The Standardization of the Emergency Department Response to Chemical, Biological, Radiological, and Nuclear (CBRN) Events: Human Factors/Ergonomics Approach

OBJECTIVE

To provide standardized recommendations for the emergency department (ED) response to chemical, biological, radiological, and nuclear (CBRN) events by combining the human factors/ergonomics method of hierarchical task analysis with the theoretical framework for Work as Imagined versus Work as Done.

METHODS

Document analyses were used to represent CBRN response operational procedures. Semi-structured interviews using scenario cards were carried out with 57 first receivers (ED staff) to represent CBRN practice at 2 acute hospitals in England.

RESULTS

Variability existed in general organizational responsibilities associated with the CBRN response. Variability was further evident in top level CBRN tasks and CBRN phases at both EDs. Operational procedures focused on tasks such as documentation, checking, and timing. CBRN practice focused on patient needs through assessment, treatment, and diagnosis.

CONCLUSION

The findings provide top-down and bottom-up insights to enhance the ED CBRN response through standardization. The standardized CBRN action card template embeds the choice approach to standardization. The standardized CBRN framework implements the streamlined categorization of CBRN phases. Work as Imagined versus Work as Done is a useful theoretical framework to unpack a complex sociotechnical system, and hierarchical task analysis is an effective system mapping tool in health care.

Major Incident Hospital Simulations in Hospital Based Health Care: A Scoping Review

Major incidents are occurring in increasing frequency, and place significant stress on existing health-care systems. Simulation is often used to evaluate and improve the capacity of health systems to respond to these incidents, although this is difficult to evaluate. A scoping review was performed, searching 2 databases (PubMed, CINAHL) following PRISMA guidelines. The eligibility criteria included studies addressing whole hospital simulation, published in English after 2000, and interventional or observational research. Exclusion criteria included studies limited to single departments or prehospital conditions, pure computer modelling and dissimilar health systems to Australia. After exclusions, 11 relevant studies were included. These studies assessed various types of simulation, from tabletop exercises to multihospital events, with various outcome measures. The studies were highly heterogenous and assessed as representing variable levels of evidence. In general, all articles had positive conclusions with respect to the use of major incidence simulations. Several benefits were identified, and areas of improvement for the future were highlighted. Benefits included improved understanding of existing Major Incident Response Plans and familiarity with the necessary paradigm shifts of resource management in such events. However, overall this scoping review was unable to make definitive conclusions due to a low level of evidence and lack of validated evaluation.

COVID-19: lessons learnt and priorities in trauma and orthopaedic surgery

The COVID-19 pandemic is the most serious health crisis of our time. Global public measures have been enacted to try to prevent healthcare systems from being overwhelmed. The trauma and orthopaedic (T&O) community has overcome challenges in order to continue to deliver acute trauma care to patients and plan for challenges ahead. This review explores the lessons learnt, the priorities and the controversies that the T&O community has faced during the crisis. Historically, the experience of major incidents in T&O has focused on mass casualty events. The current pandemic requires a different approach to resource management in order to create a long-term, system-sustaining model of care alongside a move towards resource balancing and facilitation. Significant limitations in theatre access, anaesthetists and bed capacity have necessitated adaptation. Strategic changes to trauma networks and risk mitigation allowed for ongoing surgical treatment of trauma. Outpatient care was reformed with the uptake of technology. The return to elective surgery requires careful planning, restructuring of elective pathways and risk management. Despite the hope that mass vaccination will lift the pressure on bed capacity and on bleak economic forecasts, the orthopaedic community must readjust its focus to meet the challenge of huge backlogs in elective caseloads before looking to the future with a robust strategy of integrated resilient pathways. The pandemic will provide the impetus for research that defines essential interventions and facilitates the implementation of strategies to overcome current barriers and to prepare for future crises.

Paediatric major incident simulation and the number of discharges achieved using a major incident rapid discharge protocol in a major trauma centre: a retrospective study

OBJECTIVES

Hospitals have the responsibility of creating, testing and maintaining major incident (MI) plans. Plans emphasise readiness for acceptance of casualties, though often they neglect discharge planning and care for existing inpatients to make room for the sudden influx.After collaboration and design of a discharge policy for a paediatric MI, we aimed to establish the number of beds made available (primary outcome) to assess potential surge and patient flow. We hypothesised that prompt patient discharge would improve overall departmental flow. Flow is vital for sick patients awaiting admission, for those requiring theatre and also to keep the emergency department clear for ongoing admissions.

METHOD AND SETTING

A simulated MI was declared at a London major trauma centre. Five paediatric priority 1 and 15 priority 2 and priority 3 patients were admitted. Using live bed boards, staff initiated discharge plans, and audits were conducted based on hospital bed occupancy and discharge capacity. The patients identified as dischargable were identified and folllowed up for 7 days.

RESULTS

Twenty-nine ward beds were created (42% of the total capacity). Handwritten summaries just took 13.3% of the time that electronic summaries took for the same patients by the same doctor. In-hospital transfers allowed five critically injured children into paediatric intensive care unit (PICU), and creation of a satellite PICU allowed for an additional six more if needed.

CONCLUSION

We increased level 3 capacity threefold and created 40% extra capacity for ward patients. A formalised plan helped with speed and efficiency of safe discharge during an MI. Carbon copy handwritten discharge letters allowed tracking and saved time. Robust follow-up procedures must be in place for any patients discharged.