Systematic Review of Strategies to Manage and Allocate Scarce Resources During Mass Casualty Events.
ABSTRACT STUDY OBJECTIVE: Efficient management and allocation of scarce medical resources can improve outcomes for victims of mass casualty events. However, the effectiveness of specific strategies has never been systematically reviewed. We analyze published evidence on strategies to optimize the management and allocation of scarce resources across a wide range of mass casualty event contexts and study designs. METHODS: Our literature search included MEDLINE, Scopus, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Global Health, Web of Science, and the Cochrane Database of Systematic Reviews, from 1990 through late 2011. We also searched the gray literature, using the New York Academy of Medicine's Grey Literature Report and key Web sites. We included both English- and foreign-language articles. We included studies that evaluated strategies used in actual mass casualty events or tested through drills, exercises, or computer simulations. We excluded studies that lacked a comparison group or did not report quantitative outcomes. Data extraction, quality assessment, and strength of evidence ratings were conducted by a single researcher and reviewed by a second; discrepancies were reconciled by the 2 reviewers. Because of heterogeneity in outcome measures, we qualitatively synthesized findings within categories of strategies. RESULTS: From 5,716 potentially relevant citations, 74 studies met inclusion criteria. Strategies included reducing demand for health care services (18 studies), optimizing use of existing resources (50), augmenting existing resources (5), implementing crisis standards of care (5), and multiple categories (4). The evidence was sufficient to form conclusions on 2 strategies, although the strength of evidence was rated as low. First, as a strategy to reduce demand for health care services, points of dispensing can be used to efficiently distribute biological countermeasures after a bioterrorism attack or influenza pandemic, and their organization influences speed of distribution. Second, as a strategy to optimize use of existing resources, commonly used field triage systems do not perform consistently during actual mass casualty events. The number of high-quality studies addressing other strategies was insufficient to support conclusions about their effectiveness because of differences in study context, comparison groups, and outcome measures. Our literature search may have missed key resource management and allocation strategies because of their extreme heterogeneity. Interrater reliability was not assessed for quality assessments or strength of evidence ratings. Publication bias is likely, given the large number of studies reporting positive findings. CONCLUSION: The current evidence base is inadequate to inform providers and policymakers about the most effective strategies for managing or allocating scarce resources during mass casualty events. Consensus on methodological standards that encompass a range of study designs is needed to guide future research and strengthen the evidence base. Evidentiary standards should be developed to promote consensus interpretations of the evidence supporting individual strategies.
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ABSTRACT: Introduction:Successful management of a disaster or pandemic requires implementation of pre-existing plans to minimize loss of life and maintain control. Managing the expected surges in intensive care capacity requires strategic planning from a systems perspective, and includes focused intensive care abilities and requirements as well as all individuals and organizations involved in hospital and regional planning. The suggestions in this chapter are important for all of those involved in a large-scale disaster or pandemic including front line clinicians, hospital administrators, and public health or government officials. Specifically, this paper focuses on surge logistics, those elements that provide the capability to deliver mass critical care. Methodology:The Surge Capacity topic panel developed 23 key questions focused on the following domains: systems issues; equipment, supplies and pharmaceuticals; staffing; and informatics. Literature searches were conducted to identify studies upon which evidence-based recommendations could be made. The results were reviewed for relevance to the topic and the articles screened by two topic editors for placement within one of the surge domains noted previously. Most reports were small scale, observational or used flawed modeling and hence the level of evidence on which to base recommendations was poor therefore not permitting the development of evidence based recommendations. The Surge Capacity panel subsequently followed the American College of Chest Physician's (ACCP) Guidelines Oversight Committee's methodology to develop expert opinion suggestions utilizing a modified Delphi process. Results:This paper presents 22 suggestions pertaining to surge capability mass critical care including: requirements for equipment, supplies and pharmaceuticals, staff preparation and organization, methods of mitigating overwhelming patient loads, the role of deployable critical care services and use of transportation assets to support the surge response. Conclusions:Critical care response to a disaster relies careful planning for staff and resource augmentation and involves many agencies. Maximizing use of regional resources including staff, equipment and supplies extends critical care capabilities. Regional coalitions should be established to facilitate agreements, outline operational plans, and coordinate hospital efforts to achieve pre-determined goals. Specialized physician oversight is necessary and if not available on site it may be provided through remote consultation. Triage by experienced providers, reverse triage, and service de-escalation may be used to minimize ICU resource consumption. During temporary loss of infrastructure or overwhelming of hospital resources, deployable critical care services should be considered.Chest 08/2014; · 7.13 Impact Factor
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ABSTRACT: Recently, mass casualty incidents (MCIs) have been occurring frequently and have gained international attention. There is an urgent need for scientifically proven and effective emergency responses to MCIs, particularly as the severity of incidents is continuously increasing. The emergency response to MCIs is a multi-dimensional and multi-participant dynamic process that changes in real-time. The evacuation decisions that assign casualties to different hospitals in a region are very important and impact both the results of emergency treatment and the efficiency of medical resource utilization. Previously, decisions related to casualty evacuation were made by an incident commander with emergency experience and in accordance with macro emergency guidelines. There are few decision-supporting tools available to reduce the difficulty and psychological pressure associated with the evacuation decisions an incident commander must make. In this study, we have designed a mobile-based system to collect medical and temporal data produced during an emergency response to an MCI. Using this information, our system's decision-making model can provide personal evacuation suggestions that improve the overall outcome of an emergency response. The effectiveness of our system in reducing overall mortality has been validated by an agent-based simulation model established to simulate an emergency response to an MCI.Journal of Medical Systems 12/2014; 38(12):149. · 1.37 Impact Factor
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ABSTRACT: Major short-notice or sudden impact incidents, which result in a large number of casualties, are rare events. However health services must be prepared to respond to such events appropriately. In the United Kingdom (UK), a mass casualties incident is when the normal response of several National Health Service organizations to a major incident, has to be supported with extraordinary measures. Having the right type and quantity of clinical equipment is essential, but planning for such emergencies is challenging. To date, the equipment stored for such events has been selected on the basis of local clinical judgment and has evolved without an explicit evidence-base. This has resulted in considerable variations in the types and quantities of clinical equipment being stored in different locations. This study aimed to develop an expert consensus opinion of the essential items and minimum quantities of clinical equipment that is required to treat 100 people at the scene of a big bang mass casualties event. A three round modified Delphi study was conducted with 32 experts using a specifically developed web-based platform. Individuals were invited to participate if they had personal clinical experience of providing a pre-hospital emergency medical response to a mass casualties incident, or had responsibility in health emergency planning for mass casualties incidents and were in a position of authority within the sphere of emergency health planning. Each item's importance was measured on a 5-point Likert scale. The quantity of items required was measured numerically. Data were analyzed using nonparametric statistics. Experts achieved consensus on a total of 134 items (54%) on completion of the study. Experts did not reach consensus on 114 (46%) items. Median quantities and interquartile ranges of the items, and their recommended quantities were identified and are presented. This study is the first to produce an expert consensus on the items and quantities of clinical equipment that are required to treat 100 people at the scene of a big bang mass casualties event. The findings can be used, both in the UK and internationally, to support decision makers in the planning of equipment for such incidents.BMC Emergency Medicine 02/2014; 14(1):5.