How interventions to maintain services during the COVID-19 pandemic strengthened systems for delivery of maternal and child health services: a case-study of Wakiso District, Uganda

BACKGROUND

Health systems are resilient if they absorb, adapt, and transform in response to shocks. Although absorptive and adaptive capacities have been demonstrated during the COVID-19 response, little has been documented about their transformability and strengthened service delivery systems. We aimed to describe improvements in maternal and child health service delivery as a result of investments during the COVID-19 response.

METHODS

This was a descriptive case study conducted in Wakiso District in central Uganda. It included 21 nurses and midwives as key informants and 32 mothers in three focus group discussions. Data were collected using an interview guide following the Systems Engineering Initiative for Patient Safety theoretical framework for service delivery.

RESULTS

Maternal and child health service delivery during the pandemic involved service provision without changes, service delivery with temporary changes and outcomes, and service delivery that resulted into sustained changes and outcomes. Temporary changes included patient schedule adjustments, community service delivery and negative outcomes such as increased workload and stigma against health workers. Sustained changes that strengthened service delivery included new infrastructure and supplies such as ambulances and equipment, new roles involving infection prevention and control, increased role of community health workers and outcomes such as improved workplace safety and teamwork.

CONCLUSIONS

In spite of the negative impact the COVID-19 pandemic had on health systems, it created the impetus to invest in system improvements. Investments such as new facility infrastructure and emergency medical services were leveraged to improve maternal and child health services delivery. The inter-departmental collaboration during the response to the COVID-19 pandemic resulted into an improved intra-hospital environment for other service delivery. However, there is a need to evaluate lessons beyond health facilities and whether these learnings are deliberately integrated into service delivery. Future responses should also address the psychological and physical impacts suffered by health workers to maintain service delivery.

Experience of moral distress among doctors at emergency departments in Stockholm during the Covid-19 pandemic: a qualitative interview study

PURPOSE

The COVID-19 pandemic and consequent strain on healthcare globally shed light on the concept of moral distress among healthcare workers, albeit to a smaller extent among doctors at emergency departments. This study aimed to examine moral distress as perceived by medical doctors working at emergency departments in Stockholm during the pandemic, with the purpose of investigating causes of moral distress and methods to manage moral distress.

METHODS

Semi-structured interviews were conducted with twelve doctors working at two emergency departments. A questionnaire was developed based on previous research and the interviews were analysed qualitatively through thematic analysis.

RESULTS

The themes "The factors that precipitated moral distress", "Experience of workplace support" and "Coping strategies" as well as seven subthemes and 15 codes were identified. The informants reported on various situations with different causes of moral distress. Common causes were resource depletion, such as hospital bed shortages, and following stricter triage criteria. Informants reported varying ways of managing moral distress.

CONCLUSIONS

Informants experienced moral distress when faced with challenges such as resource depletion, rules and regulations, and colleagues' decisions. The informants who chose to seek support received it from their workplace, which helped them cope with their experiences. Some informants chose to not seek support.

TAK-242 improves sepsis-associated acute kidney injury in rats by inhibiting the TLR4/NF-κB signaling pathway

OBJECTIVE

This study was designed to observe the effect of toll-like receptor 4 (TLR4)/nuclear factor kappa-B (NF-κB) pathway activity on sepsis-associated acute kidney injury (SA-AKI), thereby providing new considerations for the prevention and treatment of SA-AKI.

METHODS

The rats were divided into Sham, cecal ligation and puncture (CLP), CLP + vehicle, and CLP + TAK-242 groups. Except the Sham group, a model of CLP-induced sepsis was established in other groups. After 24 h, the indicators related to kidney injury in blood samples were detected. The pathological changes in the kidneys were observed by hematoxylin-eosin staining, and tubular damage was scored. Oxidative stress-related factors, mitochondrial dysfunction-related indicators in each group were measured; the levels of inflammatory factors in serum and kidney tissue of rats were examined. Finally, the expression of proteins related to the TLR4/NF-κB signaling pathway was observed by western blot.

RESULTS

Compared with the CLP + vehicle and CLP + TAK-242 groups, the CLP + TAK-242 group reduced blood urea nitrogen (BUN), creatinine (Cr), cystatin-C (Cys-C), reactive oxygen species (ROS), malondialdehyde (MDA), and inflammatory factors levels (p < 0.01), as well as increased superoxide dismutase (SOD) activity of CLP rats (p < 0.01). Additionally, TAK-242 treatment improved the condition of CLP rats that had glomerular and tubular injuries and mitochondrial disorders (p < 0.01). Further mechanism research revealed that TAK-242 can inhibit the TLR4/NF-κB signaling pathway activated by CLP (p < 0.01). Above indicators after TAK-242 treatment were close to those of the Sham group.

CONCLUSION

TAK-242 can improve oxidative stress, mitochondrial dysfunction, and inflammatory response by inhibiting the activity of TLR4/NF-κB signaling pathway, thereby preventing rats from SA-AKI.

Nursing student's experiences of Role-Play Scenario-Based Disaster Triage (START) training: A qualitative research

BACKGROUND

Disasters can overwhelm healthcare systems, making effective triage a crucial skill for nurses. Role-Play Scenario-Based Disaster Triage Training offers a promising approach to prepare nursing students for these situations. Understanding students' experiences with this training method can inform its development and effectiveness in fostering disaster preparedness. However, little is known about this training experience of nursing students. In particular, by examining the challenges faced by students, the emotional distress they experience and their achievements, it will provide guidance for the development of education programs in a more comprehensive and student-oriented manner.

AIM

The aim of this study is to elucidate the experiences of nursing students regarding Role-Play Scenario-Based Disaster Triage Training.

DESIGN AND METHODS

A qualitative approach was employed to comprehend participating students' experiences. Face-to-face and online semi-structured interviews were conducted with 17 students using an interview guide, and the interactions were recorded for subsequent analysis. Thematic analysis was employed to develop themes.

RESULTS

The study results emphasize the challenges experienced by students during triage training, their gains and the support they need to cope with the challenges they experience. Data were organized around four main themes: "Challenges of the triage process" with subthemes such as "Thinking of the actual earthquake moment" and "Ethical dilemmas"; "Emotional turmoil" with subthemes including "Anxiety" and "Fear and Helplessness"; "Achievements" with subthemes such as "Increase in knowledge and skills" and "The importance of the nurse"; and "Suggestions" with subthemes including "Continuous education" and "Mandatory course".

CONCLUSIONS

The findings of the study provide new insights into the experiences of nursing students during the disaster triage process. The results may contribute to the improvement of future training programs by identifying the challenges and needs faced by nursing students after disaster triage education.

Effect of early initiation of noninvasive ventilation in patients transported by emergency medical service for acute heart failure

BACKGROUND

While the indication for noninvasive ventilation (NIV) in severely hypoxemic patients with acute heart failure (AHF) is often indicated and may improve clinical course, the benefit of early initiation before patient arrival to the emergency department (ED) remains unknown.

OBJECTIVE

This study aimed to assess the impact of early initiation of NIV during emergency medical service (EMS) transportation on outcomes in patients with AHF.

DESIGN

A secondary retrospective analysis of the EAHFE (Epidemiology of AHF in EDs) registry.

SETTING

Fifty-three Spanish EDs.

PARTICIPANTS

Patients with AHF transported by EMS physician-staffed ambulances who were treated with NIV at any time during of their emergency care were included and categorized into two groups based on the place of NIV initiation: prehospital (EMS group) or ED (ED group).

OUTCOME MEASURES

Primary outcome was the composite of in-hospital mortality and 30-day postdischarge death, readmission to hospital or return visit to the ED due to AHF. Secondary outcomes included 30-day all-cause mortality after the index event (ED admission) and the different component of the composite primary endpoint considered individually. Multivariate logistic regressions were employed for analysis.

RESULTS

Out of 2406 patients transported by EMS, 487 received NIV (EMS group: 31%; EMS group: 69%). Mean age was 79 years, 48% were women. The EMS group, characterized by younger age, more coronary artery disease, and less atrial fibrillation, received more prehospital treatments. The adjusted odds ratio (aOR) for composite endpoint was 0.66 (95% CI: 0.42-1.05). The aOR for secondary endpoints were 0.74 (95% CI: 0.38-1.45) for in-hospital mortality, 0.74 (95% CI: 0.40-1.37) for 30-day mortality, 0.70 (95% CI: 0.41-1.21) for 30-day postdischarge ED reconsultation, 0.80 (95% CI: 0.44-1.44) for 30-day postdischarge rehospitalization, and 0.72 (95% CI: 0.25-2.04) for 30-day postdischarge death.

CONCLUSION

In this ancillary analysis, prehospital initiation of NIV in patients with AHF was not associated with a significant reduction in short-term outcomes. The large confidence intervals, however, may preclude significant conclusion, and all point estimates consistently pointed toward a potential benefit from early NIV initiation.

Emergency reflex action drill for traumatic cardiac arrest in a simulated pre-hospital setting; a one-group pre-post intervention study

BACKGROUND

Emergency Reflex Action Drills (ERADs) are meant to decrease stress-associated cognitive demand in high urgency situations. The aim of this study was to develop and test an ERAD for witnessed traumatic cardiac arrest (TCA), an event in which potentially reversible causes need to be systematically addressed and treated in a short period of time. We hypothesize that this ERAD (the TCA-Drill) helps ground Emergency Medical Services (EMS) nurses in overcoming performance decline during this specific high-pressure situation.

METHODS

This was a prospective, experimental one-group pre-post intervention study. Ground EMS nurses participated in a session of four simulated scenarios, with an in-between educational session to teach the TCA-Drill. Scenarios were video recorded, after which adherence and time differences were analyzed. Self-confidence on clinical practice was measured before and after the scenarios.

RESULTS

Twelve ground EMS nurses participated in this study. Overall median time to address reversible causes of TCA decreased significantly using the TCA-Drill (132 vs. 110 s; p = 0.030) compared with the conventional ALS strategy. More specifically, participants adhering to the TCA-Drill showed a significantly lower time needed for hemorrhage control (58 vs. 37 s; p = 0.012). Eight of 12 (67 %) ground EMS nurses performed the ERAD without protocol deviations. Reported self-confidence significantly increased on 11 of the 13 surveyed items.

CONCLUSIONS

The use of an ERAD for TCA (the TCA-Drill) significantly reduces the time to address reversible causes for TCA without delaying chest compressions in a simulated environment and can be easily taught to ground EMS nurses and increases self-confidence.

IMPLICATIONS FOR CLINICAL PRACTICE

The use of an ERAD for TCA (the TCA-Drill can significantly reduce the time to address reversible causes for TCA without delaying chest compression. This drill can be easily taught to ground EMS nurses and increases their self-confidence in addressing TCA-patients.

Reduced estrogenic risks of a sunscreen additive: Theoretical design and evaluation of functionally improved salicylates

Salicylic esters (SEs), the widely used ultraviolet (UV) absorbers in sunscreen products, have been found to have health risks such as skin sensitization and estrogenic effects. This study aims to design SE substitutes that maintain high UV absorbance while reducing estrogenicity. Using molecular docking and Gaussian09 software for initial assessments and further application of a combination of two-dimensional and three-dimensional quantitative structure-activity relationships (2D-QSAR and 3D-QSAR, respectively) models, we designed 73 substitutes. The best-performing molecules, ethylhexyl salicylate (EHS)-5 and EHS-15, significantly reduced estrogenicity (44.54 % and 17.60 %, respectively) and enhanced UV absorbance (249.56 % and 46.94 %, respectively). Through screening for human health risks, we found that EHS-5 and EHS-15 were free from skin sensitivity and eye irritation and exhibited reduced skin permeability compared with EHS. Furthermore, the photolysis and synthetic pathways of EHS-5 and EHS-15 were deduced, demonstrating their good photodegradability and potential synthesizability. In addition, we analyzed the mechanisms underlying the changes in estrogenic effects and UV absorption properties. We identified covalent hydrogen bond basicity and acidity Propgen value for atomic molecular properties and the highest occupied molecular orbital eigenvalue as the main factors affecting the estrogenic effect and UV absorbance of SEs, respectively. This study focuses on the design and screening of SEs, exhibiting enhanced functionality, reduced health risks, and synthetic feasibility.

Review of scientific research on air quality and environmental health risk and impact for PICTS

Air quality (AQ) significantly impacts human health, influenced by both natural phenomena and human activities. In 2021, heightened awareness of AQ's health impacts prompted the revision of the World Health Organization (WHO) guidelines, advocating for stricter pollution standards. However, research on AQ has predominantly focused on high-income countries and densely populated cities, neglecting low- and middle-income countries, particularly Pacific Island Countries, Territories, and States (PICTS). This systematic review compiles existing peer-reviewed literature on AQ research in PICTS to assess the current state of knowledge and emphasize the need for further investigation. A systematic literature search yielded 40 papers from databases including Web of Science, Scopus, and Embase. Among the 26 PICTS, only 6 (Hawai'i, Fiji, Papua New Guinea, New Caledonia, Republic of Marshall Islands, and Pacific) have been subject to AQ-related research, with 4 considering the World Health Organization (WHO) parameters and 26 addressing non-WHO parameters. Analysis reveals AQ parameters often exceed 2021 WHO guidelines for PM2.5, PM10, SO2, and CO, raising concerns among regional governments. Studies primarily focused on urban, agricultural, rural, and open ocean areas, with 15 based on primary data and 14 on both primary and secondary sources. Research interests and funding sources dictated the methods used, with a predominant focus on environmental risks over social, economic, and technological impacts. Although some papers addressed health implications, further efforts are needed in this area. This review underscores the urgent need for ongoing AQ monitoring efforts in PICTS to generate spatially and temporally comparable data. By presenting the current state of AQ knowledge, this work lays the foundation for coordinated regional monitoring and informs national policy development.

Impact of anthropometric factors on chest compression depth during CPR provided by children aged 11-14 in a community-wide study

Objective

To assess the depth of chest compressions (CC) provided by schoolchildren and their relation with providers's anthropometric characteristics.

Methods

We organized 1-hour hands-on training sessions for 11-14y.o. in volunteering schools. After training, willing subjects performed 2 min of recorded continuous CCs by means of Laerdal Resusci Anne® with CPRMeter2®, with visual feedback. Compression pace was given by metronome; instructors supervised the correct body position. Collected data included age, sex, as well as measured body weight and height.

Results

We analyzed records from N = 702 children (mean age: 12.76 ± 1.02 years, 379 (51.63%) boys) out of 761 participating in the study. Their mean median compression depth (MCD) was 46.70 ± 7.74 mm, which was below minimal effective CC depth advised by current guidelines (50 mm). This corresponded to low mean fraction of CCs ≥ 50 mm (CCF ≥ 50 mm, 42.86 ± 33.67%), and only 42.88% of children achieving at least 50% of compressions ≥ 50 mm. Boys had significantly higher mean MCD and CCF ≥ 50 mm than girls (MCD: 49.34 ± 7.05 mm vs 45.97 ± 8.07 mm, p < 0.0001; CCF ≥ 50 mm: 50.23 ± 32.90% vs 40.40 ± 34.97%, p < 0.0001). Age differentiated children who achieved at least 50% of compressions ≥50 mm from those who did not with AUC of 0.69 (for cut-off of 12.1 years: 85% sensitivity, 41% specificity), whereas weight offered an improved prediction (AUC 0.74; for cut-off 44.8 kg: 77.4% sensitivity, 61.1% specificity).

Conclusions

Sex, age and anthropometric factors are significant CC quality factors. Children with higher body weight are more likely to deliver CCF50%≥50 mm. Among the studied population, children ≥12 years old provided more effective chest compressions.

Moderate Traumatic Brain Injury in Adult Population: The Latin American Brain Injury Consortium Consensus for Definition and Categorization

Moderate traumatic brain injury (TBI) is a diagnosis that describes diverse patients with heterogeneity of primary injuries. Defined by a Glasgow Coma Scale between 9 and 12, this category includes patients who may neurologically worsen and require increasing intensive care resources and/or emergency neurosurgery. Despite the unique characteristics of these patients, there have not been specific guidelines published before this effort to support decision-making in these patients. A Delphi consensus group from the Latin American Brain Injury Consortium was established to generate recommendations related to the definition and categorization of moderate TBI. Before an in-person meeting, a systematic review of the literature was performed identifying evidence relevant to planned topics. Blinded voting assessed support for each recommendation. A priori the threshold for consensus was set at 80% agreement. Nine PICOT questions were generated by the panel, including definition, categorization, grouping, and diagnosis of moderate TBI. Here, we report the results of our work including relevant consensus statements and discussion for each question. Moderate TBI is an entity for which there is little published evidence available supporting definition, diagnosis, and management. Recommendations based on experts' opinion were informed by available evidence and aim to refine the definition and categorization of moderate TBI. Further studies evaluating the impact of these recommendations will be required.

Effects of mass casualty incidents on anxiety, depression, and post-traumatic stress disorder among doctors and nurses: a systematic review

OBJECTIVES

Doctors and nurses suffer different mental health conditions following traumatic incidents. We systematically synthesized existing evidence on the prevalence of anxiety, depression, and post-traumatic stress disorder (PTSD) and their associated risk factors among doctors and nurses following mass casualty incidents (MCIs).

STUDY DESIGN

Systematic review.

METHODS

Seven databases were searched (2010-2022) with peer-reviewed articles in English using the predefined keywords. Two reviewers screened the titles, abstracts, and full texts using the eligibility criteria and extracted data independently. We used the National Institutes of Health Quality Assessment Tools (NIH-QAT) and the Critical Appraisal Skills Programme checklist (CASP) to measure the quality appraisal of the included studies.

RESULTS

A total of 5170 articles were retrieved, and 2512 articles were assessed by title and abstract (53 were eligible for full-text review). Finally, we included 19 studies. Most were assessed as of fair quality with a considerable risk of bias. PTSD was the highest-reported mental health condition. Nurses reported higher mental conditions, particularly PTSD. Two sets of risk factors (personal and workplace) are associated with anxiety, depression, and PTSD were found.

CONCLUSIONS

MCIs have a significant impact on the mental health outcomes of emergency health workers. Preventive measures should be designed considering the high-risk group, personal, and organizational risk factors of mental health outcomes.

A cross-sectional survey of Australian service providers' emergency preparedness capabilities

PURPOSE

Emergency and disaster management planning is an emerging role with limited practical guidance on how it should be implemented by community, disability, health and rehabilitation service providers. This study examined the emergency preparedness of service providers and how they viewed their role and contributions to disaster risk reduction, including their capacity and willingness to facilitate preparedness planning with their clients.

MATERIALS AND METHODS

A questionnaire was developed and administered nationally. Descriptive statistics, multivariate regression analyses, and thematic analysis of open-ended questions provide insight on the knowledge, tools and training needs of service providers to contribute to preparedness of themselves and the people they support.

RESULTS

Facilitating emergency preparedness with people with disability was strongly associated with a high level of mental preparedness, household preparedness scores, and completion of Person-Centred Emergency Preparedness (P-CEP) training. Perceived lack of funding, insufficient tools, and exclusion of emergency planning from job descriptions were negatively associated with facilitating emergency preparedness with clients.

CONCLUSIONS

Study findings lay the groundwork for development of the role and capabilities of individual service providers including the need to equip disability, health and rehabilitation service providers with training and tools to prepare themselves and the people they support for emergencies.

Mortality predictors in earthquake victims admitted to intensive care unit in Kahramanmaraş earthquakes

BACKGROUND

The purpose of this study is to report the data for patients followed-up in our intensive care unit due to the 6th February 2023, earthquake in Kahramanmaraş, Türkiye, and to investigate parameters affecting mortality.

METHODS

The demographic characteristics of patients followed-up in intensive care due to trauma following the earthquake, the treatments administered, developing complications, lengths of stay in the hospital and intensive care, and laboratory data were scanned retrospectively and recorded. These data were then compared between the surviving and non-surviving patients.

RESULTS

Twenty-six patients, 13 (50 %) male, were followed-up in our intensive care, 24 (92 %) due to being buried under earthquake debris, and 2 (8 %) due to falling from heights. Increased Sequential Organ Failure Assessment (SOFA) (p = 0.027), higher initial serum potassium (p = 0.043), higher initial serum phosphorus (p = 0.035), higher initial and peak serum magnesium (p = 0.004 and p = 0.001), lower initial and peak bicarbonate (p = 0.021 and p = 0.012) and higher initial and peak serum base deficit values (p = 0.012 and p = 0.009) were associated with mortality. In the subgroup with crush injuries, higher initial and peak serum potassium (p = 0.001 and p = 0.025), higher initial and peak serum magnesium (p = 0.005 and p = 0.004), lower initial and peak bicarbonate (p = 0.019 and p = 0.021) and higher initial and peak serum base deficit values (p = 0.017 and p = 0.025) were associated with mortality. Multiorgan dysfunction failure developed in nine patients, sepsis in seven, dissemine intravascular coagulation in four, and acute respiratory distress syndrome in two. Fasciotomy was performed on 2 (8 %) patients and amputation on 8 (31 %). Extremity injuries were most frequently observed. 10 (38.5 %) of the 12 (46 %) patients developing acute kidney injury required renal replacement therapy. 7 (27 %) patients died during follow-up. In logistic regression analysis, higher SOFA scores, lower initial bicarbonate and BE levels, higher serum initial potassium and magnesium levels were a risk factor for mortality. Higher SOFA scores, lower initial bicarbonate and base deficit and higher initial phosphorus values affected mortality in patients with crush syndrome.

CONCLUSION

Not only increased SOFA, serum potassium, serum phosphorus, and serum magnesium, but also decreased bicarbonate, and base deficit were associated with mortality in earthquake victims with crush syndrome in ICU.

International facets of the 'chain of survival' for out-of-hospital and in-hospital cardiac arrest - A scoping review

Background

The "chain of survival" was first systematically addressed in 1991, and its sequence still forms the cornerstone of current resuscitation guidelines. The term "chain of survival" is widely used around the world in literature, education, and awareness campaigns, but growing heterogeneity in the components of the chain has led to confusion. It is unclear which of these emerging chains is most suitable, or if adaptations are needed in particular contexts to depict key actions of resuscitation in the 21st century. This scoping review provides an overview of the variety of chains of survival described.

Objectives

To identify published facets of the chain of survival, to assess views and strategies about adapting the chain, and to identify reports on how the chain of survival affects teaching, implementation, or patient outcomes.

Methods eligibility criteria and sources of evidence

A scoping review as part of the continuous evidence evaluation process of the International Liaison Committee on Resuscitation (ILCOR) was conducted. MEDLINE(R) ALL (Ovid), Embase (Ovid), APA PsycINFO (Ovid), CINAHL (Ebscohost), ERIC (Ebscohost), Web of Science (Clarivate), Scopus (Elsevier), and Cochrane Library (Wiley Online) were searched. All publications in all languages describing chains of survival were eligible, without time restrictions. Due to the heterogeneity and publication types of the relevant studies, we did not pursue a systematic review or meta-analysis.

Results

A primary search yielded 1713 studies and after screening we included 43 publications. Modified versions of the chain of survival for specific contexts were found (e.g., in-hospital cardiac arrest or paediatric resuscitation). There were also numerous versions with minor adaptations of the existing chain. Three publications suggested an impact of the use of the chain of survival on patient outcomes. No educational or implementation outcomes were reported.

Conclusion

There is a vast heterogeneity of chain of survival concepts published. Future research is warranted, especially into the concept's importance concerning educational, implementation, and clinical outcomes.

[Prehospital care of anaphylactic reactions by the air rescue and ground-based emergency services Dresden : An analysis of treatment and outcome]

BACKGROUND

Anaphylaxis can lead to a life-threatening situation. Therefore, rapid diagnosis and emergency treatment is indicated. Immediate treatment with intramuscular adrenaline (or intravascularly with sufficient medical expertise) in anaphylaxis with cardiovascular and/or respiratory symptoms is recommended by various guidelines. Previous studies have shown that anaphylaxis is often not treated according to guidelines and that adrenaline in particular is rarely administered.

OBJECTIVE

The aim of the study was to investigate the data on emergency treatment and outcomes of patients with anaphylaxis by the air rescue and ground-based emergency services Dresden. Moreover, the results of the air- and ground-based services were compared. The focus was on administration of adrenaline and outcomes.

MATERIALS AND METHODS

Data from the ground-based emergency service Dresden (from 2012 to 2016) and the air rescue service Dresden (from 2008 to 2015) related to anaphylactic reactions were analyzed retrospectively. The severity of the anaphylaxis, the emergency medication administered, further monitoring, and outcomes were analyzed.

RESULTS

Data from 152 adults/29 children were analyzed for air rescue and 1131 adults/223 children for the ground-based emergency service. Adults with grade II-IV anaphylaxis received adrenaline in 19% (air rescue) and 7% (ground rescue) of cases. Children with grade II-IV anaphylaxis received adrenaline in 7% (air rescue) and 8% (ground rescue) of cases. Immediate drug therapy led to an improvement in general condition in 96-98% (air rescue) and 72-77% (ground-based emergency service) of cases. A significant correlation was found between the administration of adrenaline and the improvement in outcome in the ground-based emergency cohort.

CONCLUSION

Guideline-compliant first-line therapy with adrenaline was not performed in the majority of the cases analyzed in this study. The significant effect of adrenaline on outcome demonstrated in this study emphases the need to improve the emergency treatment of anaphylactic reactions.

Towards reliable forecasting of healthcare capacity needs: A scoping review and evidence mapping

BACKGROUND

The COVID-19 pandemic has highlighted the critical importance of robust healthcare capacity planning and preparedness for emerging crises. However, healthcare systems must also adapt to more gradual temporal changes in disease prevalence and demographic composition over time. To support proactive healthcare planning, statistical capacity forecasting models can provide valuable information to healthcare planners. This systematic literature review and evidence mapping aims to identify and describe studies that have used statistical forecasting models to estimate healthcare capacity needs within hospital settings.

METHOD

Studies were identified in the databases MEDLINE and Embase and screened for relevance before items were defined and extracted within the following categories: forecast methodology, measure of capacity, forecast horizon, healthcare setting, target diagnosis, validation methods, and implementation.

RESULTS

84 studies were selected, all focusing on various capacity outcomes, including number of hospital beds/ patients, staffing, and length of stay. The selected studies employed different analytical models grouped in six items; discrete event simulation (N = 13, 15 %), generalized linear models (N = 21, 25 %), rate multiplication (N = 15, 18 %), compartmental models (N = 14, 17 %), time series analysis (N = 22, 26 %), and machine learning not otherwise categorizable (N = 12, 14 %). The review further provides insights into disease areas with infectious diseases (N = 24, 29 %) and cancer (N = 12, 14 %) being predominant, though several studies forecasted healthcare capacity needs in general (N = 24, 29 %). Only about half of the models were validated using either temporal validation (N = 39, 46 %), cross-validation (N = 2, 2 %) or/and geographical validation (N = 4, 5 %).

CONCLUSION

The forecasting models' applicability can serve as a resource for healthcare stakeholders involved in designing future healthcare capacity estimation. The lack of routine performance validation of the used algorithms is concerning. There is very little information on implementation and follow-up validation of capacity planning models.

Ambulance clinician use of capillary blood ketone meters to improve emergency hyperglycaemia care: A stepped-wedged controlled, mixed-methods feasibility study

AIM

To determine whether it was feasible, safe and acceptable for ambulance clinicians to use capillary blood ketone meters for 'high-risk' diabetic ketoacidosis (DKA) recognition and fluid initiation, to inform the need for a full-powered, multi-centre trial.

METHODS

Adopting a stepped-wedge controlled design, participants with hyperglycaemia (capillary blood glucose >11.0 mmol/L) or diabetes and unwell were recruited. 'High-risk' DKA intervention participants (capillary blood ketones ≥3.0 mmol/L) received paramedic-led fluid therapy. Participant demographic and clinical data were collated from ambulance and hospital care records. Twenty ambulance and Emergency Department clinicians were interviewed to understand their hyperglycaemia and DKA care experiences.

RESULTS

In this study, 388 participants were recruited (Control: n = 203; Intervention: n = 185). Most presented with hyperglycaemia, and incidence of type 1 and type 2 diabetes was 18.5% and 74.3%, respectively. Ketone meter use facilitated 'high-risk' DKA identification (control: 2.5%, n = 5; intervention: 6.5%, n = 12) and was associated with improved hospital pre-alerting. Ambulance clinicians appeared to have a high index of suspicion for hospital-diagnosed DKA participants. One third (33.3%; n = 3) of Control and almost half (45.5%; n = 5) of Intervention DKA participants received pre-hospital fluid therapy. Key interview themes included clinical assessment, ambulance DKA fluid therapy, clinical handovers; decision support tool; hospital DKA management; barriers to hospital DKA care.

CONCLUSIONS

Ambulance capillary blood ketone meter use was deemed feasible, safe and acceptable. Opportunities for improved clinical decision making, support and safety-netting, as well as in-hospital DKA care, were recognised. As participant recruitment was below progression threshold, it is recommended that future-related research considers alternative trial designs.

CLINICALTRIALS

gov: NCT04940897.

Core competencies of emergency nurses for the armed conflict context: Experiences from the field

BACKGROUND

Armed conflicts are usually associated with high mortality and morbidity rates, with unpredictable workload, injuries and illnesses. Identifying emergency nurses' views of the core competencies required to enable them to work effectively in hospitals in areas of armed conflict is critical. It is important to inform the requisite standards of care and facilitate the translation of knowledge into safe, quality care.

AIM

The aim of this study was to identify emergency nurses' perceptions of core competencies necessary to work in hospitals in the context of armed conflict.

METHOD

A descriptive qualitative phase of a mixed-method study using semi-structured interviews with participants was conducted from June to July 2019. The COREQ guideline for reporting qualitative research was followed.

FINDINGS

A sample of 15 participants was interviewed. The participant perceptions provided a different perspective of core competencies required for emergency nurses in the context of armed conflict, culminating in four main areas: (i) personal preparedness , (ii) leadership, (iii) communication and (iv) assessment and intervention.

CONCLUSION

This study identified emergency nurses' perceptions of their core competencies. Personal preparedness, leadership, communication, assessment and intervention were identified as contributing to calmness of character, confidence in care and cultural awareness for care in this setting and were essential for them to work effectively when managing victims of armed conflict in emergency departments.

IMPLICATIONS FOR NURSING PRACTICE AND HEALTH POLICY

The findings of this study are important and novel because the researchers sought the perspectives of emergency nurses who have experience in receiving patients from armed conflict firsthand. The findings will inform policymakers in those settings regarding standard of care, education and drills for hospital nurses in optimizing armed conflict care response outcomes.

A future role for health applications of large language models depends on regulators enforcing safety standards

Among the rapid integration of artificial intelligence in clinical settings, large language models (LLMs), such as Generative Pre-trained Transformer-4, have emerged as multifaceted tools that have potential for health-care delivery, diagnosis, and patient care. However, deployment of LLMs raises substantial regulatory and safety concerns. Due to their high output variability, poor inherent explainability, and the risk of so-called AI hallucinations, LLM-based health-care applications that serve a medical purpose face regulatory challenges for approval as medical devices under US and EU laws, including the recently passed EU Artificial Intelligence Act. Despite unaddressed risks for patients, including misdiagnosis and unverified medical advice, such applications are available on the market. The regulatory ambiguity surrounding these tools creates an urgent need for frameworks that accommodate their unique capabilities and limitations. Alongside the development of these frameworks, existing regulations should be enforced. If regulators fear enforcing the regulations in a market dominated by supply or development by large technology companies, the consequences of layperson harm will force belated action, damaging the potentiality of LLM-based applications for layperson medical advice.

Epidemiology and Severity of Medical Events for Mountain Bikers and Hikers Transported by Ambulance in Western Australia, 2015 to 2020

INTRODUCTION

Outdoor activities offer physical and mental health benefits. However, incidents can occur requiring ambulance transport to hospital. This study aimed to describe the epidemiology and severity of traumatic and medical incidents for mountain bikers and hikers transported by ambulance within Western Australia.

METHODS

This was a retrospective cohort study of ambulance-transported mountain bikers and hikers within Western Australia from 2015 to 2020. Data were extracted from ambulance electronic patient care records. Multivariable analyses were undertaken to identify variables associated with higher patient severity based on the National Early Warning Score 2 (NEWS2).

RESULTS

A total of 610 patients required ambulance transport to hospital while mountain biking (n=329; 54%) or hiking (n = 281; 46%). Median age of mountain bikers and hikers was 38 (24-48) y and 49 (32-63) y, respectively. Paramedics reported a fracture in 92 (28%) mountain bikers and 78 (28%) hikers. The predominant injury locations for mountain bikers were upper limbs and for hikers, lower limbs. Cases were trauma related in 92% of mountain bikers and 55% of hikers. A significant association (P<0.001) between the etiology of the ambulance callout and patient severity was found. In trauma etiology cases, the frequency of medium-risk+ NEWS2 severity was 21.4%. In medical cases, the frequency of medium-risk+ severity was 40.8%.

CONCLUSION

Both mountain bikers and hikers experienced incidents requiring ambulance transport to hospital. Incidents of a medical etiology had a higher clinical risk, as determined by the NEWS2 scores, regardless of activity being undertaken.

The optimal surface for delivery of CPR: An updated systematic review and meta-analysis

Aim

To determine the effect of CPR delivery surface (e.g. firm mattress, floor, backboard) on patient outcomes and CPR delivery.

Methods

We searched MEDLINE, Embase, Web of Science and the Cochrane Central Register of Controlled Trials for studies published since 2019 that evaluated the effect of CPR delivery surface in adults and children on patient outcomes and CPR depth (PROSPERO CRD42023467583). We included manikin studies due to a lack of human studies. We identified pre-2019 studies from the 2020 ILCOR evaluation of this topic. Two reviewers independently screened titles/abstracts and full-text papers, extracted data and assessed risk of bias. Evidence certainty for each outcome was evaluated using GRADE methodology. Where appropriate, we pooled data in a meta-analysis, using a random-effects model.

Results

Database searches identified 489 citations. We included six studies published since 2019. We analysed these studies together with the eleven studies included in the previous ILCOR review. All included studies were manikin randomised controlled trials. Certainty of evidence was low. Interventions including placing the patient on the floor or the use of backboard had minimal impact on achieving greater compression depth. Meta-analyses of floor versus firm hospital mattress or firm home mattress found a mean difference of 5.36 mm (95% CI -1.59 to 12.32) and 2.11 mm (95% CI -3.23 to 7.45) respectively.

Conclusion

The use of a backboard led to a small 2 mm increase in chest compression depth in meta-analysis of multiple mannikin trials. Use of a firm mattress or transitioning to the floor did not affect chest compression depth.

"1990 Suwa Seriya" the national pre-hospital care ambulance service of Sri Lanka; a narrative review describing the EMS system with special emphasis on Out of Hospital Cardiac Arrest (OHCA) in Sri Lanka

Background

Sri Lanka is a leading nation in healthcare provision in the South Asia. Notably, it recorded amongst the lowest maternal and neonatal mortality rates in the region. However a significant deficit in improving all-cause mortality rates was the absence of a cohesive system of pre-hospital care.

Method

This narrative review delves into the evolution of Sri Lanka's Emergency Medical Services (EMS) system over the past decade. It examines the historical context, challenges encountered, and the transformative role of the "1990 Suwa Seriya" ambulance service on all causes of morbidity and mortality rates including out-of-hospital cardiac arrest (OHCA).

Results

The review elucidates the path from no organised pre-hospital system in 2015 to a comprehensive free to public, pre-hospital care emergency ambulance service that effectively serves 22 million people nationa-wide in 6 short years. Collaborations with emergency medicine, novel approaches to training and credentialing, as well as evolving research initiatives illustrate an approach to be emulated in countries with emerging pre-hospital systems. 1990 Suwa Seriya's response during the COVID-19 pandemic and its implications on public perception are discussed in conjunction with efforts to limit morbidity and mortality from OHCA.

Conclusion

In conclusion, the article underscores 1990 Suwa Seriya's dedication to continuous improvement and its potential as a model for bolstering emergency healthcare. By addressing challenges, fostering collaborations, and adapting to crises like the COVID-19 pandemic, 1990 Suwa Seriya exemplifies a pathway towards elevating pre-hospital care standards in lower-middle-income countries (LMICs).

Upper- vs. Whole-Body Cooling During Exercise with Thermal Protective Clothing in the Heat

INTRODUCTION: Firefighters operating in hot environments face challenges from protective garments that restrict heat dissipation, resulting in increased core temperature, thermal discomfort, and performance decline. Cooling vests represent a viable solution. The study aim was to compare effectiveness of the same amount of cooling power to the upper body (UB) or whole body (WB) in alleviating thermoregulatory and physiological stress, enhancing cognitive function, and reducing ratings of thermal discomfort and exertion, during 60 min of exercise in a hot environment (40°C, 40% relative humidity) while wearing firefighter turnout gear.METHODS: Eight healthy individuals (27.5 ± 3 y) participated in three conditions with either no cooling (Control) or active cooling with a liquid perfused shirt (UB cooling), or with a liquid perfused shirt and pants (WB cooling). In each trial, subjects performed three sets of 15 min of stepping (20 steps ⋅ min-1) and 5 min of rest.RESULTS: Both cooling strategies were beneficial compared to having no cooling at all. Subjects could only complete two exercise bouts during Control, but they completed all three bouts with active cooling. WB cooling provided an advantage over UB cooling for core and skin temperature, and thermal comfort and sensation. The advantage in minimizing the increase in core temperature was only evident during the third exercise bout.DISCUSSION: Active cooling is advantageous under these conditions. WB cooling provided some benefits vs UB cooling during heavy intensity exercise; however, it is uncertain whether these benefits would be observed during light-to-moderate exercise, which more likely reflects an actual firefighting scenario.Mansouri F, Talebian Nia M, Villar R, Cornish SM, Giesbrecht GG. Upper- vs. whole-body cooling during exercise with thermal protective clothing in the heat. Aerosp Med Hum Perform. 2024; 95(9):659-666.

Patient Preferences for Out-of-Hospital Cardiac Arrest Care in South Africa: A Discrete Choice Experiment

OBJECTIVE

This study examined the trade-offs low-resource setting community members were willing to make in regard to out-of-hospital cardiac arrest care using a discrete choice experiment survey.

METHODS

We administered a discrete choice experiment survey to a sample of community members 18 years or older across South Africa between April and May 2022. Participants were presented with 18 paired choice tasks comprised of 5 attributes (distance to closest adequate facility, provider of care, response time, chances of survival, and transport cost) and a range of 3 to 5 levels. We used mixed logit models to evaluate respondents' preferences for selected attributes.

RESULTS

Analyses were based on 2228 responses and 40 104 choice tasks. Patients valued care with the shortest response time, delivered by the highest qualified individuals, which placed them within the shortest distance of an adequate facility, gave them the highest chance of survival, and costed the least. In addition, patients preferred care delivered by their family members over care delivered by the lay public. The highest mean willingness-to-pay for increased survival is 11 699 South African rand (ZAR), followed by distance to health facility (8108 ZAR), and response time (5678 ZAR), and the lowest for increasing specialization of provider (1287 ZAR).

CONCLUSIONS

In low-resource settings, it may align with patients' preference to include targeted resuscitation training for family members of individuals with high-risk for cardiac arrest as a part of out-of-hospital cardiac arrest intervention strategies.

Comparison of Laws that Impact Volunteer Response in Three Disaster-Prone Southeastern States

OBJECTIVE

As natural disasters become more frequent and severe, the ability of impacted states to rapidly scale up their capacity to respond and facilitate recovery through volunteers is ever more crucial. However, the legal landscape that may facilitate or hamper augmentation through volunteers has yet to be fully explored.

DESIGN

This study utilized policy surveillance methodology to code relevant laws identified in searches using the Emergency Law Inventory database and Westlaw.

SETTING

We assessed laws in three natural disaster-prone states: North Carolina, South Carolina, and Georgia.

MAIN OUTCOME MEASURES

We assessed the presence of liability protection, license reciprocity, and scope of practice laws for health care volunteers.

RESULTS

Of the three assessed legal domains, liability protection for health care volunteers across all states contained the most robust language. Liability protections apply unless the health care volunteers act with reckless disregard, willful misconduct, or gross negligence. However, nuance exists based on which organizations (state vs charitable) volunteers are affiliated with to qualify for coverage. License reciprocity for out-of-state specific health care professions entering the impacted states was available across all three states. However, only Georgia enacted federal model legislation that provides additional flexibility regarding credentialing and liability protections. Lastly, very few laws addressed the scope of practice in impacted states.

CONCLUSIONS

Comparisons of laws that impact the ability of health care volunteers to respond and recover from disasters are scarce. More research needs to be performed to better understand the laws that impact volunteers in emergencies, particularly as the public health system is overtasked when providing services to impacted communities.

Learner Perception of Disaster Simulation Modalities: A Pilot Study

BACKGROUND

Both simulation and tabletop exercises are used in disaster training, but the efficacy of one approach versus the other is lacking.

PURPOSE

This pilot study explored the satisfaction, confidence, and perception of effectiveness among nursing students regarding 2 disaster preparedness training methods: simulation and tabletop exercises.

METHODS

A comparative quasi-experimental design assessed the effectiveness of 2 simulation experiences. Validated effectiveness and confidence survey tools were completed by 126 self-selected senior prelicensure baccalaureate nursing students after the completion of simulation experiences.

RESULTS

Tabletop exercises may be more effective to build confidence and understand pathophysiology. Full-scale simulations may be more effective in facilitating participant expression of feelings and providing a constructive evaluation of the simulation.

CONCLUSIONS

Variability among facilitators may have impacted the results of this pilot project. Further research is needed to enhance understanding of the effectiveness of tabletop and full-scale simulations for disaster preparedness in nursing education.

The Economic Impact of Community Paramedics Within Emergency Medical Services: A Systematic Review

BACKGROUND AND OBJECTIVE

Globally, emergency medical services (EMSs) report that their demand is dominated by non-emergency (such as urgent and primary care) requests. Appropriately managing these is a major challenge for EMSs, with one mechanism employed being specialist community paramedics. This review guides policy by evaluating the economic impact of specialist community paramedic models from a healthcare system perspective.

METHODS

A multidisciplinary team (health economics, emergency care, paramedicine, nursing) was formed, and a protocol registered on PROSPERO (CRD42023397840) and published open access. Eligible studies included experimental and analytical observational study designs of economic evaluation outcomes of patients requesting EMSs via an emergency telephone line ('000', '111', '999', '911' or equivalent) responded to by specialist community paramedics, compared to patients attended by usual care (i.e. standard paramedics). A three-stage systematic search was performed, including Peer Review of Electronic Search Strategies (PRESS) and Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). Two independent reviewers extracted and verified 51 unique characteristics from 11 studies, costs were inflated and converted, and outcomes were synthesised with comparisons by model, population, education and reliability of findings.

RESULTS

Eleven studies (n = 7136 intervention group) met the criteria. These included one cost-utility analysis (measuring both costs and consequences), four costing studies (measuring cost only) and six cohort studies (measuring consequences only). Quality was measured using Joanna Briggs Institute tools, and was moderate for ten studies, and low for one. Models included autonomous paramedics (six studies, n = 4132 intervention), physician oversight (three studies, n = 932 intervention) and/or special populations (five studies, n = 3004 intervention). Twenty-one outcomes were reported. Models unanimously reduced emergency department (ED) transportation by 14-78% (higher quality studies reduced emergency department transportation by 50-54%, n = 2639 intervention, p < 0.001), and costs were reduced by AU$338-1227 per attendance in four studies (n = 2962). One study performed an economic evaluation (n = 1549), finding both that the costs were reduced by AU$454 per attendance (although not statistically significant), and consequently that the intervention dominated with a > 95% chance of the model being cost effective at the UK incremental cost-effectiveness ratio threshold.

CONCLUSIONS

Community paramedic roles within EMSs reduced ED transportation by approximately half. However, the rate was highly variable owing to structural (such as local policies) and stochastic (such as the patient's medical condition) factors. As models unanimously reduced ED transportation-a major contributor to costs-they in turn lead to net healthcare system savings, provided there is sufficient demand to outweigh model costs and generate net savings. However, all models shift costs from EDs to EMSs, and therefore appropriate redistribution of benefits may be necessary to incentivise EMS investment. Policymakers for EMSs could consider negotiating with their health department, local ED or insurers to introduce a rebate for successful community paramedic non-ED-transportations. Following this, geographical areas with suitable non-emergency demand could be identified, and community paramedic models introduced and tested with a prospective economic evaluation or, where this is not feasible, with sufficient data collection to enable a post hoc analysis.

The Perceptions and Experiences of Older People Living in the Aftermath of Lombok Earthquakes, Indonesia: A Qualitative Study

INTRODUCTION

Despite the growing knowledge of people's vulnerability following natural disasters, the perspective of older people has received limited attention. This study aimed to explore the perceptions and experiences of older people encountering the 2018 Lombok earthquakes.

METHODS

This exploratory qualitative study involved 16 older people living in one of the villages most affected by the 2018 earthquakes in Lombok Island, Nusa Tenggara Barat, Indonesia. The data were collected in June 2019 using semi-structured interviews. Participants' responses were digitally recorded and transcribed verbatim for analysis. The data were analysed using qualitative content analysis managed in NVivo.

RESULTS

From older people's perspectives, three themes were generated: surviving the disaster, dealing with life changes and navigating through challenges and hope. Each theme comprised two categories, which reflected the journey of older people from the early to the later phase of the disaster.

CONCLUSIONS

Older people experienced critical conditions and difficulties both physically and mentally. They also experienced various emotional responses before accepting living situations following a disaster. Nurses should play a role in fulfilling the physical and mental health needs of older people in post-disaster conditions.

IMPLICATIONS FOR PRACTICE

This study can inform nurses and other key stakeholders about the needs of older people during and after natural disasters. Nurses need to be equipped with the skills and abilities to identify and meet the needs of older people in difficult situations and with limited resources.

Lessons of the Boom: A Playbook for Crisis Centers to Prevent, Survive, and Respond to Active Assailants, Targeted Violence, and Mass Violence

Modern crisis centers need to be prepared for mass shootings, active assailant incidents, and related forms of targeted violence. While crisis engagement has traditionally been seen as a "right of boom" or post-incident responder, crisis leaders need to prepare their teams to identify people at risk for violence, use tools like Behavioral Threat Assessment and Management to reduce risk in those persons, and prepare their teams for potential incidents in their community. Evidence suggests that acute stressors are a common proximal risk factor for severe violence implying a potential synergy for using crisis services as a tool for prevention of violence.

Medical Triage: Ethical Implications and Management Strategies

Natural or man-made medical disasters have repeatedly affected human communities. The impact on health care resources may vary depending on the magnitude of each crisis, catastrophe or pandemic, and the resources available. Medical triage protocols serve as invaluable tools to address clinical needs, particularly when resources, including supplies, equipment, and personnel, are limited. Although resources should be allocated to maximize the benefit, resource allocations need to be ethically sound. Existing triage protocols have inherent limitations.

Wilderness Medical Society Clinical Practice Guidelines for Medical Direction of Search and Rescue Teams

The Wilderness Medical Society convened a panel to review available evidence supporting practices for medical direction of search and rescue teams. This panel included of members of the Wilderness Medical Society Search and Rescue Committee, the National Association of EMS Physicians Wilderness Committee, and leadership of the Mountain Rescue Association. Literature about definitions and terminology, epidemiology, currently accepted best practices, and regulatory and legal considerations was reviewed. The panel graded available evidence supporting practices according to the American College of Chest Physicians criteria and then made recommendations based on that evidence. Recommendations were based on the panel's collective clinical experience and judgment when published evidence was lacking.

Exploring athletes' gendered views of coaches and their impact of coach competency ratings

This study draws on social role theory, role congruity theory, and the black sheep effect to explore athletes' gendered perceptions of coach competence. The study relied on a sample of 308 New Zealand athletes across sports levels and modalities who completed an online survey. Participants were randomly assigned to one of four vignettes, in which coach gender (female vs. male) and coaching style (communal vs. agentic) were manipulated, and athlete gender was considered. The results show that male and female coaches did not receive significantly different coach competency scores (relational and strategic competencies), that a communal coaching style was linked to higher ratings in both relational and strategic competencies, and that the interplay of athlete gender, coach gender, and gender conforming/non-conforming coaching style did not significantly affect coach competence scores. However, participants' comments to the open-ended question presented at the end of the survey suggest that athletes still hold gendered views of coaching competence at the elite level. We discuss the research and practical implications of our findings.

Spatial dependence of non-traumatic out-of-hospital cardiac arrest in a Swiss region: A retrospective analysis

Background

Out-of-hospital cardiac arrest (OHCA) incidence and survival often vary within regions according to patient-related and contextual factors. This study aims to establish the overall spatial dependence of incidence, bystander cardiopulmonary resuscitation (BCPR) and 48-h survival of OHCA with their associated demographic and socioeconomic characteristics in a Swiss region.

Methods

We conducted a retrospective study using data of all OHCAs recorded between 2007 and 2019 in the canton of Vaud and, more specifically, in the Lausanne area. Provision of BCPR and 48-h survival were analysed using Getis-Ord Gi statistics and OHCA incidence by local Moran's I with empirical Bayes standardised rates. Demographic and socioeconomic characteristics were compared between incidence clusters generated by local Moran's I method.

Results

Significant spatial variations of OHCA incidence, BCPR and 48-h mortality were observed. Although BCPR was statistically more likely in rural areas, 48-h survival was improved in a few main cities. At the cantonal level, postcode areas with a higher incidence of OHCAs were less densely inhabited with lower salary levels, more Swiss citizens, and an older population. At city level, small area variations were detected within urban neighbourhoods. The more affected hectares with more OHCAs were less inhabited, with a better median salary, more Swiss citizens, and off-centre.

Conclusions

Spatial variations associated with demographic and socioeconomic factors were observed for OHCA incidence and survival, with sparsely populated areas particularly at risk. These data suggest an unmet need for targeted prevention interventions and structural modifications of the existing prehospital system at the cantonal level.

Exercise related versus non exercise related out of hospital cardiac arrest - A retrospective single-center study

Background

Physical activity prevents cardiovascular disease, but it may also trigger acute cardiac events like sudden cardiac death in patients with underlying heart disease. The chance of surviving an out-of-hospital cardiac arrest remains low, despite improving medical treatment and rescue chain. Prior studies signaled increased survival in exercise related out-of-hospital cardiac arrest.

Objective

The aim of this study was to evaluate the differences between exercise related out-of-hospital cardiac arrest and out-of-hospital cardiac arrest during daily activity in an urban setting.

Methods

Retrospective analysis of all out-of-hospital cardiac arrests from 2014 to 2021 treated at a cardiac arrest center of a tertiary hospital. The primary outcome was survival to discharge. Secondary outcomes included differences in pre-hospital care, in-hospital treatment, hypoxic ischemic encephalopathy, and laboratory parameters.

Results

478 OHCA patients were reviewed of which 432 patients (exercise related 36 (8.4%) vs. daily activity 396 (91.6%)) were included in the analysis. Patients suffering an exercise related arrest were younger (57 vs 65 years, p = 0.002) and mostly male (88.9 vs 74.5%, p = 0.054).The exercise related cohort received bystander cardiopulmonary resuscitation (77.8 vs 53.4%, p = 0.005) to a higher extent and had a shorter no-flow time (1.5 vs 2 min, p = 0.049). Exercise related arrest patients more often presented with a shockable rhythm (80.6 vs 64.1%, p = 0.032).At hospital admission exercise related arrest patients had a higher initial pH (7.24 vs 7.19, p = 0.015). In the exercise related group, a cardiac cause was numerically more frequent compared to the daily activity group (80.6 vs 68.7%, p = 0.09). In both groups myocardial infarction (47.2 vs 43.2%) was the most common cause, but a primary arrhythmic event (33.3 vs 25.5%) was more often documented in exercise related arrest patients. Exercise related arrest was mostly related to endurance training (52.8%) followed by ball sports (19.4%) and occurred directly during exercise in 77.8% of cases. Patients suffering exercise related arrest had higher survival till discharge (66.7 vs 47.7%, p = 0.036).

Conclusion

Based on this observational data from a highly selected group of out-of-hospital cardiac arrest patients treated at a cardiac arrest center, patients suffering an exercise related out-of-hospital cardiac arrest, differed in substantial characteristics and in the first line response compared to daily activity out-of-hospital cardiac arrest patients. The better survival to discharge of the exercise related out-of-hospital cardiac arrest group might be driven by these beneficial differences. This study underlines the need for public awareness for the importance of a fast first response and a broad distribution of automated external defibrillators in public sport areas since most of the exercise related out-of-hospital cardiac arrest patients presented with a cardiac cause and an initial shockable rhythm.

Pediatric kidney care experience after the 2023 Türkiye earthquake

BACKGROUND

Two earthquakes on 6 February 2023 destroyed 10 cities in Türkiye. We report our experience with pediatric victims during these catastrophes, with a focus on crush syndrome related-acute kidney injury (Crush-AKI) and death.

METHOD

Web-based software was prepared. Patient demographics, time under rubble (TUR), admission laboratory data, dialysis, and kidney and overall outcomes were recorded.

RESULTS

A total of 903 injured children (median age 11.62 years) were evaluated. Mean TUR was 13 h (interquartile range 32.5, max 240 h). Thirty-one of 32 patients with a TUR of >120 h survived. The patient who was rescued after 10 days survived. Two-thirds of the patients were given 50 mEq/L sodium bicarbonate in 0.45% sodium chloride solution on admission day. Fifty-eight percent of patients were given intravenous fluid (IVF) at a volume of 2000-3000 mL/m2 body surface area (BSA), 40% at 3000-4000 mL/m2 BSA and only 2% at >4000 mL/m2 BSA. A total of 425 patients had surgeries, and 48 suffered from major bleeding. Amputations were recorded in 96 patients. Eighty-two and 66 patients required ventilator and inotropic support, respectively. Crush-AKI developed in 314 patients (36% of all patients). In all, 189 patients were dialyzed. Age >15 years, creatine phosphokinase (CK) ≥20 950 U/L, TUR ≥10 h and the first-day IVF volume <3000-4000 mL/m2 BSA were associated with Crush-AKI development. Twenty-two deaths were recorded, 20 of 22 occurring in patients with Crush-AKI and within the first 4 days of admission. All patients admitted after 7 days survived.

CONCLUSIONS

These are the most extensive pediatric kidney disaster data obtained after an earthquake. Serum CK level was significantly associated with Crush-AKI at the levels of >20 950 U/L, but not with death. Adolescent age and initial IVF of less than 3000-4000 mL/m2 BSA were also associated with Crush-AKI. Given that mildly injured victims can survive longer periods in the disaster field, we suggest uninterrupted rescue activity for at least 10 days.

Damage Control Training: A Cross-sectional Survey of Health care Personnel of French Emergency Medicine Structures

INTRODUCTION

Terrorist threats are a worldwide phenomenon. The injuries caused with military weapons or explosives are multiple and unusual for civilian care services. Damage control (DC) training has then become a critical need. In response to the November 2015 attacks, the French authorities launched a national DC training campaign for emergency care personnel. The aim was to describe the implementation of DC training campaign and its perception according to the respondent's profession, DC teaching levels, and the history of terrorist attacks in the last decade of the hospital center's activities.

MATERIALS AND METHODS

A survey was distributed to all Casualty Department staff in France. The answers were collected between June 9, 2020 and July 22, 2020. The project was qualified as not involving humans and participation was on voluntary basis. The study is out of the French Jardé law.

RESULTS

Two-thirds of the 1,525 respondents considered themselves trained in DC (emergency physicians [76.8%], nurse anesthetists [68.1%], and ambulance drivers [65.3%]). Less than half considered their theoretical (41.1%) and practical (44.7%) knowledge excellent or good. More than 95% of the untrained personnel wanted to receive this type of training. Trained personnel were in favor of annual refresher training (95.7%) and training for practical applications (95.1%). Personnel at teaching centers were more frequently trained than personnel at nonteaching centers (respectively 75.3% and 64.3%, P < .0001) and had applied their knowledge significantly more often (50.1% vs. 43.4%, P = .038). They often considered their knowledge to be excellent (respectively 50.8% vs. 42.4%, P = .064).

CONCLUSION

The training of emergency personnel in DC is far from being generalized in France. Among the trained personnel, it was often deemed insufficient, in theory and in practice. There was an inequity of training in favor of those in teaching centers. It is therefore essential that training in DC techniques in France be continued, generalized, improved, and standardized throughout the country in order to guarantee an optimal response from the health care systems in the event of new terrorist attacks.

Nord-Ost: Russia's Medical Failure in the 2002 Crisis

The 2002 hostage crisis at a Moscow theater transfixed the attention of the world. While the initial assault, led by Spetsnaz commandos, successfully secured the building, the Russian security force's utter failure at coordinating with medical services led to the preventable deaths of over 100 hostages.

Point of Care Ultrasounds Obtained by Novice Physician Assistant Residents (POCUS ON PAR)

INTRODUCTION

The integration of Point of Care Ultrasound (POCUS) into the care of trauma patients, specifically the E-FAST, has improved the accuracy of initial diagnoses and improved time to surgical intervention in critically ill patients. Physician assistants (PAs) are critically important members of any military trauma resuscitation team and are often team leaders in a pre-hospital setting. They may receive training in ultrasound but there are little data to support their use or evaluate their effectiveness in using POCUS. We designed a study to evaluate the image quality of an E-FAST Exam performed by Emergency Medicine Physician Assistant (EMPA) Fellows and Emergency Medicine (EM) Interns following identical training. Our hypothesis is that image quality obtained by EMPAs will be non-inferior to those images obtained by EM Interns.

MATERIALS AND METHODS

This is a prospective single-blinded study comparing the image quality of E-FAST exams performed by first year EM interns and first year EMPA fellows. All participants completed standard POCUS training prior to enrollment in the study. A total of 8 EMPAs and 8 EM first year residents completed 10 recorded E-FAST exams to be used as study images. Participants also viewed a 15-question slide show containing images of positive (6) and negative (9) E-FAST exams and recorded their interpretations. Images were reviewed by expert reviewers who were blinded to which images were collected by which group. An image quality score was recorded for each view as well as an overall image quality score. Image quality was rated on a 1 to 5 image quality scale.

RESULTS

For overall image quality, the mean score for EMPAs was 3.6 ± 0.5 and for EM residents was 3.2 ± 0.5 with statistical significance favoring better image quality from the EMPAs. The time to completion for the EFAST exam for EMPAs was 4.8 ± 1.3 minutes and for interns it was 3.4 ± 1.4 minutes (P value = 0.02). There was no difference in image interpretation quiz scores between the groups (mean score 92% among interns and 95% among PAs).

CONCLUSIONS

POCUS is an imaging modality which is very portable and relatively inexpensive which makes it ideal for military medicine. PAs are essential members of military trauma teams, and often run an initial trauma resuscitation. Being able to correctly identify patients who have free fluid early in the course of treatment allows for more correct evacuation criteria to ensure the sickest patients get to care the fastest. Although there are limited data to support POCUS use by non-physicians, our data support a growing body of evidence that it is not the profession or baseline medical education that determines an individual's ability to use and incorporate ultrasound into bedside and clinical practice. Our study shows that with training and experience PAs or other members of the military health care team can use the EFAST to better care for trauma patients.

School Violence Exposure as an Adverse Childhood Experience: Protocol for a Nationwide Study of Secondary Public Schools

BACKGROUND

Poor mental health and adverse childhood experiences (ACEs) predict extensive adverse outcomes in youth, including increases in long-term risk for chronic disease and injury, impaired emotional development, and poor academic outcomes. Exposure to school violence, specifically intentional gun violence, is an increasingly prevalent ACE. The anticipation of school shootings has led to the implementation of school safety and security interventions that may increase anxiety, depression, and other indicators of poor mental well-being among students and staff alike. Despite this, the association between exposure to existing school safety interventions and early adolescent student mental health outcomes, while accounting for one's history of ACEs, has not been previously investigated.

OBJECTIVE

The study protocol described here aims to determine whether there is a significant difference in the prevalence of mental health outcomes, perceived school safety, and academic engagement between adolescent students (grades 6-12) at schools who have experienced a school shooting and those who have not; whether existing interventions to promote school safety and security are associated with poor mental health outcomes among students and school staff; and what the strength of the association between school safety interventions and mental health outcomes among students and teachers is in schools that have experienced a school shooting versus schools that have never experienced a school shooting.

METHODS

This observational study will collect cross-sectional survey data from a nationwide sample of students, teachers, and principals at 12 secondary public schools across the United States. The participants come from 6 randomly selected exposure schools that have either experienced a recent (<2 years ago) intentional school shooting or have experienced an intentional school shooting less recently (>2 years ago). Data from these schools are being directly compared with 6 secondary schools that have never experienced a school shooting.

RESULTS

Institutional review board approval for this research project was obtained and the study subsequently began its recruitment and data collection phase in January 2024. Data collection is currently ongoing and the expected completion date is January 2025. The analytic plan is designed to determine if the strength of the association between school safety interventions and mental health outcomes differs among students and school staff in schools with varying levels of school violence exposure. Analyses will be used to evaluate the role of ACEs on the relationships among exposure to an intentional school shooting, exposure to school safety strategies, and student outcomes (ie, mental health and well-being, perceptions of school safety, and educational outcomes).

CONCLUSIONS

The results from this study promise to generate meaningful and novel findings on the extent to which having a prior history of ACEs moderates the relationships among exposure to intentional school gun violence, school safety strategies, and student outcomes (ie, mental health and well-being, and perceptions of school safety).

TRIAL REGISTRATION

ClinicalTrials.gov NCT06153316; https://clinicaltrials.gov/study/NCT06153316.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56249.

Implementation of the World Health Organization Minimum Dataset for Emergency Medical Teams to Create Disaster Profiles for the Indonesian SATUSEHAT Platform Using Fast Healthcare Interoperability Resources: Development and Validation Study

Background

The National Disaster Management Agency (Badan Nasional Penanggulangan Bencana) handles disaster management in Indonesia as a health cluster by collecting, storing, and reporting information on the state of survivors and their health from various sources during disasters. Data were collected on paper and transferred to Microsoft Excel spreadsheets. These activities are challenging because there are no standards for data collection. The World Health Organization (WHO) introduced a standard for health data collection during disasters for emergency medical teams (EMTs) in the form of a minimum dataset (MDS). Meanwhile, the Ministry of Health of Indonesia launched the SATUSEHAT platform to integrate all electronic medical records in Indonesia based on Fast Healthcare Interoperability Resources (FHIR).

Objective

This study aims to implement the WHO EMT MDS to create a disaster profile for the SATUSEHAT platform using FHIR.

Methods

We extracted variables from 2 EMT MDS medical records-the WHO and Association of Southeast Asian Nations (ASEAN) versions-and the daily reporting form. We then performed a mapping process to match these variables with the FHIR resources and analyzed the gaps between the variables and base resources. Next, we conducted profiling to see if there were any changes in the selected resources and created extensions to fill the gap using the Forge application. Subsequently, the profile was implemented using an open-source FHIR server.

Results

The total numbers of variables extracted from the WHO EMT MDS, ASEAN EMT MDS, and daily reporting forms were 30, 32, and 46, with the percentage of variables matching FHIR resources being 100% (30/30), 97% (31/32), and 85% (39/46), respectively. From the 40 resources available in the FHIR ID core, we used 10, 14, and 9 for the WHO EMT MDS, ASEAN EMT MDS, and daily reporting form, respectively. Based on the gap analysis, we found 4 variables in the daily reporting form that were not covered by the resources. Thus, we created extensions to address this gap.

Conclusions

We successfully created a disaster profile that can be used as a disaster case for the SATUSEHAT platform. This profile may standardize health data collection during disasters.

Patients' Expectations of Doctors' Clinical Competencies in the Digital Health Care Era: Qualitative Semistructured Interview Study Among Patients

BACKGROUND

Digital technologies have impacted health care delivery globally, and are increasingly being deployed in clinical practice. However, there is limited research on patients' expectations of doctors' clinical competencies when using digital health care technologies (DHTs) in medical care. Understanding these expectations can reveal competency gaps, enhance patient confidence, and contribute to digital innovation initiatives.

OBJECTIVE

This study explores patients' perceptions of doctors' use of DHTs in clinical care. Using Singapore as a case study, it examines patients' expectations regarding doctors' communication, diagnosis, and treatment skills when using telemedicine, health apps, wearable devices, electronic health records, and artificial intelligence.

METHODS

Findings were drawn from individual semistructured interviews with patients from outpatient clinics. Participants were recruited using purposive sampling. Data were analyzed qualitatively using thematic analysis.

RESULTS

Twenty-five participants from different backgrounds and with various chronic conditions participated in the study. They expected doctors to be adept in handling medical data from apps and wearable devices. For telemedicine, participants expected a level of assessment of their medical conditions akin to in-person consultations. In addition, they valued doctors recognizing when a physical examination was necessary. Interestingly, eye contact was appreciated but deemed nonessential by participants across all age bands when electronic health records were used, as they valued the doctor's efficiency more than eye contact. Nonetheless, participants emphasized the need for empathy throughout the clinical encounter regardless of DHT use. Furthermore, younger participants had a greater expectation for DHT use among doctors compared to older ones, who preferred DHTs as a complement rather than a replacement for clinical skills. The former expected doctors to be knowledgeable about the algorithms, principles, and purposes of DHTs such as artificial intelligence technologies to better assist them in diagnosis and treatment.

CONCLUSIONS

By identifying patients' expectations of doctors amid increasing health care digitalization, this study highlights that while basic clinical skills remain crucial in the digital age, the role of clinicians needs to evolve with the introduction of DHTs. It has also provided insights into how DHTs can be integrated effectively into clinical settings, aligning with patients' expectations and preferences. Overall, the findings offer a framework for high-income countries to harness DHTs in enhancing health care delivery in the digital era.

Non-invasive versus arterial pressure monitoring in the pre-hospital critical care environment: a paired comparison of concurrently recorded measurements

BACKGROUND

Blood pressure monitoring is important in the pre-hospital management of critically ill patients. Non-invasive blood pressure (NIBP) measurements are commonly used but the accuracy of standard oscillometric cuff devices may be affected by extremes of physiology and adverse conditions (e.g. vibration) during transport. This study aimed to quantify the accuracy of NIBP measurements amongst patients requiring pre-hospital critical care.

METHODS

A retrospective cohort study was undertaken using data from patients treated by a pre-hospital critical team between 1st May 2020 and 30th April 2023 that had NIBP measured concurrently with invasive blood pressure (IBP) arterial manometry. An acceptable difference was determined a priori to be < 20mmHg for systolic blood pressure (SBP) and diastolic blood pressure (DBP), and < 10mmHg for mean arterial pressure (MAP). The primary outcome was "pairwise agreement", i.e. the proportion of paired observations that fell within this range of acceptability. Bland-Altman plots were constructed together with 95% limits of agreement to visualise differences between pairs of data. Associations with patient age, reason for critical care, transport status, haemodynamic shock, severe hypertension, and arterial catheter position were explored in univariate analyses and by fitting multivariable logistic regression models.

RESULTS

There were 2,359 paired measurements from 221 individual patients with a median age of 57. The most frequent reason for transport was cardiac arrest (79, 35.7%). Bland-Altman analyses suggested unacceptably wide limits of agreement with NIBP overestimating both SBP and MAP during hypotension and underestimating these values during hypertension. Haemodynamic shock (SBP < 90mmHg) was independently associated with reduced pairwise agreement for SBP (adjusted odds ratio [aOR] 0.52, 95% CI 0.35 to 0.77), DBP (aOR 0.65, 95% CI 0.42 to 0.99) and MAP (aOR 0.53, 95% CI 0.36 to 0.78) and severe hypertension (SBP > 160mmHg) with reduced pairwise agreement for SBP (aOR 0.17, 95% CI 0.11 to 0.27). There was no association between patient transport and agreement between the methods for SBP, DBP, or MAP.

CONCLUSIONS

Non-invasive blood pressure measurements are often inaccurate in the pre-hospital critical care setting, particularly in patients with haemodynamic instability. Clinicians should be cautious when interpreting NIBP measurements and consider direct arterial pressure monitoring when circumstances allow.

Optimal weight-based epinephrine dosing for patients with a low likelihood of survival following out-of-hospital cardiac arrest

INTRODUCTION

Cardiac arrest patients presenting with non-shockable rhythms have a low probability of survival, and epinephrine is one of the few pharmaceutical options for this group. The recommended 1.0 mg adult dose is extrapolated from early animal studies and lacks adjustment for patient weight. Although several prior studies have investigated "low-" and "high-" dose epinephrine, none have identified a benefit to either strategy.

AIMS

To identify an optimal weight-based epinephrine dose for return-of-spontaneous-circulation (ROSC) after a single bolus among patients with low likelihood of survival.

METHODS

Included were adult patients who experienced a witnessed, non-traumatic out-of-hospital cardiac arrest prior to EMS arrival. Patients with shockable presenting rhythms or receiving bystander CPR were excluded. The AUROC was used to assess the predictive value of epinephrine dose (mg/kg) for ROSC following a single bolus. From the ROC curve, the optimal threshold dosage (OTD) was determined using the Youden Index. A logistic regression model calculated the adjusted odds ratio of OTD on ROSC.

RESULTS

A total of 2,463 patients met inclusion criteria, of which 190 (7.7%) attained ROSC after the first epinephrine administration. The dosage AUROC for ROSC was 0.603 (p < 0.01). As calculated by the Youden index, the OTD was 0.013 mg/kg. Patients receiving ≥ OTD were more likely to attain ROSC after a single epinephrine bolus (OR = 2.25,p < 0.001).

CONCLUSIONS

Among patients with a low likelihood of survival, the optimal dose of epinephrine for attaining ROSC with a single bolus of epinephrine was 0.013 mg/kg. These findings should inspire further investigation into optimal dosing strategies for epinephrine.

Paramedics' experiences and observations: work-related emotions and well-being resources during the initial months of the COVID-19 pandemic-a qualitative study

BACKGROUND

As first responders, paramedics are an extremely important part of the care chain. COVID-19 significantly impacted their working circumstances. We examined, according to the experiences and observations of paramedics, (1) what kinds of emotions the Emergency Medical Service (EMS) personnel experienced in their new working circumstances, and (2) what work-related factors became resources for the well-being of EMS personnel during the initial months of the COVID-19 pandemic.

METHODS

This qualitative study utilized reflective essay material written by experienced, advanced-level Finnish paramedics (n = 30). The essays used in this study were written during the fall of 2020 and reflected the period when Finland had declared a state of emergency (on 17.3.2020) and the Emergency Powers Act was implemented. The data was analyzed using an inductive thematic analysis.

RESULTS

The emotions experienced by the EMS personnel in their new working circumstances formed three themes: (1) New concerns arose that were constantly present; (2) Surviving without proper guidance; and (3) Rapidly approaching breaking point. Three themes were formed from work-related factors that were identified as resources for the well-being of the EMS personnel. These were: (1) A high level of organizational efficiency was achieved; (2) Adaptable EMS operations; and (3) Encouraging atmosphere.

CONCLUSIONS

Crisis management practices should be more attentive to personnel needs, ensuring that managerial and psychological support is readily available in crisis situations. Preparedness that ensures effective organizational adaptation also supports personnel well-being during sudden changes in working circumstances.

The impact of surge capacity enhancement training for nursing managers on hospital disaster preparedness and response: an action research study

INTRODUCTION

Hospitals as the main providers of healthcare services play an essential role in the management of disasters and emergencies. Nurses are one of the important and influential elements in increasing the surge capacity of hospitals. Accordingly, the present study aimed to assess the effect of surge capacity enhancement training for nursing managers on hospital disaster preparedness and response.

METHODS

All nursing managers employed at Motahari Hospital in Tehran took part in this interventional pre- and post-test action research study. Ultimately, a total of 20 nursing managers were chosen through a census method and underwent training in hospital capacity fluctuations. The Iranian version of the "Hospital Emergency Response Checklist" was used to measure hospital disaster preparedness and response before and after the intervention.

RESULTS

The overall hospital disaster preparedness and response score was 184 (medium level) before the intervention and 216 (high level) after the intervention. The intervention was effective in improving the dimensions of hospital disaster preparedness, including "command and control", "triage", "human resources", "communication", "surge capacity", "logistics and supply", "safety and security", and "recovery", but had not much impact on the "continuity of essential services" component.

CONCLUSION

The research demonstrated that enhancing the disaster preparedness of hospitals can be achieved by training nursing managers using an action research approach. Encouraging their active participation in identifying deficiencies, problems, and weaknesses related to surge capacity, and promoting the adoption and implementation of suitable strategies, can enhance overall hospital disaster preparedness.

Impact of the Great East Japan Earthquake followed by the nuclear power plant accident on the nursing students' academic progress in Soma, Fukushima, Japan: a retrospective cohort study with questionnaire survey

BACKGROUND

The Great East Japan Earthquake and the subsequent Fukushima nuclear power plant accident in 2011 posed significant challenges to the educational sector, particularly affecting nursing students in the disaster area. However, to the best of our knowledge, there are no reports on the effects of the natural disaster coupled with the nuclear accident on the nursing students. Therefore, this study aimed to determine the impact of the Fukushima disasters on rate of academic failure events in nursing education.

METHODS

A retrospective cohort approach was conducted, focusing on 677 students from Soma Nursing School admitted between 2001 and 2017. Four failure events-failure to pass the national examination, student retention, suspension, and withdrawal from school-were compared between three time periods: pre-disaster, early peri-disaster, and later peri-disaster. This analysis was followed by a questionnaire survey among the students and an interview with faculty members to gain further insights.

RESULTS

Of the student cohort, 17% had at least one failure event. Students in the later peri-disaster phase faced an elevated failure rate at 29%. Variables such as being male, admission during later peri-disaster period, and local pre-admission residence played a significant role in these failure events in multivariate logistic regression analysis (adjusted odds ratio [95% confidence interval, p value]; 2.63 [1.49-4.64, < 0.001], 3.207 [2.00-5.15, < 0.001], and 1.84 [1.12-3.02, 0.02], respectively).

CONCLUSIONS

This study highlights the impact of the Great East Japan Earthquake and the following nuclear accident on nursing education. The elevated failure rates in the later peri-disaster period emphasize the challenges posed by continuing disaster phases. Thus, there is a need for intensified and tailored strategies in nursing education in disaster-affected regions.