Ann R. Knebel

Systematic review of strategies to manage and allocate scarce resources during mass casualty events.

STUDY OBJECTIVE Efficient management and allocation of scarce medical resources can improve outcomes for victims of mass casualty events. However, the effectiveness of specific strategies has never been systematically reviewed. We analyze published evidence on strategies to optimize the management and allocation of scarce resources across a wide range of mass casualty event contexts and study designs. METHODS Our literature search included MEDLINE, Scopus, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Global Health, Web of Science, and the Cochrane Database of Systematic Reviews, from 1990 through late 2011. We also searched the gray literature, using the New York Academy of Medicines Grey Literature Report and key Web sites. We included both English- and foreign-language articles. We included studies that evaluated strategies used in actual mass casualty events or tested through drills, exercises, or computer simulations. We excluded studies that lacked a comparison group or did not report quantitative outcomes. Data extraction, quality assessment, and strength of evidence ratings were conducted by a single researcher and reviewed by a second; discrepancies were reconciled by the 2 reviewers. Because of heterogeneity in outcome measures, we qualitatively synthesized findings within categories of strategies. RESULTS From 5,716 potentially relevant citations, 74 studies met inclusion criteria. Strategies included reducing demand for health care services (18 studies), optimizing use of existing resources (50), augmenting existing resources (5), implementing crisis standards of care (5), and multiple categories (4). The evidence was sufficient to form conclusions on 2 strategies, although the strength of evidence was rated as low. First, as a strategy to reduce demand for health care services, points of dispensing can be used to efficiently distribute biological countermeasures after a bioterrorism attack or influenza pandemic, and their organization influences speed of distribution. Second, as a strategy to optimize use of existing resources, commonly used field triage systems do not perform consistently during actual mass casualty events. The number of high-quality studies addressing other strategies was insufficient to support conclusions about their effectiveness because of differences in study context, comparison groups, and outcome measures. Our literature search may have missed key resource management and allocation strategies because of their extreme heterogeneity. Interrater reliability was not assessed for quality assessments or strength of evidence ratings. Publication bias is likely, given the large number of studies reporting positive findings. CONCLUSION The current evidence base is inadequate to inform providers and policymakers about the most effective strategies for managing or allocating scarce resources during mass casualty events. Consensus on methodological standards that encompass a range of study designs is needed to guide future research and strengthen the evidence base. Evidentiary standards should be developed to promote consensus interpretations of the evidence supporting individual strategies.

Allocation of scarce resources after a nuclear detonation: setting the context

The purpose of this article is to set the context for this special issue of Disaster Medicine and Public Health Preparedness on the allocation of scarce resources in an improvised nuclear device incident. A nuclear detonation occurs when a sufficient amount of fissile material is brought suddenly together to reach critical mass and cause an explosion. Although the chance of a nuclear detonation is thought to be small, the consequences are potentially catastrophic, so planning for an effective medical response is necessary, albeit complex. A substantial nuclear detonation will result in physical effects and a great number of casualties that will require an organized medical response to save lives. With this type of incident, the demand for resources to treat casualties will far exceed what is available. To meet the goal of providing medical care (including symptomatic/palliative care) with fairness as the underlying ethical principle, planning for allocation of scarce resources among all involved sectors needs to be integrated and practiced. With thoughtful and realistic planning, the medical response in the chaotic environment may be made more effective and efficient for both victims and medical responders.

Radiation event medical management (REMM): website guidance for health care providers.

Planning for andexercising the medical response to potential chemical, biological, radiological, nuclear, andexplosive (CBRNE) terrorist events are new responsibilities for most health care providers. Among potential CBRNE events, radiological and/or nuclear (rad/nuc) events are thought to have received the least attention from health care providers andplanners. To assist clinicians, the U.S. Department of Health andHuman Services (HHS) has created a new, innovative tool kit, the Radiation Event Medical Management (REMM) web portal (http://remm.nlm.gov). Goals of REMM include providing (1) algorithm-style, evidence-based, guidance about clinical diagnosis andtreatment during mass casualty rad/nuc events; (2) just-in-time, peer-reviewed, usable information supported by sufficient background material andcontext to make complex diagnosis andmanagement issues understandable to those without formal radiation medicine expertise; (3) a zip-file of complete web portal files downloadable in advance so the site would be available offline without an Internet connection; (4) a concise collection of the printable, key documents that can be taken into the field during an event; (5) a framework for medical teams andindividuals to initiate rad/nuc planning andtraining; and(6) an extensive bibliography of key, peer-reviewed, andofficial guidance documents relevant to rad/nuc responses. Since its launch, REMM has been well received by individual responders andteams across the country andinternationally. It has been accessed extensively, particularly during training exercises. Regular content updates andaddition of new features are ongoing. The article reviews the development of REMM andsome of its key content areas, features, andplans for future development.

Scarce resources for nuclear detonation: project overview and challenges.

Aterrorist nuclear detonation of 10 kilotons would have catastrophic physical, medical, and psychological consequences and could be accomplished with a device in a small truck. Tens of thousands of injured and ill survivors and uninjured, concerned citizens would require medical care or at least an assessment and instructions. In proximity to the incident location, there would be a huge imbalance between the demand for medical resources and their availability.1-3 Beyond the immediate blast area, much of the infrastructure would remain intact. Most people would reach medical care by selfreferral and require sorting and assessment to determine what medical intervention is necessary, appropriate, and possible.

Medical response to a nuclear detonation: creating a playbook for state and local planners and responders.

For efficient and effective medical responses to mass casualty events, detailed advanced planning is required. For federal responders, this is an ongoing responsibility. The US Department of Health and Human Services (DHHS) prepares playbooks with formal, written plans that are reviewed, updated, and exercised regularly. Recognizing that state and local responders with fewer resources may be helped in creating their own event-specific response plans, subject matter experts from the range of sectors comprising the Scarce Resources for a Nuclear Detonation Project, provided for this first time a state and local planners playbook template for responding to a nuclear detonation. The playbook elements are adapted from DHHS playbooks with appropriate modification for state and local planners. Individualization by venue is expected, reflecting specific assets, populations, geography, preferences, and expertise. This playbook template is designed to be a practical tool with sufficient background information and options for step-by-step individualized planning and response.

In search of parsimony: reliability and validity of the Functional Performance Inventory-Short Form.

Purpose: The 65-item Functional Performance Inventory (FPI), developed to quantify functional performance in patients with chronic obstructive pulmonary disease (COPD), has been shown to be reliable and valid. The purpose of this study was to create a shorter version of the FPI while preserving the integrity and psychometric properties of the original. Patients and methods: Secondary analyses were performed on qualitative and quantitative data used to develop and validate the FPI long form. Seventeen men and women with COPD participated in the qualitative work, while 154 took part in the mail survey; 54 completed 2-week reproducibility assessment, and 40 relatives contributed validation data. Following a systematic process of item reduction, performance properties of the 32-item short form (FPI-SF) were examined. Results: The FPI-SF was internally consistent (total scale α = 0.93; subscales: 0.76–0.89) and reproducible (r = 0.88; subscales: 0.69–0.86). Validity was maintained, with significant (P < 0.001) correlations between the FPI-SF and the Functional Status Questionnaire (activities of daily living, r = 0.71; instrumental activities of daily living, r = 0.73), Duke Activity Status Index (r = 0.65), Bronchitis-Emphysema Symptom Checklist (r = −0.61), Basic Need Satisfaction Inventory (r = 0.61) and Cantril’s Ladder of Life Satisfaction (r = 0.63), and Katz Adjustment Scale for Relatives (socially expected activities, r = 0.51; free-time activities, r = −0.49, P < 0.01). The FPI-SF differentiated patients with an FEVl% predicted greater than and less than 50% (t = 4.26, P < 0.001), and those with severe and moderate levels of perceived severity and activity limitation (t = 9.91, P < 0.001). Conclusion: Results suggest the FPI-SF is a viable alternative to the FPI for situations in which a shorter instrument is desired. Further assessment of the instrument’s performance properties in new samples of patients with COPD is warranted.

Medical Planning and Response for a Nuclear Detonation: A Practical Guide

This article summarizes major points from a newly released guide published online by the Office of the Assistant Secretary for Preparedness and Response (ASPR). The article reviews basic principles about radiation and its measurement, short-term and long-term effects of radiation, and medical countermeasures as well as essential information about how to prepare for and respond to a nuclear detonation. A link is provided to the manual itself, which in turn is heavily referenced for readers who wish to have more detail.

Comparison of Different Methods of Obtaining Orthostatic Vital Signs

The purpose of this study was to compare two lying and standing procedures for measuring orthostatic vital signs. Thirty-five normotensive participants (mean age 21.6 years) participated in a randomized crossover study. Measures of blood pressure (BP), heart rate, and dizziness were collected at different lying and standing times. All subjects participated in a standardized walk paced at 4 miles per hour prior to lying. Using analysis of variance (ANOVA) with post hoc contrasts, the mean systolic BP differed between 5 and 10 minutes of lying (F = 21.33,p < .001) and the mean diastolic BP tended to differ between those time points (F = 5.23,p < .03). The mean standing systolic BP and dizziness rating were different between 0 and 2-minute intervals (F = 8.36,p < .01 andF = 7.15,p < .10). In normotensive participants following standardized exercise, orthostatic vital signs stabilized after lying 10 minutes.

Health related quality of life and disease severity in patients with alpha-1 antitrypsin deficiency.

Study question: To describe health-related quality of life (HRQL) in individuals with alpha-1 antitrypsin (AAT) deficiency, examine the cross-sectional relationship between disease severity and HRQL, and explore changes in lung function and HRQL over time in a subset of these individuals. Material/Methods: Forty-five adults with AAT deficiency and moderate to severe emphysema completed the Chronic Respiratory Disease Questionnaire (CRQ), six-minute walk distance (6-MWD) and pulmonary function tests (PFTs). Twenty of the 45 were followed for two additional years with repeated measurements of CRQ and PFTs. Results: The mean ± SD age was 49 ± 8 years. Initial CRQ subscale scores were: dyspnea 17.5 ± 4.3; fatigue 17.0 ± 5.46; emotional function 33.1 ± 8.67; and mastery 21.7 ± 4.65. No relationship was found between percent predicted forced expiratory volume in one second (FEV1%) and CRQ score; 6 MWD and fatigue correlated significantly (r = 0.32, p < 0.05). Repeated PFT and CRQ measurements in 20 subjects showed statistically significant declines in FEV1 and slow vital capacity (SVC), but no change in CRQ scores. Conclusions: Results suggest persons with AAT deficiency face challenges to HRQL that are similar to older adults with chronic pulmonary disease. Further research is needed on the nature of the relationship between disease severity and HRQL in this population.

End-of-life issues in AIDS: the research perspective

In 1999 alone, HIV/AIDS-associated illnesses caused the deaths of about 2.8 million people worldwide, including an estimated 480 000 younger than 15 years1. Some 13.2 million children have lost their mothers or both parents since the epidemic began1. In this paper we describe research initiatives being pursued at the National Institute of Nursing Research, but first we examine existing publications to provide some background information.