Introduction: Diverse decision-making is needed in managing mass casualty incidents (MCIs), by emergency medical services (EMS). The aim of the study was to review consensus among international experts concerning policies of EMS management during MCIs. Methods: Applicability of 21 EMS policies was tested through a 2-cycle modified e-Delphi process, in which 38 multi-disciplinary experts from 10 countries participated. Threshold for approving proposed solutions was defined as consensus of amp;gt;80%. Policies that did not achieve the targeted consensus were reviewed to detect variability according to respondents origin country. Results: 16 policies were endorsed in the first cycle including collaboration between ambulance service providers; implementing a unified mode of operation; preparing criteria for ground versus aerial evacuation; and, developing support systems for caregivers exposed to violence. An additional policy which proposed that senior EMS officers should not necessarily act as on-site MCI commanders was endorsed in the second cycle. Demographic breakdown of views concerning non-consensual policies revealed differences according to countries of origin. Assigning ambulances to off-duty team members was highly endorsed by experts from Israel and South Africa and strongly rejected by European respondents. Avoiding entry to risk areas until declared safe was endorsed by European, Asian and Oceanic experts, but rejected by Israeli, South African and North American experts. Conclusions: Despite uniqueness of countries and EMS agencies, solutions to most dilemmas were applicable to all organizations, regardless of location or affiliation. Cultural diversity was found concerning readiness to implement military-civilian collaboration in MCIs and a rigid separation between work-leisure responsibilities. (C) 2017 Elsevier Ltd. All rights reserved.

Purpose The aim of the study was to analyze the surgical needs of patients seeking emergency care at the Mosul General Hospital in the final phase of the battle of Mosul in northern Iraq between an international military coalition and rebel forces. During the conflict, the International Red Committee of the Red Cross (ICRC) supported the hospital with staff and resources. Ceasefire in the conflict was declared at the end of July 2017. Methods Routinely collected hospital data from the ICRC-supported Mosul General Hospital from June 6, 2017, to October 1, 2017 were collected and analyzed retrospectively. All patients with weapon-related injuries as well as all patients with other types of injuries or acute surgical illness were included. Results Some 265 patients were admitted during the study period. Non-weapon-related conditions were more common than weapon-related (55.1%). The most common non-weapon-related condition was appendicitis followed by hernia and soft tissue wounds. Blast/fragment was the most frequent weapon-related injury mechanism followed by gunshot. The most commonly injured body regions were chest and abdomen. Children accounted for 35.3% of all weapon-related injuries. Patients presented at the hospital with weapon-related injuries more than 2 months after the official declaration of ceasefire. A majority of the non-weapon-related, as well as the weapon-related conditions, needed surgery (88.1% and 87.6%, respectively). Few postoperative complications were reported. Conclusions The number of children affected by the fighting seems to be higher in this cohort compared to previous reports. Even several months after the fighting officially ceased, patients with weapon-related injuries were presenting. Everyday illnesses or non-weapon-related injuries dominated. This finding underlines the importance of providing victims of conflicts with surgery for life-threatening conditions, whether weapon related or not.

Key PointsQuestionWhat are the outcomes after mesh inguinal hernia repair performed by medical doctors compared with surgeons in Ghana? FindingsIn this cohort study of 242 men with primary reducible inguinal hernia, there was no significant difference in hernia recurrence at 1 year after inguinal hernia repair with mesh performed by medical doctors compared with surgeons (0.9% vs 2.8%). MeaningThis study shows that medical doctors can be trained to perform inguinal hernia repair with mesh in men with good results in a low-resource setting and appears to support surgical task sharing to combat the global burden of hernia disease. ImportanceInguinal hernia is the most common general surgical condition in the world. Although task sharing of surgical care with nonsurgeons represents one method to increase access to essential surgery, the safety and outcomes of this strategy are not well described for hernia repair. ObjectiveTo compare outcomes after inguinal hernia repair with mesh performed by medical doctors and surgeons in Ghana. Design, Setting, and ParticipantsThis prospective cohort study was conducted from February 15, 2017, to September 17, 2018, at the Volta Regional Hospital in Ho, Ghana. Following successful completion of a training course, 3 medical doctors and 2 surgeons performed inguinal hernia repair with mesh according to the Lichtenstein technique on 242 men with primary, reducible inguinal hernia. Main Outcomes and MeasuresThe primary end point was hernia recurrence at 1 year. The noninferiority limit was set at 5 percentage points. Secondary end points included postoperative complications at 2 weeks and patient satisfaction, pain, and self-assessed health status at 1 year. ResultsTwo-hundred forty-two patients were included; 119 men underwent operations performed by medical doctors and 123 men underwent operations performed by surgeons. Preoperative patient characteristics were similar in both groups. Two-hundred thirty-seven patients (97.9%) were seen at follow-up at 2 weeks, and 223 patients (92.1%) were seen at follow-up at 1 year. The absolute difference in recurrence rate between the medical doctor group (1 [0.9%]) and the surgeon group (3 [2.8%]) was -1.9 (1-tailed 95% CI, -4.8; Pamp;lt;.001), demonstrating noninferiority of the medical doctors. There were no statistically significant differences in postoperative complications (34 [29.1%] vs 29 [24.2%]), patient satisfaction (112 [98.2%] vs 108 [99.1%]), severe chronic pain (1 [0.9%] vs 4 [3.7%]), or self-assessed health (85.9 vs 83.7 of 100) for medical doctors and surgeons. Conclusions and RelevanceThis study shows that medical doctors can be trained to perform elective inguinal hernia repair with mesh in men with good results and high patient satisfaction in a low-resource setting. This finding supports surgical task sharing to combat the global burden of hernia disease. This cohort study compares the outcomes associated with inguinal hernia repair performed by medical doctors vs surgeons in Ghana.

Syftet med föreliggande studie var att genom intervjuer med beredskapssamordnare från Sveriges landsting försöka skapa en bild av hur uppfattningen var att skadeplatsen såg ut idag och skulle kunna kommat att förändras på sikt. Vidare önskade intervjustudien söka svar på frågor som rörde komplexiteten på skadeplatsen genom att diskutera ledningsförhållanden, samverkan med andra aktörer, alarmerings- och dirigeringsfunktionernas roll i det svenska sjukvårdsystemet samt hur ett möjligt arbete med ett återtagande av förmågan till ett civilt försvar skulle påverka systemet i sin helhet. Överlag har detta syfte uppnåtts genom ett rikt material kring relevanta frågeställningar som belyst ett flertal kritiska aspekter både i dagens situation men även för framtiden.

Resultatet ger en relativt entydig bild av hur situationen uppfattas på landstingsnivå idag av personalen som behandlar beredskapsfrågorna. Den bild som målas upp fokuserar kanske främst på en upplevd avsaknad av centrala och nationellt övergripande styrningar vilket menligt påverkar förmågan att lyfta ledningsförmågan från regional till nationell nivå vid en större händelse som överstiger den regionala förmågan. Den svenska modellen för att hantera samhällsstörningar av idag är väl anpassad för att hantera händelser inom ramen för det egna länets geografiska område. Befintliga koncept för samverkan och samordning bedöms fungera bra i vardagen, exempelvis vid de vanligaste fallen av skadeplatser: trafik och brand. Detta innebär dock att systemet fungerar väl under förutsättning att händelsen är begränsad i såväl tid och rum som vad avser antalet drabbade. En större händelse eller flera händelser samtidigt på olika platser, särskilt om det finns försvårande faktorer såsom utsläpp av farliga ämnen eller en högre hotbild, skapar försvårande omständigheter som upplevs svårhanterliga idag. I ett framtida scenario upplevs även risken för dessa händelser och terrorattacker att öka. Avhängigheten av IT samt ett samhälle som i allt högre grad förlitar sig på ”just in time”-leveranser gör att sårbarheten har ökat och upplevs fortsätta göra det även i framtiden. Andra viktiga områden som lyfts är nuvarande och befarad framtida brist på kompetent personal samt att utbildnings- och övningsverksamhet inte kan bedrivas i önskvärd utsträckning, delvis på grund av personalbrist och –omsättning.

Vidare syns den generella uppfattningen vara att det saknas ett tydligt ledarskap på nationell nivå då det sällan, om alls, utkommer några direkta styrningar rörande vad som skall uppnås och i vilken utsträckning. Detta har också påvisats i avsnittet ovan rörande före-, under- och efterperspektivet där det finns en klart övervägande del synpunkter på de två förstnämnda perspektiven. Nationell styrning är alltså något som uppfattas vara efterfrågat och då inte bara avseende ledning under insats utan även i frågor rörande enhetlig utrustning och metodik samt utbildnings- och övningsfrågor. Få respondenter har tagit upp efterperspektivet i någon större utsträckning men då det har förekommit har det framförallt berört erfarenhetshanteringsfrågor och den brist som upplevs finnas inom detta specifika område idag. Erfarenheter från den egna verksamheten, såväl i vardagen som vid insatser vid allvarliga händelser, behöver tas om hand, följas upp och sedan utgöra grund för ett levande utvecklingsarbete.

Background

An important aspect of disaster medicine is to be proactive and respond quickly when disaster strikes. In Sweden, the role responsible for swift medical response on the regional level is the designated duty officer.

Methods

A large exercise to assess national medical response ability was conducted. Seven medical regional staffs (a total of 93 individuals participated as tested participants) were involved in handling a large train accident scenario. The exercise was run for 5 hours, where the different regional staffs were located at their regular command posts. The exercise was organized using Emergo Train Systems.

Results

Several capabilities were identified during the exercise as important for the organization to maintain the ability to handle a similar event: documentation and operational picture, communication and terminology, command of resources, strategy for distribution of resources, national co-ordination, and exercise development.

The designated duty officers were central to the exercise in several aspects: 1) in developing and verifying a realistic scenario and preparing background information, 2) as participants in the exercise, 3) assessors of the staffs’ behaviors, and 4) as domain experts when interpreting the exercise outcome.

Conclusions

Using subject matter experts is central to many research domains. However, the more complex a situation is the larger the demand of expertise is. The technical platform allows for coordinating complex exercises, whereas the subject matter expert in terms of the designated duty officer is required to guarantee validity and reliability in these large-scale exercises.

Key messages:

• Running complex scenarios to train and test abilities requires subject matter experts in both planning, preparation, implementation, and assessment.

• Sophisticated simulator and training platforms, such as Emergo Train Systems, facilitates while the designated duty officers are necessary to guarantee validity and reliability in the exercise.

This study concerns communication in a crisis management exercise with a resilience perspective. The staff’s communication during a crisis management exercise, a simulating a ferry fire, facilitated by DARWIN, a European research project in resilience, is analysed with thematic analysis and understood through the Systemic Resilience (SyRes) model (Lundberg & Johansson, 2015)which combines different aspects of resilience.

The main themes found are The Staff’s Decision Making, Operational Care of Affected Persons,and Communication. The staff’s decision makingconsist of the following subthemes: SituationAnalysis, Value of Measuresand Delegation.Operational care of Affected Personsinvolves the themes Transport,and Healthcare. Communicationconsists of the subthemes Stakeholders, and External Communication. The themes are connected in the way that in order to make informed decisions about the operational care ofaffected persons, the staff need to communicate with external stakeholders. 

The themes could be understood through the functions in the SyRes model as they share elements with, could be seen as parts of, or in another way could fit into the adaptive functions of the SyRes model.

This study found themes in the communication of a staff in crisis management. These themes seem to be central for this staff, are reflected in the SyRes model and would reflect what is important for a staff to behave resilient. That is why it would be suggested to examine if the staff’s in crisis management are supported in their work involving these themes.

Händelsen: Tågolyckan inträffade på morgonen den 22 februari 2012 när ett lokaltåg okontrollerat körde in i stoppanordningen i slutet av perrongen på Once station, i centrala Buenos Aires. Hastigheten var mellan 20 och 27 km i timmen, men stoppet var så kraftigt att vagn nummer två trängde sex meter in i vagn nummer ett. Sammanlagt skadades cirka 850 personer varav 51 avled, de flesta omkom i samband med att de två första vagnarna klämdes ihop. Bidragande faktorer till att så många skadades var, ett överfullt tåg av äldre modell, som var dåligt underhållet, och kördes av en organisation med låg säkerhetsmedvetenhet. Händelsen visar att en masskadesituation kan uppstå även vid låga hastigheter. Räddningsinsatsen var omfattande: ett hundratal ambulanser, tre helikoptrar och mer än 500 räddningsarbetare engagerades för att omhänderta skadade och fördela dem mellan huvudstadens 13 akutsjukhus. Beredskapen i Buenos Aires var god vid denna händelse, tack vare genomförda risk- och sårbarhetsanalyser, övningar och utbildningsinsatser. Den argentinska akutmedicinska responsorganisationen och sjukhusen arbetade i stor utsträckning enligt samma katastrofmedicinska principer som i Sverige. Händelsen kunde därför analyseras utifrån ett svenskt perspektiv.

Erfarenheter: Sverige har varit relativt förskonat från tågolyckor med många svårt skadade. Däremot har tillbuden ökat kraftigt och järnvägssystemet är idag slitet och överbelastat. Det finns därför anledning att studera inträffade tågolyckor i världen för att dra lärdom av internationella erfarenheter av olika skadebegränsande faktorer som kan vara av betydelse för svensk katastrofmedicinsk beredskap. Det går att dra flera lärdomar ifrån tågolyckan på Once-stationen.

Nedan redovisas ett antal sammanfattande slutsatser från händelsen med relevans för den svenska beredskapen:

• Det finns en risk att händelser med många svårt skadade kan inträffa även vid låga hastigheter.

• Tågens konstruktion, utformningen av koppel och deformationszoner, samt materielens förslitningsgrad är av stor betydelse för säkerheten.

• Risken att passagerare, bagage och lösa föremål kastas runt i tågvagnen vid en häftig inbromsning är påtaglig.

• Buffertstopp som är konstruerade så att de ger upphov till ett abrupt stopp, utgör en riskfaktor för allvarliga deformationsförlopp och skador, även vid låga hastigheter. TÅGOLYCKAN PÅ ONCE STATION, BUENOS AIRES 2012 SOCIALSTYRELSEN 9

• Brister i företags och myndigheters kvalitetssäkring av sin verksamhet bidrar till att risken för händelser som tågolyckan på Once-stationen inträffar.

• Varningar om tekniska fel som inte tas på allvar i organisationens säkerhetsarbete utgör en riskfaktor.

• Bristande träning bland räddningspersonal i de räddningstekniska svårigheter som kan uppstå vid en tågolycka, till exempel att ta loss fastklämda, kan bidra till att hantering av drabbade fördröjs.

• Förmågan att bedöma situationen och prioritera bland de drabbade i samråd med medicinskt ansvarig kan sannolikt vara av stor betydelse för att minska insatstiden till de svårast klämda och skadade.

• Samtliga sjukhus bör ha en i förväg fastställd förmåga att ta emot patienter vid förstärknings- respektive katastrofläge, så att särskild sjukvårdsledning på regional nivå har möjlighet att snabbt fördela ett stort antal skadade.

• En väl fungerande plan för krisstöd och samlad anhörigupplysning underlättar för den somatiska vården. Brister i en sådan plan får stora konsekvenser för allmänhetens förtroende.

• För att hantera en lika stor tågolycka i Sverige kan flera regioner behöva engageras, vilket ställer stora krav på ledningsförmågan i den drabbade regionen. Dessutom behövs en effektiv samverkan mellan lokal, regional och nationell nivå. Det är därför nödvändigt med en gemensam nationell ledningsmodell vid särskild händelse, gemensamma kris- och katastrofmedicinska utbildningar och regelbundna övningar.

The Stop The Bleed initiative was developed by the Department of Homeland Security to educate lay providers in bleeding reduction strategies. The current study evaluated: (1)three tourniquet instructions using a simulated tourniquet task and (2)participant confidence levels in tourniquet use and lay provider training. Thirty participants with limited clinical experience applied a tourniquet to a simulated limb using one of three instruction sets. Twelve of these participants (40%) participated in a tourniquet training session and focus group to discuss each instruction set. Participants preferred the most simple and pictoral instruction set, and identified opportunities for improvement in each set. Participant confidence in tourniquet use increased significantly following the task and the focus group. After the focus group, participant confidence in instructing lay providers on proper tourniquet use significantly increased. Adding key steps, contextual pictures, and indicators of success to instructions could support lay providers stop the bleed in life-threatening situations

Background: Understanding injury patterns specific for paediatric casualties of armed conflict is essential to facilitate preparations by organizations that provide medical care in conflict areas. The aim of this retrospective cohort study is to identify injury patterns and treatment requirements that are specific for paediatric patients in conflict zones.

Methods: Characteristics of children (age < 15 years) treated in medical facilities supported by the International Committee of the Red Cross (ICRC) between 1988 and 2014 in Kabul, Kao-i-Dang, Lokichogio, Kandahar, Peshawar, Quetta and Goma were analysed; patient characteristics were compared between treatment facilities and with those of adult patients (age ≥ 15 years).

Results: Of the patients listed in the database, 15% (5843/38,088) were aged < 15 years. The median age was 10 years (IQR 6-12); 75% (4406/5843) were male. Eighty-six percent (5012/5,843) of the admitted children underwent surgery, with a median of 2 surgeries per patient (IQR 1-3). When compared with adult patients, children were more frequently seen with fragment injuries, burns and mine injuries; they had injuries to multiple body regions more often and had higher in-hospital mortality rates.

Conclusions: Children more often sustained injuries to multiple body regions and had higher in-hospital mortality than adults. These findings could have implications for how the ICRC and other organizations prepare personnel and structure logistics to meet the treatment needs of paediatric victims of armed conflicts.

Background Humanitarian organizations such as the International Committee of the Red Cross (ICRC) provide worldwide protection and medical assistance for victims of disaster and conflict. It is important to gain insight into the training needs of the medical professionals who are deployed to these resource scarce areas to optimally prepare them. This is the first study of its kind to assess the self-perceived preparedness, deployment experiences, and learning needs concerning medical readiness for deployment of ICRC medical personnel. Methods All enlisted ICRC medical employees were invited to participate in a digital questionnaire conducted during March 2017. The survey contained questions about respondents personal background, pre-deployment training, deployment experiences, self-perceived preparedness, and the personal impact of deployment. Results The response rate (consisting of nurses, surgeons, and anesthesiologists) was 54% (153/284). Respondents rated their self-perceived preparedness for adult trauma with a median score of 4.0 on a scale of 1 (very unprepared) to 5 (more than sufficient); and for pediatric trauma with a median score of 3.0. Higher rates of self-perceived preparedness were found in respondents who had previously been deployed with other organizations, or who had attended at least one master class, e.g., the ICRC War Surgery Seminar (p amp;lt; 0.05). Additional training was requested most frequently for pediatrics (65/150), fracture surgery (46/150), and burns treatment (45/150). Conclusion ICRC medical personnel felt sufficiently prepared for deployment. Key points for future ICRC pre-deployment training are to focus on pediatrics, fracture surgery, and burns treatment, and to ensure greater participation in master classes.

Recent crises and disasters, both natural and man-made have led to the conclusion that there is a need for a resilient approach to preparing for and dealing with such events is needed. In this context, the DARWIN project aims to improve response to expected and unexpected crises affecting critical infrastructures and social structures by developing management guidelines on resilience concepts and innovative training modules for crisis management. The guidelines will cover essential resilience abilities of stakeholders to anticipate, monitor, respond, adapt, learn and evolve, to ensure efficient operation in face of crises. This paper uses a selection of resilience concepts to illustrate how resilience management guidelines can be used to understand and improve crises management. The application of the concepts to this specific case is an experiment to guide further work. This experiment shows that resilience guidelines should enable discovery on how multiple actors operate in a flexible manner and adapt in rapidly changing environment. Further work, needs to specify a set of guidelines co-developed and tested with end-users.

Introduction:

The Stop the Bleed campaign in the United States aims to teach bleeding control techniques, such as tourniquets, to the public. Educational consortium guidelines advocate using brief web- or video-based material. Another option is posters or flyers distributed at, for example, workplaces or public spaces.

Aim:

The aim of the current study was to evaluate the relative efficacy between a flyer and a video to teach tourniquet application skills to members of the public in Sweden.

Methods:

A total of 38 participants (27 male, 11 female) from the general public completed the study. Their ages ranged from 19 to 73 (M=32, SD=14). None had prior experience with tourniquet applications. One group (n=18) received tourniquet instructions on a flyer and one (n=20) received a 5-minute video instruction. Both groups completed pre- and post-questionnaires and a practical tourniquet application test.

Results:

Independent samples t-tests showed that the video-based instructions resulted in fewer application errors (M=1.40 out of 10, SD=1.19) compared to the flyer group (M=3.61, SD=2.40), t(36)=3.651, p=0.001, and higher post-task satisfaction (M=3.89 out of 5, SD=0.74 compared to M=3.39, SD=1.15). However, the flyer-group was faster (M=86.22 seconds, SD=27.28) compared to the video group (M=112.25, SD=42.22), t(36)=2.229, p=0.032.

Discussion:

Video instructions appear superior to flyers in terms of teaching correct tourniquet application to the general public. The longer total application time includes steps taken after bleeding control has been achieved (e.g. securing tourniquet straps and time notation), which may have contributed to the application time difference. The results support the educational guidelines that suggest video-based instructions for teaching basic tourniquet skills to laypeople are more effective.

Introduction: Head nurses at emergency departments often assume responsibility for managing the initial response to a major incident, and to create surge capacity. Training is essential to enable these nurses to perform an effective disaster response. Evaluating the effects of such training is however complicated as real skill only can be demonstrated during a real major incident. Self-efficacy has been proposed as an alternative measure of training effectiveness. Purpose: The aim of this study was to examine if short, small-scale computer-based simulation exercises could improve head emergency nurses general and specific self-efficacy and initial incident management skills. Method: A within-group pretest-posttest design was used to examine 13 head nurses general and specific self efficacy before and after an intervention consisting of three short computer based simulation exercises during a 1-h session. Management skills were assessed using the computer simulation tool DigEmergo. Results: The exercises increased the head nurses general self-efficacy but not their specific self-efficacy. After completing the first two exercises they also exhibited improved management skills as indicated by shorter time to treatment for both trauma and in-hospital patients. Conclusion: This study indicates that short computer based simulation exercises provide opportunities for head nurses to improve management skills and increase their general self-efficacy.

Study/Objective: The study aims at validating a novel device (RespiHeart) for monitoring vital parameters in traumatically injured patients. Background: There is a need for a simple-to-use method for monitoring of vital parameters in the prehospital setting. RespiHeart is a small medical device that is attached to the sternum. It sends light of defined wavelengths into the underlying vasculature, and measures the reflected light. The resulting signals are then treated using proprietary algorithms to obtain heart rate and respiratory rate. The device has the capability to also measure oxygen saturation, temperature and movement. Methods: The device was tested during training sessions for medical personnel, where various traumatic wounds were inflicted on anesthetized pigs. The training was primarily focused on teaching acute lifesaving interventions. The RespiHeart device was applied to the animal and used to monitor vital parameters throughout the training session. A total of 22 animals were included in the study. The data gathered from Respiheart were compared to results from a pulse oximeter and ventilator connected to the animal. Statistical comparison were performed using linear regression and Bland-Altman plots to analyze agreement of methods. Results: The heart rate as measured by the pulse oximeter was correlated to the rate reported by RespiHeart. The R2 was 0.9946 with a p-value of less than 0.0001. Bland-Altman analysis of heart rate revealed a bias of -0.06127 (95% CI -2.219- 2.097). The respiratory rate as set on the ventilator was correlated to the rate reported by RespiHeart. The R2 was 0.9978 with a p-value of less than 0.0001. Bland-Altman analysis of respiratory rate revealed a bias of -0.008584 (95% CI -0.42-0.4028). Conclusion: The results obtained in this study demonstrate a high degree of correlation between the data obtained from RespiHeart and the pulse oximeter and ventilator. This renders RespiHeart as a promising device for prehospital use.

Introduction: In a patient going into shock, blood is redistributed from the periphery to the central circulation, making an assessment of skin perfusion useful in a prehospital setting. Capillary refill time (CRT) is the time required for a pressure blanched skin site to reperfuse. Currently, CRT is tested by manually applying pressure for 5s to the skin and observing the time before reperfusion. Guidelines state that CRT should be 2-3s in a healthy patient. Shortcomings in this procedure include lack of standardization of pressure, subjective assessment of the time for reperfusion, and not accounting for the patient’s skin temperature.

Aim: To develop a standardized objective procedure for testing CRT in the prehospital setting.

Method: The study protocol was approved by the Ethics Committee at Linköping University (M200-07, 2015-99-31). An electro-pneumatic device exerting constant force (9N) over 5s was developed. CRT was measured using the Tissue Viability Imager (Wheelsbridge AB, Sweden) which relies on polarization spectroscopy. To simulate hypothermic conditions, healthy volunteers were subjected to low ambient temperature (8°C). Blood loss was simulated using a custom-built lower body negative pressure (LBNP) chamber. In both scenarios, the CRT test was carried out on three test sites (finger pulp, forehead, and sternum).

Results: CRT on the finger pulp and sternum was shown to be increased following the hypothermic conditions, but not on the forehead. Skin temperature on the three sites followed the same pattern, with the forehead being virtually unchanged. Tests performed during LBNP revealed an apparent effect on CRT following the simulated blood loss, with prolonged CRT for all sites tested.

Discussion: A successful methodology for objective assessment of CRT was developed, which was validated on healthy volunteers following hypothermia or simulated blood loss. Ongoing work will investigate a combination of hypothermia and blood loss to more accurately simulate the prehospital setting.

Connective tissue growth factor (CCN2/CTGF) and transforming growth factor 1 (TGF-1) are important regulators of skin wound healing, but controversy remains regarding their expression in epithelial cell lineages. Here, we investigate the expression of CCN2 in keratinocytes during reepithelialisation and its regulation by TGF-1. CCN2 was detected in the epidermis of healing full-thickness porcine wounds. Human keratinocytes were incubated with or without 10 ng/ml TGF-1, and signalling pathways were blocked with 10-M SIS3 or 20-M PD98059. Semi-quantitative real-time PCR was used to study CCN2 mRNA expression, and western blot was used to measure CCN2, phosphorylated-ERK1/2, ERK1/2, phosphorylated-Smad3 and Smad2/3 proteins. CCN2 was transiently expressed in neoepidermis at the leading edge of the wound in vivo. In vitro, CCN2 expression was induced by TGF-1 at 2 hours (7amp;lt;boldamp;gt;amp;lt;/boldamp;gt;5 +/- 1amp;lt;boldamp;gt;amp;lt;/boldamp;gt;9-fold mRNA increase and 3amp;lt;boldamp;gt;amp;lt;/boldamp;gt;0 +/- 0amp;lt;boldamp;gt;amp;lt;/boldamp;gt;6-fold protein increase) and 12 hours (5amp;lt;boldamp;gt;amp;lt;/boldamp;gt;4 +/- 1amp;lt;boldamp;gt;amp;lt;/boldamp;gt;9-fold mRNA increase and 3amp;lt;boldamp;gt;amp;lt;/boldamp;gt;3 +/- 0amp;lt;boldamp;gt;amp;lt;/boldamp;gt;6-fold protein increase). Compared with inhibiting the SMAD pathway, inhibiting the mitogen-activated protein kinase (MAPK) pathway was more effective in reducing TGF-1-induced CCN2 mRNA and protein expression. Inhibition of the MAPK pathway had minimal impact on the activity of the SMAD pathway. CCN2 is expressed in keratinocytes in response to tissue injury or TGF-1. In addition, TGF-1 induces CCN2 expression in keratinocytes through the ras/MEK/ERK pathway. A complete understanding of CCN2 expression in keratinocytes is critical to developing novel therapies for wound healing and cutaneous malignancy.

Background: The pre-hospital triage process aims at identifying and prioritizing patients in the need of prompt intervention and/or evacuation. The objective of the present study was to evaluate triage decision skills in a Mass Casualty Incident drill. The study compares two groups of participants in Advanced Trauma Life Support and Pre-Hospital Trauma Life Support courses. Methods: A questionnaire was used to deal with three components of triage of victims in a Mass Casualty Incident: decision-making; prioritization of 15 hypothetical casualties involved in a bus crash; and prioritization for evacuation. Swedish Advanced Trauma Life Support and Pre-Hospital Trauma Life Support course participants filled in the same triage skills questionnaire just before and after their respective course. Results: One hundred fifty-three advanced Trauma Life Support course participants were compared to 175 Pre-Hospital Trauma Life Support course participants. The response rates were 90% and 95%, respectively. A significant improvement was found between pre-test and post-test for the Pre-Hospital Trauma Life Support group in regards to decision-making. This difference was only noticeable among the participants who had previously participated in Mass Casualty Incident drills or had experience of a real event (pre-test mean +/- standard deviation 2.4 +/- 0.68, post-test mean +/- standard deviation 2.60 +/- 0.59, P = 0.04). No improvement was found between pre-test and post-test for either group regarding prioritization of the bus crash casualties or the correct identification of the most injured patients for immediate evacuation. Conclusions: Neither Advanced Trauma Life Support nor Pre-Hospital Trauma Life Support participants showed general improvement in their tested triage skills. However, participation in Mass Casualty Incident drills or experience of real events prior to the test performed here, were shown to be advantageous for Pre-Hospital Trauma Life Support participants. These courses should be modified in order to assure proper training in triage skills.

Background

Improved trauma management can reduce the time between injury and medical interventions, thus decreasing morbidity and mortality. Triage at the emergency department is essential to ensure prioritization and timely assessment of injured patients. The aim of the present study was to investigate how a lack of formal triage system impacts timely intervention and mortality in a sub-Saharan referral hospital. Further, the study attempts to assess potential benefits of triage towards efficient management of trauma patients in one middle income country.

Methods

A prospective descriptive study was conducted. Adult trauma patients admitted to the emergency department during an 8-month period at Moi Teaching and Referral Hospital in Eldoret, Kenya, were included. Mode of arrival and vital parameters were registered. Variables included in the analysis were Injury Severity Score, time before physician’s assessment, length of hospital stay, and mortality. The patients were retrospectively categorized according to the Rapid Emergency Triage and Treatment System (RETTS) from patient records.

Results

A total of 571 patients were analyzed, with a mean Injury Severity Score of 12.2 (SD 7.7) with a mean length of stay of 11.6 (SD 18.3) days. The mortality rate was 1.8%. The results obtained in this study illustrate that trauma patients admitted to the emergency department at Eldoret are not assessed in a timely fashion, and the time frame recommendations postulated by RETTS are not adhered to. Assessment of patients according to the triage algorithm used revealed a significantly higher average Injury Severity Score in the red category than in the other color categories.

Conclusion

The results from this study clearly illustrate a lack of correct prioritization of patients in relation to the need for timely assessment. This is further demonstrated by the retrospective triage classification of patients, which identified patients with high ISS as in urgent need of care. Since no significant difference in to time to assessment regardless of injury severity was observed, the need for a well-functioning triage system is apparent.

Background: In a mass casualty situation, medical personnel must rapidly assess and prioritize patients for treatment and transport. Triage is an important tool for medical management in disaster situations. Lack of common international and Swedish triage guidelines could lead to confusion. Attending the Advanced Trauma Life Support (ATLS) provider course is becoming compulsory in the northern part of Europe. The aim of the ATLS guidelines is provision of effective management of single critically injured patients, not mass casualties incidents. However, the use of the ABCDE algorithms from ATLS, has been proposed to be valuable, even in a disaster environment. The objective for this study was to determine whether the mnemonic ABCDE as instructed in the ATLS provider course, affects the ability of Swedish physician's to correctly triage patients in a simulated mass casualty incident.Methods: The study group included 169 ATLS provider students from 10 courses and course sites in Sweden; 153 students filled in an anonymous test just before the course and just after the course. The tests contained 3 questions based on overall priority. The assignment was to triage 15 hypothetical patients who had been involved in a bus crash. Triage was performed according to the ABCDE algorithm. In the triage, the ATLS students used a colour-coded algorithm with red for priority 1, yellow for priority 2, green for priority 3 and black for dead. The students were instructed to identify and prioritize 3 of the most critically injured patients, who should be the first to leave the scene. The same test was used before and after the course.Results: The triage section of the test was completed by 142 of the 169 participants both before and after the course. The results indicate that there was no significant difference in triage knowledge among Swedish physicians who attended the ATLS provider course. The results also showed that Swedish physicians have little experience of real mass casualty incidents and exercises.Conclusion: The mnemonic ABCDE doesn't significantly affect the ability of triage among Swedish physicians. Actions to increase Swedish physicians' knowledge of triage, within the ATLS context or separately, are warranted.

The American College of Surgeons (ACS) and the Department of Homeland Security (DHS) encourage the use of tourniquets as part of the “Stop the Bleed” campaign. Both have provided instructions for layperson tourniquet application in order to save the life of a hemorrhaging trauma victim. This study sought to compare the impact of using ACS and DHS instructions with manufacturer-provided instructions for the completion of simulated tourniquet application steps. Thirty surgical trainees completed a simulated tourniquet application with one of the three instruction sets. Their completion time and success for each step were measured. Participants that received ACS instructions failed the fewest number of steps (p < 0.01) and completed the task faster (Mean (SD) = 70 (33) seconds) compared to those with the manufacturer-provided instructions (p < 0.01). Tourniquet instruction sets need to be refined in order to optimize the success rate of just-in-time guidance for tourniquet application.

Objective

The American College of Surgeons (ACS) encourages clinicians to provide training to laypeople on tourniquet application. It is unclear whether clinicians are confident in their abilities and equipped with adequate knowledge, skills, and resources. This study aimed to determine surgical trainee knowledge and attitudes regarding tourniquet application and compare the effectiveness of instructions.

Methods

Thirty surgical trainees performed a tourniquet application simulation using a Combat Application Tourniquet and one of the three instructions sets developed by ACS, Department of Homeland Security, and the tourniquet manufacturer. Participants reported tourniquet knowledge, attitudes, and confidence and discussed the instructions. One instruction set was updated and compared to the original set with 20 new trainees.

Results

Participants with ACS instructions passed the greatest number of steps (p < 0.01) and completed the task significantly faster compared to those with manufacturer instructions (p < 0.01). Participants (80%) reported favorable views toward tourniquets but 30–60% did not align with to ACS tourniquet guidelines. Focus group participants suggested revisions to the ACS instructions. Comparing the original and revised version of these instructions resulted in no significant improvements.

Conclusions

ACS instructions provide guidance; however, improvements to tourniquet instruction are needed for success in controlling exsanguinating hemorrhage.

Introduction The treatment of burn wounds and hypopigmentation conditions often require autologous transplantation of keratinocytes and melanocytes. Tracking transplanted cells to ascertain their contribution to tissue recapitulation presents a challenge. This study demonstrates a methodology based on passive staining with carboxyfluorescein hydroxysuccinimidyl ester ( CFSE) that enables localization of cells in tissue sections to investigate the fate of transplanted cells in wound re-epithelialisation. Methods Viability and migration of CFSE-stained keratinocytes and melanocytes were investigated using viability staining and scratch assays, while proliferation of cells was measured using flow cytometry. In addition, CFSE-stained keratinocytes and melanocytes were transplanted to a human ex vivo wound model, either in suspension, or with the aid of macroporous gelatine microcarriers. Wounds were analysed seven, 14 and 21 days post transplantation using cryosectioning and fluorescence microscopy. Sections from wounds with transplanted co-cultured keratinocytes and melanocytes were stained for pancytokeratin to distinguish keratinocytes. Results CFSE-staining of keratinocytes and melanocytes did not affect the viability, migration or proliferation of the cells. Transplanted cells were tracked in ex vivo wounds for 21 days, illustrating that the staining had no effect on wound re-epithelialisation. In conclusion, this study presents a novel application of CFSE-staining for tacking transplanted primary human keratinocytes and melanocytes.

Background In the past decades, surgical management of limb injuries in high-resource settings has improved. The possibility of limb salvage has increased. It is not known whether similar changes have transpired in resource-scarce conflict settings. Methods Retrospective cohort study using routinely collected patient data from the International Committee of the Red Cross hospitals in Pakistan was conducted. Consecutive data from 2009 to 2012 (535 patients) and randomly selected data from 1992 to 1995 (463 patients) were used. Only patients with weapon-related limb injuries were included. Differences in surgical procedures were assessed with logistic regression to adjust for confounding factors. Results Less injuries were related to mines in 2009-2012 than in 1992-1995 (3.7% vs. 20.3%, p amp;lt; 0.0001), but injuries from bombs, shells and fragments were more frequent (38.5% vs. 19.4%, p amp;lt; 0.0001) as were injuries with only a small degree of tissue damage (42.0% vs. 31.1%, p = 0.0004). In the logistic regression, the time period did not affect the risk of amputation, debridement, length of hospital stay or in-hospital mortality. The use of external fixation (OR 0.56, 95% CI 0.33-0.96, p = 0.04), split skin grafts (OR 0.31, 95% CI 0.21-0.45, p amp;lt; 0.0001) and blood transfusion (OR 0.43, 95% CI 0.28-0.66, p = 0.0001) was less frequent in 2009-2012. Conclusion In this resource-scarce conflict setting, the risk of amputation appears unchanged over time, while the use of external fixation and split skin grafts was less common in 2009-2012 than in 1992-1995. These results contrast with the improved limb salvage results seen in high-resource settings. It likely reflects the challenges of providing advanced limb-preserving techniques in a resource-scarce setting.

Background: A previous study has shown no measurable improvement in triage accuracy among physicians attending the Advanced Trauma Life Support (ATLS) course and suggests a curriculum revision regarding triage. Other studies have indicated that cooperative learning helps students acquire knowledge. Objective: The present study was designed to evaluate the effectiveness of trauma cards in triage training for firemen. Methods: Eighty-six firemen were randomly assigned into two groups: the trauma card group and the direct instruction group. Both groups received the same 30-min PowerPoint lecture on how to perform triage according to the Sort Assess Lifesaving interventions Treatment and transport (SALT) Mass Casualty Triage Algorithm. In the trauma card group, the participants were divided into groups of 3-5 and instructed to triage 10 trauma victims according to the descriptions on the trauma cards. In the direct instruction group, written forms about the same 10 victims were used and discussed as a continuation of the PowerPoint lecture. Total training time was 60 min for both groups. A test was distributed before and after the educational intervention to measure the individual triage skills. The same test was applied again 6 months later. Results: There was a significant improvement in triage skills directly after the intervention and this was sustained 6 months later. No significant difference in triage skills was seen between the trauma card group and the direct instruction group. Previous experience of multi-casualty incidents, years in service, level of education or age did not have any measurable effects on triage accuracy. Conclusions: One hour of triage training with the SALT Mass Casualty Triage Algorithm was enough to significantly improve triage accuracy in both groups of firemen with sustained skills 6 months later. Further studies on the first assessment on scene versus patient outcome are necessary to provide evidence that this training can improve casualty outcome. The efficacy and validity of trauma cards for disaster management training need to be tested in future studies.

The aim of the study was to evaluate the Swedish medical systems response to a mass casualty burn incident in a rural area with a focus on national coordination of burn care. Data were collected from two simulations of a mass casualty incident with burns in a rural area in the mid portion of Sweden close to the Norwegian border, based on a large inventory of emergency resources available in this area as well as regional hospitals, university hospitals and burn centres in Sweden and abroad. The simulation system Emergo Train System (R) (ETS) was used and risk for preventable death and complications were used as outcome measures: simulation I, 18.5% (n = 13) preventable deaths and 15.5% (n = 11) preventable complications; simulation II, 11.4% (n = 8) preventable deaths and 11.4% (n = 8) preventable complications. The last T1 patient was evacuated after 7 h in simulation I, compared with 5 h in simulation II. Better national coordination of burn care and more timely distribution based on the experience from the first simulation, and possibly a learning effect, led to a better patient outcome in simulation II. The experience using a system that combines both process and outcome indicators can create important results that may support disaster planning.

Background

Timely decisions concerning mobilization and allocation of resources and distribution of casualties are crucial in medical management of major incidents. The aim of this study was to evaluate documented initial regional medical responses to major incidents by applying a set of 11 measurable performance indicators for regional medical command and control and test the feasibility of the indicators.

Methods

Retrospective data were collected from documentation from regional medical command and control at major incidents that occurred in two Swedish County Councils. Each incident was assigned to one of nine different categories and 11 measurable performance indicators for initial regional medical command and control were systematically applied. Two-way analysis of variance with one observation per cell was used for statistical analysis and the post hoc Tukey test was used for pairwise comparisons.

Results

The set of indicators for regional medical command and control could be applied in 102 of the130 major incidents (78%), but 36 incidents had to be excluded due to incomplete documentation. The indicators were not applicable as a set for 28 incidents (21.5%) due to different characteristics and time frames. Based on the indicators studied in 66 major incidents, the results demonstrate that the regional medical management performed according to the standard in the early phases (1–10 min after alert), but there were weaknesses in the secondary phase (10–30 min after alert). The significantly lowest scores were found for Indicator 8 (formulate general guidelines for response) and Indicator 10 (decide whether or not resources in own organization are adequate).

Conclusions

Measurable performance indicators for regional medical command and control can be applied to incidents that directly or indirectly involve casualties provided there is sufficient documentation available. Measurable performance indicators can enhance follow- up and be used as a structured quality control tool as well as constitute measurable parts of a nationally based follow-up system for major incidents. Additional indicators need to be developed for hospital-related incidents such as interference with hospital infrastructure.

Study/Objective: The purpose of this paper is to describe the procedure of identifying and developing quality indicators during educational activities. In addition, the steps taken to assure the validity and reliability of the indicators are presented.

Background: In Sweden a national effort has been made to structure the work processes for crisis preparedness. That is, the process for regional health point of contact and the designated duty officer, has been modified in an attempt to support a shared view regarding collaboration and command during societal disturbances. The effort consists of education and training of designated duty officers, while also developing quality indicators for assessing the work process before the designated duty officer declare a major incident.

Methods: The work of identifying and developing the quality indicators was carried out in focus groups with domain experts.

Results: Initially the work processes of the designated duty officer were thoroughly analyzed and described. The work process was separated into three distinct phases. Focus was on the first two phases. These process steps, have thereafter been connected to concrete behaviors or products that are assessed. The quality indicators are directed towards two levels; if a process step has been carried out within the time-frame, and also the performance quality of an indicator. For example, has an operational picture been established within three minutes of the alarm call? If so, what was the quality of the decision based on, the event description, the consequence description, or the measures description?

Conclusion: The aim of the quality indicators is to make sure that educational activities that are performed does in fact result in actual, and measurable impact. This approach confirms to what extent the activities are successful.

Study/Objective: The objective of this research is to document and evaluate the technical and educational needs for the emergency response system in Pristina, Kosovo. This is a current work in progress, and the part reported here focuses on the needs so far identified through Hierarchical Task Analyses (HTA) of the current dispatch system.

Background: There is currently a lack of support systems for the emergency services in Pristina. Specifically, there are no support systems to aid coordination of the resources available to the emergency dispatch. This might delay emergency care to patients in need. This project relies on a Man-Technology-Organization (MTO) perspective and aims to create additional capacity for all parts (M, T, and O) in the emergency response chain.

Methods: The ongoing research project will be conducted in several phases; the first of which is a data collection phase to analyze the needs of the emergency services as an advanced  socio-technical  system.  This  phase  relies  on interviews with staff and an analysis of the current technology in use.

Results: Eight interviews have been conducted so far in the project. The HTA analyses of the collected data material for the different roles (dispatch, ambulance, and ER-staff) show that there are several time-consuming subtasks that might delay the dispatch of emergency services. Through the HTAs, improvement needs has been identified for all three MTO areas: the human area, the technological area, and the organizational area.

Conclusion: The overall goal of this project is to create capacity and increase system resilience by introducing educational and technical interventions aimed at reducing or removing the identified, inefficient tasks. This increased capacity should result in faster and more time-efficient prehospital emergency response and, through this, improved patient outcome. The next phase of the project will implement interventions aimed at the needs identified in this project.

Denna rapport syftar till att presentera ett teoretiskt och metodologiskt underlag för att studera framtidens skadeplats. Rapporten är en del av forskningsprogrammet Effektiva räddningsinsatser på Framtidens Skadeplats som finns vid Centrum för Respons och Räddningssystem (CARER) vid Linköpings universitet. Effektiva räddningsinsatser på framtidens skadeplats är ett 5-årigt forskningsprogram som finansieras av Myndigheten för Stöd och Beredskap (MSB). Programmet tar utgångspunkt i den praktiska hanteringen av olyckor och andra akuta händelser och fokuserar även hur denna hantering bör förändras i takt med samhällsutvecklingen och hur man kan utveckla kunskap, metoder, och teknik som leder till effektiva räddningsinsatser. Denna rapport ska ses som en del av programmets första arbetspaket som handlar om kunskapsutveckling och prognostisering runt vilka olyckor som sker var, när, hur, vilka som skadas och vilka konsekvenser/(kaskad)effekter olika typer av händelser får.

Målet med denna rapport är att skapa ett underlag för kommande aktiviteter inom forskningsprogrammet genom att beskriva olika skadeplatsscenarier med utgångspunkt i ett antal faktorer för att klassificera och strukturera olika typer av skadeplatser. Faktorerna som används utvecklas i denna rapport genom litteraturstudier, och kan summeras i följande fyra, övergripande kategorier: 1) Typ av händelse, 2) omfattning och allvarlighetsgrad, 3) område och utbredning, samt

4) tidsaspekter. Utifrån faktorerna konstrueras ett antal framtida skadeplatsscenarier. I linje med MSBs tidigare framtidsanalyser syftar dessa inte till att förutspå de vanligaste eller mest troliga framtida skadeplatserna. Snarare är syftet att på ett strukturerat och detaljerat sätt beskriva möjliga framtida skadeplatser som är av särskilt intresse ur ett praktiker- och forskningsperspektiv.

Totalt har 8 scenarier skapats. De är förankrade i de relevanta faktorer som framtagits för klassificering och strukturering och är skalbara och variationsrika i de faktorer de täcker. Tidshorisonten för scenarierna är ca 20 år framåt i tiden. De åtta scenarierna är följande:

1. Tågolycka i väglöst land och kallt klimat
2. Brand i hyreshus i socialt oroligt område
3. Antagonistisk attack mot en utsatt grupp
4. Mindre trafikolycka i glesbygd
5. Mindre trafikolycka på tungt trafikerad väg
6. Dammbrist och översvämning av Luleälven
7. Fartygsolycka med utsläpp av giftiga ämnen
8. Drunkning med eftersök

Dessa scenarier kommer att användas i det fortsatta arbetet med att studera hur man skapar effektiva räddningsinsatser på framtidens skadeplats genom utveckling av organisation, teknik, och metodik.

Objective:

We sought to investigate whether expert–novice differences in visual search behavior found in other domains also apply to accident scenes and the emergency response domain.

Background:

Emergency service professionals typically arrive at accidents only after being dispatched when a civilian witness has called an emergency dispatch number. Differences in visual search behavior between the civilian witness (usually a novice in terms of emergency response) and the professional first responders (experts at emergency response) could thus result in the experts being given insufficient or erroneous information, which would lead them to arrive unprepared for the actual situation.

Method:

A between-subjects, controlled eye-tracking experiment with 20 novices and 17 experts (rescue and ambulance service personnel) was conducted to explore expert–novice differences in visual search of accident and control images.

Results:

The results showed that the experts spent more time looking at task-relevant areas of the accident images than novices did, as predicted by the information reduction hypothesis. The longer time was due to longer fixation durations rather than a larger fixation count.

Conclusion:

Expert–novice differences in visual search are present in the emergency domain. Given that this domain is essential to saving lives and also relies heavily on novices as the first link in the chain of response, such differences deserve further exploration.

Application:

Visual search behavior from experts can be used for training purposes. Eye-tracking studies of novices can be used to inform the design of emergency dispatch interviews.

Study/Objective: In this study, we aimed to design a questionnaire battery for course and simulation exercise evaluation, and pilot-test the battery by evaluating a course on Advanced Prehospital Trauma Care (APTC).

Background: Many course evaluations suffer from simplistic metrics, such as whether the course participants “enjoyed” the course. In contrast, the current study sought to measure (self-estimated) pre- and post-course knowledge, relevant to specific learning objectives, as well as questions pertaining to specific factors of the simulation exercises used in the course (eg, fidelity/realism, learning objective fit, transferability of tools/procedures, usefulness, among others) were selected based on simulation theory and simulation-based training literature.

Methods: Data were collected during a course on APTC. Twelve students participated. The mean professional experience was 15.5 years. The participants completed an informed consent form prior to the study. They completed a pre-course questionnaire, a post-course questionnaire, and a course evaluation form.

Results: The mean self-estimated improvement in theoretical knowledge pertaining to the course objectives was 8.23 on a 0 to 10 scale, and 8.25 for practical skills. Greatest improvement was in advanced airway management, physiological reactions to hypothermia, pneumothorax interventions, special considerations for patients injured by explosives (eg, blast injuries and burns), and medical decision making during an active shooter scenario. The evaluation of the simulation exercises received high marks (mean rating 4.53 [3.92-4.92] out of 5.0) on all aspects. The participants rated the overall course quality at 4.67 (on a 0 to 5 scale), with the simulations, practical exercises, and the structure of moving from theory to practice being mentioned as particularly positive.

Conclusion: Overall, the results showed that the APTC course received high marks on almost all measured factors. Further validation of the questionnaires is needed before general implementation of the battery can be recommended. Such implementation would benefit diverse course development and quality assurance

OBJECTIVE:

This study reports on an initial test using a validated workload measurement method, the NASA Task Load Index (TLX), as an indicator of joint emergency exercise effectiveness. Prior research on emergency exercises indicates that exercises must be challenging, ie, result in high workload, to be effective. However, this is often problematic with some participants being underloaded and some overloaded. The NASA TLX was used to test for differences in workload between commanders and subordinates and among three different emergency response organizations during a joint emergency exercise.

DESIGN:

Questionnaire-based evaluation with professional emergency responders.

SETTING:

The study was performed in conjunction with a large-scale interorganizational joint emergency exercise in Sweden.

PARTICIPANTS:

A total of 20 participants from the rescue services, 12 from the emergency medical services, and 12 from the police participated in the study (N=44). Ten participants had a command-level role during the exercise and the remaining 34 were subordinates.

MAIN OUTCOME MEASURE(S):

The main outcome measures were the workload subscales of the NASA TLX: mental demands, physical demands, temporal demands, performance, effort, and frustration.

RESULTS:

The results showed that the organizations experienced different levels of workload, that the commanders experienced a higher workload than the subordinates, and that two out of three organizations fell below the twenty-fifth percentile of average workload scores compiled from 237 prior studies.

CONCLUSIONS:

The results support the notion that the NASA TLX could be a useful complementary tool to evaluate exercise designs and outcomes. This should be further explored and verified in additional studies.

The aim was to investigate professional confidence in the roles of ambulance and medi- cal incident commander (AIC and MIC), and how it influences achievement of perfor- mance indicators at an incident site. A web survey based on theoretical constructs (e.g., social identity, efficacy, accountability) and questions about prehospital emergency care connected to the roles were used (n = 426 Swedish ambulance nurses and emer- gency medical technicians). The results showed that social identity, independence and occupation were moderators for professional confidence. Organizational support, rela- tional trust and independence were moderators for achieving performance indicators. Strengthening group identification and independence as MIC and independence and support for women as AIC together with a stronger organizational support can increase professional confidence and improve performance.

This paper presents preliminary analysis from a validation study of a novel emergency medicine command and control training and evaluation simulator: DIGEMERGO®. The simulated emergency scenario was a surge capacity event at a generic emergency department, in which the participants took on a management role as the emergency department’s coordinating head nurse. A between group validation design with medical expert and novice participants was used. Initial analysis examined three triage measures associated with surge capacity management performance: time to triage, amount of patients triaged, and triage accuracy. The results show that experts were significantly more accurate at triaging in-hospital patients, but not incoming trauma patients. No significant differences in time or number of patients triaged was found. These initial results partially indicate simulator validity, but trauma patient triage accuracy suffered from a confounding variable in the triage system used. Analysis of additional measures is undergoing to further investigate validity claims.

Health care organizations employ simulation-based team training (SBTT) to improve skill, communication and coordination in a broad range of critical care contexts. Quantitative approaches, such as team performance measurements, are predominantly used to measure SBTTs effectiveness. However, a practical evaluation method that examines how this approach supports cognition and teamwork is missing. We have applied Distributed Cognition for Teamwork (DiCoT), a method for analysing cognition and collaboration aspects of work settings, with the purpose of assessing the methodology's usefulness for evaluating SBTTs. In a case study, we observed and analysed four Emergo Train System® simulation exercises where medical professionals trained emergency response routines. The study suggests that DiCoT is an applicable and learnable tool for determining key distributed cognition attributes of SBTTs that are of importance for the simulation validity of training environments. Moreover, we discuss and exemplify how DiCoT supports design of SBTTs with a focus on transfer and validity characteristics. Practitioner Summary: In this study, we have evaluated a method to assess simulation-based team training environments from a cognitive ergonomics perspective. Using a case study, we analysed Distributed Cognition for Teamwork (DiCoT) by applying it to the Emergo Train System®. We conclude that DiCoT is useful for SBTT evaluation and simulator (re)design.

Objective

This abstract presents early findings on a user evaluation of DigEmergo - a digital training simulator prototype for disaster and emergency management. The overall goal of this research project was to design a flexible tool for training and evaluation of emergency response. Therefore we developed DigEmergo; a digital simulator based on Emergo Train System® (ETS; a globally used tabletop simulator) using electronic whiteboards.

Background

Disaster and emergency response requires competent and coordinated teams. However, training such teams efficiently is complicated. Full-scale high-fidelity simulations are both expensive to perform and difficult to evaluate. Thus, there is a need for scalable environments, such as digital simulations, to train medical decision-making and team coordination.

Methods

The DigEmergo prototype ran on an 87-inch multi-touch digital whiteboard and was evaluated using a training scenario and methodology adapted from ETS. Nine participants with prior ETS experience participated in the evaluation, which was led by two instructors. After completed scenarios first impressions were discussed and questionnaires including open-ended questions were completed.

Results

Preliminary results of the qualitative analysis show that the participants were positive towards DigEmergo. Several participants commented on instructor benefits, e.g. ease of setting up exercises and automatic statistics for after action reviews. Common concerns were potential technical issues, that multiple digital whiteboards are needed to avoid clutter, and loss of flexibility as digital whiteboards are less common than regular whiteboards.

Conclusion

Experienced users of ETS identified both advantages and disadvantages with a digital version of ETS. Identified benefits concerned the instructors’ tasks, increased control, and automatic data collection. Perceived disadvantages mainly related to concerns regarding the size of the digital whiteboard and potential technical issues. The participants also identified development potential, e.g. a small-scale tablet version of ETS for frequent training. Future work include analysis of collected evaluation data and additional prototype development.

Background Training of medical professionals is important to improve care during mass-causality events. Therefore, it is essential to extend knowledge on how to design valid and usable simulation-based training environments.

Purpose This article investigates how distributed cognition and simulation theory concepts can guide design of simulation-based training environments. We present the design and user evaluation of DigEmergo, a simulator for training and assessing emergency medicine management.

Design approach A prior Distributed Cognition in Teamwork (DiCoT) analysis of the Emergo Train System (ETS) guided the design process. The design objective of DigEmergo was to be useful, usable, retain distributed cognition features of ETS, and strengthen validity and output reliability.

Evaluation Eight expert ETS instructors participated in a formative system evaluation. The Technology Assessment Model (TAM) questionnaire was used to measure usefulness and ease of use. Observations and post-test interviews were conducted to contextualize the measures.

Results The results showed that DigEmergo was perceived as somewhat to quite useful and somewhat easy to use. Overall, expert users considered DigEmergo promising and successful in retaining core ETS features.

Conclusions The study indicates that a design methodology based on distributed cognition and simulation theory can be successfully combined to guide simulator (re)design and strengthen simulator validity.

Den 3 mars 2016 fick Socialstyrelsen i uppdrag av regeringen att öva hälsooch sjukvårdens förmåga att hantera en allvarlig händelse med många skadade. Myndigheten beslutade att genomföra övningen som en funktionell simuleringsövning med motspel. De övade utvärderades med hjälp av mätbara kvalitetsindikatorer som tidigare identifierats inom ramen för Socialstyrelsens arbete med att ta fram en gemensam modell för särskild sjukvårdsledning vid allvarlig händelse. Inför övningen skapades ett scenario som var utmanande för hälso- och sjukvården men, för att möjliggöra genomförandet inte innefattade alla potentiella komplexa faktorer. En kritisk observation är att analysen utifrån en övning bör vara restriktiv med slutsatser ifall dessa inte samtidigt kan styrkas utifrån tidigare övningar eller verkliga händelser. Övningens scenario samt patienternas skadepanorama och utfall visualiserades med hjälp av simuleringsverktyget Emergo Train System® och dess instruktörer vid Katastrofmedicinskt Centrum i Linköping. Ett väsentligt mål med övningen var att den ska utgöra ett underlag för att stärka förmågan inom hälso- och sjukvården genom att identifiera utvecklingsområden. I rapporten redovisas under övningen identifierade förmågor och utvecklingsområden som myndigheten bedömer som viktiga för att upprätthålla, säkra och förbättra förmågan att hantera allvarliga händelser: • Dokumentation och lägesbild • Kommunikation och terminologi • Mobilisering och dirigering av resurser • Fördelningsstrategi och gränssättande kapacitet • Nationell samordning • Övningsteknisk utveckling En gemensam lägesbild är viktig efter som det stödjer de involverade aktörerna i arbetet med att värdera behovet av stöd under pågående händelse. Därför var en viktig del i övningens utvärdering huruvida påverkade landsting hade förmågan att snabbt skapa sig en uppfattning om aktuellt behov, tillgängliga resurser och hur ytterligare pre- hospitala samt hospitala resurser skulle kunna mobiliseras. Dessa kritiska faktorer skapar förutsättningar för att korrekta fördelningsstrategier för de skadande patienterna ska kunna utarbetas. Övning Tyko visade att staber med hög upplevd arbetsbelastning och låg upplevd situationsmedvetenhet hade svårt att värdera sitt eget behov av stöd från andra aktörer. Att i förväg ha kännedom om vilken typ av stöd man behöver och kan förvänta sig i olika situationer kräver ett arbete för att identifiera detta redan i före-perspektivet. Det går inte att utesluta att en annan överblick av tillgängliga resurser och en annan förutsägbarhet i vad som kan förväntas av andra hade föranlett en annan fördelningsstrategi som hade förbättrat patientfallet i övningen. För att avgöra effektiviteten av fattade beslut i enlighet med framtagna strategier behövs även en förmåga till 8 HÄLSO- OCH SJUKVÅRDENS FÖRMÅGA ATT HANTERA EN ALLVARLIG HÄNDELSE MED MÅNGA SKADADE SOCIALSTYRELSEN uppföljning huruvida tagna beslut får förväntad effekt inom rimlig tid, under övningen observerades kommunikationsproblem gällande kvittens, förfrågan och bekräftelse. En viktig sammanfattande slutsats som Socialstyrelsen drar inför fortsatt arbete är att myndigheten ska verka för att etablera en funktion för nationell samordning med syfte att ge förutsättningar till en bättre behovs- och resursmatchning vid stora skadeutfall. Inom ramen för en sådan samordning bör gemensamma triage och larmkriterier, medicinska bedömningskriterier och skadeklassificeringar, gemensamma rapportmallar och system för distribution av diagnostiskt material samt gemensam terminologi m.m. inkluderas. Metoder och teknik för framtagandet och kommunikationen av fördelningsnycklar och aktuella kapacitetsbedömningar över tid behöver tas fram för att skapa förutsättningar för en aktuell bild av resurstillgången. Socialstyrelsen vill skapa förutsättningar för ett nationellt kompetenscentrum med inriktning på ökad förmåga och samordning i hela traumavårskedjan. I detta arbete kan även arbetet med Socialstyrelsens förmåga till nationell samordning under pågående händelse utarbetas, definieras och implementeras. Myndigheten vill slutligen lyfta fram att en samlad nationell plan för både trauma- och katastrofmedicinsk utbildning och övning ger ytterligare förutsättningar att upprätthålla och öka förmågan att hantera allvarliga händelser. Dessa viktiga slutsatser avser myndigheten ta med sig in i sitt fortsatta arbete med att stärka hälso-och sjukvårdens förmåga vid allvarlig händelse.

Socialstyrelsens uppdrag kring traumavård har utförts mot bakgrund av ett antal allvarliga händelser i omvärlden. Flera av de lärdomar som har dragits av sådana händelser, exempelvis händelserna i Norge sommaren 2011, har relevans även för utvecklingen av den svenska traumavården. En av lärdomarna för möjligheten att hantera en allvarlig händelse med ett stort antal skadade är betydelsen av att ha en väl fungerande traumavård i vardagen. Det är därför viktigt att betona att krisberedskap måste utgå från och bygga på den förmåga som finns i aktörernas dagliga verksamhet. Socialstyrelsen har inom ramen för uppdraget kartlagt den vardagliga traumavården både genom en bred enkätundersökning samt genom regionala platsbesök. Dessutom har internationella besök i länder som har erfarenhet av särskilt inrättade system för traumavård genomförts. Landstingen organiserar sin hälso- och sjukvård, och däribland sin traumavård på olika sätt. Detta leder i sin tur till att dokumentation och arbetssätt skiljer sig åt vilket kan medföra problem särskilt i samband med allvarliga händelser vilka ofta kräver omfattande samarbete såväl mellan sjukhus som mellan landsting och andra aktörer. För att överbrygga sådana skillnader krävs enligt Socialstyrelsen noggrant, och i möjligaste mån, enhetligt utarbetade planer och rutiner liksom en väl utvecklad, reglerad och inövad samverkan. Kartläggningen visar dock att detta brister i många fall i dagsläget. Socialstyrelsen har mot bakgrund av detta lämnat åtgärdsförslag i syfte att stärka traumavården i hela dess kedja, från det prehospitala omhändertagandet och transportmedicin - till frågor kring kompetensutveckling och tillgång till utrustning inom ramen för den hospitala traumavården. Socialstyrelsens förslag riktas till de enskilda landstingen och utgår från vad som behöver finnas på plats för att stärka ledning, styrning och kompetensförsörjning, exempelvis vad gäller framtagande av kriterier och dokumentation. Förslagen är av övergripande karaktär och ska ses som ett första steg i ett arbete där gemensamma insatser mellan olika aktörer, inte minst mellan landstingen själva, kommer att vara nödvändiga för att åstadkomma dessa förbättringar. I rapporten presenteras även ett antal strategiska vägval som i huvudsak riktar sig till den nationella nivån. Det mest centrala vägvalet, som kräver ett nationellt initiativ, är införandet av ett nivåindelat traumavårdsystem i likhet med vad som finns internationellt. Ett sådant system skulle kunna organiseras i nätverk med prehospital vård, traumaenheter samt traumacentrum på nationell nivå med möjligheter att ta emot patienter från olika regioner beroende på skadetyp. Sådana centrum skulle också kunna tillhandahålla kompetens och stöd till andra nivåer i systemet samt utveckla forskning, kvalitetsuppföljning m.m. Det system som beskrivs i denna rapport knyter på många sätt an till utredningen om den högspecialiserade vården (dir 2014:56 Utveckling av den högspecialiserade vården). Föreliggande rapport och det betänkande som ska lämnas den 25 november 2015 bör således läsas i ett sammanhang. Ytterligare strategiska vägval som bör hanteras är enligt Socialstyrelsen en utveckling av den nationella samverkan inom det civil-militära området, utbildnings- och kompetensfrågor samt deltagandet i det nordiska samarbetet. Det är Socialstyrelsens förhoppning att denna rapport, tillsammans med den nationella statliga nivåns arbete med kunskapsstyrning av svensk krisberedskap och traumavård, kan ligga till grund för ett fortsatt arbete med att utveckla förmågan att hantera en allvarlig händelse med ett stort antal skadade.

Objective

To describe the effect of low ambient temperature on skin temperature and capillary refill (CR) time in forehead, sternum and finger pulp.

Methods

An observational, nonrandomized experimental study on 15 healthy subjects (6 females) in a cold room (8°C). Outcome measures were skin temperature and quantified CR test after application of a standardized blanching pressure (9 N/cm2) using digital photographic polarization spectroscopy to generate CR times.

Results

The finger pulp showed marked temperature fall and prolonged CR times (>10 seconds). The CR registrations of the forehead and sternum were more comparable to curves observed in a control material at room temperature, and skin temperature falls were less marked. CR times were not prolonged in forehead measurements. At the sternum, some individuals showed CR times beyond guideline recommendations despite only a marginal reduction in skin temperature.

Conclusions

Low ambient temperature is a strong independent factor for CR time at peripheral sites. Reservation about sternum as a site of measurement is warranted since cold provocation produced prolonged CR times in some individuals. We found that the forehead is the most thermostable of the 3 sites and thus the preferred site to avoid ambient temperature artifact in measuring CR time.

In the present study we describe an outbreak where PVL positive MRSA belonging to spa-type t002 and multi-locus sequence type ST2659 persisted in a Swedish dairy herd for at least two years, despite efforts to hinder transmission between animals and between the farmer and his animals. This is the first description of persistence and spread of MRSA in a dairy herd in Sweden. Sampling of animals in the herd was initiated by the finding of MRSA in the farmer and was performed at eight occasions from November 2012 to September 2014. In total, MRSA was detected in 25 animals and in 16 of these MRSA was detected in milk samples. In addition, MRSA was also detected in bulk milk samples. Whole genome sequencing (WGS) of twelve isolates from farmer (n?=?1), animals (n?=?9) and bulk milk (n?=?2) revealed high relatedness, implying a common source. MRSA may initially have been transmitted from humans to cows with further spread within the herd. WGS showed minor differences in one isolate (loss of phage FN315) which could indicate adaption of the strain to an animal host.

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