Colleen M. Donovan

Hand Washing Practices Among Emergency Medical Services Providers

Introduction Hand hygiene is an important component of infection control efforts. Our primary and secondary goals were to determine the reported rates of hand washing and stethoscope cleaning in emergency medical services (EMS) workers, respectively. Methods We designed a survey about hand hygiene practices. The survey was distributed to various national EMS organizations through e-mail. Descriptive statistics were calculated for survey items (responses on a Likert scale) and subpopulations of survey respondents to identify relationships between variables. We used analysis of variance to test differences in means between the subgroups. Results There were 1,494 responses. Overall, reported hand hygiene practices were poor among pre-hospital providers in all clinical situations. Women reported that they washed their hands more frequently than men overall, although the differences were unlikely to be clinically significant. Hygiene after invasive procedures was reported to be poor. The presence of available hand sanitizer in the ambulance did not improve reported hygiene rates but improved reported rates of cleaning the stethoscope (absolute difference 0.4, p=0.0003). Providers who brought their own sanitizer were more likely to clean their hands. Conclusion Reported hand hygiene is poor amongst pre-hospital providers. There is a need for future intervention to improve reported performance in pre-hospital provider hand washing.

Blast Physics and Pathophysiology of Explosive Injuries

INTRODUCTION The medical professional’s approach to a blast incident and the resulting patients is a difficult one. Explosions, whether accidental or intentional, wreak physical and psychological havoc on the patients, as well as the medical professionals involved with incident response and caring for the victims. It is further complicated by the fact that most first responders and physicians have little to no experience handling the aftereffects of an explosion, which only adds anxiety to the situation. Data in the United States have indicated approximately 200 injuries or fatalities per year from bombing incidents; with approximately 40,000 physicians practicing emergency medicine and severalfold more emergency responders, one could go his or her entire career without encountering a blast injury. As with any unfamiliar situation, understanding the basics of the inciting factors and the pathophysiology of blast injury can provide a strong foundation on how to treat and, ideally, prevent the sequelae of an explosion.

Organization and Operations Management at the Health Care Facility

INTRODUCTION Here we describe the organizational and operational considerations for pre-event planning and postevent implementation in a health care facility in regard to a mass casualty incident created by an explosion. Although a blast event is a specific subset of mass casualty incidents, from the hospital perspective, it is distinguished from other mass casualty events by the nature of the injuries and the uncertainty of secondary attacks, which have the potential to be perpetrated on the hospital itself. Plans for a blast-related mass casualty response should not be radically different from response plans for other types of mass casualty incidents but must include a response that considers the unique types of injuries that result from blasts. While developing plans for dealing with blast events, hospitals should as much as possible imbed the specific processes necessary for treating casualties of an explosion into routine hospital practices. Those processes, which are not routinely practiced in the hospital, are likely to be forgotten during the stress and pressure of mass casualty events; relearning them during a crisis slows the response of the hospital staff to the larger incident. For example, to avoid confusion, plans should be made to use the same patient identification system in a mass casualty event as is used during day-to-day patient care. In mass casualty incidents, a critical consideration is surge anticipation. Hospitals must prepare for a sudden influx of large numbers of victims in a very short period. Experience in Israel suggests that hospital personnel may have as few as 10 minutes after initial notification before casualties start arriving. The arrival of the first casualties may actually be the first indication that an event has occurred. Because this patient surge cannot be diverted or deferred, medical administrators and providers must rapidly augment space, beds, staff, and supplies to accommodate this casualty influx. The Centers for Disease Control and Prevention has

EMS Dispatches during Hurricanes Irene and Sandy in New Jersey

Abstract Background: Hurricanes Irene and Sandy heavily impacted New Jersey. Investigating EMS dispatch trends during these storms may allow us to prepare for future disasters. Objectives: Our objectives to characterize the types of EMS dispatches immediately before, during, and after landfall compared to a control period. Methods: This retrospective study was conducted at a large EMS dispatch center that provides first responders, Basic Life Support (BLS), Advanced Life Support (ALS), and critical care transport services to an area with approximately 20 receiving hospitals including a Level I Trauma Center. At peak staffing, there are 8–10 ALS vehicles, 25 BLS vehicles, and 3 critical care transport vehicles deployed. We included of the day of landfall and seven days before and after. We compared dispatch data to a control period in 2010 that mirrored Hurricane Sandy the dates of. Descriptive statistics and two way ANOVA were used to assess dispatch, gender and age differences. Results: We found Hurricane Sandy dispatches peaked 2 days after landfall. Both ALS and BLS had an increase in age in the post-Sandy period compared to the pre-Sandy (ALS 58.5 to 64.2, p = 0.005, ANOVA p = 0.078; BLS 47.4 to 56.3, p < 0.001, ANOVA p = 0.001). There were 17 “hurricane related” (loss of power related issues, oxygen supply depleted, evacuation) and 15 carbon monoxide dispatches in the post-Sandy period and none in the others, including peri-Irene. The average age of cardiac arrest dispatches was lower in the post-Irene group compared to pre-Irene (74.3 to 47.8, p = 0.023). There were no critical care requests before or after Hurricane Sandy, but there were 14 around Hurricane Irene and 10 surrounding the control period. Conclusions: Dispatch data can inform natural disaster planning. Education efforts can focus on geriatric patients, as well as resource distribution planning for an increase in geriatric populations. However, pattern variability between storms shows further study is needed to clarify exactly which resources should be utilized in order to maintain an ideal response to a natural disaster.

EMS providers do not use FOAM for education

BackgroundFree open access to medical education (FOAM, #FOAM) is the free availability of educational materials on various medicine topics. We hope to evaluate the use of social media and FOAM by emergency medical services (EMS) providers.MethodsWe designed an online survey distributed to EMS providers with questions about demographics and social media/FOAM use by providers. The survey was sent to the American College of Emergency Physicians (ACEP) EMS Listserv of medical directors and was asked to be distributed to their respective agencies. The survey was designed to inquire about the providers’ knowledge of FOAM and social media and their use of the above for EMS education.ResultsThere were 169 respondents out of a total of 523 providers yielding a response rate of 32.3%. Fifty-three percent of respondents are paramedics, 37% are EMT-Basic trained, and the remainder (16%) were “other.”The minority (20%) of respondents had heard of FOAM. However, 54% of respondents had heard of “free medical education online” regarding pertinent topics. Of the total respondents who used social media for education, 31% used Facebook and 23% used blogs and podcasts as resources for online education.Only 4% of respondents stated they produced FOAM content. Seventy-six percent of respondents said they were “interested” or “very interested” in using FOAM for medical education. If FOAM provided continuing medical education (CME), 83% of respondents would be interested in using it.ConclusionSocial media is not used frequently by EMS providers for the purposes of FOAM. There is interest within EMS providers to use FOAM for education, even if CME was not provided. FOAM can provide a novel area of education for EMS.

Organization and Operations Management at the Explosive Incident Scene

INTRODUCTION The scene of a mass casualty incident is a chaotic, stressful environment. Explosive incident scenes, especially those related to terrorism, add increased levels of fear and potential injury to both civilians and health care providers. They frequently destabilize infrastructure in multiple ways. This article discusses best practices for management of the out-of-hospital explosion scene. The majority of the recommendations are based on expert panel consensus as described in the introductory article. On completion of this article, the reader will have been introduced to several key concepts that may be applied to his or her system in planning for an explosive incident. Because health care and emergency response systems vary considerably from region to region, we do not provide detailed incident plans, but offer a strategic base on which a more specific plan may be built. In the world of disaster management, the Incident Command System is widely used and provides a common language for health care providers. The system is a framework developed to coordinate response to mass casualty incidents. The branches of the Incident Command System are divided into operations, logistics, planning, and finance/ administration. The Federal Emergency Management Agency (FEMA) Incident Command System for emergency medical services (EMS) introduces 6 stages of incident management: planning and training, initial response, operations, stabilization, demobilization, and termination. We will use these 6 stages in this article as a framework for the discussion of management at the explosive incident scene. Furthermore, the National Incident Management System is a standard approach to disaster management that implements the Incident Command System. It was designed to help integrate and coordinate between all levels of responding, from the municipal government through the

Management of Explosive Incidents: Overview of the Project and Summary of Best Practices Consensus Statements of the Expert Panel

INTRODUCTION The project was conducted by the University Center for Disaster Preparedness and Emergency Response at Robert Wood Johnson University Hospital under a grant from the US ArmyTelemedicine andAdvancedTechnologyResearchCenter of the US Army Medical Research and Materiel Command. The project team compiled information fromopen-source publications and from subject matter experts reflecting the US military experience in Operation Iraqi Freedom and Operation Enduring Freedom, US civilian experience from civilian out-of-hospital and hospital health care systems, and Israeli civilian and military experience. A table top exercise, conducted in 2 phases during 2 days, was held to probe for omissions and inconsistencies in the planning effort. The final recommendations were presented at an international symposium in Washington, DC.

Medical Management at the Explosive Incident Scene

INTRODUCTION Blast scene medical management requires out-of-hospital personnel to perform several roles for their patients, including rapid triage, direct patient care, and transport. They must also practice constant vigilance and situational awareness and attempt to preserve evidence when possible. Below we present a brief summary for out-of-hospital providers to remember when responding to an incident scene.

Medical Management at the Health Care Facility

GENERAL CONSIDERATIONS Patient Arrival and Triage In the aftermath of a blast event, the arrival patterns and initial triage of patients vary. Depending on the size of the facility and its proximity to the event, its baseline capabilities, and the preparedness of the first responders, the volume of patients will range from single digits to hundreds. In the recent Boston Marathon bombings of April 15, 2013, 3 spectators were killed and 281 casualties were treated at 27 local hospitals. In a mature trauma system, first responders are best positioned to triage victims with life-threatening injuries to designated trauma centers. Given the emotional effect of a blast event and the usual proximity of trauma centers to potential targets (major cities, transportation hubs, etc), the trauma center will likely receive a significant percentage of patients who do not actually require specialized trauma care. Once victims arrive at the health care facility, the initial triage must be multidisciplinary, coordinated, and rehearsed. A combination of experienced nurses, surgeons, and emergency physicians is required for adequate triage, during which patients can be rapidly categorized into groups, depending on the severity of injuries and the resources needed. A commonly used methodology in North America is the Simple Triage and Rapid Treatment system, whereby red, yellow, green, and black tags are used to identify immediate, delayed, minimal, and deceased or expectant patients, respectively. Although initial or primary triage is a crucial part of mass casualty incident patient care, triage is an ongoing process throughout the entire event. Individual patients must be frequently reevaluated and decisions made to maintain, upgrade, or downgrade their status relative to that of other patients to ensure the most efficient patient flow through the system. This type of continuous triage and surgical or medical decisionmaking requires experience. A senior