Evolving need for alternative triage management in public health emergencies: a Hurricane Katrina case study

Access to healthcare for people with disabilities in South Africa: Bad at any time, worse during COVID-19?

People with disabilities, especially those living in low- and middle-income countries, experience significant challenges in accessing healthcare services and support. At times of disasters and emergencies, people with disabilities are further marginalised and excluded. During the coronavirus disease 2019 (COVID-19) pandemic, many people with disabilities are unable to access healthcare facilities, receive therapeutic interventions or rehabilitation, or gain access to medication. Of those who are able to access facilities, many experience challenges, and at times direct discrimination, accessing life-saving treatment such as intensive care unit admission and ventilator support. In addition, research has shown that people with disabilities are at higher risk of contracting the virus because of factors that include the need for interpersonal caregivers and living in residential facilities. We explore some of the challenges that people with disabilities residing in South Africa currently experience in relation to accessing healthcare facilities.

Comparison of Two Evacuation Shelter Operating Policies and the Role of Public Health Nurses after the Great East Japan Earthquake: A Qualitative Study

This study describes shelter operations by public health nurses (PHNs) in Kesennuma City, located near the epicenter of the Great East Japan Earthquake, which occurred on March 11, 2011. The data were semi-structured interviews with 10 PHNs, 2 nutritionists, and 2 general administrators conducted from July 2013 to January 2014. All transcripts were analyzed using the constructivist grounded theory approach. We identified two operating methods for shelters: shelters stationed by PHNs in the Old City, and shelters patrolled by PHNs in the merged district. These methods were compared using four themes. In emergency situations, "operational periods," a predetermined short term for a leader to perform his/her duties responsibly, could be adopted for relatively small organizations on the frontline. PHNs must not only attempt to operate shelters on their own but also encourage residents to manage the shelters as well. Moreover, human resource allocation should be managed independently of personal factors, as strong relationships between shelter residents would sometimes disturb the flexibility of the response. Even when a situation requires PHNs to stay in shelters, frequent collecting of information and updating the plan according to response progress will help to maintain effective shelter operations.

Healthcare in Extreme and Austere Environments: Responding to the Ethical Challenges

Clinicians may increasingly find themselves practicing, by choice or necessity, in resource-poor or extreme environments. This often requires altering typical patterns of practice with a different set of medical and ethical considerations than are usually faced by clinicians practicing in hospitals in the United States and Europe. Practitioners may be required to alter their usual scope of practice or their standard ways of medically treating patients. Limited resources will also often place clinicians in the position of having to make decisions about fairly allocating healthcare, which will alter the physician-patient relationship. This does not absolve physicians and other healthcare practitioners of providing the best quality of care that can be given under the circumstances. In addition, the lack of a well-developed healthcare infrastructure and limited resources will require working with established providers to determine the needs of the community, and what types of healthcare are feasible given these limitations. The essays in this issue of HEC Forum encourage readers to reflect on the unique ethical challenges faced in the extreme or austere environment.

COVID-19, disability and the context of healthcare triage in South Africa: Notes in a time of pandemic

During disasters, when resources and care are scarce, healthcare workers are required to make decisions and prioritise which patients receive life-saving resources over others. To assist healthcare workers in standardising resources and care, triage policies have been developed. However, the current COVID-19 triage policies and practices in South Africa may exclude or disadvantage many disabled people, especially people with physical and intellectual impairments, from gaining intensive care unit (ICU) access and receiving ventilators if becoming ill. The exclusion of disabled people goes against the principles established in South Africa's Constitution, in which all people are regarded as equal, have the right to life and inherent dignity, the right to access healthcare, as well as the protection of dignity. In addition, the triage policy contravenes the United Nations Convention on the Rights of Persons with Disabilities, which the South African government has signed and ratified. This article raises debates about whose lives matter and whose lives are 'worth' saving over others, and although the focus is on South Africa, the issues may be relevant to other countries where life-saving resources are being rationed.

Attitudes of the Public to Receiving Medical Care during Emergencies through Remote Physician-Patient Communications

Providing health services through remote communications for sub-acute health issues during emergencies may help reduce the burden of the health care system and increase availability of care. This study aimed to investigate the attitudes of the public towards receiving medical services and providing medical information through remote communication in times of emergencies. During the pandemic outbreak of the novel coronavirus (COVID-19), pandemic outbreak, 507 participants answered a structured online survey, rating their mean willingness to receive medical care and provide medical information, on a four-point Likert scale. Furthermore, demographic characteristics, social media use, and trust in data protection was collected. The mean willingness to receive medical services was 3.1 ± 0.6 and the mean willingness to provide medical information was 3.0 ± 0.7, with a strong significant correlation between the two (r = 0.76). The multiple regression model identified higher trust in data protection, level of education, and social media use as statistically significant predictors for a higher willingness to receive medical information while the first two predicted willingness to provide information. The findings suggest an overall positive attitude to receive medical care through remote communications.

Triage

This review provides an overview of triaging critically ill or injured patients during mass casualty incidents due to events such as disasters, pandemics, or terrorist incidents. Questions clinicians commonly have, including "what is triage?," "when to triage?," "what are the types of disaster triage?," "how to triage?," "what are the ethics of triage?," "how to govern triage?," and "what research is required on triage?," are addressed.

Triage by Resource Allocation for INpatients: A Novel Disaster Triage Tool for Hospitalized Pediatric Patients

OBJECTIVE

To develop a disaster triage tool for the evacuation of hospitalized neonatal and pediatric populations.

METHODS

We expanded an existing neonatal disaster triage tool for the evacuation of a children's hospital. We assessed inpatients using bedside visual assessments and chart review to categorize patients transport level based on local emergency medical services protocols and expert opinion. The tool was refined by using multiple Plan Do Study Act cycles. Primary outcome was the number of each level of transport required for hospital evacuation. Secondary outcome was improved efficiency of obtaining information about specific transport needs for evacuation.

RESULTS

We evaluated 1382 patients both visually and through electronic chart review over 10 random days. Accordance between visual assessment and electronic chart review reached 96.3%. During a 2 hour statewide disaster drill, no hospital units completed self-assessed transport needs for their patients; a single nurse used Triage by Resource Allocation in INpatients to determine transportation needs in less than 1 hour. (Disaster Med Public Health Preparedness. 2018;12:692-696).

The Development of an Evacuation Protocol for Patients with Ventricular Assist Devices During a Disaster

Introduction Health care providers are on the forefront of delivering care and allocating resources during a disaster; however, very few are adequately trained to respond in these situations. Furthermore, there is a void in the literature regarding the specific care needs of patients with ventricular assist devices (VADs) in a disaster setting. This project aimed to develop an evidenced-based protocol to aid health care providers during the evacuation of patients with VADs during a disaster.

METHODS

This is a qualitative study that used expert review, tabletop discussion, and a survey of health care professionals to develop and evaluate an evacuation protocol. The protocol was revised after each stage of review in order to reach a consensus document.

RESULTS

The project concluded with the finalization of a protocol which addresses evacuation and patient triage, and also includes an algorithm to determine which staff members should be evacuated with patients, transportation resources, evacuation documentation, and items patients need during evacuation. The protocol also addressed steps to be taken in the event that evacuation efforts fail and how to manage outpatient VAD patients seeking assistance.

CONCLUSIONS

This protocol provides guidance for the care of VAD patients in the event of a disaster and evacuation. Protocols such as this address difficult scenarios and should be created prior to a disaster to assist staff in making difficult decisions. These documents should be created using multi-disciplinary feedback via the consensus model as well as the Institute of Medicine (IOM; National Academy of Medicine; Washington, DC USA) "Crisis Standards of Care." Davis KJ , Suyama J , Lingler J , Beach M . The development of an evacuation protocol for patients with ventricular assist devices during a disaster. Prehosp Disaster Med. 2017;32(3):333-338.

Toward a US Army Pacific (USARPAC) rapid deployment medical component in support of Human Assistance/Disaster Relief (HA/DR) operations: challenges with "Going in Light"

Background

This article reports the exploratory development and study efforts regarding the viability of a novel “going-in light” or “Going Light” medical component in support of US Army Pacific (USARPAC) Humanitarian Assistance/Disaster Relief (HA/DR) missions, namely, a BLU-MED^® incremental modular equipment package along with a Rapid Deployment Medical Team (RDMT). The study was conducted to uncover a way for the U.S. Army to: (1) better medically support the greater U.S. military Pacific Command, (2) prepare the Army for Pacific HA/DR contingencies, and (3) imprint a swift presence and positive contribution to Pacific HA/DR operations.

Methods

The findings were derived from an intensive quasi-Military Decision Making Planning (MDMP) process, specifically, the Oracle Delphi. This process was used to: (1) review a needs assessment on the profile of disasters in general and the Pacific in particular and (2) critically examine the viability and issues surrounding a Pacific HA/DR medical response of going in light and incrementally.

Results

The Pacific area of operations contains 9 of 15 countries most at risk for disasters in the most disaster-prone region of the world. So, it is not a matter of whether a major, potentially large-scale lethal disaster will occur but rather when. Solid empirical research has shown that by every outcome measured Joint Forces (Army, Navy, Air Force, and Marines) medical HA/DR operations have been inordinately successful and cost-effective when they employed U.S. Army medical assets inland near disasters’ kinetic impact and combined sister services’ logistical support and expertise. In this regard, USARPAC has the potential to go in light and successfully fill a vital HA/DR medical response gap with the RDMT and a BLU-MED^®. However, initially going in fast and light and expanding and contracting as the situation dictates comes with subsequent challenges as briefly described herein that must be addressed.

Conclusions

The challenges to going in light are not insurmountable “show stoppers.” They can be identified and addressed through planning and preparation. Hopefully, the acquisition rapid response light components will equip commanders with more effective options with which to conduct Pacific HA/DR operations and be a focal point for effective joint operations.

Evacuation of a Tertiary Neonatal Centre: Lessons from the 2016 Kumamoto Earthquakes

BACKGROUND

Newborn infants hospitalised in the neonatal intensive care unit (NICU) are vulnerable to natural disasters. However, publications on evacuation from NICUs are sparse. The 2016 Kumamoto Earthquakes caused serious damage to Kumamoto City Hospital and its level III regional core NICU. Local/neighbour NICU teams and the disaster-communication team of a neonatal academic society cooperated to evacuate 38 newborn infants from the ward.

OBJECTIVE

The aim of this paper was to highlight potential key factors to improve emergency NICU evacuation and coordination of hospital transportation following natural disasters.

METHODS

Background variables including clinical risk scores and timing/destination of transportation were compared between infants, who subsequently were transferred to destinations outside of Kumamoto Prefecture, and their peers.

RESULTS

All but 1 of the infants were successfully evacuated from their NICU within 8 h. One very-low-birth-weight infant developed moderate hypothermia following transportation. Fourteen infants were transferred to NICUs outside of Kumamoto Prefecture, which was associated with the diagnosis of congenital heart disease, dependence on respiratory support, higher risk scores, and longer elapsed time from the decision to departure. There was difficulty in arranging helicopter transportation because the coordination office of the Disaster Medical Assistance Team had requisitioned most air/ground ambulances and only helped arrange ground transportations for 13 low-risk infants. Transportation for all 10 high-risk infants (risk scores greater than or equal to the upper quartile) was arranged by local/neighbour NICUs.

CONCLUSIONS

Although the overall evacuation process was satisfactory, potential risks of relying on the adult-based emergency transportation system were highlighted. A better system needs to be developed urgently to put appropriate priority on vulnerable infants.

Triage: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement

BACKGROUND

Pandemics and disasters can result in large numbers of critically ill or injured patients who may overwhelm available resources despite implementing surge-response strategies. If this occurs, critical care triage, which includes both prioritizing patients for care and rationing scarce resources, will be required. The suggestions in this chapter are important for all who are involved in large-scale pandemics or disasters with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials.

METHODS

The Triage topic panel reviewed previous task force suggestions and the literature to identify 17 key questions for which specific literature searches were then conducted to identify studies upon which evidence-based recommendations could be made. No studies of sufficient quality were identified. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process. Suggestions from the previous task force that were not being updated were also included for validation by the expert panel.

RESULTS

The suggestions from the task force outline the key principles upon which critical care triage should be based as well as a path for the development of the plans, processes, and infrastructure required. This article provides 11 suggestions regarding the principles upon which critical care triage should be based and policies to guide critical care triage.

CONCLUSIONS

Ethical and efficient critical care triage is a complex process that requires significant planning and preparation. At present, the prognostic tools required to produce an effective decision support system (triage protocol) as well as the infrastructure, processes, legal protections, and training are largely lacking in most jurisdictions. Therefore, critical care triage should be a last resort after mass critical care surge strategies.

Utstein-style template for uniform data reporting of acute medical response in disasters

BACKGROUND

In 2003, the Task Force on Quality Control of Disaster Management (WADEM) published guidelines for evaluation and research on health disaster management and recommended the development of a uniform data reporting tool. Standardized and complete reporting of data related to disaster medical response activities will facilitate the interpretation of results, comparisons between medical response systems and quality improvement in the management of disaster victims.

METHODS

Over a two-year period, a group of 16 experts in the fields of research, education, ethics and operational aspects of disaster medical management from 8 countries carried out a consensus process based on a modified Delphi method and Utstein-style technique.

RESULTS

The EMDM Academy Consensus Group produced an Utstein-style template for uniform data reporting of acute disaster medical response, including 15 data elements with indicators, that can be used for both research and quality improvement.

CONCLUSION

It is anticipated that the Utstein-style template will enable better and more accurate completion of reports on disaster medical response and contribute to further scientific evidence and knowledge related to disaster medical management in order to optimize medical response system interventions and to improve outcomes of disaster victims.

Challenges in disaster data collection during recent disasters

Gathering essential health data to provide rapid and effective medical relief to populations devastated by the effects of a disaster-producing event involves challenges. These challenges include response to environmental hazards, security of personnel and resources, political and economic issues, cultural barriers, and difficulties in communication, particularly between aid agencies. These barriers often impede the timely collection of key health data such as morbidity and mortality, rapid health and sheltering needs assessments, key infrastructure assessments, and nutritional needs assessments. Examples of these challenges following three recent events: (1) the Indian Ocean tsunami; (2) Hurricane Katrina; and (3) the 2010 earthquake in Haiti are reviewed. Some of the innovative and cutting-edge approaches for surmounting many of these challenges include: (1) the establishment of geographical information systems (GIS) mapping disaster databases; (2) establishing internet surveillance networks and data repositories; (3) utilization of personal digital assistant-based platforms for data collection; (4) involving key community stakeholders in the data collection process; (5) use of pre-established, local, collaborative networks to coordinate disaster efforts; and (6) exploring potential civil-military collaborative efforts. The application of these and other innovative techniques shows promise for surmounting formidable challenges to disaster data collection.

Allocating scarce resources in disasters: emergency department principles

Decisions about medical resource triage during disasters require a planned structured approach, with foundational elements of goals, ethical principles, concepts of operations for reactive and proactive triage, and decision tools understood by the physicians and staff before an incident. Though emergency physicians are often on the front lines of disaster situations, too often they have not considered how they should modify their decisionmaking or use of resources to allow the "greatest good for the greatest number" to be accomplished. This article reviews key concepts from the disaster literature, providing the emergency physician with a framework of ethical and operational principles on which medical interventions provided may be adjusted according to demand and the resources available. Incidents may require a range of responses from an institution and providers, from conventional (maximal use of usual space, staff, and supplies) to contingency (use of other patient care areas and resources to provide functionally equivalent care) and crisis (adjusting care provided to the resources available when usual care cannot be provided). This continuum is defined and may be helpful when determining the scope of response and assistance necessary in an incident. A range of strategies is reviewed that can be implemented when there is a resource shortfall. The resource and staff requirements of specific incident types (trauma, burn incidents) are briefly considered, providing additional preparedness and decisionmaking tactics to the emergency provider. It is difficult to think about delivering medical care under austere conditions. Preparation and understanding of the decisions required and the objectives, strategies, and tactics available can result in better-informed decisions during an event. In turn, adherence to such a response framework can yield thoughtful stewardship of resources and improved outcomes for a larger number of patients.

Health care system planning for and response to a nuclear detonation

The hallmark of a successful response to a nuclear detonation will be the resilience of the community, region, and nation. An incident of this magnitude will rapidly become a national incident; however, the initial critical steps to reduce lives lost, save the lives that can be saved with the resources available, and understand and apply resources available to a complex and dynamic situation will be the responsibility of the local and regional responders and planners. Expectations of the public health and health care systems will be met to the extent possible by coordination, cooperation, and an effort to produce as consistent a response as possible for the victims. Responders will face extraordinarily stressful situations, and their own physical and psychological health is of great importance to optimizing the response. This article illustrates through vignettes and supporting text how the incident may unfold for the various components of the health and medical systems and provides additional context for the discipline-related actions outlined in the state and local planners' playbook.

Does triage to critical care during a pandemic necessarily result in more survivors?

OBJECTIVE

The 2009 H1N1 pandemic reinforced the need for a planned response to increased demand for critical care. Triage protocols have been proposed incorporating the exclusion of specified subgroups of patients from critical care. There have been no studies that explore the theoretical underpinning of triage at referral, and it is not clear under what circumstances triage would confer the intended benefits. We sought to explore the mechanisms whereby triage could lead to fewer deaths across a critical care population in the context of a pandemic.

DESIGN

We constructed a mathematical model based on queuing theory to compare the estimated short-term survival achieved by using a critical care service with and without triage at referral. Illustrative scenarios concerning a hypothetical critical care population were constructed to explore the roles of length of stay and critical care survival in determining the impact of triage and to identify "tipping points" of demand at which triage would result in more survivors.

SETTING

Not applicable as this was a data-free mathematical modeling exercise.

MAIN RESULTS

We identified circumstances in which triage would be expected to result in more survivors and circumstances in which it would not. In some scenarios, excluding patient groups solely on the basis of anticipated length of stay could be effective due to a more efficient use of critical care bed days.

CONCLUSIONS

The impact of triage is dependent on the level of demand and on the scale of achievable differences between included and excluded groups in terms of anticipated length of stay and critical care survival. It cannot be assumed that triage can or will result in fewer deaths. It should be remembered that there are considerations other than population-level short-term survival when determining the objectives of triage and its ethical implementation.

Emergency medical services transport decisions in posttraumatic circulatory arrest: are national practices congruent?

OBJECTIVE

To catalog the 9-1-1 emergency medical services (EMS) transport practices for posttraumatic circulatory arrest patients (PTCAPs) in the majority of the nation's largest municipalities and to compare those practices to guidelines recommended by the National Association of EMS Physicians (NAEMSP) and American College of Surgeons Committee on Trauma (ACSCOT).

METHODS

A survey was conducted in 33 of the nation's largest cities primarily to determine whether or not individual EMS systems transport PTCAPs to hospitals and, if so, whether or not the initial electrocardiographic (ECG) rhythm or mechanism of injury affected those transport decisions.

RESULTS

All 33 cities (100%) responded. Seven (21%) indicated that EMS would transport an "asystolic blunt trauma patient" emergently or "leave the transport decision to paramedic judgment" despite NAEMSP-ACSCOT guidelines to terminate resuscitation in such cases. Likewise, 15 (46%) of the 33 EMS agencies would transport "asystolic penetrating trauma patients" emergently. Similarly, 27 (82%) would transport penetrating injury patients and 20 (61%) would transport blunt trauma patients with persistent ECG activity but no palpable pulses. However, only five systems had policies that included a minimum ECG heart rate criterion for transport, and all agencies that monitor ECG (n = 32) would transport PTCAPs found with ventricular fibrillation.

CONCLUSIONS

Many of the nation's highest volume EMS systems transport certain PTCAPs emergently, contrary to NAEMSP-ACSCOT guidelines to terminate resuscitative efforts in such cases. Reasons for these discrepancies should be evaluated to help better delineate applicable consensus guidelines for large urban EMS agencies.

Predicting dissemination of a disaster mental health "Train-the-Trainer" program

OBJECTIVE

  Disaster mental health (DMH) is vital to comprehensive disaster preparedness for communities. A train-the-trainer (TTT) model is frequently used in public health to disseminate knowledge and skills to communities, although few studies have examined its success. We report on the development and implementation of a DMH TTT program and examine variables that predict dissemination.

METHODS

  This secondary analysis examines 140 community-based mental health providers' participation in a TTT DMH program in 2005-2006. Instructors' dissemination of the training was followed for 12 months. Bivariate and multivariate analyses were conducted to predict dissemination of the training program.

RESULTS

  Sixty percent of the trainees in the DMH TTT program conducted training programs in the 12-month period following being trained. The likelihood of conducting training programs was predicted by a self-report measure of perceptions of transfer of training. The number of individuals subsequently trained (559) was predicted by prior DMH training and sex. No other variables predicted dissemination of DMH training.

CONCLUSIONS

  The TTT model was moderately successful in disseminating DMH training. Intervention at the organizational and individual level, as well as training modifications, may increase cost-effective dissemination of DMH training.

The Needs of Children in Natural or Manmade Disasters

Disasters have been described as “events of sufficient scale, asset depletion, or numbers of victims to overwhelm medical resources” [1] or as “a serious disruption of the functioning of a community or a society causing widespread human, material, economic or environmental losses that exceed the ability of the affected community or society to cope using its own resources” [2]. Importantly, that definition goes on to state: “A disaster is a function of the risk process. It results from the combination of hazards, conditions of vulnerability and insufficient capacity or measures to reduce the potential negative consequences of risk.”