J. James

A consensus-based educational framework and competency set for the discipline of disaster medicine and public health preparedness.

BACKGROUND Various organizations and universities have developed competencies for health professionals and other emergency responders. Little effort has been devoted to the integration of these competencies across health specialties and professions. The American Medical Association Center for Public Health Preparedness and Disaster Response convened an expert working group (EWG) to review extant competencies and achieve consensus on an educational framework and competency set from which educators could devise learning objectives and curricula tailored to fit the needs of all health professionals in a disaster. METHODS The EWG conducted a systematic review of peer-reviewed and non-peer reviewed published literature. In addition, after-action reports from Hurricane Katrina and relevant publications recommended by EWG members and other subject matter experts were reviewed for congruencies and gaps. Consensus was ensured through a 3-stage Delphi process. RESULTS The EWG process developed a new educational framework for disaster medicine and public health preparedness based on consensus identification of 7 core learning domains, 19 core competencies, and 73 specific competencies targeted at 3 broad health personnel categories. CONCLUSIONS The competencies can be applied to a wide range of health professionals who are expected to perform at different levels (informed worker/student, practitioner, leader) according to experience, professional role, level of education, or job function. Although these competencies strongly reflect lessons learned following the health system response to Hurricane Katrina, it must be understood that preparedness is a process, and that these competencies must be reviewed continually and refined over time.

Core Competencies for Disaster Medicine and Public Health

Effective preparedness, response, and recovery from disasters require a well-planned, integrated effort with experienced professionals who can apply specialized knowledge and skills in critical situations. While some professionals are trained for this, others may lack the critical knowledge and experience needed to effectively perform under stressful disaster conditions. A set of clear, concise, and precise training standards that may be used to ensure workforce competency in such situations has been developed. The competency set has been defined by a broad and diverse set of leaders in the field and like-minded professionals through a series of Web-based surveys and expert working group meetings. The results may provide a useful starting point for delineating expected competency levels of health professionals in disaster medicine and public health.

Disaster Triage Systems for Large-scale Catastrophic Events

Large-scale catastrophic events typically result in a scarcity of essential medical resources and accordingly necessitate the implementation of triage management policies to minimize preventable morbidity and mortality. Accomplishing this goal requires a reconceptualization of triage as a population-based systemic process that integrates care at all points of interaction between patients and the health care system. This system identifies at minimum 4 orders of contact: first order, the community; second order, prehospital; third order, facility; and fourth order, regional level. Adopting this approach will ensure that disaster response activities will occur in a comprehensive fashion that minimizes the patient care burden at each subsequent order of intervention and reduces the overall need to ration care. The seamless integration of all orders of intervention within this systems-based model of disaster-specific triage, coordinated through health emergency operations centers, can ensure that disaster response measures are undertaken in a manner that is effective, just, and equitable.

Improving the art and science of disaster medicine and public health preparedness.

Media reports from around the world contain stories almost daily of natural or man-made disasters and their consequences. Although it is tempting to attribute these reports to both proliferation of the modern media (with 24-hour-a-day, 7-days-a-week coverage) and the publics appetite for bad news, it is also true that natural disasters are increasing in magnitude and frequency and will continue to affect immense numbers of people. The reasons for this increase are multifactorial but are based in large measure on 3 important developments that are related: (1) overpopulation, (2) population migration to cities (urbanization) and to coastal areas, and (3) climate change.

Personal Derived Health Information: A Foundation to Preparing the United States for Disasters and Public Health Emergencies

BACKGROUND In the days following a disaster/public health emergency, there is great effort to ensure that everyone receives appropriate care and lives are saved. However, evacuees following a disaster/public health emergency often lack access to personal health information that is vital to receive or maintain quality care. Delayed treatment and interruptions of medication regimens often contribute to excess morbidity and mortality following a disaster/public health emergency. This study sought to define a set of minimum health information elements that can be maintained in a personal health record (PHR) and given to first responders/receivers within the first 96 hours of a disaster/public health response to improve clinical health outcomes. METHODS A mixed methods approach of qualitative and quantitative data gathering and analyses was completed. Expert panel members (n = 116) and existing health information elements were sampled for this study; 55% (n = 64) of expert panel members had clinical credentials and determined the health information. From an initial set of 6 sources, a step-wise process using a Likert scale survey and thematic data analyses, including interrater reliability and validity checks, produced a set of minimum health information elements. RESULTS The results identified 30 essential elements from 676 existing health information elements, a reduction of approximately 95%. The elements were grouped into 7 domains: identification, emergency contact, health care contact, health profile -past medical history, medication, major allergies/diet restrictions, and family information. CONCLUSIONS Leading experts in clinical disaster preparedness identified a set of minimum health information elements that first responders/receivers must have to ensure appropriate and timely care. If this set of elements is used as the fundamental information for a PHR, and automatically updated and validated during clinical encounters and medication changes, it is conceivable that following large-scale disasters clinical outcomes may be improved and more lives may be saved.

The transmission and interpretation of emergency department radiographs

Twenty-five radiographic studies representative of the spectrum of trauma cases that might present to an emergency department were selected from actual cases presenting at Brooke Army Medical Center (BAMC) in San Antonio, Texas. The studies were then transmitted from a local television studio via satellite back to BAMC and three other Army hospitals. A panel of 29 physicians (11 radiologists, 7 emergency physicians, and 11 others from various specialty areas) viewed the images on commercial grade television sets and attempted to make a diagnosis. The diagnostic accuracy of the radiologists (86%) was significantly better than that of the other two groups (77% each). However, given the overall expense of a teleradiology network, this difference in accuracy - especially when translated into clinically significant errors - might not justify the establishment of such a network in terms of cost-effectiveness.

Developing a consensus framework for an effective and efficient disaster response health system: a national call to action.

Eighteen national organizations, representing medicine, dentistry, nursing, hospital systems, public health, and emergency medical services, have worked together to create a framework for a national and regional disaster response health system that is scalable, multidisciplinary, and seamless, and based on an all-hazards approach. In July 2005 and June 2006 the American Medical Association (AMA) and the American Public Health Association (APHA) convened the AMA/APHA Linkages Leadership Summit, with funding from the Centers for Disease Control and Prevention under the Terrorism Injuries: Information Dissemination and Exchange (TIIDE) program. As cofacilitators, James J. James, MD, DrPH, MHA, director of the AMA Center for Public Health Preparedness and Disaster Response, and Georges Benjamin, MD, FACP, FACEP(E), APHA executive director, met with leaders from 16 national medical, dental, hospital, nursing, hospital systems, public health, and emergency medical services organizations in Chicago (2005) and New Orleans (2006) to deliberate the deficiencies in the medical and public health disaster response system and the lack of necessary linkages between key components of this system: the health care, emergency medical services, and public health sectors. The goal was to reach consensus on a set of overarching recommendations to improve and sustain health system preparedness and to combine each organizations advocacy expertise and experience to promote a shared policy agenda. The full summit report contains 53 consensus-based recommendations, which will serve as the framework for a coordinated national agenda for strengthening health system preparedness for terrorism and other disasters. The 9 most overarching critical recommendations from the report are highlighted here. Although the summit report presents important perspectives on the subject of preparedness for public health emergencies, we must understand that preparedness is a process and that these recommendations must be reviewed and refined continually over time.

Emerging Infectious Disease (EID) Communication During the 2009 H1N1 Influenza Outbreak: Literature Review (2009-2013) of the Methodology Used for EID Communication Analysis

OBJECTIVE This year alone has seen outbreaks of epidemics such as Ebola, Chikungunya, and many other emerging infectious diseases (EIDs). We must look to the responses of recent outbreaks to help guide our strategies in current and future outbreaks or we risk repeating the same mistakes. The objective of this paper was to conduct a systematic literature review of the methodology used by studies that examined EID communication during the 2009 H1N1 pandemic outbreak through different communication channels or by analyzing contents and strategies. METHODS This was a systematic review of the literature (n=61) studying risk communication strategies of H1N1 influenza, published between 2009 and 2013, and retrieved from searches of computerized databases, hand searches, and authoritative texts by use of specific search criteria. Searches were followed by review, categorization, and mixed qualitative and quantitative content analysis. RESULTS Of 41 articles that used quantitative methods, most used surveys (n=35); some employed content analyses (n=4) and controlled trials (n=2). The 16 articles that employed qualitative methods relied on content analyses (n=10), semi-structured interviews (n=2) and focus groups (n=4). Four more articles used mixed-methods or nonstandard methods. Seven different topic categories were found: risk perception and effects on behaviors, framing the risk in the media, public concerns, trust, optimistic bias, uncertainty, and evaluating risk communication. CONCLUSIONS Up until 2013, studies tended to be descriptive and quantitative rather than discursive and qualitative and to focus on the role of the media as representing information and not as a medium for actual communication with the public. Several studies from 2012, and increasingly more in 2013, addressed issues of discourse and framing and the complexity of risk communication with the public. Formative evaluations that use recommendations from past research when designing communication campaigns from the first stages of crises are recommended. Research should employ diverse triangulation processes based on representatives from different stakeholders. Further studies should address the potential offered by social media to create dialogue with individuals and the public at large.

Postexposure immunization and prophylaxis of bloodborne pathogens following a traumatic explosive event: preliminary recommendations.

BACKGROUND No definitive guidelines have been established in the United States for postexposure immunization and prophylaxis (PEP) to hepatitis B and C viruses (HBV, HCV) and human immunodeficiency virus (HIV) in the event of a traumatic explosive event. METHODS The American Medical Associations Center for Public Health Preparedness and Disaster Response assembled a US-Israeli panel of experts, including representatives from disaster medicine, trauma surgery, occupational health, and infectious disease to determine guidelines for adult and pediatric victims following a traumatic explosive event. The panel reviewed the existing Israeli and United Kingdom protocols, previously published Centers for Disease Control and Prevention guidance on occupational and nonoccupational exposures to HBV, HCV, and HIV, before reaching consensus on preliminary guidelines for the United States. RESULTS These guidelines recommend an age-appropriate dose and schedule for HBV PEP for individuals presenting from the scene with nonintact skin or mucous membrane exposure, and they also consider HCV and HIV testing in individuals presenting with possible nonintact skin or mucous membrane exposure. The guidelines do not recommend PEP for individuals presenting from the scene with possible superficial skin exposure. CONCLUSIONS These recommendations offer PEP guidance for bloodborne pathogens and are limited in scope. These recommendations do not address general wound PEP such as tetanus or the need for antibiotics. It is hoped that these guidelines will fill an urgent gap in preparedness until definitive, comprehensive guidelines from the Centers for Disease Control and Prevention are published.

The Evolving Role of Dental Responders on Interprofessional Emergency Response Teams

Disaster and pandemic response events require an interprofessional team of health care responders to organize and work together in high-pressure, time-critical situations. Civilian oral health care professionals have traditionally been limited to forensic identification of human remains. However, after the bombing of the Twin Towers in New York, federal agencies realized that dentists can play significant roles in disaster and immunization response, especially on interprofessional responder teams. Several states have begun to incorporate dentists into the first responder community. This article discusses the roles of dental responders and highlights legislative advancements and advocacy efforts supporting the dental responder.