know what role you would play if an MIP came into effect while you are on call?We compared data from MTCs and non-MTCs using multinomial mixed proportional odds models. RESULTS: There was a modest difference between responses from individuals at MTCs and non-MTCs for question 2 (OR=2.43, CI=1.03 to 5.73, p=0.04) but no evidence of a difference between question 1 (OR=1.41, CI=0.55 to 3.63, p=0.47) and question 3 (OR=1.78, CI=0.86 to 3.69, p=0.12). Emergency medicine and anaesthetic registrars showed significantly higher preparedness and knowledge across all domains. No evidence of a systematic difference in specialty response by MTC or otherwise was identified. CONCLUSIONS: Confidence in using MIPs among specialty registrars in England remains low. Doctors at MTCs tended to be better prepared and more knowledgeable, but this effect was only marginally significant. We make several recommendations to improve education on major incidents.

Systematic review of medical student willingness to volunteer and preparedness for pandemics and disasters.

OBJECTIVE: This systematic review aimed to estimate the willingness of students to volunteer during a disaster, and how well-prepared medical students are for volunteering by assessing their knowledge and medical school curriculum of disaster and pandemic medicine. RESULTS: A total of 37 studies met inclusion criteria including 11 168 medical students and 91 medical schools. 24 studies evaluated knowledge (64.9%), 16 evaluated volunteering (43.2%) and 5 evaluated medical school curricula (13.5%). Weighted mean willingness to volunteer during a disaster was 68.4% (SD=21.7%, range=26.7%-87.8%, n=2911), and there was a significant difference between those planning to volunteer and those who actually volunteered (p<0.0001). We identified a number of modifiable barriers which may contribute to this heterogeneity. Overall, knowledge of disasters was poor with a weighted mean of 48.9% (SD=15.1%, range=37.1%-87.0%, n=2985). 36.8% of 76 medical schools curricula included teaching on disasters. However, students only received minimal teaching (2-6 hours). CONCLUSIONS: This study demonstrates that there is a large number of students who are willing to volunteer during pandemics. However, they are unlikely to be prepared for these roles as overall knowledge is poor, and this is likely due to minimal teaching on disasters at medical school. During the current COVID-19 pandemic and in future disasters, medical students may be required to volunteer as auxiliary staff. There is a need to develop infrastructure to facilitate this process as well as providing education and training to ensure students are adequately prepared to perform these roles safely.

Establishing a COVID-19 treatment centre in Israel at the initial stage of the outbreak: challenges, responses and lessons learned.

Anticipating the need for a COVID-19 treatment centre in Israel, a designated facility was established at Sheba Medical Center-a quaternary referral centre. The goals were diagnosis and treatment of patients with COVID-19 while protecting patients and staff from infection and ensuring operational continuity and treatment of patients with non-COVID. Options considered included adaptation of existing wards, building a tented facility and converting a non-medical structure. The option chosen was a non-medical structure converted to a hospitalisation facility suited for COVID-19 with appropriate logistic and organisational adaptations. Operational principles included patient isolation, unidirectional workflow from clean to contaminated zones and minimising direct contact between patients and caregivers using personal protection equipment (PPE) and a multimodal telemedicine system. The ED was modified to enable triage and treatment of patients with COVID-19 while maintaining a COVID-19-free environment in the main campus. This system enabled treatment of patients with COVID-19 while maintaining staff safety and conserving the operational continuity and the ability to continue delivery of treatment to patients with non-COVID-19.

UK healthcare staff experiences and perceptions of a mass casualty terrorist incident response: a mixed-methods study.

INTRODUCTION: System learning from major incidents is a crucial element of improving preparedness for response to any future incidents. Sharing good practice and limitations stimulates further actions to improve preparedness and prevents duplicating mistakes. METHODS: This convergent parallel mixed methods study comprises data from responses to an online survey and individual interviews with healthcare staff who took part in the responses to three terrorist incidents in the UK in 2017 (Westminster Bridge attack, Manchester Arena Bombing and London Bridge attack) to understand limitations in the response and share good practices. RESULTS: The dedication of NHS staff, staff availability and effective team work were the most frequently mentioned enabling factors in the response. Effective coordination between teams and a functional major incident plan facilitated an effective response. Rapid access to blood products, by positioning the blood bank in the ED, treating children and parents together and sharing resources between trauma centres were recognised as very effective innovative practices. Recent health emergency preparedness exercises (HEPEs) were valued for preparing both Trusts and individual staff for the response. Challenges included communication between ambulance services and hospitals, difficulties with patient identification and tracking and managing the return to 'normal' work patterns post event. Lack of immediately available clinical protocols to deal with blast injuries was the most commonly mentioned clinical issue. The need for psychosocial support for responding and supporting staff was identified. DISCUSSION: Between-agencies communication and information sharing appear as the most common recurring problems in mass casualty incidents (MCIs). Recent HEPEs, which allowed teams, interdisciplinary groups, and different agencies to practice responding to similar simulated incidents, were important and informed actions during the real response. Immediate and delayed psychosocial support should be in place for healthcare staff responding to MCIs.

Telehealth in the time of COVID-19.

Telehealth or using technology for a remote medical encounter has become an efficient solution for safe patient care during the severe acute respiratory syndrome coronavirus 2 or COVID-19 pandemic. This medium allows patient immediate healthcare access without the need for an in-person visit. We designed a time-sensitive, practical, effective and innovative scale-up of telehealth services as a response to the demand for COVID-19 evaluation and testing. As more patients made appointments through the institution's telehealth programme, we increased the number of clinicians available. JeffConnect, the acute care telehealth programme, was expanded to increase staffing from a standing staff of 37-187 doctors within 72 hours. Telehealth care clinicians primarily trained in emergency medicine, internal medicine and family medicine followed a patient decision pathway to risk stratify patients into three groups: home quarantine no testing, home quarantine with outpatient COVID-19 testing and referral for in-person evaluation in the ED, for symptomatic and potentially unstable patients.

What is the inter-rater agreement of injury classification using the WHO minimum data set for emergency medical teams?

BACKGROUND: In 2017, the WHO produced its first minimum data set (MDS) for emergency medical team (EMT) daily reporting during the sudden-onset disasters (SODs), following expert consensus. The MDS was deliberately designed to be simple in order to improve the rate of data capture; however, it is new and untested. This study assesses the inter-rater agreement between practitioners when performing the injury aspect of coding within the WHO EMT MDS. METHODS: 25 clinical case vignettes were developed, reflecting potential injuries encountered in an SOD. These were presented online from April to July 2018 to practitioners who have experience of/training in managing patients in SODs The practitioners were from UK-Med's members, Australian Medical Assistance Team's Northern Territory members and New Zealand Medical Assistance Team members. Practitioners were asked to code injuries according to WHO EMT MDS case classifications. Randolph's kappa statistic for free-marginal multirater data was calculated for the whole dataset as well as subgroups to ascertain inter-rater agreement. RESULTS: 86 practitioners responded (20.6% response rate), giving >2000 individual case responses. Overall agreement was moderate at 67.9% with a kappa of 0.59 (95% CI 0.49 to 0.69). Despite subgroups of paramedics (kappa 0.63, 95% CI 0.53 to 0.72), doctors (kappa 0.61, 95% CI 0.52 to 0.69) and those with disaster experience (kappa 0.62, 95% CI 0.52 to 0.71) suggesting slightly higher agreement, their CIs (and those of other subgroups) suggest overall similar and moderate levels of practitioner agreement in classifying injuries according to the MDS categories. CONCLUSIONS: An inter-rater agreement of 0.59 is moderate, at best, however, it gives ministries of health some sense of how tightly they may interpret injury data derived from daily reports using WHO EMT MDS. Furthermore, this kappa is similar to established but more complex (thus more contextually impractical) injury scores. Similar studies, with weighting for injury likelihood using sample data from SODs would further refine the level of expected inter-rater agreement.

Emergency department preparation for COVID-19: accelerated care units.

By 11 February 2020 when the WHO named the novel coronavirus (SARS-CoV-2) and the disease it causes (COVID-19), it was evident that the virus was spreading rapidly outside of China. Although San Francisco did not confirm its first locally transmitted cases until the first week of March, our ED and health system began preparing for a potential COVID-19 surge in late February 2020.In this manuscript, we detail how the above responses were instrumental in the rapid deployment of two military-grade negative-pressure medical tents, named accelerated care units (ACU). We describe engagement of our workforce, logistics of creating new care areas, ensuring safety through personal protective equipment access and conservation, and the adaptive leadership challenges that this process posed.We know of no other comprehensive examples of how EDs have prepared for COVID-19 in the peer-reviewed literature. Many other EDs both in and outside of California have requested access to the details of how we operationalised our ACUs to facilitate their own planning. This demonstrates the urgent need to disseminate this information to our colleagues. Below we describe the process of developing and launching our ACUs as a potential model for other EDs around the country.

Emergency medicine response to the COVID-19 pandemic in England: a phenomenological study.

BACKGROUND: The COVID-19 pandemic has stretched EDs globally, with many regions in England challenged by the number of COVID-19 presentations. In order to rapidly share learning to inform future practice, we undertook a thematic review of ED operational experience within England during the pandemic thus far. METHODS: A rapid phenomenological approach using semistructured telephone interviews with ED clinical leads from across England was undertaken between 16 and 22 April 2020. Participants were recruited through purposeful sampling with sample size determined by data saturation. Departments from a wide range of geographic distribution and COVID-19 experience were included. Themes were identified and included if they met one of three criteria: demonstrating a consistency of experience between EDs, demonstrating a conflict of approach between emergency departments or encapsulating a unique solution to a common barrier. RESULTS: Seven clinical leads from type 1 EDs were interviewed. Thematic redundancy was achieved by the sixth interview, and one further interview was performed to confirm. Themes emerged in five categories: departmental reconfiguration, clinical pathways, governance and communication, workforce and personal protective equipment. CONCLUSION: This paper summarises learning and innovation from a cross-section of EDs during the first UK wave of the COVID-19 pandemic. Common themes centred around the importance of flexibility when reacting to an ever-changing clinical challenge, clear leadership and robust methods of communication. Additionally, experience in managing winter pressures helped inform operational decisions, and ED staff demonstrated incredible resilience in demanding working conditions. Subsequent surges of COVID-19 infections may occur within a more challenging context with no guarantee that there will be an associated reduction in A&E attendance or cessation of elective activity. Future operational planning must therefore take this into consideration.

Occupational exposures and programmatic response to COVID-19 pandemic: an emergency medical services experience.

Rigorous assessment of occupational COVID-19 risk and personal protective equipment (PPE) use is not well-described. We evaluated 9-1-1 emergency medical services (EMS) encounters for patients with COVID-19 to assess occupational exposure, programmatic strategies to reduce exposure and PPE use. We conducted a retrospective cohort investigation of laboratory-confirmed patients with COVID-19 in King County, Washington, USA, who received 9-1-1 EMS responses from 14 February 2020 to 26 March 2020. We reviewed dispatch, EMS and public health surveillance records to evaluate the temporal relationship between exposure and programmatic changes to EMS operations designed to identify high-risk patients, protect the workforce and conserve PPE. There were 274 EMS encounters for 220 unique COVID-19 patients involving 700 unique EMS providers with 988 EMS person-encounters. Use of 'full' PPE including mask (surgical or N95), eye protection, gown and gloves (MEGG) was 67%. There were 151 person-exposures among 129 individuals, who required 981 quarantine days. Of the 700 EMS providers, 3 (0.4%) tested positive within 14 days of encounter, though these positive tests were not attributed to occupational exposure from inadequate PPE. Programmatic changes were associated with a temporal reduction in exposures. When stratified at the study encounters midpoint, 94% (142/151) of exposures occurred during the first 137 EMS encounters compared with 6% (9/151) during the second 137 EMS encounters (p<0.01). By the investigation's final week, EMS deployed MEGG PPE in 34% (3579/10 468) of all EMS person-encounters. Less than 0.5% of EMS providers experienced COVID-19 illness within 14 days of occupational encounter. Programmatic strategies were associated with a reduction in exposures, while achieving a measured use of PPE.

Crisis clinical pathway for COVID-19.

The pandemic of COVID-19 has been particularly severe in the New York City area, which has had one of the highest concentrations of cases in the USA. In March 2020, the EDs of New York-Presbyterian Hospital, a 10-hospital health system in the region, began to experience a rapid surge in patients with COVID-19 symptoms. Emergency physicians were faced with a disease that they knew little about that quickly overwhelmed resources. A significant amount of attention has been placed on the problem of limited supply of ventilators and intensive care beds for critically ill patients in the setting of the ongoing global pandemic. Relatively less has been given to the issue that precedes it: the demand on resources posed by patients who are not yet critically ill but are unwell enough to seek care in the ED. We describe here how at one institution, a cross-campus ED physician working group produced a care pathway to guide clinicians and ensure the fair and effective allocation of resources in the setting of the developing public health crisis. This 'crisis clinical pathway' focused on using clinical evaluation for medical decision making and maximising benefit to patients throughout the system.

Strategic planning and response to COVID-19 in a London emergency department.

For many of us in emergency medicine, rising to the challenge of the COVID-19 crisis will be the single most exciting and challenging episode of our careers. Lessons have been learnt on how to make quick and effective changes without being hindered by the normal restraints of bureaucracy. Changes that would normally have taken months to years to implement have been successfully introduced over a period of several weeks. Although we have managed these changes largely by command and control, compassionate leadership has identified leaders within our team and paved the way for the future. This article covers the preparation and changes made in response to COVID-19 in a London teaching hospital.

Emergency department 'outbreak rostering' to meet challenges of COVID-19.

The COVID-19 outbreak has posed unique challenges to the emergency department rostering. Additional infection control, the possibility of quarantine of staff and minimising contact among staff have significant impact on the work of doctors in the emergency department. Infection of a single healthcare worker may require quarantine of close contacts at work. This may thus affect a potentially large number of staff. As such, we developed an Outbreak Response Roster. This Outbreak Response Roster had fixed teams of doctors working in rotation, each team that staff the emergency department in turn. Members within teams remained constant and were near equally balanced in terms of manpower and seniority of doctors. Each team worked fixed 12 hours shifts with as no overlapping of staff or staggering of shifts. Handovers between shifts were kept as brief as possible. All these were measures to limit interactions among healthcare workers. With the implementation of the roster, measures were also taken to bolster the psychological wellness of healthcare workers. With face-to-face contact limited, we also had to maintain clear, open channels for communication through technology and continue educating residents through innovative means.

Close air support: enhancing emergency care in the COVID-19 pandemic.

The COVID-19 pandemic has taken the world by storm and overwhelmed healthcare institutions even in developed countries. In response, clinical staff and resources have been redeployed to the areas of greatest need, that is, intensive care units and emergency rooms (ER), to reinforce front-line manpower. We introduce the concept of close air support (CAS) to augment ER operations in an efficient, safe and scalable manner. Teams of five comprising two on-site junior ER physicians would be paired with two CAS doctors, who would be off-site but be in constant communication via teleconferencing to render real-time administrative support. They would be supervised by an ER attending. This reduces direct viral exposure to doctors, conserves precious personal protective equipment and allows ER physicians to focus on patient care. Medical students can also be involved in a safe and supervised manner. After 1 month, the average time to patient disposition was halved. General feedback was also positive. CAS improves efficiency and is safe, scalable and sustainable. It has also empowered a previously untapped group of junior clinicians to support front-line medical operations, while simultaneously protecting them from viral exposure. Institutions can consider adopting our novel approach, with modifications made according to their local context.

Preparation for the next major incident: are we ready? A 12-year update.

OBJECTIVES: A major incident is any emergency that requires special arrangements by the emergency services and generally involves a large number of people. Recent such events in England have included the Manchester Arena bombing and the Grenfell Tower disaster. Hospitals are required by law to keep a major incident plan (MIP) outlining the response to such an event. In a survey conducted in 2006 we found a substantial knowledge gap among key individuals that would be expected to respond to the enactment of an MIP. We set out to repeat this survey study and assess any improvement since our original report. METHODS: We identified NHS trusts in England that received more than 30 000 patients through the emergency department in the fourth quarter of the 2016/2017 period. We contacted the on-call anaesthetic, emergency, general surgery, and trauma and orthopaedic registrar at each location and asked each individual to answer a short verbal survey assessing their confidence in using their hospital's MIP. RESULTS: Of those eligible for the study, 62% were able to be contacted and consented to the study. In total 50% of respondents had read all or part of their hospital's MIP, 46.8% were confident that they knew where their plan was stored, and 36% knew the role they would play if a plan came into effect. These results show less confidence among middle-grade doctors compared with 2006. CONCLUSIONS: Confidence in using MIPs among specialty registrars in England is still low. In light of this, we make a number of recommendations designed to improve the education of hospital doctors in reacting to major incidents.

Improvised first aid techniques for terrorist attacks.

Terrorist acts occur every day around the world. Healthcare professionals are often present as bystander survivors in these situations, with none of the equipment or infrastructure they rely on in their day-to-day practice. Within several countries there has been a move to disseminate the actions to take in the event of such attacks: in the UK, Run, Hide, Tell, and in the USA, Fight Back This paper outlines how a very basic medical knowledge combined with everyday high-street items can render highly effective first aid and save lives. We discuss and summarise modern improvised techniques. These include the ABCDE approach of treating catastrophic haemorrhage before airway management, bringing together improvised techniques from the military and wilderness medicine. We explain how improvised tourniquets, wound dressings, splinting and traction devices can be fabricated using items from the high street: nappies, tampons, cling film, duct tape and tablecloths. Cervical spine immobilisation is a labour-intensive protocol that is often practised defensively. With little evidence to support the routine use of triple immobilisation, this should be replaced with a common sense dynamic approach such as the Montana neck brace. Acid or alkali attacks are also examined with simple pragmatic advice. Analgesia is discussed in the context of a prehospital setting. Pharmacy-obtained oral morphine and diclofenac suppositories can be used to treat moderate pain without relying on equipment for intravenous/intraosseous infusion in prolonged hold situations. The differentiation between concealment and cover is summarised: scene safety remains paramount.

Marauding terrorist attack (MTA): prehospital considerations.

Terrorist attacks are increasing each year as are the number of deaths associated with them. Recent incidents have seen a shift in tactics with the use of multiple terrorists across multiple locations with firearms or knives, referred to as the marauding terrorist attack. These methods are becoming more prevalent alongside the use of vehicles deliberately aimed at pedestrians. Management of these incidents can be challenging. Not only it involves a large number of casualties but also the management of a dynamic scene in terms of both location and threat from attack. In order to improve response, and potentially outcomes, a system or response needs to have preplanned and practised procedures in place. This article reviews major incident management for those unfamiliar with current prehospital practice and details some of the findings from recent marauding terrorist firearm attacks, in particular the evolution of newer scene management tools such as 3 Echo and THREAT. It highlights the importance of haemorrhage control and the public initiatives focusing on actions during a terrorist incident.

Procedural sedation and analgesia in the emergency room of a field hospital after the Nepal earthquake.

Procedural sedation and analgesia (PSA) should be a priority in the emergency care of injured children. This humanistic approach is particularly important in paediatric victims of disaster, because these patients are prone to psychological distress secondary to the traumatic event. Following the Nepal earthquake, an Israeli field hospital (IFH) was deployed in Kathmandu. We report our experience with PSA in the emergency room (ER) of the IFH. 22 children underwent surgery in the operating room and 10 underwent PSA in the ER by paediatric emergency physicians: 6 had wound debridement, 2 had fracture reduction and 2 had laceration repair. All the procedures were successfully completed in the ER and no patient required intubation or admission to the intensive care unit due to an adverse event. The present study is the first report of the practice of paediatric PSA by non-anaesthesiologists in a field hospital.