DEALING WITH DISASTER DATABASES - WHAT CAN WE LEARN FROM HEALTH AND SYSTEMATIC REVIEWS?: Application in practice

Minimum data set harmonization in the management of cross-border Multi Casualty Incidents. Modified Delphi (VALKYRIES-H2020 project)

INTRODUCTION

There is a need to develop harmonized procedures and a Minimum Data Set (MDS) for cross-border Multi Casualty Incidents (MCI) in medical emergency scenarios to ensure appropriate management of such incidents, regardless of place, language and internal processes of the institutions involved. That information should be capable of real-time communication to the command-and-control chain. It is crucial that the models adopted are interoperable between countries so that the rights of patients to cross-border healthcare are fully respected.

OBJECTIVE

To optimize management of cross-border Multi Casualty Incidents through a Minimum Data Set collected and communicated in real time to the chain of command and control for each incident. To determine the degree of agreement among experts.

METHOD

We used the modified Delphi method supplemented with the Utstein technique to reach consensus among experts. In the first phase, the minimum requirements of the project, the profile of the experts who were to participate, the basic requirements of each variable chosen and the way of collecting the data were defined by providing bibliography on the subject. In the second phase, the preliminary variables were grouped into 6 clusters, the objectives, the characteristics of the variables and the logistics of the work were approved. Several meetings were held to reach a consensus to choose the MDS variables using a Modified Delphi technique. Each expert had to score each variable from 1 to 10. Non-voting variables were eliminated, and the round of voting ended. In the third phase, the Utstein Style was applied to discuss each group of variables and choose the ones with the highest consensus. After several rounds of discussion, it was agreed to eliminate the variables with a score of less than 5 points. In phase four, the researchers submitted the variables to the external experts for final assessment and validation before their use in the simulations. Data were analysed with SPSS Statistics (IBM, version 2) software.

RESULTS

Six data entities with 31 sub-entities were defined, generating 127 items representing the final MDS regarded as essential for incident management. The level of consensus for the choice of items was very high and was highest for the category 'Incident' with an overall kappa of 0.7401 (95% CI 0.1265-0.5812, p 0.000), a good level of consensus in the Landis and Koch model. The items with the greatest degree of consensus at ten were those relating to location, type of incident, date, time and identification of the incident. All items met the criteria set, such as digital collection and real-time transmission to the chain of command and control.

CONCLUSIONS

This study documents the development of a MDS through consensus with a high degree of agreement among a group of experts of different nationalities working in different fields. All items in the MDS were digitally collected and forwarded in real time to the chain of command and control. This tool has demonstrated its validity in four large cross-border simulations involving more than eight countries and their emergency services.

Development of a Flash Flood Confidence Index from Disaster Reports and Geophysical Susceptibility

The analysis of historical disaster events is a critical step towards understanding current risk levels and changes in disaster risk over time. Disaster databases are potentially useful tools for exploring trends, however, criteria for inclusion of events and for associated descriptive characteristics is not standardized. For example, some databases include only primary disaster types, such as ‘flood’, while others include subtypes, such as ‘coastal flood’ and ‘flash flood’. Here we outline a method to identify candidate events for assignment of a specific disaster subtype—namely, ‘flash floods’—from the corresponding primary disaster type—namely, ‘flood’. Geophysical data, including variables derived from remote sensing, are integrated to develop an enhanced flash flood confidence index, consisting of both a flash flood confidence index based on text mining of disaster reports and a flash flood susceptibility index from remote sensing derived geophysical data. This method was applied to a historical flood event dataset covering Ecuador. Results indicate the potential value of disaggregating events labeled as a primary disaster type into events of a particular subtype. The outputs are potentially useful for disaster risk reduction and vulnerability assessment if appropriately evaluated for fitness of use.

Infrastructural Aspects of Rain-Related Cascading Disasters: A Systematic Literature Review

Cascading disasters progress from one hazard event to a range of interconnected events and impacts, with often devastating consequences. Rain-related cascading disasters are a particularly frequent form of cascading disasters in many parts of the world, and they are likely to become even more frequent due to climate change and accelerating coastal development, among other issues. (1) Background: The current literature review extended previous reviews of documented progressions from one natural hazard event to another, by focusing on linkages between rain-related natural hazard triggers and infrastructural impacts. (2) Methods: A wide range of case studies were reviewed using a systematic literature review protocol. The review quality was enhanced by only including case studies that detailed mechanisms that have led to infrastructural impacts, and which had been published in high-quality academic journals. (3) Results: A sum of 71 articles, concerning 99 case studies of rain-related disasters, were fully reviewed. Twenty-five distinct mechanisms were identified, as the foundation for a matrix running between five different natural hazards and eight types of infrastructural impacts. (4) Conclusion: Relatively complex quantitative methods are needed to generate locality-specific, cascading disaster likelihoods and scenarios. Appropriate methods can leverage the current matrix to structure both Delphi-based approaches and network analysis using longitudinal data.

Stakeholders' experiences with the evidence aid website to support 'real-time' use of research evidence to inform decision-making in crisis zones: a user testing study

Background

Humanitarian action in crisis zones is fraught with many challenges, including lack of timely and accessible research evidence to inform decision-making about humanitarian interventions. Evidence websites have the potential to address this challenge. Evidence Aid is the only evidence website designed for crisis zones that focuses on providing research evidence in the form of systematic reviews. The objective of this study is to explore stakeholders’ views of Evidence Aid, contributing further to our understanding of the use of research evidence in decision-making in crisis zones.

Methods

We designed a qualitative user-testing study to collect interview data from stakeholders about their impressions of Evidence Aid. Eligible stakeholders included those with and without previous experience of Evidence Aid. All participants were either currently working or have worked within the last year in a crisis zone. Participants were asked to perform the same user experience-related tasks and answer questions about this experience and their knowledge needs. Data were analysed using a deductive framework analysis approach drawing on Morville’s seven facets of the user experience — findability, usability, usefulness, desirability, accessibility, credibility and value.

Results

A total of 31 interviews were completed with senior decision-makers (n = 8), advisors (n = 7), field managers (n = 7), analysts/researchers (n = 5) and healthcare providers (n = 4). Participant self-reported knowledge needs varied depending on their role. Overall, participants did not identify any ‘major’ problems (highest order) and identified only two ‘big’ problems (second highest order) with using the Evidence Aid website, namely the lack of a search engine on the home page and that some full-text articles linked to/from the site require a payment. Participants identified seven specific suggestions about how to improve Evidence Aid, many of which can also be applied to other evidence websites.

Conclusions

Stakeholders in crisis zones found Evidence Aid to be useful, accessible and credible. However, they experienced some problems with the lack of a search engine on the home page and the requirement for payment for some full-text articles linked to/from the site.

Disaster preparedness and response improvement: comparison of the 2010 Haiti earthquake-related diagnoses with baseline medical data

Supplemental Digital Content is available in the text.

Objectives

Disaster medicine research generally lacks control groups. This study aims to describe categories of diagnoses encountered by the Belgian First Aid and Support Team after the 2010 Haiti earthquake and extract earthquake-related changes from comparison with comparable baseline data. The hypothesis is that besides earthquake-related trauma, medical problems emerge soon, questioning an appropriate composition of Foreign Medical Teams and Interagency Emergency Health Kits.

Methods

Using a descriptive cohort study design, diagnoses of patients presenting to the Belgian field hospital were prospectively registered during 4 weeks after the earthquake and compared with those recorded similarly by Médecins Sans Frontières in the same area and time span in previous and later years.

Results

Of 7000 triaged postearthquake patients, 3500 were admitted, of whom 2795 were included and analysed. In the fortnight after the earthquake, 90% suffered from injury. In the following fortnight, medical diseases emerged, particularly respiratory (23%) and digestive (14%). More than 53% developed infections within 3 weeks after the event. Médecins Sans Frontières registered 6407 patients in 2009; 6033 in 2011; and 7300 in 2012. A comparison indicates that postearthquake patients suffered significantly less from violence, but more from wounds, respiratory, digestive and ophthalmological diseases.

Conclusion

This is the first comparison of postearthquake diagnoses with baseline data. Within 2 weeks after the acute phase of an earthquake, respiratory, digestive and ophthalmological problems will emerge to the prejudice of trauma. This fact should be anticipated when composing Foreign Medical Teams and Interagency Emergency Health Kits to be sent to the disaster site.

SIMEDIS: a Discrete-Event Simulation Model for Testing Responses to Mass Casualty Incidents

It is recognized that the study of the disaster medical response (DMR) is a relatively new field. To date, there is no evidence-based literature that clearly defines the best medical response principles, concepts, structures and processes in a disaster setting. Much of what is known about the DMR results from descriptive studies and expert opinion. No experimental studies regarding the effects of DMR interventions on the health outcomes of disaster survivors have been carried out. Traditional analytic methods cannot fully capture the flow of disaster victims through a complex disaster medical response system (DMRS). Computer modelling and simulation enable to study and test operational assumptions in a virtual but controlled experimental environment. The SIMEDIS (Simulation for the assessment and optimization of medical disaster management) simulation model consists of 3 interacting components: the victim creation model, the victim monitoring model where the health state of each victim is monitored and adapted to the evolving clinical conditions of the victims, and the medical response model, where the victims interact with the environment and the resources at the disposal of the healthcare responders. Since the main aim of the DMR is to minimize as much as possible the mortality and morbidity of the survivors, we designed a victim-centred model in which the casualties pass through the different components and processes of a DMRS. The specificity of the SIMEDIS simulation model is the fact that the victim entities evolve in parallel through both the victim monitoring model and the medical response model. The interaction between both models is ensured through a time or medical intervention trigger. At each service point, a triage is performed together with a decision on the disposition of the victims regarding treatment and/or evacuation based on a priority code assigned to the victim and on the availability of resources at the service point. The aim of the case study is to implement the SIMEDIS model to the DMRS of an international airport and to test the medical response plan to an airplane crash simulation at the airport. In order to identify good response options, the model then was used to study the effect of a number of interventional factors on the performance of the DMRS. Our study reflects the potential of SIMEDIS to model complex systems, to test different aspects of DMR, and to be used as a tool in experimental research that might make a substantial contribution to provide the evidence base for the effectiveness and efficiency of disaster medical management.

Prioritization of themes and research questions for health outcomes in natural disasters, humanitarian crises or other major healthcare emergencies

People making decisions about interventions, actions and strategies for natural disasters, humanitarian crises and other major healthcare emergencies need access to reliable evidence to help ensure that the choices they make are likely to do more good than harm. However, there are many gaps in this evidence base in a wide range of areas. This paper reports a priority setting exercise that was coordinated by Evidence Aid to identify thirty priorities for up-to-date systematic reviews of the effects of interventions, actions and strategies on health outcomes, which would be particularly relevant to those involved in disaster risk reduction, planning response and recovery at an international level. It builds from an ongoing needs assessment that had identified a couple of hundred relevant research questions, which were grouped under 43 themes. Ten of these themes were prioritized by an online survey and the questions attached to these themes were then discussed at a face-to-face meeting, leading to the generation of a list of 30 top priority questions which is presented in this paper. We recognize that a different group of people might have come to different priorities but regard this as an important starting point, and the extensive efforts that were made to be inclusive in gathering opinions should help ensure their wide relevance.

The use of systematic reviews and other research evidence in disasters and related areas: preliminary report of a needs assessment survey

Objectives: This paper presents the initial data analysis for a survey to identify the attitudes towards systematic reviews and research of those involved in the humanitarian response to natural disasters and other crises; their priorities for evidence, and their preferences for accessing this information. Methods: Snowballing sampling techniques were used to recruit participants who identified themselves as humanitarian aid workers, with or without experience in providing funding to aid agencies. An online questionnaire with both quantitative and qualitative questions was made available to participants using a variety of e-mail lists. Quantitative responses from 85 participants to a selection of questions were descriptively analysed using SPSS. Results: Findings indicated that respondents had positive opinions about systematic reviews and using research evidence when planning and responding to disasters. Seventy participants answered the question on the usefulness of reviews before, during and after disasters and, of these, 83% said that systematic reviews are useful in disasters, and the remaining 17% said they did not know. No-one selected the option that systematic reviews are not useful. The most preferred format for access to systematic reviews was the whole reviews, supplemented by comments from experts in the humanitarian sector (61%), 33% choose access to the full review, 20% choose the summary of reviews and 50% choose summary of reviews plus context-specific information. Inadequate access was the most commonly reported barrier to the use of systematic reviews (70%). This was followed by the lack of time to use reviews (59%) and insufficient knowledge about reviews (49%). Respondents selected scientific evidence as the most preferred type of evidence for influencing their decisions (80%), 11% ranked personal experience highest, 6% said their organisation’s usual practice, 1% said anecdotal evidence and 1% said intuition would be their first choice. 69% of participants “strongly agreed” that evidence from systematic reviews could have a positive role in humanitarian interventions and a further 29% “agreed” with the same statement. 66% thought they would like to access them when a natural disaster is not known to be imminent, compared to 34% who said that they would not wish to access systematic reviews at such a time. 70% would like to access systematic reviews during the period of prediction that a disaster will happen Conclusion: These preliminary findings from the Evidence Aid survey emphasise the need for “global” evidence but also the need that this be supplemented by local and context-specific knowledge. Systematic reviews could play a central role in improving the effectiveness of humanitarian aid in the planning, delivery and recovery phases of a disaster. Keywords: Evidence base, humanitarian planning, delivery and recovery, systematic review

Interventions to improve the use of systematic reviews in decision-making by health system managers, policy makers and clinicians

BACKGROUND

Systematic reviews provide a transparent and robust summary of existing research. However, health system managers, national and local policy makers and healthcare professionals can face several obstacles when attempting to utilise this evidence. These include constraints operating within the health system, dealing with a large volume of research evidence and difficulties in adapting evidence from systematic reviews so that it is locally relevant. In an attempt to increase the use of systematic review evidence in decision-making a number of interventions have been developed. These include summaries of systematic review evidence that are designed to improve the accessibility of the findings of systematic reviews (often referred to as information products) and changes to organisational structures, such as employing specialist groups to synthesise the evidence to inform local decision-making.

OBJECTIVES

To identify and assess the effects of information products based on the findings of systematic review evidence and organisational supports and processes designed to support the uptake of systematic review evidence by health system managers, policy makers and healthcare professionals.

SEARCH METHODS

We searched The Cochrane Library, MEDLINE, EMBASE, CINAHL, Web of Science, and Health Economic Evaluations Database. We also handsearched two journals (Implementation Science and Evidence and Policy), Cochrane Colloquium abstracts, websites of key organisations and reference lists of studies considered for inclusion. Searches were run from 1992 to March 2011 on all databases, an update search to March 2012 was run on MEDLINE only.

SELECTION CRITERIA

Randomised controlled trials (RCTs), interrupted time-series (ITS) and controlled before-after studies (CBA) of interventions designed to aid the use of systematic reviews in healthcare decision-making were considered.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted the data and assessed the study quality. We extracted the median value across similar outcomes for each study and reported the range of values for each median value. We calculated the median of the two middlemost values if an even number of outcomes were reported.

MAIN RESULTS

We included eight studies evaluating the effectiveness of different interventions designed to support the uptake of systematic review evidence. The overall quality of the evidence was very low to moderate.Two cluster RCTs evaluated the effectiveness of multifaceted interventions, which contained access to systematic reviews relevant to reproductive health, to change obstetric care; the high baseline performance in some of the key clinical indicators limited the findings of these studies. There were no statistically significant effects on clinical practice for all but one of the clinical indicators in selected obstetric units in Thailand (median effect size 4.2%, range -11.2% to 18.2%) and none in Mexico (median effect size 3.5%, range 0.1% to 19.0%). In the second cluster RCT there were no statistically significant differences in selected obstetric units in the UK (median effect RR 0.92; range RR 0.57 to RR 1.10). One RCT evaluated the perceived understanding and ease of use of summary of findings tables in Cochrane Reviews. The median effect of the differences in responses for the acceptability of including summary of findings tables in Cochrane Reviews versus not including them was 16%, range 1% to 28%. One RCT evaluated the effect of an analgesic league table, derived from systematic review evidence, and there was no statistically significant effect on self-reported pain. Only one RCT evaluated an organisational intervention (which included a knowledge broker, access to a repository of systematic reviews and provision of tailored messages), and reported no statistically significant difference in evidence informed programme planning.Three interrupted time series studies evaluated the dissemination of printed bulletins based on evidence from systematic reviews. A statistically significant reduction in the rates of surgery for glue ear in children under 10 years (mean annual decline of -10.1%; 95% CI -7.9 to -12.3) and in children under 15 years (quarterly reduction -0.044; 95% CI -0.080 to -0.011) was reported. The distribution to general practitioners of a bulletin on the treatment of depression was associated with a statistically significant lower prescribing rate each quarter than that predicted by the rates of prescribing observed before the distribution of the bulletin (8.2%; P = 0.005).

AUTHORS' CONCLUSIONS

Mass mailing a printed bulletin which summarises systematic review evidence may improve evidence-based practice when there is a single clear message, if the change is relatively simple to accomplish, and there is a growing awareness by users of the evidence that a change in practice is required. If the intention is to develop awareness and knowledge of systematic review evidence, and the skills for implementing this evidence, a multifaceted intervention that addresses each of these aims may be required, though there is insufficient evidence to support this approach.

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.