Truth hurts - hard lessons from Australia's largest mass casualty exercise with contaminated patients

A Survey Study of Public Health Nurses’ Knowledge in Disaster Management in Indonesia

AIM: This descriptive survey study examines the level of public health nurses’ (PHNs) knowledge regarding disaster management. The knowledge was examined according to three disaster phases, including preparedness, response, and recovery phase. MATERIALS & METHODS: A stratified proportionate random sampling method was employed to recruit 252 PHNs of Aceh Province, Indonesia. The data were collected during November and December of 2010 by using the questionnaire developed by the researchers. They were analyzed using frequencies, percentages, means, standard deviations, and minimum and maximum scores. Additional analyses were performed to identify potential contributing factors to the PHNs' knowledge using the Spearman rank correlation (rs) and the Mann-Whitney U test. RESULTS: The finding showed that PHNs' knowledge in disaster management was moderate (M=70.73%, SD=8.41), and nearly half of the subjects (42.5%) were categorized in this level. The lowest mean score was found in the response phase (64.75%), and four items with the lowest percentage of correct answers were also found in this phase. CONCLUSION: The low level of knowledge for the response phase can be used to flag health policymakers and public health centers (PHC) to develop appropriate educational training and disaster drills for PHNs in collaboration with stakeholders in the community.

Mass Casualty Decontamination Guidance and Psychosocial Aspects of CBRN Incident Management: A Review and Synthesis

INTRODUCTION

Mass casualty decontamination is an intervention employed by first responders at the scene of an incident involving noxious contaminants.  Many countries have sought to address the challenge of decontaminating large numbers of affected casualties through the provision of rapidly deployable temporary showering structures, with accompanying decontamination protocols.  In this paper we review decontamination guidance for emergency responders and associated research evidence, in order to establish to what extent psychosocial aspects of casualty management have been considered within these documents. The review focuses on five psychosocial aspects of incident management: likely public behaviour; responder management style; communication strategy; privacy/ modesty concerns; and vulnerable groups.

METHODS

Two structured literature reviews were carried out; one to identify decontamination guidance documents for first responders, and another to identify evidence which is relevant to the understanding of the psychosocial aspects of mass decontamination.  The guidance documents and relevant research were reviewed to identify whether the guidance documents contain information relating to psychosocial issues and where it exists, that the guidance is consistent with the existing evidence-base.

RESULTS

Psychosocial aspects of incident management receive limited attention in current decontamination guidance.  In addition, our review has identified a number of gaps and inconsistencies between guidance and research evidence.  For each of the five areas we identify: what is currently presented in guidance documents, to what extent this is consistent with the existing research evidence and where it diverges.  We present a series of evidence-based recommendations for updating decontamination guidance to address the psychosocial aspects of mass decontamination.

CONCLUSIONS

Effective communication and respect for casualties' needs are critical in ensuring decontamination is completed quickly and effectively.  We identify a number of areas requiring further research including: identifying effective methods for communicating in an emergency; better understanding of the needs of vulnerable groups during decontamination; effective training for emergency responders on psychosocial issues, and pre-incident public education for incidents involving emergency decontamination.  It is essential that the psychosocial aspects of mass decontamination are not neglected in the pursuit of solely technical solutions.

A large-scale mass casualty simulation to develop the non-technical skills medical students require for collaborative teamwork

BACKGROUND

There is little research on large-scale complex health care simulations designed to facilitate student learning of non-technical skills in a team-working environment. We evaluated the acceptability and effectiveness of a novel natural disaster simulation that enabled medical students to demonstrate their achievement of the non-technical skills of collaboration, negotiation and communication.

METHODS

In a mixed methods approach, survey data were available from 117 students and a thematic analysis undertaken of both student qualitative comments and tutor observer participation data.

RESULTS

Ninety three per cent of students found the activity engaging for their learning. Three themes emerged from the qualitative data: the impact of fidelity on student learning, reflexivity on the importance of non-technical skills in clinical care, and opportunities for collaborative teamwork. Physical fidelity was sufficient for good levels of student engagement, as was sociological fidelity. We demonstrated the effectiveness of the simulation in allowing students to reflect upon and evidence their acquisition of skills in collaboration, negotiation and communication, as well as situational awareness and attending to their emotions. Students readily identified emerging learning opportunities though critical reflection. The scenarios challenged students to work together collaboratively to solve clinical problems, using a range of resources including interacting with clinical experts.

CONCLUSIONS

A large class teaching activity, framed as a simulation of a natural disaster is an acceptable and effective activity for medical students to develop the non-technical skills of collaboration, negotiation and communication, which are essential to team working. The design could be of value in medical schools in disaster prone areas, including within low resource countries, and as a feasible intervention for learning the non-technical skills that are needed for patient safety.

Applying crowd psychology to develop recommendations for the management of mass decontamination

Mass decontamination is a public health intervention employed by emergency responders following a chemical, biological, or radiological release. It involves a crowd of people whose interactions with each other and with the emergency responders managing the incident are likely to affect the success of the decontamination process. The way in which members of the public collectively experience decontamination is likely to affect their behavior and hence is crucial to the success of the decontamination process. Consequently, responders and the responsible authorities need to understand crowd psychology during mass emergencies and disasters. Recently, the social identity approach to crowd psychology has been applied to explain public perceptions and behavior during mass emergencies. This approach emphasizes that crowd events are characteristically intergroup encounters, in which the behavior of one group can affect the perceptions and behavior of another. We summarize the results from a program of research in which the social identity approach was applied to develop and test recommendations for the management of mass decontamination. The findings from this program of research show that (1) responders' perceptions of crowd behavior matter; (2) participants value greater communication and this affects their compliance; and (3) social identity processes explain the relationship between effective responder communication and relevant outcome variables, such as public compliance, public cooperation, and public anxiety. Based on this program of research, we recommend 4 responder management strategies that focus on increasing public compliance, increasing orderly and cooperative behavior among members of the public, reducing public anxiety, and respecting public needs for privacy.

Self-care Decontamination within a Chemical Exposure Mass-casualty Incident

Growing awareness and concern for the increasing frequency of incidents involving hazardous materials (HazMat) across a broad spectrum of contaminants from chemical, biological, radiological, and nuclear (CBRN) sources indicates a clear need to refine the capability to respond successfully to mass-casualty contamination incidents. Best results for decontamination from a chemical agent will be achieved if done within minutes following exposure, and delays in decontamination will increase the length of time a casualty is in contact with the contaminate. The findings presented in this report indicate that casualties involved in a HazMat/CBRN mass-casualty incident (MCI) in a typical community would not receive sufficient on-scene care because of operational delays that are integral to a standard HazMat/CBRN first response. This delay in response will mean that casualty care will shift away from the incident scene into already over-tasked health care facilities as casualties seek aid on their own. The self-care decontamination protocols recommended here present a viable option to ensure decontamination is completed in the field, at the incident scene, and that casualties are cared for more quickly and less traumatically than they would be otherwise. Introducing self-care decontamination procedures as a standard first response within the response community will improve the level of care significantly and provide essential, self-care decontamination to casualties. The process involves three distinct stages which should not be delayed; these are summarized by the acronym MADE: Move/Assist, Disrobe/Decontaminate, Evaluate/Evacuate.

MonteithRG, PearceLDR. Self-care decontamination within a chemical exposure mass-casualty incident. Prehosp Disaster Med. 2015;30(3):1–9.

Effective responder communication improves efficiency and psychological outcomes in a mass decontamination field experiment: implications for public behaviour in the event of a chemical incident

The risk of incidents involving mass decontamination in response to a chemical, biological, radiological, or nuclear release has increased in recent years, due to technological advances, and the willingness of terrorists to use unconventional weapons. Planning for such incidents has focused on the technical issues involved, rather than on psychosocial concerns. This paper presents a novel experimental study, examining the effect of three different responder communication strategies on public experiences and behaviour during a mass decontamination field experiment. Specifically, the research examined the impact of social identity processes on the relationship between effective responder communication, and relevant outcome variables (e.g. public compliance, public anxiety, and co-operative public behaviour). All participants (n = 111) were asked to visualise that they had been involved in an incident involving mass decontamination, before undergoing the decontamination process, and receiving one of three different communication strategies: 1) ‘Theory-based communication’: Health-focused explanations about decontamination, and sufficient practical information; 2) ‘Standard practice communication’: No health-focused explanations about decontamination, sufficient practical information; 3) ‘Brief communication’: No health-focused explanations about decontamination, insufficient practical information. Four types of data were collected: timings of the decontamination process; observational data; and quantitative and qualitative self-report data. The communication strategy which resulted in the most efficient progression of participants through the decontamination process, as well as the fewest observations of non-compliance and confusion, was that which included both health-focused explanations about decontamination and sufficient practical information. Further, this strategy resulted in increased perceptions of responder legitimacy and increased identification with responders, which in turn resulted in higher levels of expected compliance during a real incident, and increased willingness to help other members of the public. This study shows that an understanding of the social identity approach facilitates the development of effective responder communication strategies for incidents involving mass decontamination.

Modelling mass casualty decontamination systems informed by field exercise data

In the event of a large-scale chemical release in the UK decontamination of ambulant casualties would be undertaken by the Fire and Rescue Service (FRS). The aim of this study was to track the movement of volunteer casualties at two mass decontamination field exercises using passive Radio Frequency Identification tags and detection mats that were placed at pre-defined locations. The exercise data were then used to inform a computer model of the FRS component of the mass decontamination process. Having removed all clothing and having showered, the re-dressing (termed re-robing) of casualties was found to be a bottleneck in the mass decontamination process during both exercises. Computer simulations showed that increasing the capacity of each lane of the re-robe section to accommodate 10 rather than five casualties would be optimal in general, but that a capacity of 15 might be required to accommodate vulnerable individuals. If the duration of the shower was decreased from three minutes to one minute then a per lane re-robe capacity of 20 might be necessary to maximise the throughput of casualties. In conclusion, one practical enhancement to the FRS response may be to provide at least one additional re-robe section per mass decontamination unit.

Disaster preparedness in an Australian urban trauma center: staff knowledge and perceptions

INTRODUCTION

A substantial barrier to improving disaster preparedness in Australia is a lack of prescriptive national guidelines based on individual hospital capabilities. A recent literature review revealed that only one Australian hospital has published data regarding its current preparedness level.

OBJECTIVES

To establish baseline levels of disaster knowledge, preparedness, and willingness to respond to a disaster among one hospital's staff, and thus enable the implementation of national disaster preparedness guidelines based on realistic capabilities of individual hospitals.

METHODS

An anonymous questionnaire was distributed to individuals and departments that play key roles in the hospital's external disaster response. Questions concerned prior education and experience specific to disasters, general preparedness knowledge, perceived preparedness of themselves and their department, and willingness to respond to a disaster from a conventional and/or chemical, biological, or radiological incident.

RESULTS

Responses were received from 140 individuals representing nine hospital departments. Eighty-three participants (59.3%) had previously received disaster education; 53 (37.9%) had attended a disaster simulation drill, and 18 (12.9%) had responded to an actual disaster. The average disaster preparedness knowledge score was 3.57 out of 10. The majority of respondents rated themselves as "not really" prepared and were "unsure" of their respective departments' level of preparedness. Most respondents indicated a willingness to participate in both a conventional incident involving burns and/or physical trauma, and an incident involving chemical, biological or radiological (CBR) weapons.

CONCLUSIONS

Australian hospital staff are under-prepared to respond to a disaster because of a lack of education, insufficient simulation exercises, and limited disaster experience. The absence of specific national standards and guidelines through which individual hospitals can develop their capabilities further compounds the poverty in preparedness.

Emergency department personal protective equipment requirements following out-of-hospital chemical biological or radiological events in Australasia

Recent events have led to a revision in ED equipment, preparedness and training for disasters. However, clinicians must still decide when, and what level of personal protection is required when a toxic threat exists. If possible, clear, simple and achievable protocols are required in such situations. Following an off‐site Australasian chemical biological or radiological incident, current evidence indicates that the initial receiving ED staff will be adequately protected from all known chemical biological and radiological inhalational threats by wearing a properly fitted P2 (N95) mask, or its equivalent. Protection from serious contact injury is offered by wearing double gloves, disposable fluid‐repellent coveralls or gown, eye protection, surgical mask, and ideally, a cap and shoe covers; in conjunction with universal precautions and procedures.