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STUDY OBJECTIVE: Anecdotal evidence suggests that the population displaced to shelters from Hurricane Katrina had a significant burden of disease, socioeconomic vulnerability, and marginalized health care access. For agencies charged with providing health care to at-risk displaced populations, knowing the prevalence of acute and chronic disease is critical to direct resources and prevent morbidity and mortality. METHODS: We performed a 2-stage 18-cluster sample survey of 499 evacuees residing in American Red Cross shelters in Louisiana 2 weeks after landfall of Hurricane Katrina. In stage 1, shelters with a population of more than 100 individuals were randomly selected, with probability proportional to size sampling. In stage 2, 30 adult heads of household were randomly chosen within shelters by using a shelter log or a map of the shelter where no log existed. Survey questions focused on demographics, socioeconomic indicators, acute and chronic burden of disease, and health care access. RESULTS: Two thirds of the sampled population was single, widowed, or divorced; the majority was female (57.6%) and black (76.4%). Socioeconomic indicators of under- and unemployment (52.9%), dependency on benefits or assistance (38.5%), lack of home ownership (66.2%), and lack of health insurance (47.0%) suggested vulnerability. One third lacked a health provider. Among those who arrived at shelters with a chronic disease (55.6%), 48.4% lacked medication. Hypertension, hypercholesterolemia, diabetes, pulmonary disease, and psychiatric illness were the most common chronic conditions. Risk factors for lacking medications included male sex (odds ratio [OR] 1.58; 95% confidence interval [CI] 0.96 to 2.59) and lacking health insurance (OR 2.25; 95% CI 1.21 to 4.20). More than one third (34.5%) arrived at the shelter with symptoms warranting immediate medical intervention, including dehydration (12.0%), dyspnea (11.5%), injury (9.4%), and chest pain (9.7%). Risk factors associated with presenting to shelters with acute symptoms included concurrent chronic disease with medication (OR 2.60; 95% CI 1.98 to 3.43), concurrent disease and lacking medication (OR 2.22; 95% CI 1.36 to 3.63), and lacking health insurance (OR 1.83; 95% CI 1.10 to 3.02). CONCLUSION: A population-based understanding of vulnerability, health access, and chronic and acute disease among the displaced will guide disaster health providers in preparation and response. [ABSTRACT FROM AUTHOR]

Medical surge events require effective coordination between multiple partners. Unfortunately, the information technology (IT) systems currently used for information-sharing by emergency responders and managers in the United States are insufficient to coordinate with health care providers, particularly during large-scale regional incidents. The numerous innovations adopted for the COVID-19 response and continuing advances in IT systems for emergency management and health care information-sharing suggest a more promising future. This article describes: (1) several IT systems and data platforms currently used for information-sharing, operational coordination, patient tracking, and resource-sharing between emergency management and health care providers at the regional level in the US; and (2) barriers and opportunities for using these systems and platforms to improve regional health care information-sharing and coordination during a large-scale medical surge event. The article concludes with a statement about the need for a comprehensive landscape analysis of the component systems in this IT ecosystem.

The congressionally authorized National Disaster Medical System Pilot Program was created in December 2019 to strengthen the medical surge capability, capacity, and interoperability of affiliated healthcare facilities in 5 regions across the United States. The COVID-19 pandemic provided an unprecedented opportunity to learn how participating healthcare facilities handled medical surge events during an active public health emergency. We applied a modified version of the Barbisch and Koenig 4-S framework ( staff, stuff, space, systems ) to analyze COVID-19 surge management practices implemented by healthcare stakeholders at 5 pilot sites. In total, 32 notable practices were identified to increase surge capacity during the COVID-19 pandemic that have potential applications for other healthcare facilities. We found that systems was the most prevalent domain of surge capacity among the identified practices. Systems and staff were discussed across all 5 pilot sites and were the 2 domains co-occurring most often within each surge management practice. These results can inform strategies for scaling up and optimizing medical surge capability, capacity, and interoperability of healthcare facilities nationwide. This study also specifies areas of surge capacity worthy of strategic focus in the pilot's planning and implementation efforts while more broadly informing the US healthcare system's response to future large-scale, medical surge events.

The National Disaster Medical System (NDMS) Pilot Program was authorized by Congress to improve the interoperability, capabilities, and capacity of the NDMS. To develop a roadmap for planning and research, the mixed methods Military-Civilian NDMS Interoperability Study (MCNIS) was conducted in 2020-2021. The initial qualitative phase of the study identified critical themes for improvement: (1) coordination, collaboration, and communication; (2) funding and incentives to increase private sector preparedness; (3) staffing capacity and competencies; (4) clinical and support surge capacity; (5) training, education, and exercises between federal and private sector partners; and (6) metrics, benchmarks, and modeling to track NDMS performance. These qualitative findings were subsequently refined, validated, and prioritized through a quantitative survey. Expert respondents ranked 64 statements based on weaknesses and opportunities identified during the qualitative phase. Data were collected using Likert scales, and multivariate proportions and confidence intervals were estimated to compare and prioritize each statement's level of support. Pairwise tests were conducted for each item-to-item pair to determine statistically significant differences. The survey results corroborated the earlier qualitative findings, with all weaknesses and opportunities ranked as important by a majority of respondents. Survey results also pointed to specific priorities for interventions within the 6 previously identified themes. As with the qualitative study, the survey found that the most common weaknesses and opportunities were related to coordination, collaboration, and communication, especially regarding information technology and planning at the federal and regional levels. These priority interventions are now being developed, implemented, and validated at 5 pilot partner sites.

Background: In 2021, 702 people died in mass shooting incidents (MSIs) in the US. To define the best healthcare response to MSIs, the Uniformed Services University's National Center for Disaster Medicine and Public Health hosted a consensus conference of emergency medical services (EMS) clinicians, emergency medicine (EM) physicians, and surgeons who provided medical response to six of the nation's largest recent mass shootings., Study Design: The study consisted of a 3-round modified Delphi process. A planning committee selected 6 MSI sites with the following criteria: the MSI occurred in 2016 or later, and must have resulted in at least 15 people killed and injured. The MSI sites were Orlando, FL, Las Vegas, NV, Sutherland Springs, TX, Parkland, FL, El Paso, TX, and Dayton, OH. Fifteen clinicians participated in the conference. All participants had EMS, EM, or surgery expertise and responded to 1 of the 6 MSIs. The first round consisted of a 2-part survey. The second and third rounds consisted of site-specific presentations followed by specialty-specific discussion groups to generate consensus recommendations., Results: The 3 specialty-specific groups created 8 consensus recommendations in common. These 8 recommendations addressed readiness training, public education, triage, communication, patient tracking, medical records, family reunification, and mental health services for responders. There were an additional 11 recommendations created in common between 2 subgroups, either EMS and EM (2), EM and surgery (7), or EMS and surgery (2)., Conclusions: There are multiple common recommendations identified by EMS, EM, and surgery clinicians who responded to recent MSIs. Clinicians, emergency planners, and others involved in preparing and executing a response to a future mass shooting event may benefit from considering these consensus lessons learned., (Copyright © 2022 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The coronavirus disease 2019 (COVID-19) pandemic dramatically accelerated a growing trend toward online and asynchronous education and professional training, including in the disaster medicine and public health sector. This study analyzed the impact of the COVID-19 pandemic on the growth of the TRAIN Learning Network (TRAIN) for the year 2020 and evaluated pandemic-related changes in use patterns by disaster and public health professionals., Methods: The TRAIN database was queried to determine the change in the number of registered users, total courses completed, and courses completed related to COVID-19 during 2020., Results: In 2020, a total of 755,222 new users joined the platform - nearly 3 times the average added annually over the preceding 5 y (2015-2019). TRAIN users completed 3,259,074 training courses in 2020, more than double the average number of training courses that were completed annually from 2015-2019. In addition, 17.8% of all newly added disaster and public health training courses in 2020 were specifically related to COVID-19., Conclusion: Online education provided by TRAIN is a critical tool for just-in-time disaster health training following a disaster event or public health emergency, including in a global health crisis such as a pandemic.

Abstract: A scoping review was conducted to describe the history of the National Disaster Medical System (NDMS) in the context of US military medical preparedness for a large-scale overseas military conflict. National Disaster Medical System civilian hospitals would serve as backups to military treatment facilities if both US Department of Defense and US Department of Veterans Affairs hospitals reached capacity during such a conflict. Systematic searches were used to identify published works discussing the NDMS in the scientific and gray literature. Results were limited to publicly available unclassified English language works from 1978 to January 2022; no other restrictions were placed on the types of published works. Full-text reviews were conducted on identified works (except student papers and dissertations) to determine the extent to which they addressed NDMS definitive care. Data charting was performed on a final set of papers to assess how these works addressed NDMS definitive care. The search identified 54 works published between 1984 and 2022. More than half of the publications were simple descriptions of the NDMS (n = 30 [56%]), and most were published in academic or professional journals (n = 38 [70%]). Only nine constituted original research. There were recurrent criticisms of and recommendations for improving the definitive care component of the NDMS. The lack of published literature on NDMS definitive care supports the assertion that the present-day NDMS may lack the capacity and military-civilian interoperability necessary to manage the casualties resulting from a large-scale overseas military conflict., (Copyright © 2022 Written work prepared by employees of the Federal Government as part of their official duties is, under the U.S. Copyright Act, a “work of the United States Government” for which copyright protection under Title 17 of the United States Code is not available. As such, copyright does not extend to the contributions of employees of the Federal Government.)

The definitive care component of the National Disaster Medical System (NDMS) may not be able to effectively manage tens of thousands of casualties resulting from a catastrophic disaster incident or overseas conflict. To address this potential national security threat, Congress authorized the US Secretary of Defense to conduct the NDMS Pilot Program to improve the interoperability, special capabilities, and patient capacity of the NDMS. The pilot's first phase was the Military-Civilian NDMS Interoperability Study, designed to identify broad themes to direct further NDMS research. Researchers conducted a series of facilitated discussions with 49 key NDMS federal and civilian (private sector) stakeholders to identify and assess weaknesses and opportunities for improving the NDMS. After qualitative analysis, 6 critical themes emerged: (1) coordination, collaboration, and communication between federal and private sector NDMS partners; (2) funding and incentives for improved surge capacity and preparedness for NDMS partners; (3) staffing capacity and competencies for government and private NDMS partners; (4) surge capacity, especially at private sector healthcare facilities; (5) training, education, and exercises and knowledge sharing between federal and private sector NDMS partners; and (6) metrics, benchmarks, and modeling for NDMS partners to track their NDMS-related capabilities and performance. These findings provide a roadmap for federal-level changes and additional operations research to strengthen the NDMS definitive care system, particularly in the areas of policy and legislation, operational coordination, and funding.

The national response to the coronavirus disease 2019 (COVID-19) pandemic has highlighted critical weaknesses in domestic health care and public health emergency preparedness, despite nearly 2 decades of federal funding for multiple programs designed to encourage cross-cutting collaboration in emergency response. Health-care coalitions (HCCs), which are funded through the Hospital Preparedness Program, were first piloted in 2007 and have been continuously funded nationwide since 2012 to support broad collaborations across public health, emergency management, emergency medical services, and the emergency response arms of the health-care system within a geographical area. This commentary provides a SWOT (strengths, weaknesses, opportunities, and threats) analysis to summarize the strengths, weaknesses, opportunities, and threats related to the current HCC model against the backdrop of COVID-19. We close with concrete recommendations for better leveraging the HCC model for improved health-care system readiness. These include better evaluating the role of HCCs and their members (including the responsibility of the HCC to better communicate and align with other sectors), reconsidering the existing framework for HCC administration, increasing incentives for meaningful community participation in HCC preparedness, and supporting next-generation development of health-care preparedness systems for future pandemics.

Objective: The aim of this study was to investigate the performance of key hospital units associated with emergency care of both routine emergency and pandemic (COVID-19) patients under capacity enhancing strategies., Methods: This investigation was conducted using whole-hospital, resource-constrained, patient-based, stochastic, discrete-event, simulation models of a generic 200-bed urban U.S. tertiary hospital serving routine emergency and COVID-19 patients. Systematically designed numerical experiments were conducted to provide generalizable insights into how hospital functionality may be affected by the care of COVID-19 pandemic patients along specially designated care paths, under changing pandemic situations, from getting ready to turning all of its resources to pandemic care., Results: Several insights are presented. For example, each day of reduction in average ICU length of stay increases intensive care unit patient throughput by up to 24% for high COVID-19 daily patient arrival levels. The potential of 5 specific interventions and 2 critical shifts in care strategies to significantly increase hospital capacity is also described., Conclusions: These estimates enable hospitals to repurpose space, modify operations, implement crisis standards of care, collaborate with other health care facilities, or request external support, thereby increasing the likelihood that arriving patients will find an open staffed bed when 1 is needed.

Objective: To review and analyze After Action Reports from jurisdictions in Texas following Hurricanes Katrina and Rita in 2005 and Hurricane Harvey in 2017 in order to assess the utility of AARs as a quality improvement measurement tool., Methods: The authors searched the Homeland Security Digital Library, the Assistant Secretary for Preparedness and Response Technical Resources, Assistance Center, and Information Exchange, and Google Scholar for any AARs that covered the response phase of at least one of the 3 hurricanes, mentioned the state of Texas, and suggested solutions to problems. The authors applied public health emergency management (PHEM) domains, as outlined by Rose et al, to frame the AAR analysis. AARs were coded by 2 reviewers independently, with a third acting as adjudicator. As an example, the problem statements in 2005 and 2017 AARs from 1 statewide agency were compared., Results: Sixteen AARs met the inclusion criteria. There were 500 identified problem-solution sets mapped to a PHEM domain. The content was unevenly distributed, with most issues coming under PHEM 2: Policies, Plans, Procedures, and Partnerships at 45.2% in the 2005 hurricanes and 39.9% in 2017. AARs lacked consistent format and were often prepared by the response agencies themselves. Five consistent issues were raised in 2005 and again in 2017. These were volunteer management and credential verification, donations management, information sharing, appropriately identifying those requiring a medical needs shelter, and inadequate transportation to support evacuation., Conclusion: Because of the lack of objective data, inconsistent format, unevenly distributed content, and lack of adherence to any framework, AARs are fraught with shortcomings as a tool for PHEM. Inclusion of more objective reporting measures is urgently needed., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Study Objectives: To quantify the readiness of individual academic emergency departments (EDs) in the United States for an outbreak of pandemic influenza. Methods, design, and setting: Cross-sectional assessment of influenza pandemic preparedness level of EDs in the United States via survey of medical directors and department chairs from the 135 academic emergency medicine departments in the United States. Preparedness assessed using a novel score of 15 critical preparedness indicators. Data analysis consisted of summary statistics, χ 2 , and ANOVA., Participants: ED medical directors and department chairs., Results: One hundred and thirty academic emergency medicine departments contacted; 66 (50.4 percent) responded. Approximately half (56.0 percent) stated their ED had a written plan for pandemic influenza response. Mean preparedness score was 7.2 (SD = 4.0) out of 15 (48.0 percent); only one program (1.5 percent) achieved a perfect score. Respondents from programs with larger EDs (=30 beds) were more likely to have a higher preparedness score (p < 0.035), an ED pandemic preparedness plan (p = 0.004) and a hospital pandemic preparedness plan (p = 0.007). Respondents from programs with larger EDs were more likely to feel that their ED was prepared for a pandemic or other major disease outbreak (p = 0.01). Only one-third (34.0 percent) felt their ED was prepared for a major disease outbreak, and only 27 percent felt their hospital was prepared to respond to a major disease outbreak., Conclusions: Significant deficits in preparedness for pandemic influenza and other disease outbreaks exist in US EDs, relative to HHS guidelines, which appear to be related in part to ED size. Further study should be undertaken to determine the barriers to appropriate pandemic preparedness, as well as to develop and validate preparedness metrics.

Objective: To assess the level of pandemic preparedness at emergency departments (EDs) around the country and to better understand current barriers to preparedness in the United States represented by health professionals in the American College of Emergency Physician (ACEP) Disaster Medicine Section (DMS). Methods, design, and setting: A cross-sectional survey of ACEP DMS members was performed. A total of 300 members were surveyed both via e-mail and with paper surveys during the 2009 ACEP Scientific Assembly DMS Meeting. An optional comments section was included for section members' perspectives on barriers to preparedness. A 15-item pandemic preparedness score was calculated for each respondent based on key preparedness indicators as defined by the authors. Results were analyzed with descriptive statistics, χ 2 analysis, Cochran-Armitage trend test, and analysis of variance. Free text comments were coded and subjected to frequency-based analysis., Results: A total of 92 DMS members completed the survey with a response rate of 31 percent. Although 85 percent of those surveyed indicated that their hospital had a plan for pandemic influenza response and other infectious disease threats, only 68 percent indicated that their ED had a plan, and 52 percent indicated that their hospital or ED had conducted disaster preparedness drills. Only 57 percent indicated that there was a plan to augment ED staff in the event of a staffing shortage, and 63 percent indicated that there were adequate supplies of personal protective equipment. While 63 percent of respondents indicated that their ED had a plan for distribution of vaccines and antivirals, only 32 percent of EDs had a plan for allocation of ventilators. A total of 42 percent of respondents felt that their ED was prepared in the event of a pandemic influenza or other disease outbreak, and only 35 percent felt that their hospital was prepared. The average pandemic preparedness score among respondents was 8.30 of a total of 15. Larger EDs were more likely to have a higher preparedness score (p = 0.03) and more likely to have a pandemic preparedness plan (p = 0.037). Some major barriers to preparedness cited by section members included lack of local administration support, challenges in funding, need for dedicated disaster preparedness personnel, staffing shortages, and a lack of communication among disaster response agencies, particularly at the federal level., Conclusions: There appear to be significant gaps in pandemic influenza and other infectious disease outbreak planning among the hospitals where ACEP DMS members work. This may reflect a broader underlying inadequacy of preparedness measures.

Objective: The Centers for Disease Control and Prevention developed 15 National Public Health Emergency and Preparedness Response Capabilities (NPHPRCs) to serve as national standards for health-related core capabilities. The objective of this study is to determine the level of federal funding allocated for research related to NPHPRCs during 2008-2017., Methods: An online search of http://www.USAspending.gov was performed to identify federal awards, grants, contracts from 2008-2017 related to research associated with NPHPRCs. Inclusion criteria were identifiable as research and disaster-related; US-based; and specific reference to any of the NPHPRCs. A panel of 3 experts reviewed each entry for inclusion., Results: The search identified 15 278 transactions representing US $29.2 billion in awards. After exclusions, 93 entries were found to be related to NPHPRCs, averaging US $2 783 136 annually. Funding notably dropped to US $168 684 in 2010 and ceased entirely in 2016. Ten (67%) of NPHPRCs received funding. Eighty-percent of funding focused on 4 capabilities. Three federal agencies funded 80% of research. Sixteen (24%) of the 47 recipients received 80% of all funding., Conclusion: US federal investments in research and development related to NPHPRCs have been highly variable over the past decade. One-third of NPHPRCs receive no funding. There are notable gaps in funding, content, continuity, and scope of participation.

Objective: To characterize the strengths and weaknesses of the current status of disaster research evidence; and to identify potential interventions specific to the disciplines of medicine, public health, and social sciences., Design: A mixed method study using nominal group technique and a strengths, weaknesses, opportunities, and threats (SWOT) analysis., Participants: Subject matter experts (SMEs) in the fields of medicine, public health, and social sciences who are engaged in disaster research., Results: The nominal group technique achieved 100 percent response rate. After coding and analysis, ten distinct disaster research evidence themes were identified: awareness; evidence quality; funding; human resources; interdisciplinary studies; politics; research process; research topics; sectoral collaboration; and "other." Strengths in each area were limited but focused on quality and workforce pipeline. Weaknesses were limited funding and low research quality. Opportunities included improving methods and increased interdisciplinary collaboration. The threats most consistently identified were limited funding and political influences on disaster research funding., Conclusions: Disaster research experts from three disciplines identified a number of barriers and facilitators to improving disaster-related research. The limited, inconsistent, and episodic funding and the politics related to it were the greatest and most common barriers. This weakness needs to be strategically addressed to significantly advance the field of disaster research.

Objective: Disaster-related research funding in the United States has not been described. This study characterizes Federal funding for disaster-related research for 5 professional disciplines: medicine, public health, social science, engineering, emergency management., Methods: An online key word search was performed using the website, www.USAspending.gov, to identify federal awards, grants, and contracts during 2011-2016. A panel of experts then reviewed each entry for inclusion., Results: The search identified 9145 entries, of which 262 (3%) met inclusion criteria. Over 6 years, the Federal Government awarded US $69 325 130 for all disaster-related research. Total funding levels quadrupled in the first 3 years and then halved in the last 3 years. Half of the funding was for engineering, 3 times higher than social sciences and emergency management and 5 times higher than public health and medicine. Ten (11%) institutions received 52% of all funding. The search returned entries for only 12 of the 35 pre-identified disaster-related capabilities; 6 of 12 capabilities appear to have received no funding for at least 2 years., Conclusion: US federal funding for disaster-related research is limited and highly variable during 2011-2016. There are no clear reasons for apportionment. There appears to be an absence of prioritization. There does not appear to be a strategy for alignment of research with national disaster policies.

Objective: A hospital-wide difficult airway response team was developed in 2008 at The Johns Hopkins Hospital with three central pillars: operations, safety monitoring, and education. The objective of this study was to assess the outcomes of the educational pillar of the difficult airway response team program, known as the multidisciplinary difficult airway course (MDAC)., Design: The comprehensive, full-day MDAC involves trainees and staff from all provider groups who participate in airway management. The MDAC occurs within the Johns Hopkins Medicine Simulation Center approximately four times per year and uses a combination of didactic lectures, hands-on sessions, and high-fidelity simulation training. Participation in MDAC is the main intervention being investigated in this study. Data were collected prospectively using course evaluation survey with quantitative and qualitative components, and prepost course knowledge assessment multiple choice questions (MCQ). Outcomes include course evaluation scores and themes derived from qualitative assessments, and prepost course knowledge assessment MCQ scores., Setting: Tertiary care academic hospital center PARTICIPANTS: Students, residents, fellows, and practicing physicians from the departments of Surgery, Otolaryngology Head and Neck Surgery, Anesthesiology/Critical Care Medicine, and Emergency Medicine; advanced practice providers (nurse practitioners and physician assistants), nurse anesthetists, nurses, and respiratory therapists., Results: Totally, 23 MDACs have been conducted, including 499 participants. Course evaluations were uniformly positive with mean score of 86.9 of 95 points. Qualitative responses suggest major value from high-fidelity simulation, the hands-on skill stations, and teamwork practice. MCQ scores demonstrated significant improvement: median (interquartile range) pre: 69% (60%-81%) vs post: 81% (72%-89%), p < 0.001., Conclusions: Implementation of a MDAC successfully disseminated principles and protocols to all airway providers. Demonstrable improvement in prepost course knowledge assessment and overwhelmingly positive course evaluations (quantitative and qualitative) suggest a critical and ongoing role for the MDAC course., (Copyright © 2018 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

IntroductionInterventions to reduce disability from acute orthopedic injuries require a primary assessment of knowledge and need. There are no previous studies to assess this need in the remote provincial islands of the Philippines, an area recurrently affected by natural disaster.ProblemA preliminary assessment of orthopedic knowledge and need was performed to be expanded for regional or national implementation., Methods: Two independent surveys were conducted of households and mid-level providers who represent the first contact of care. The goal of the survey was to describe the local health care system, to identify barriers to care, and to assess gaps in knowledge for acute traumatic orthopedic injuries. Both surveys were conducted in June of 2015.Population proportional sampling assessed a total of 100 households from 25 local Barangay communities. Questions focused on existing knowledge of acute traumatic orthopedic injuries and barriers to care.The mid-level provider survey focused on knowledge and barriers to care regarding acute traumatic orthopedic injuries. A total of 10 school nurses and Barangay midwives representing 25 local Barangay were surveyed., Results: In the household population survey, 84% of respondents reported cost was either always or sometimes a barrier to care; 73% cited transportation as a barrier to care. A total of 68% of respondents reported that they would seek care at the provincial hospital for a suspected broken bone; 28% percent of respondents did not believe broken bones making an arm or leg crooked could be corrected without surgery. Only 55% percent believed care should be sought within six hours of injury, and 37% stated that more than three days after an injury was an appropriate timeframe to seek care.Of the mid-level providers surveyed, 90% reported that they would refer possible broken bones to a higher level of care. Aggregate ranking of barriers to care from greatest to least were: cost, transportation, knowledge of time sensitive nature of treatment, religious beliefs, and other (not specified). In all, 100% reported that an education initiative regarding acute orthopedic injuries would increase the number of patients seeking care within 12 hours., Conclusion: The survey describes perceived barriers to care and gaps in knowledge for acute orthopedic injuries. With some modification, this survey tool could be expanded and utilized on a regional or national level to assess gaps in knowledge and barriers to acute orthopedic care. CourtneyCS, KirschTD. Orthopedic knowledge and need in the Provincial Philippines: pilot study of a population-based survey. Prehosp Disaster Med. 2018;33(3):293-298.

Objective: The objective was to determine whether brief, Web-based instruction several weeks prior to tourniquet application improves layperson success compared to utilizing just-in-time (JiT) instructions alone., Background: Stop the Bleed is a campaign to educate laypeople to stop life-threatening hemorrhage. It is based on U.S. military experience with lifesaving tourniquet use. While previous research shows simple JiT instructions boost laypeople's success with tourniquet application, the optimal approach to educate the public is not yet known., Methods: This is a prospective, nonblinded, randomized study. Layperson participants from the Washington, DC, area were randomized into: 1) an experimental group that received preexposure education using a website and 2) a control group that did not receive preexposure education. Both groups received JiT instructions. The primary outcome was the proportion of subjects that successfully applied a tourniquet to a simulated amputation. Secondary outcomes included mean time to application, mean placement position, ability to distinguish bleeding requiring a tourniquet from bleeding requiring direct pressure only, and self-reported comfort and willingness to apply a tourniquet., Results: Participants in the preexposure group applied tourniquets successfully 75% of the time compared to 50% success for participants with JiT alone (p < 0.05, risk ratio = 1.48, 95% confidence interval = 1.21-1.82). Participants place tourniquets in a timely fashion, are willing to use them, and can recognize wounds requiring tourniquets., Conclusions: Brief, Web-based training, combined with JiT education, may help as many as 75% of laypeople properly apply a tourniquet. These findings suggest that this approach may help teach the public to Stop the Bleed.

Health care coalitions play an increasingly important role in both preparedness for, response to, and recovery from large scale disaster events occurring across the United States. The actions taken by the South East Texas Regional Advisory Council (SETRAC) in response to the landfall of Hurricane Harvey, and the consequential flooding that ensued, serve as an excellent example of how health care coalitions are increasingly needed to play a unifying role in response. This paper highlights a number of the strategic planning, operational planning and response, information sharing, and resource coordination and management activities that were undertaken for the response to Hurricane Harvey. The successful response to this devastating storm in the Houston, Texas area serves as an example to other regions across the country as they work to implement the 2017-2022 health care capabilities articulated by the Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response. (Disaster Med Public Health Preparedness. 2017;11:637-639).

In an effort to enhance education, training, and learning in the disaster health community, the National Center for Disaster Medicine and Public Health (NCDMPH) gathered experts from around the nation in Bethesda, Maryland, on September 8, 2016, for the 2016 Disaster Health Education Symposium: Innovations for Tomorrow. This article summarizes key themes presented during the disaster health symposium including innovations in the following areas: training and education that saves lives, practice, teaching, sharing knowledge, and our communities. This summary article provides thematic content for those unable to attend. Please visit http://ncdmph.usuhs.edu/ for more information. (Disaster Med Public Health Preparedness. 2017;11:160-162).

To better understand the impact of national and global efforts to contain the Ebola virus disease epidemic of 2014–15 in Liberia, we provide a detailed timeline of the major interventions and relate them to the epidemic curve.  In addition to personal experience in the response, we systematically reviewed situation reports from the Liberian government, UN, CDC, WHO, UNICEF, IFRC, USAID, and local and international news reports to create the timeline. We extracted data on the timing and nature of activities and compared them to the timeline of the epidemic curve using the reproduction number—the estimate of the average number of new cases caused by a single case.  Interventions were organized around five major strategies, with the majority of resources directed to the creation of treatment beds. We conclude that no single intervention stopped the epidemic; rather, the interventions likely had reinforcing effects, and some were less likely than others to have made a major impact. We find that the epidemic’s turning coincided with a reorganization of the response in August–September 2014, the emergence of community leadership in control efforts, and changing beliefs and practices in the population. Ebola Treatment Units were important for Ebola treatment, but the vast majority of these treatment centre beds became available after the epidemic curve began declining. Similarly, the United Nations Mission for Ebola Emergency Response was launched after the epidemic curve had already turned.  These findings have significant policy implications for future epidemics and suggest that much of the decline in the epidemic curve was driven by critical behaviour changes within local communities, rather than by international efforts that came after the epidemic had turned. Future global interventions in epidemic response should focus on building community capabilities, strengthening local ownership, and dramatically reducing delays in the response.

Objective: Personal preparedness is a core activity but has been found to be frequently inadequate. Smart phone applications have many uses for the public, including preparedness. In 2012 the American Red Cross began releasing "disaster" apps for family preparedness and recovery. The Hurricane App was widely used during Hurricane Sandy in 2012., Methods: Patterns of download of the application were analyzed by using a download tracking tool by the American Red Cross and Google Analytics. Specific variables included date, time, and location of individual downloads; number of page visits and views; and average time spent on pages., Results: As Hurricane Sandy approached in late October, daily downloads peaked at 152,258 on the day of landfall and by mid-November reached 697,585. Total page views began increasing on October 25 with over 4,000,000 page views during landfall compared to 3.7 million the first 3 weeks of October with a 43,980% increase in views of the "Right Before" page and a 76,275% increase in views of the "During" page., Conclusions: The Hurricane App offered a new type of "just-in-time" training that reached tens of thousands of families in areas affected by Hurricane Sandy. The app allowed these families to access real-time information before and after the storm to help them prepare and recover. (Disaster Med Public Health Preparedness. 2016;page 1 of 6).

Background: American tackle football is the most popular high-energy impact sport in the United States, with approximately 9 million participants competing annually. Previous epidemiologic studies of football-related injuries have generally focused on specific geographic areas or pediatric age groups. Our study sought to examine patient characteristics and outcomes, including hospital charges, among athletes presenting for emergency department (ED) treatment of football-related injury across all age groups in a large nationally representative data set., Methods: Patients presenting for ED treatment of injuries sustained playing American tackle football (identified using International Classification of Diseases, Ninth Revision, Clinical Modification code E007.0) from 2010 to 2011 were studied in the Nationwide Emergency Department Sample. Patient-specific injuries were identified using the primary International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code and categorized by type and anatomical region. Standard descriptive methods examined patient demographics, diagnosis categories, and ED and inpatient outcomes and charges., Results: During the study period 397363 football players presented for ED treatment, 95.8% of whom were male. Sprains/strains (25.6%), limb fractures (20.7%), and head injuries (including traumatic brain injury; 17.5%) represented the most presenting injuries. Overall, 97.9% of patients underwent routine ED discharge with 1.1% admitted directly and fewer than 11 patients in the 2-year study period dying prior to discharge. The proportion of admitted patients who required surgical interventions was 15.7%, of which 89.9% were orthopedic, 4.7% neurologic, and 2.6% abdominal. Among individuals admitted to inpatient care, mean hospital length of stay was 2.4days (95% confidence interval, 2.2-2.6) and 95.6% underwent routine discharge home. The mean total charge for all patients was $1941 (95% confidence interval, $1890-$1992) with substantial injury type-specific variability. Overall, at the US population, estimated total charges of $771299862 were incurred over the 2-year period., Conclusion: In this nationally representative sample, most ED-treated injuries associated with football were not acutely life threatening and very few required major therapeutic intervention. This study provides a cross-sectional overview of ED presentation for acute football-related injury across age groups at the population level in recent years. Longitudinal studies may be warranted to examine associations between the patterns of injury observed in this study and long-term outcomes among American tackle football players., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Patient triage is necessary to manage excessive patient volumes and identify those with critical conditions. The most common triage system used today, Emergency Severity Index (ESI), focuses on resources utilized and critical outcomes., Objective: This study derives and validates a computer-based electronic triage system (ETS) to improve patient acuity distribution based on serious patient outcomes., Methods: This cross-sectional study of 25,198 (97 million weighted) adult emergency department visits from the 2009 National Hospital Ambulatory Medical Care Survey. The ETS distributes patients by using a composite outcome based on the estimated probability of mortality, intensive care unit admission, or transfer to operating room or catheterization suite. We compared the ETS with the ESI based on the differentiation of patients, outcomes, inpatient hospitalization, and resource utilization., Results: Of the patients included, 3.3% had the composite outcome and 14% were admitted, and 2.52 resources/patient were used. Of the 90% triaged to low-acuity levels, ETS distributed patients evenly (Level 3: 30%; Level 4: 30%, and Level 5: 29%) compared to ESI (46%, 34%, and 7%, respectively). The ETS better-identified patients with the composite outcome present in 40% of ETS Level 1 vs. 17% for ESI and the ETS area under the receiver operating characteristic curve (AUC) was 0.83 vs. ESI 0.73. Similar results were found for hospital admission (ETS AUC = 0.83 vs. ESI AUC = 0.72). The ETS demonstrated slight improvements in discriminating patient resource utilization., Conclusions: The ETS is a triage system based on the frequency of critical outcomes that demonstrate improved differentiation of patients compared to the current standard ESI., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: On November 8, 2013, Typhoon Haiyan (Yolanda) made landfall in the Philippines. The literature characterizing the medical, surgical, and obstetrics burden following typhoons is lacking. This study aimed to improve disaster preparedness by analyzing medical diagnoses presenting to a city district hospital before, during, and after Typhoon Haiyan., Methods: The assessment of disease burden and trends was based on logbooks from a local hospital and a nongovernmental organization field hospital for the medicine, surgical, and obstetrics wards before, during, and after the typhoon., Results: The hospital provided no services several days after typhoon impact, but there was an overall increase in patient admissions once the hospital reopened. An increase in gastroenteritis, pneumonia, tuberculosis, and motor vehicle collision-related injuries was seen during the impact phase. A dengue fever outbreak occurred during the post-impact phase. There was a noticeable shift in a greater percentage of emergent surgical cases performed versus elective cases during the impact and post-impact phases., Conclusion: Overall, several public health measures can prevent the increase in illnesses seen after a disaster. To prepare for the nonfatal burden of disease after a typhoon, health care facilities should increase their resources to accommodate the surge in patient volume.

Determining how clinicians should meet their professional obligations to treat patients with Ebola virus disease in nonepidemic settings necessitates considering measures to minimize risks to clinicians, the context of care, and fairness. Minimizing risks includes providing appropriate equipment and training, implementing strategies for reducing exposure to infectious material, identifying a small number of centers to provide care, and determining which risky procedures should be used when they pose minimal likelihood of appreciable clinical benefit. Factors associated with the clinical environment, such as the local prevalence of the disease, the nature of the setting, and the availability of effective treatment, are also relevant to obligations to treat. Fairness demands that the best possible medical care be provided for health care professionals who become infected and that the rights and interests of relevant stakeholders be addressed through policy-making processes. Going forward it will be essential to learn from current approaches and to modify them based on data.