key: cord-1022311-2iu4txq9 authors: Tankel, James; Einav, Sharon title: Preparing for mass casualty events despite COVID-19 date: 2021-11-15 journal: Br J Anaesth DOI: 10.1016/j.bja.2021.11.012 sha: f7e22337f87d59e1a24cdca92ca9124e828d0481 doc_id: 1022311 cord_uid: 2iu4txq9 Preparedness for mass casualty events is essential at local, national and global levels. Much more needs to be done by all stakeholders to avoid unnecessary morbidity and mortality despite the challenges that COVID-19 continues to present. In this editorial, we highlight the challenges and solutions for mass casualty incident preparations. Four stages which must take place during patient triage and treatment to ensure that medical facilities can return to normal function after a MCE has been described: guaranteeing the safety of patients and staff members; gradual resumption of immobilized hospital functions; establishment of external support; and creation of long-term medical services 3 . Although international guidelines that detail the planning requirements for MCE are widely available 4 , such guidelines often fail to include preparation for long-term healthcare demands in the wake of such events. Rather they tend to focus on resuscitation and damage control in the first 24 hours following the event or disaster. Further limiting set guidelines is the diverse nature of MCE and the variability of the geographical locations in which they occur. For instance, in the USA 60.9% of all MCEs occur in the urban setting and only 16.6% in rural areas 5 . Conversely, in Korea only 30.4% of MCEs occur in urban areas and the remainder occur in rural locations 6 . Preparation for MCEs must take into account these differences and therefore planning should focus on common themes and limitations (the "all hazards approach"). The principles underlying this approach and the existing gaps in preparedness despite this approach are discussed below. Equipment and consumable availability have always been central to MCE planning. However, hospitals may be reluctant to purchase such resources as it is financially burdensome and does not deliver objective and measurable benefits 7 . Implementation of standard operating procedures or universal guidelines may be a reasonable solution to this problem by improving cost effectiveness. An alternative approach is regional rather than local stockpiling. For instance, in parts of the USA, regional facilities have been developed that can deliver equipment within 12 h if needed. However, a survey of the equipment stored in such facilities found half missing or unusable 8 . This highlights that stockpiling does not ensure that adequate supplies will be available at a time of need. Constant efforts are required to reassess the content of stored supplies and ensure that they are indeed suitable for use and ready for immediate deployment. Moreover, regionalization of storage facilities is reliant upon robust contingency plans to ensure supply deployment. No less important is the ability to identify the supplies most likely to be required. Most equipment and consumables prepared for MCEs will vary depending on the services that they are designed to provide for and the events or natural disasters most likely to occur locally. However, some of the equipment required may be trivialized or taken for granted and therefore overlooked. For example, during hurricane Sandy the most needed equipment by staff involved in the evacuation J o u r n a l P r e -p r o o f of hospitals was flashlights 9 . Shortages in basic supplies such as oxygen, electricity and water have also been described following a MCEs. Simulations of MCEs may point to resources otherwise overlooked and are useful for revising supply lists. Supply shortages may be compounded when operational and logistical support cannot be maintained. This typically occurs during natural disasters due to concurrent damage to infrastructure and during pandemics because of their prolonged nature. For manmade MCEs, data from both developed 10 and less developed counties 11 suggest that emergency department and hospital supplies often suffice for the initial 72 h following the event. In this issue of the British Journal of Anaesthesia Tallach and colleagues report that clinicians involved in MCEs rarely felt that physical resources were a rate-limiting factor in provision of treatment 12 . In the setting of MCEs, transport both into and out from the hospital must be planned. Transport routes should be devised based on the assumption of bi-directional movement, and flow in one direction should not hinder the other. Transport into the hospital. Timely prehospital treatment of patients involved in MCEs has been shown to correlate with improved outcomes 13 . Prior experience reveals that when more than one hospital is available the key factor determining hospital selection is not only specific expertise but also proximity to the scene as this affords the emergency response teams a shorter return trip to the location of the MCE. Distribution of patients between multiple hospitals also increases overall system surge capacity as individual centers are more likely to maintain a higher standard of care when they are not inundated. In some MCEs dispersal of patients from the scene of the incident may be limited due to the destruction of transportation routes, self-evacuation, safety concerns and traffic bottle necks. Therefore, transport decisions need to be dynamic and factor in robust communication networks between hospitals, police and appropriate tiers of government. When land routes are unavailable, air transport may be utilized. Although this mode of transportation is resource and time consuming, if air transport is readily available it can support speedy evacuation to an appropriate center. Another key aspect of transport to and from the hospital is effective triage. Whilst under-triage (which typically occurs in female and elderly patients) is associated with missed injuries, overtriage can lead to hospital inundation with a resultant increase in morbidity and mortality 14 . Multiple triage methods have been studied with some performing better than others during a MCE 15 . Regardless of the method used, the most important aspect of triage is repetition. Repeated Transport from the hospital. Patients may need to be evacuated or transferred to alternative facilities for several reasons. These include damage to vital hospital infrastructure, insufficient beds (termed "leapfrogging"), or to receive services better suited to individual patient needs. Such patient movements include planned transfer of following initial stabilization and urgent evacuation of unstable patients due to insufficient resources. Both situations require advance planning. A written plan for urgent evacuations can mitigate real-time disagreement between treating physicians regarding evacuation priorities. Such discrepancies do occur and harm efficiency at times of great need. For instance, during hurricane Sandy "processes were inconsistent for patient prioritization" 9 . Such plans should also include whether staff are needed to accompany the patient, what equipment is required as well as movement pathways within the facility. The cost of creating a system that encourages movement between facilities is that inter-hospital transfers are both staff and resource dependent. Redundancy is thus needed within hospitals and emergency services to ensure patient movement between facilities does not come at the cost of patient care at either the sending or receiving hospital. Also included in patient transfer is the need to transmit data between treating sites. This includes demographic data and family contact numbers as well as results and treatments provided thus far. Electronic systems have been found to contain 25% fewer mistakes than handwritten medical records in the mass casualty setting 16 . This suggests a preference should be made towards using electronic charts when possible. However, an alternative manual method must always be available in case either internet access or compatible interfaces are unavailable. Planning for MCEs increases early hospital surge capacity thereby avoiding unnecessary morbidity and mortality early in the response to a MCE. Less sick patients often arrive to the hospital before those who suffered more significant injuries. Such patients may inundate the J o u r n a l P r e -p r o o f emergency department if they are not triaged appropriately and sent to alternative treatment areas. Moreover, hospitals should have a contingency plan to ensure appropriate design and sufficient infrastructure to enable efficient one-way patient flow and prevent delays in treatment. This may require the rapid establishment of temporary treatment areas near or within the hospital providing varying levels of care as well as the staff to support them. Identification of potential bottlenecks in patient flow is also important. Advances in technology can help reduce these, such as improvements in computed tomography imaging modalities that allow quicker transfer and interpretation of cross-sectional imaging 17 . Establishment of patient tracking systems within the hospital can also aid with patient flow. Following the initial surge, for those who have been appropriately triaged, investigated and treated, access to an appropriate level of care can be challenging. Ward beds may be full, operating theatres occupied and limited beds available in the intensive care unit. Therefore, early involvement of ward and ICU staff is vital to ensure that additional beds and critical care capacity are made available, where possible, for incoming patients. As MCEs occur without warning, adequate preparation requires prior staff training and education. Events that have occurred should also be seen as an opportunity for improving training and preparation. Training and education. Based on citations from experts that have participated in terror-related multiple casualty incidents Tallach and colleagues 12 highlight the need for "education on specific injuries, revision of plans, and exercises". Lack of immediately available clinical protocols to deal with unique and specific injuries has also been noted as a major area of vulnerability 18 . As physicians and surgeons increasingly subspecialize, they may struggle to treat the wide range of injuries faced in MCEs. The combined effort of multiple specialists is therefore a prerequisite for effective management of patients during MCEs. For this reason, transdisciplinary education, which increases depth, breadth and integration of knowledge, should be the focus of mass casualty training. Such training encourages shared-decision making that transcends different disciplines. This is particularly pertinent with regards to the concept of expectant care described above. A large part of preparing staff revolves around simulation-based training. Such training is not only essential for preparation, but also for the identification of service deficiencies. What makes J o u r n a l P r e -p r o o f such training particularly important is its positive impact on non-disaster related daily operations 19 . Debriefing. Debriefing after MCEs is important for learning and highlighting deficiencies in care. Open discussion of such deficiencies is only possible in a culture of non-blame. Whilst compulsory debriefing sessions are unlikely to reduce the incidence of participant post-traumatic stress disorder 20 , such sessions may improve future clinical outcomes 21 . Despite this documented benefit, only 9.5-62% of hospitals have post-disaster recovery assistance programs available, including counseling and support services 10, 22 . Whilst compulsory programs may not be needed, counselling and support programs are vital to ensure the short-and long-term recovery of staff who are in need, particularly as subsequent MCEs could generate cumulative psychological trauma. Ultimately the resource consistently most difficult to cultivate and yet most commonly needed in every MCE is trained and experienced healthcare staff. Although education is key, "systemic learning is hindered by mismatches between top-down steering and bottom-up initiatives" 23 . Therefore, it is vital that strict command and control mechanisms are designed a priori and rigorously implemented and adhered to during MCEs. The implementation of command-and-control mechanisms is particularly pertinent as many plans and training exercises involve only the emergency department. It is imperative to include the hospital as a whole in preparation for MCEs, as departments not trained in the management of trauma and mass casualty patient pathways consistently become key stakeholders in patient care. In the hours and days following a MCE, resource consumption transitions from the emergency department to the operating theatre, intensive care unit and then to the wards. This results in a significant reduction in routine hospital function in the days and weeks following a MCE. Prolonged system overload negatively affects the care for patients not directly involved in the MCE for a variety of reasons. Elective care may be temporarily suspended, even at the cost of potential lost income to the treating facilities. Therefore, command and control plans must include contingency to prioritize care for patients requiring urgent treatment who are not casualties of the event. One solution is utilize a "backdoor" policy for non-MCE patients that occupy critical beds and are sufficiently stable such that they can be transferred to alternative healthcare facilities. J o u r n a l P r e -p r o o f Union Terrorism Situation and Trend Report, Publications Office of the European Union Mass Shootings in the US During the COVID-19 Pandemic The Great East Japan Earthquake: Tohoku University Hospital's efforts and lessons learned Mass casualty management systems. 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