Emergency preparedness for biological and chemical incidents: a survey of anesthesiology residency programs in the United States

How Can Personal Protective Equipment Be Best Used and Reused: A Closer Look at Donning and Doffing Procedures

OBJECTIVE

The aim of this study was to examine safety-related contamination threats and risks to health-care workers (HCWs) due to the reuse of personal protective equipment (PPE) among emergency department (ED) personnel.

METHODS

We used a Participatory Design (PD) approach to conduct task analysis (TA) of PPE use and reuse. TA identified the steps, risks, and protective behaviors involved in PPE reuse. We used the Centers for Disease Control and Prevention (CDC) guidance for PPE donning and doffing specifying the recommended task order. Then, we convened subject matter experts (SMEs) with relevant backgrounds in Patient Safety, Human Factors and Emergency Medicine to iteratively identify and map the tasks, risks, and protective behaviors involved in the PPE use and reuse.

RESULTS

Two emerging threats were associated with behaviors in donning, doffing, and re-using PPE: (i) direct exposure to contaminant, and (ii) transmission/spread of contaminant. Protective behaviors included: hand hygiene, not touching the patient-facing surface of PPE, and ensuring a proper fit and closure of all PPE ties and materials.

CONCLUSIONS

TA was helpful revealed that the procedure for donning and doffing of re-used PPE does not protect ED personnel from contaminant spread and risk of exposure, even with protective behaviors present (e.g., hand hygiene, respirator use, etc.). Future work should make more apparent the underlying risks associated with PPE use and reuse.

Resilience and Protection of Health Care and Research Laboratory Workers During the SARS-CoV-2 Pandemic: Analysis and Case Study From an Austrian High Security Laboratory

The SARS-CoV-2 pandemic has highlighted the interdependency of healthcare systems and research organizations on manufacturers and suppliers of personnel protective equipment (PPE) and the need for well-trained personnel who can react quickly to changing working conditions. Reports on challenges faced by research laboratory workers (RLWs) are rare in contrast to the lived experience of hospital health care workers. We report on experiences gained by RLWs (e.g., molecular scientists, pathologists, autopsy assistants) who significantly contributed to combating the pandemic under particularly challenging conditions due to increased workload, sickness and interrupted PPE supply chains. RLWs perform a broad spectrum of work with SARS-CoV-2 such as autopsies, establishment of virus cultures and infection models, development and verification of diagnostics, performance of virus inactivation assays to investigate various antiviral agents including vaccines and evaluation of decontamination technologies in high containment biological laboratories (HCBL). Performance of autopsies and laboratory work increased substantially during the pandemic and thus led to highly demanding working conditions with working shifts of more than eight hours working in PPE that stressed individual limits and also the ergonomic and safety limits of PPE. We provide detailed insights into the challenges of the stressful daily laboratory routine since the pandemic began, lessons learned, and suggest solutions for better safety based on a case study of a newly established HCBL (i.e., BSL-3 laboratory) designed for autopsies and research laboratory work. Reduced personal risk, increased resilience, and stress resistance can be achieved by improved PPE components, better training, redundant safety measures, inculcating a culture of safety, and excellent teamwork.

Paediatric patients in mass casualty incidents: a comprehensive review and call to action

The paediatric population is disproportionately affected during mass casualty incidents (MCIs). Several unique characteristics of children merit special attention during natural and man-made disasters because of their age, physiology, and vulnerability. Paediatric anaesthesiologists play a critical part of MCI care for this population, yet there is a deficit of publications within the anaesthesia literature addressing paediatric-specific MCI concerns. This narrative review article analyses paediatric MCI considerations and compares differing aspects between care provision in Australia, the UK, and the USA. We integrate some of the potential roles for anaesthesiologists with paediatric experience, which include preparation, command consultation, in-field care, pre-hospital transport duties, and emergency department, operating theatre, and ICU opportunities. Finally, we propose several methods by which anaesthesiologists can improve their contribution to paediatric MCI care through personal education, training, and institutional involvement.

The Multiple Casualty Scenario: Role of the Anesthesiologist

Purpose of Review

Mass casualty disasters (natural and man-made) present an acute, critical situation that taxes healthcare resources and clinician acumen. This review summarizes the characteristics and management skill sets that anesthesiologists possess that make them valuable clinicians during mass casualty events and why we as anesthesiologists must continually educate ourselves on this important topic.

Recent Findings

Anesthesiologists should be involved in all aspects of emergency preparedness—mitigation, planning, response, and recovery. The anesthesia department should have a plan for how it will deal with managing patients during natural and man-made (unintentional or intentional) disasters, one that takes into account a risk hazard analysis and institutional goals. Unfortunately, most practicing anesthesiologists have not had training and ongoing education for such events, and few academic centers train anesthesiology residents and staff to prepare for mass casualty scenarios.

Summary

The everyday clinical practice of anesthesiologists involves the utilization of some of the skills (vascular access, tracheal intubation) commonly required to successfully manage mass casualty scenarios. Anesthesiologists’ knowledge of anti-cholinesterases makes them subject matter experts on nerve agent poisoning, and their experience managing trauma patients will serve them well, depending on the nature of the mass casualty event. Practicing anesthesiologists however need to continually educate themselves on their role during mass casualty events. and current anesthesiology residency programs should develop a curriculum and incorporate simulation training to better prepare future generations of anesthesiologists.

Hospital Preparedness Plans for Chemical Incidents and Threats: A Systematic Review

In a wide range of events, people may be acutely exposured to chemical substances. Particular hospital preparedness plans and vital resources are essential for appropriate health-care measures. The present study aimed to conduct a systematic review to summarize and evaluate the existing evidence on hospital preparedness plans or protocols against chemical incidents and threats. In this aim, through May 15, 2018, 5 electronic databases were searched in MEDLINE (PubMed, Scopus, Web of Science, Cochrane Library, and Google Scholar) for the following key words: hospital preparedness, plan, protocol, chemical incident, and chemical threat. The final review included 11 peer-reviewed papers that met inclusion criteria. The systematic review was performed using the Preferred Reporting Items for the Systematic reviews and Meta-Analysis protocol (PRISMA) (www.prisma-statement.org). Finally, of 16,540 selected papers, 11 papers were included in the final analysis. The thematic analyses revealed 11 major categories of chemical incidents and threats planning, such as planning requirements, planning prerequisites, preparation team member (multidisciplinary team), decontamination, personal protective equipment, education and training, job descriptions and roles, communication, database, staff /volunteer organization, as well as planning barriers and challenges for chemical incidents. Most countries have launched hospital preparedness planning against chemical incidents and threat activities, but the preparedness of hospitals is often less than desirable. Many items, such as databases, hospital preparation team members, communications, etc., are still challenging.

Virtual-world hospital simulation for real-world disaster response: Design and validation of a virtual reality simulator for mass casualty incident management

BACKGROUND

Mass casualty incidents are unfortunately becoming more common. The coordination of mass casualty incident response is highly complex. Currently available options for training, however, are limited by either lack of realism or prohibitive expense and by a lack of assessment tools. Virtual worlds represent a potentially cost-effective, immersive, and easily accessible platform for training and assessment. The aim of this study was to assess feasibility of a novel virtual-worlds-based system for assessment and training in major incident response.

METHODS

Clinical areas were modeled within a virtual, online hospital. A major incident, incorporating virtual casualties, allowed multiple clinicians to simultaneously respond with appropriate in-world management and transfer plans within limits of the hospital's available resources. Errors, delays, and completed actions were recorded, as well as Trauma-NOnTECHnical Skills (T-NOTECHS) score. Performance was compared between novice and expert clinician groups.

RESULTS

Twenty-one subjects participated in three simulations: pilot (n = 7), novice (n = 8), and expert groups (n = 6). The novices committed more critical events than the experts, 11 versus 3, p = 0.006; took longer to treat patients, 560 (299) seconds versus 339 (321) seconds, p = 0.026; and achieved poorer T-NOTECHS scores, 14 (2) versus 21.5 (3.7), p = 0.003, and technical skill, 2.29 (0.34) versus 3.96 (0.69), p = 0.001. One hundred percent of the subjects thought that the simulation was realistic and superior to existing training options.

CONCLUSION

A virtual-worlds-based model for the training and assessment of major incident response has been designed and validated. The advantages of customizability, reproducibility, and recordability combined with the low cost of implementation suggest that this potentially represents a powerful adjunct to existing training methods and may be applicable to further areas of surgery as well.

Reporting for duty during mass casualty events: a survey of factors influencing emergency medicine physicians

BACKGROUND

Academic medical centers play a major role in disaster response, and residents frequently serve as key resources in these situations. Studies examining health care professionals' willingness to report for duty in mass casualty situations have varying response rates, and studies of emergency medicine (EM) residents' willingness to report for duty in disaster events and factors that affect these responses are lacking.

OBJECTIVE

We sought to determine EM resident and faculty willingness to report for duty during 4 disaster scenarios (natural, explosive, nuclear, and communicable), to identify factors that affect willingness to work, and to assess opinions regarding disciplinary action for physicians unwilling to work in a disaster situation.

METHODS

We surveyed residents and faculty at 7 US teaching institutions with accredited EM residency programs between April and November 2010.

RESULTS

A total of 229 faculty and 259 residents responded (overall response rate, 75.4%). Willingness to report for duty ranged from 54.1% for faculty in a natural disaster to 94.2% for residents in a nonnuclear explosive disaster. The 3 most important factors influencing disaster response were concern for the safety of the family, belief in the physician's duty to provide care, and availability of protective equipment. Faculty and residents recommended minimal or no disciplinary action for individuals unwilling to work, except in the infectious disease scenario.

CONCLUSIONS

Most EM residents and faculty indicated they would report for duty. Residents and faculty responses were similar in all but 1 scenario. Disciplinary action for individuals unwilling to work generally was not recommended.

Tactical and operational response to major incidents: feasibility and reliability of skills assessment using novel virtual environments

OBJECTIVES

To determine feasibility and reliability of skills assessment in a multi-agency, triple-site major incident response exercise carried out in a virtual world environment.

METHODS

Skills assessment was carried out across three scenarios. The pre-hospital scenario required paramedics to triage and treat casualties at the site of an explosion. Technical skills assessment forms were developed using training syllabus competencies and national guidelines identified by pre-hospital response experts. Non-technical skills were assessed using a seven-point scale previously developed for use by pre-hospital paramedics. The two in-hospital scenarios, focusing on a trauma team leader and a silver/clinical major incident co-ordinator, utilised the validated Trauma-NOTECHS scale to assess five domains of performance. Technical competencies were assessed using an ATLS-style competency scale for the trauma scenario. For the silver scenario, the assessment document was developed using competencies described from a similar role description in a real-life hospital major incident plan. The technical and non-technical performance of all participants was assessed live by two experts in each of the three scenarios and inter-assessor reliability was computed. Participants also self-assessed their performance using identical proformas immediately after the scenarios were completed. Self and expert assessments were correlated (assessment cross-validation).

RESULTS

Twenty-three participants underwent all scenarios and assessments. Performance assessments were feasible for both experts as well as the participants. Non-technical performance was generally scored higher than technical performance. Very good inter-rater reliability was obtained between expert raters across all scenarios and both technical and non-technical aspects of performance (reliability range 0.59-0.90, Ps<0.01). Significant positive correlations were found between self and expert assessment in technical skills across all three scenarios (correlation range 0.52-0.84, Ps<0.05), although no such correlations were observed in non-technical skills.

CONCLUSIONS

This study establishes feasibility and reliability of virtual environment technical and non-technical skills assessment in major incident scenarios for the first time. The development for further scenarios and validated assessment scales will enable major incident planners to utilise virtual technologies for improved major incident preparation and training.

Major incident preparation for acute hospitals: current state-of-the-art, training needs analysis, and the role of novel virtual worlds simulation technologies

BACKGROUND

There is growing evidence that health systems in developed countries are poorly prepared to deal with major incidents.

STUDY OBJECTIVES

This study aimed to determine the skills required for successful major incident response, the factors that contribute to a successful major incident exercise, and whether there is a role for using novel simulation training (virtual worlds) in preparing for major incidents.

METHODS

This was a qualitative semi-structured interview study. Fourteen health care staff with experience of major incident planning and training in the United Kingdom were recruited. Interviews were content-analyzed to identify emergent themes.

RESULTS

The aims and benefits of current exercises were categorized into three major themes: Organizational, Interpersonal, and Cognitive. Participants felt that the main objective of current exercises is to see how a major incident plan is implemented, rather than training individual staff. Communications was the most frequently commented-on area requiring improvement. Participants felt that lack of constructive feedback reduced the effectiveness of the exercises. All participants commented that virtual worlds technology could be successfully utilized for training. The creation of an immersive environment, increased training opportunity, and improved participant feedback were thought to be amongst the greatest benefits.

CONCLUSION

There are clear deficiencies with current major incident preparation. Utilizing virtual worlds technology as an adjunct to existing exercises could improve training and response in the future.

Emergency preparedness in the 21st century: training and preparation modules in virtual environments

OBJECTIVES

To determine the feasibility of evidence-based design and use of low-cost virtual world environments for preparation and training in multi-agency, multi-site, major incident response.

METHODS

A prospective cohort feasibility study was carried out. One pre-hospital, and two in-hospital major incident scenarios, were created in an accessible virtual world environment. 23 pre-hospital and hospital-based clinicians each took part in one of three linked major incident scenarios: a pre-hospital bomb blast site, focusing on the roles of the team leader and triage person; a blast casualty in a resuscitation room, focusing on the role of the trauma team leader; a hospital command and control scenario focusing on the role of the clinical major incident co-ordinator/silver commander. Participants supplied both quantitative and qualitative feedback.

RESULTS

Using a systematic, evidence-based approach, three scenarios were successfully developed and tested using low-cost virtual worlds (Second Life and OpenSimulator). All scenarios were run to completion. 95% of participants expressed a desire to use virtual environments for future training and preparation. Pre-hospital responders felt that the immersive virtual environment enabled training in surroundings that would be inaccessible in real-life.

CONCLUSIONS

The feasibility and face/content validity of using low-cost virtual worlds for multi-agency major incident simulation has been established. Major incident planners and trainers should explore utilising this technology as an adjunct to existing methodologies. Future work will involve development of robust assessment metrics.

Emergency preparedness: addressing a residency training gap

As the importance of physician involvement and leadership in crisis preparedness is recognized, the literature suggests that few physicians are adequately trained to practice effectively in a large-scale crisis situation. A logical method for addressing the emergency preparedness training deficiency identified across several medical specialties is to include disaster and emergency preparedness training in residency curricula. In this article, the authors outline the development and implementation of an emergency preparedness curriculum for the Johns Hopkins General Preventive Medicine Residency (JHGPMR) from 2004 to 2006. The curriculum consists of two components. The first was developed for the academic year in the JHGPMR and includes didactic lectures, practical exercises to apply new knowledge, and an opportunity to integrate the knowledge and skills in a real-world exercise. The second, developed for the practicum year of the residency, includes Web-based lectures and online content and culminates in a tabletop preparedness exercise. Topics for both components include weapons of mass destruction, risk communication and personal preparedness, aspects of local emergency response planning, and mental health and psychological aspects of terrorism. On the basis of the emergency preparedness training gap that has been identified in the literature, and the success of the three-year experience in implementing a preparedness training curriculum in the JHGPMR, the authors recommend incorporation of competency-based emergency preparedness training for residencies of all specialties, and offer insights into how the described curriculum could be adapted for use in other residency settings.

Bioterrorism training in U.S. emergency medicine residencies: has it changed since 9/11?

OBJECTIVES

To assess the change in prevalence of bioterrorism training among emergency medicine (EM) residencies from 1998 to 2005, to characterize current training, and to identify characteristics of programs that have implemented more intensive training methods.

METHODS

This was a national cross sectional survey of the 133 U.S. EM residencies participating in the 2005 National Resident Matching Program; comparison with a baseline survey from 1998 was performed. Types of training provided were assessed, and programs using experiential methods were identified.

RESULTS

Of 112 programs (84.2%) responding, 98% reported formal training in bioterrorism, increased from 53% (40/76) responding in 1998. In 2005, most programs with bioterrorism training (65%) used at least three methods of instruction, mostly lectures (95%) and disaster drills (80%). Fewer programs used experiential methods such as field exercises or bioterrorism-specific rotations (35% and 13%, respectively). Compared with other programs, residency programs with more complex, experiential methods were more likely to teach bioterrorism-related topics at least twice a year (83% vs. 59%; p = 0.018), to teach at least three topics (60% vs. 40%; p = 0.02), and to report funding for bioterrorism research and education (74% vs. 45%; p = 0.007). Experiential and nonexperiential programs were similar in program type (university or nonuniversity), length of program, number of residents, geographic location, and urban or rural setting.

CONCLUSIONS

Training of EM residents in bioterrorism preparedness has increased markedly since 1998. However, training is often of low intensity, relying mainly on nonexperiential instruction such as lectures. Although current recommendations are that training in bioterrorism include experiential learning experiences, the authors found the rate of these experiences to be low.