Introduction

Ambulance services have the primary role of providing rapid stretcher transport of patients to an emergency department (ED). Increasingly, ambulance officers are trained to administer emergency medical care prior to hospital arrival in a wide range of life-threatening illnesses with the expectation that earlier and/or more advanced treatment will improve outcomes.

Dispatch

Many countries now have a single telephone number for immediate access to the ambulance service in cases of emergency, such as 911 in North America, 999 in the UK and 000 in Australasia. However, the accurate dispatch of the correct ambulance skill set in the optimal time frame is complex. It is inappropriate to dispatch all ambulances on a ‘code 1’ (lights and sirens) response, since this entails some level of risk to the ambulance officers and other road users. On the other hand, it may be difficult to accurately identify life-threatening illnesses or injuries using information gained from telephone communication alone, especially from bystanders. Also, it is inappropriate to dispatch ambulance officers with advanced life-support training to routine cases where these skills are not required.

In order to have consistent, accurate dispatch of the appropriate skill set in the optimal time frame, many ambulance services are now using computer-aided dispatch programs. These computer programs have structured questions for use by call-takers with some limited medical training. Pivotal to accurate dispatch is identification of the chief complaint, followed by subsequent structured questions to determine the severity of the illness. The answers to these questions allow the computerized system to recommend the optimal skill set and speed of response. This computer algorithm is medically determined according to local protocols and practices and provides consistency of dispatch.

Most ambulance services generally have at least four dispatch codes. A code 1 (or local equivalent terminology) is used for conditions that are considered immediately life-threatening. For these, emergency warning devices (lights and sirens) are routinely used. The possibility of life-saving therapy arriving as soon as possible is judged as outweighing the potential hazard of a rapid response. In a code 2 (or equivalent) response, the condition is regarded as being urgent and emergency warning devices are used only when traffic is heavy. In a code 3 response, an attendance by ambulance within an hour is deemed medically appropriate. Finally, non-emergency or ‘booked’ calls are transports arranged at a designated time negotiated by the caller and the ambulance service.

Despite continuous developments in computer algorithms, accurate telephone identification of life-threatening conditions may be difficult. For example, identification of patients who are deceased (beyond resuscitation),¹ in cardiac arrest² or suffering acute coronary syndrome³ has been shown to lack the very high sensitivity and specificity that might be expected.

The dispatch centre also has a role for telephone instructions on bystander cardiopulmonary resuscitation⁴ and first aid.

Clinical skills

Ambulance service protocols vary considerably around the world. Since there are few randomized controlled trials to provide high-quality evidence-based guidance for pre-hospital care, there is still much controversy and considerable variation in the ambulance skill set in different ambulance services worldwide.

Many ambulance services provide a number of levels of skill set, dispatching ambulance officers trained in basic life support (including defibrillation) to non-emergency or urgent cases and more highly trained ambulance officers (designated as advanced life-support paramedics or intensive-care paramedics) to patients with an immediately life-threatening condition for which advanced life-support skills may be appropriate. In addition, ambulance services may correspond with other emergency services (such as fire fighters) to provide rapid-response defibrillation.

The rationale for common pre-hospital interventions is outlined in the following sections.

Trauma care

Pre-hospital trauma care may be considered as either basic trauma life support (clearing of the airway, administration of supplemental oxygen, control of external haemorrhage, spinal immobilization, splinting of fractures and the administration of inhaled analgesics) or advanced life support including intubation of the trachea, intravenous (i.v.) cannulation and fluid therapy, and the administration of i.v. analgesia.

Cardiac care

Other medical emergencies

Introduction

Retrieval medicine is a term used to describe the branch of emergency medicine involved with the retrieval and transport of patients from remote locations to primary hospital treatment sites. Retrieval is the process whereby medical teams are transported from central hospitals to peripheral areas with the intention of treating, stabilizing and transporting patients back to these centres. The most common form is a secondary retrieval where the patient is transferred from one healthcare facility to another. A primary retrieval is where the patient is retrieved direct from the scene or incident. However, the clinical distinction between primary and secondary retrieval becomes less clear in smaller healthcare settings where staff are unfamiliar with management of critically ill or injured patients.

Retrieval is more than simply retrieving patients. The process more importantly encompasses the transportation of personnel and expertise from a tertiary centre to a peripheral location. It would not be cost-effective to place specialists from every field in every rural location even if the workforce was available. In addition, the volume of suitable work in each location would be insufficient to adequately maintain specialist skills. Transporting specialist services to the rural patient when needed is more economical than supplying each rural area with a fixed, dedicated specialist service and allows these specialists to maintain skills. The general concepts of a retrieval service also include provision of rural areas with an information and advice network that can be accessed at any time, a bed-finding facility at receiving institutions and activation of the retrieval team when required. The rural practitioner therefore has the capacity to gain expert advice or the means for transporting patients when necessary from a single phone call. The alternative of the remote practitioner having to make multiple phone calls to find a bed as well as simultaneously managing the patient is not an accepted standard of care. This provision of an information and support network is more essential than the transport itself. The term ‘retrieval’ unfortunately focuses upon the transport itself, distracting from the other vital system components.

Principles of transport

Speed of transport is not the prime consideration in retrieval medicine. The overriding principle is to provide the best possible care whilst exposing the patient to the least possible risk. The times of greatest risk are during transit and transfer. Every transfer is an opportunity for line disconnection, interference with monitoring equipment, injury to patients and staff and loss of information if escorts are changed. Difficulties associated with transit are discussed below. Reducing the number of transfers and spending as little time as possible in transit minimize the time the patient is exposed to the greatest risk.

Another principle of retrieval is that the level of medical care should be maintained or increased at each stage of transfer from the peripheral to central institution. This principle has been adopted in the recommendations of the specialties involved in critical care transport in Australasia.¹ In general the retrieval team can provide a level of care above that available at the referring hospital whereas a team sent from the peripheral hospital will be unable to provide the same level of care in transit as in their own hospital. Utilizing peripheral location staff as transport escorts may also significantly affect the level of care available at that location. For smaller locations this effect may be critical.

Organization structure and staffing

Physicians involved in retrieval medicine are typically from the critical care specialties of emergency medicine, intensive care and anaesthesia. Specific training in the retrieval environment is essential for familiarization of the different equipment and vastly different environments of noisy, moving vehicles, limited patient access, altitude and prolonged periods without on-site assistance.

Retrieval systems vary greatly in organizational structure. Some are run out of single departments. Others are hospital-based units and others again are external non-government and/or charitable organizations employing clinicians directly. Each system has advantages and disadvantages, with the selected model strongly influenced by workforce supply and funding structures.

Modes of transport

The mechanism by which the medical team is transported varies with individual circumstances. Road transport is the most readily available and requires the least resources. Transport by helicopter is more expensive and takes time to activate but enables greater distances to be covered in a shorter time period. If helicopters can land at each location there is no need for secondary ambulance transfers. Fixed-wing aircraft share similar drawbacks, can cover even greater distances but require special landing strips and the need for secondary transfers to and from airstrips. Loading and unloading patients in appropriately configured aircraft is almost identical to land ambulance transfers. Issues specific to altitude will be addressed later.

When road transport can be achieved in less than 1–2 h this is normally the cost-effective choice. Transport by air has the disadvantages of increased cost and problems associated with altitude. The greatest benefit of aerial transport is in reducing the time spent in transit and therefore minimizing the time at greatest risk. Figure 26.2.1 shows the time differences between road and helicopter transport. Overall time from incident to arrival at a central hospital may not be significantly reduced by use of a helicopter if road transport is immediately available. The time spent in transit, however, and therefore the time the patient is exposed to maximum risk is significantly reduced. The time taken for the retrieval team to reach a patient is also minimized by use of helicopter transport where road distances are prolonged. The choice between helicopter and fixed wing is a balance between avoiding secondary transfers with helicopters and more rapid flight with fixed wings. Beyond helicopter flight times of 1 h (~250 km), fixed wing becomes increasingly preferable. Helicopter use beyond 400 km is unusual. The transport distance, terrain covered and the specific condition of the patient all influence the decision on the mode of transportation. It is inappropriate to transport some patients by air whilst others require pressurization to ground level in order to be transported safely. The final decision will rest with the retrieval team familiar with the options available. The team should be contacted early in order to arrange the most appropriate transport as quickly as possible.

Fig. 26.2.1 Comparison of road and helicopter transport times. Times of high risk are shown as red (in transit) and arrows (transfers). Although helicopter transport does not significantly reduce overall time, it significantly reduces the high-risk time in transit without increasing the number of transfers.

Preparation for transport

It is very difficult to perform even simple tasks in a moving vehicle. Planes and helicopters are particularly noisy, with unexpected movements and light fluctuations. Listening to heart sounds, respiratory sounds or even taking a pulse may be impossible. Despite this there are several examples in the literature of the successful performance of intubation, i.v. cannulation and other procedures in aircraft.^2,3 Although this is reassuring, it should be considered a failure of pre-flight preparation to be put in the position where such a procedure becomes necessary in transit. If a procedure is considered to be likely or possibly needed before arrival at the destination, serious consideration should be given to performing that procedure prior to departure. It is essential to have lines secured, redundant lines operational in case of emergencies and contingency plans prepared for common and potentially serious complications. In practice this means checking that each vascular access is patent, operational and sufficiently secured to withstand sudden turbulence. Some lines may require suturing to achieve this. It is prudent to have at least one i.v. line that is patent but not in use in order to provide access in an unexpected emergency. Wherever practicable, a single port at a secure site can be used for several infusions, thus freeing up other ports.

Conscious patients should be asked how they feel about aerial transport as early as possible. Urinary catheters may be needed for long flights if patients are unable to void before or likely to need to do so in flight. Antiemetics should be administered early and anxious patients may require sedation. Unconscious patients require gastric and urinary catheterization and confirmation of position, and the patency and security of endotracheal tubes and other invasive devices must be checked before departure. Medical gases are dry, and heat–moisture exchangers or other forms of humidification for ventilated patients are essential to reduce tube occlusion from dried secretions.

Restless, anxious or combative patients are a danger to themselves and everyone else in the confines of an ambulance or aircraft. Sedation should be liberally used. It may even be necessary to intubate some patients for safety reasons prior to departure. Careful discussion with conscious patients prior to departure will usually reveal anxieties related to air transport. Reassurance and pharmacotherapy are more effective the earlier they are given.

Patient comfort in transport is important. The type of mattress used should be considered well in advance. The most comfortable and practical solutions are beanbag-filled vacuum mattresses. Multiple commercial brands are available, all sharing the same design characteristics. The mattresses are insufflated with air and the patient is allowed to settle in comfortably. Air is then evacuated by wall suction or with a hand pump whilst the mattress is moulded to the patient. Moulding to the head and neck and around splinted limbs is possible. Most mattresses are covered in waterproof material, have handles for ease of transfer and are radiolucent. Plain radiography and computerized tomography (CT) scanning can be performed without the need to transfer the patient. The stiffness of the evacuated mattress and the carry handles may make transfer for procedures such as CT scanning easier than with conventional methods. Some emergency departments use these vacuum mattresses routinely in major resuscitation bays.

A final check with the patient and relatives is wise prior to departure. Contact details for and of significant others as well as informed estimations of arrival times help to reduce communication difficulties. Time should be set aside for answering any questions prior to departure. Written information detailing where the patient is to be taken, the names of the transporting crew and phone numbers for further information relieves much anxiety on the part of relatives and friends.

Common problems in transit

Estimating transport time is difficult. Assumptions by non-transport personnel are generally half to one-third of actual times. Considerable time is required for familiarization with the patient and in transferring from one transport modality to the next. Hasty transfers without adequate familiarization increase complications. Oxygen supplies are crucial in longer transports. The amount needed should be calculated to last for at least twice and preferably triple the estimated journey time. If a minimum supply only is taken, any complication or delay may prove fatal. It is also wise to have several cylinders and a spare regulator as a safeguard in the event of equipment failure.

Monitoring and equipment used in transport should be in accordance with recommended standards. Detailed guidelines are available.¹ Most patients require continuous ECG, pulse oximetry and blood pressure monitoring as a minimum. Equipment must be selected carefully. Display screens must be visible in daylight and battery life must be appropriate for duration of transport with a large capacity for additional work. It should always be assumed that the next task will occur immediately without the opportunity to recharge batteries. Consideration should be given to the placement of invasive lines for potentially unstable patients. Use of arterial lines significantly reduces battery requirements for non-invasive blood pressure monitoring. Equipment alarms must be clearly visible as auditory alarms are difficult or impossible to hear in moving vehicles, especially helicopters.

Infusions may be delivered by pumps or syringe drivers. Infusion pumps are more accurate and are essential for critical infusions such as inotropes. However, they are relatively heavy and require specific tubing. Syringe drivers are lighter and require no specialized tubing. However, they are less accurate, must be shielded from sunlight to prevent rubber plungers drying and seizing when exposed and therefore should only be used for less critical infusions.

Loading and unloading are critical times. The combination of patient, stretcher and equipment can be very heavy. Injuries to patients and personnel may occur unless extreme care is taken. Equipment and lines can be damaged or dislodged. The concentration required easily distracts attention from the patient, monitor alarms may not be heard and critical incidents can occur most easily at these times. For all these reasons transfers are considered the most at-risk time for the patient. Reducing the number of transfers is a priority in care.

Defibrillation in moving vehicles creates some special problems. Movement artefact may make it impossible to synchronize for cardioversion or may make rhythm interpretation difficult. Positioning and operating a standard defibrillator can be almost impossible in a moving vehicle. Patients should be assessed prior to departure for likelihood of the need for defibrillation in-flight and this possibility discussed with the pilot. High-risk patients, such as those with acute myocardial infarction or those with known arrhythmias, can be prepared before the journey. All contact with metal should be avoided by wrapping the patient in blankets and sheets, with special attention paid to stretcher edges. Self-adherent defibrillation pads should be applied to the thorax prior to transport. This improves signal quality as well as providing good insulation. A major problem is with residual current leakage. If DC shock is indicated in-flight the pilot must be consulted prior to any attempt. Current leakage and microshocks have the potential to damage and disable electronic equipment. The pilot may elect to allow the DC shock, to turn off electronic equipment first or not permit the procedure. The final decision in these circumstances is a balance between the treatment of the patient and the safety of the aircraft and crew. Only the pilot can make this decision. A pre-informed pilot may be able to avoid situations where defibrillation would be denied.

Special problems associated with travelling at altitude

All transport is associated with motion sickness. Staff tend to become accustomed whilst first-time travellers (including patients) are most affected. Antiemetics should be discussed and administered early whenever possible. Another related condition reducing performance of medical attendants is the sopite syndrome. This condition is characterized by yawning, drowsiness, disinclination for either physical or mental work and lack of participation in group activities.⁴ It is not directly related to the degree of turbulence, is not responsive to anti-motion-sickness medications and, unlike motion sickness, there appears to be little adaptation with time. As many as two-thirds of air attendants are affected to some degree, making this condition an important cause of reduced performance during transport.⁵

Travelling at altitude exposes patients and crew to reduced atmospheric pressure. The two most important consequences of this are hypoxia and expansion of gases. Most fixed-wing aircraft can pressurize the interior of the craft to sea level or above, making these complications avoidable. Medical helicopters do not have the option of pressurization but may elect to fly at low altitudes. Pressurization to sea level causes excessive fuel demand and additional stress on the aircraft. As a compromise, most commercial and medical aircraft will pressurize to an equivalent altitude of 5000–7000 ft whilst travelling at 30 000–40 000 ft. At this cabin altitude ambient PO₂ is reduced to 60 mmHg and trapped gases expand by one-third of their volume. Breathing cabin air produces an Sa–O₂ of 90% under these conditions. For healthy individuals this poses no problem. For unwell or oxygen-dependent patients, however, being on the shoulder of the Hb–O₂ dissociation curve can be dangerous with only small decreases in PO₂ from this point inducing large falls in Sa–O₂. Supplemental O₂ or increased pressurization may be required.

Expansion of trapped gas can produce disastrous consequences. All pneumothoraces, no matter how small, require venting prior to elevation to altitude. Heimlick valves are preferable to underwater seal drains during transport as underwater seal apparatus is disturbed by movement and is at greater risk of damage and breakage. Air trapped in small bowel (for instance in ileus) can produce considerable discomfort. Gas at either end of the gastrointestinal tract can vent spontaneously. Middle ear gas can be particularly painful on ascent and descent. Patients should be taught equalization techniques such as the Valsalva, Frenzel or Toynbee manoeuvres. The Valsalva manoeuvre reduces cardiac venous return and may be associated with syncope. The most effective technique is the Frenzel manoeuvre, which is carried out with the mouth, nostrils and epiglottis closed. Air in the nasopharynx is then compressed by the action of the muscles of the mouth and tongue. This technique not only generates higher nasopharyngeal pressures than the Valsalva manoeuvre, it opens the eustachian tubes at lower pressures. The easiest taught technique is the Toynbee manoeuvre, which raises pharyngeal pressure by swallowing with the mouth closed and nostrils occluded. In babies and young children, the angle of entry of the eustachian tubes into the nasopharynx is less acute and hence ear problems in flight are less common. Older children and some adults are unable to learn the various techniques.⁶ Nasal decongestants prior to departure or sweets to suck on during descent may be of benefit. If a patient is unable to clear the ears, pain increases until the tympanic membrane ruptures with sudden relief of discomfort.

Expansion of gases has consequences for medical equipment. Air in an endotracheal tube cuff expands, increasing cuff pressure on ascent. Although modern high-volume, low-pressure cuffs minimize this effect, the increased pressure may cause tracheal damage if left unchecked for long periods. On descent the volume falls, making tube displacement more likely and increasing the likelihood of leakage around the cuff. Loss of ventilatory volumes and aspiration may result. The cuff pressure should be monitored on ascent and descent and adjusted as necessary. An alternative practice is to fill the cuff with sterile fluid such as normal saline. This makes it impossible to monitor the pressure in the cuff and is not necessary if the air-filled cuff is monitored appropriately.

Ascent to altitude may cause or increase the symptoms of decompression illness. The use of portable hyperbaric chambers or pressurization to sea level may be required. In aircraft where pressurization is not possible the lowest safe altitude is the next best alternative. These requirements must be discussed with the pilot as soon as they are known and certainly well prior to departure.

Decisions on flight safety

At times a choice must be made whether or not it is safe to fly. The decision is based on meteorological conditions and other circumstances. The final decision must always rest with the pilot. Crew safety is under the direction of the pilot whose decision is absolute. No patient is worth more than the crew.

Future directions

Medical equipment is becoming more complex as well as smaller and lighter. Sophisticated ventilators, multilumen infusion devices and complicated equipment such as intra-aortic balloon pumps can already be transported in surface and aerial craft. Non-invasive pressure-monitoring equipment has been developed, enabling beat-to-beat measurement of arterial and other pressures and real-time cardiac output monitoring. This evolution of equipment will continue, making it possible to transport increasingly complex cases with greater safety and less need for invasive interventions.

The capacity for interactive communication with remote areas is increasing at an accelerated rate. Multimedia communications allow teleconferencing, data transmission of electrocardiograms, and radiological images and video viewing of patients with increasing clarity. Pilot systems have already been developed whereby surgeons can perform operations with the aid of video cameras and remote control devices without the need to leave the central institutions. The further development of this technology will greatly reduce the need to transfer patients and allow comprehensive management in rural locations.

Introduction

Disaster preparedness and response involve a complex, multidisciplinary process of which emergency medicine comprises one component. Government agencies, fire fighters, law enforcement, ambulance services, civil defence, the Red Cross and other aid organizations may all have a role to play. The health and medical management of disasters can also cut across professional disciplines and require contributions from emergency medicine, public health, primary care, surgery, anaesthetics and intensive care.

From the health perspective, different types of disasters are frequently associated with well-described patterns of morbidity and mortality. The clinical and public health needs of an affected community will, therefore, also vary according to the type and extent of disaster. Emergency physicians should understand the health and medical consequences of the various types of disasters in order to determine their own roles in preparedness and response. In practice, emergency physicians will be most actively involved in the response to an acute-onset disaster that involves multiple casualties, such as a transportation incident. Several other types of disasters, including floods and cyclones, are generally associated with few, if any, casualties. The health and medical needs in these settings usually involve augmenting public health and primary-care services.

The aims of this chapter are to familiarize emergency physicians with disaster epidemiology and disaster management arrangements, and to provide an overview of the medical response to a disaster involving multiple casualties. While the chapter focuses on health and medical issues, it should be remembered that the effects of disasters are often widespread and long term. Disasters cause significant social, economic and environmental losses that can have a devastating effect on the general wellbeing of the affected community.

Definitions and classification

There is no internationally accepted definition of disaster or disaster classification. There are, however, increasingly consistent uses of terms among stakeholder organizations. Common to most definitions is the concept that following a disaster the capacity of the impacted community to respond is exceeded and there is, therefore, a need for external assistance. The World Health Organization characterizes a disaster as a phenomenon that produces large-scale disruption of the normal healthcare system, presents an immediate threat to public health and requires external assistance for response. The Australian Emergency Manual defines disaster as an event that overwhelms normal community and organizational arrangements and requires extraordinary responses to be instituted. The Center for Research on the Epidemiology of Disasters (CRED), which compiles the data behind the annual World Disasters Report of the International Federation of Red Cross and Red Crescent Societies, stipulates a quantitative surveillance definition involving one of the following: 10 or more people killed, 100 or more people affected, declaration of state of emergency or an appeal for international assistance.¹

Disaster management is the range of activities designed to establish and maintain control over disaster and emergency situations, and to provide a framework for helping at-risk populations avoid or recover from the impact of a disaster. It addresses a much broader array of issues than health alone, including hazard identification, vulnerability analysis and risk assessment. Disaster medicine can be defined as the study and application of clinical care, public health, mental health and disaster management to the prevention, preparedness, response and recovery from the health problems arising from disasters.² This must be achieved in cooperation with other agencies and disciplines involved in comprehensive disaster management. In practice, emergency medicine and public health are the two specialties most intimately involved in disaster medicine.

A mass casualty incident is an event causing illness or injury in multiple patients simultaneously through a similar mechanism, such as a major vehicular crash, structural collapse, explosion or exposure to a hazardous material.

Disasters are commonly classified as natural versus technological/human-generated (Box 26.3.1).¹ Disasters may also be classified according to other characteristics, including acute versus gradual onset, short versus long duration, unifocal versus multifocal distribution, common versus rare and primary versus secondary. Classifications of disaster magnitude exist for selected natural hazards, such as earthquakes and hurricanes/cyclones; however, there is currently no standard classification of severity of disaster impact.

Epidemiology

Globally, the types of disasters associated with the greatest numbers of deaths are complex emergencies (CEs). These are crises characterized by political instability, armed conflict, large population displacements, food shortages and collapse of public health infrastructure. Because of insecurity and poor access to the affected population, aggregate epidemiological data for CEs are somewhat limited. However, between 1998 and 2004 in the eastern region of the Democratic Republic of Congo, 3.9 million people lost their lives due to the consequences of the major humanitarian crisis afflicting that country.³ Incredibly, this was more than three times the total number of deaths globally due to natural and technological disasters during the decade of the 1990s. Based on United Nations definitions, there were 27 ongoing CEs in 2007, involving over 30 countries and impacting on the lives of hundreds of millions of people.⁴ Thirteen (44%) of these crises were ongoing in Africa, with 10 (37%) occurring in Asia.

According to information compiled by the International Federation of the Red Cross, there has been a significant increase in the total number of natural and technological disasters worldwide during the past 30 years. From 1996 to 2005, an average of approximately 641 such disasters was documented annually, peaking at 801 in 2000. While the total number of people killed by natural and technological disasters is approximately 93 000 per year, there is a wide annual range (21 888 in 2000 to 251 768 in 2004 due to the Indian Ocean tsunami). Moreover, the total number affected has almost trebled over the past three decades. It is estimated that approximately 250 million people are directly affected on an annual basis. Selected data are presented in Figures 26.3.1 and 26.3.2.

Fig. 26.3.1 Global disasters incidence by hazard 1996–2005.

Adapted from: International Federation of the Red Cross. World Disasters Report 2006: Focus on neglected crises. IFRC, Geneva; 2006.

Fig. 26.3.2 Global disasters deaths by hazard 1996–2005.

Adapted from: International Federation of the Red Cross. World Disasters Report 2006: Focus on neglected crises. IFRC, Geneva; 2006.

The commonest types of disasters across the globe are transportation incidents, floods, windstorms, industrial incidents, building collapses, droughts/famines and earthquakes/tsunamis (see Fig. 26.3.1). Asia is the region of the world most prone to natural and technological disasters, recording 41% of such incidents between 1996 and 2005. It is followed by Africa (22%), the Americas (20%), Europe (14%) and Oceania (3%). Compared with other regions of the world, Australasia and Oceania clearly have a relatively low incidence of disasters. Over the past 10 years the commonest causes of natural disasters in Australia have been floods, severe storms and cyclones. Nationally, an average of 33 lives are lost per year due to disasters in Australia. In addition, over 68 000 people are affected annually, through injury, displacement, financial loss, damage or loss of homes and businesses. Historically, the leading causes of death from natural disasters have been heatwaves, followed by cyclones, floods and bushfires. Human-generated disasters resulting in multiple casualties have occurred more frequently in Australia in recent years. The commonest causes of mass casualty incidents have been bus crashes, structural fires, mining incidents, aviation incidents and train crashes.

The impact of disasters has been less in New Zealand, where only 28 lives were lost among 9040 persons affected over the last decade. The pattern of natural disasters also differs, with the commonest major events being floods, earthquakes and landslides. The North Island of New Zealand has six active volcanoes, with the last attributed loss of life occurring in 1953.

Data reporting on the incidence of terrorism has recently been complicated by changing definitions and political motivations of the reporting agencies. In spite of the controversies and complexities surrounding the reporting, the number of international terrorist attacks has increased significantly since 2000, following a steady decline during the latter half of the 1990s.⁵ There were on average 229 international terrorist attacks between 1997 and 2006, with a peak of 395 in 2004. Over that period, an average of 694 persons per year were killed, with a peak of 3184 in 2001 (including 2982 deaths due to the September 11 attacks by Al Qaeda in the USA). This is just a very small fraction of the total number deaths attributed to natural and technological disasters and CEs. The regions documenting the highest number of international terrorist attacks over that period have been the Middle East (51%), Western Europe (13%), South Asia (11%), Africa (6%), and Southeast Asia and Oceania (4%).

Disaster epidemiology globally, including the Australasian region, is being impacted by climate change. Global warming has already been associated with an increase in the frequency and unpredictability of weather-related disasters, such as heatwaves, floods and droughts. There is also evidence of increased intensity of tropical cyclones,⁶ as has been reflected by recent experience with hurricane Katrina (2005) and cyclone Larry (2006). Rising temperatures have already been implicated in the spread of infectious disease vectors, including malaria-carrying mosquitoes. Other important diseases are also sensitive to changing temperatures and rainfall, including dengue, malnutrition and diarrhoea. The health-related and other impacts of climate change will not be evenly distributed. Disasters associated with global warming are particularly likely to threaten the lives and livelihoods of coastal communities, those living in low-lying islands (e.g. due to rising sea levels), and in arid and high mountain zones.

Socioeconomic impact

Disasters have the potential for major socioeconomic impact, costing the international community billions of dollars annually. In developing countries, years of development work and investment can be devastated by a single disaster. During the 10 years to 2005, disasters caused a global average of approximately US$73.4 billion damage per year. Windstorms were the costliest disaster over the decade, accounting for 43% of disaster-associated costs, led by hurricane Katrina at US$125 billion, which caused 40% of all windstorm damage. Terrorist attacks on major financial centres, such as the World Trade Center in New York have demonstrated the potential for tens of billions of direct economic impact, enormous social consequences and political repercussions for mismanaged disaster response. These figures may be overshadowed by pandemic disease, such as from avian influenza, for which economic cost estimates range to upwards of US$1 trillion.⁷

In Australia, disasters have cost an average of A$ 1.14 billion annually. Over the past 30 years, floods, storms, then cyclones have caused the greatest disaster-related economic losses in Australia. The most economically costly disasters were cyclone Tracy (1974), the Newcastle earthquake (1989) and the Sydney hailstorm (1999).

Economic estimates, of course, are unable to reflect the true scale of human suffering associated with disasters. While we can often document the mortality, morbidity and financial losses associated with disasters, it is impossible to quantify the associated personal, psychological, social, cultural and political losses.

Disaster management/emergency management

As emergency physicians play a vital role in the medical aspects of disaster management, they should be familiar with the four underlying concepts on which these arrangements are based.

Disaster planning

Disaster planning is the process by which a community develops a comprehensive strategy to effectively manage and respond to disasters. It is a collaborative effort that requires cooperation between government agencies, community services and private organizations. The ultimate goals of the planning process include clarification of the capabilities, roles and responsibilities of responding agencies, and the strengthening of emergency networks. Other operational issues, such as emergency communications and public warning systems, will also be addressed.

A critical concept in disaster planning is the graduated response. The initial response to an event begins at the local level. More resources can subsequently be requested from regional, state or national levels, as required, to supplement those of the local providers. Compatibility between plans at the different levels is therefore necessary. A hierarchy of disaster management plans exists in which plans at lower levels dovetail with those of the next highest level. Command and control arrangements, as well as the roles and responsibilities described in a particular plan, must be compatible with the other plans to which it relates. Emergency physicians must be aware of these requirements if they are to constructively contribute to the development of state, regional and hospital disaster plans.

Several high-profile terrorist events (e.g. World Trade Center attack in New York) and important gatherings (e.g. APEC Leaders Meeting in Sydney) have highlighted the need for specific planning for terrorist events. Such planning will frequently involve collaboration with relevant military, security and intelligence agencies, and a consideration of the tactics used by terrorists. Over the past decade 73% of international terrorist attacks have used conventional weapons, including explosives and small arms. Other terrorist tactics include assassinations, hijacking and kidnapping. Unconventional attacks, including those that using jet airliners as weapons of mass destruction, or chemical, biological and radiological weapons have constituted only 0.5% of international terrorist attacks. Nonetheless, prudent planning for these types of incidents is also required, observing the all-hazards approach.

Disaster exercises must be conducted regularly to test the response and recovery aspects of the plan. Exercises range from desktop simulations to realistic scenarios with moulaged patients in the field. If conducted appropriately, they should effectively test whether the objectives of the plan have been met and provide the opportunity for disaster response training. Disaster planning is a continuous process, and plans need to be regularly reviewed and updated. Disaster exercises may provide insights into areas in which the plan needs to be improved.

Planning and responding for international disasters have become more relevant for Australasian health professionals in light of the recent terrorist attacks in Bali (2002 and 2005), the Indian Ocean tsunami (2004) and the earthquake in Pakistan and India (2005). Such planning and response can be advised by the internationally recognized Sphere Minimum Standards in Disaster Response⁸ and in collaboration with important international agencies, such as the United Nation’s Office for Coordination of Humanitarian Affairs. Sphere specifies standards in six sectors of disaster response: water and sanitation, food security, food aid, nutrition, shelter and health services. These standards are relevant for all disasters and represent an extremely useful reference to guide planning and response for domestic incidents as well.

Disaster response activities

Urban search and rescue

Urban search and rescue (USAR) is the science of locating, reaching, treating and safely extricating survivors who remain trapped following a structural collapse. Search and rescue response capabilities have increased significantly in recent years, due to advances in rescue technology and in emergency services.

In the period immediately following a structural collapse, many survivors are rescued by uninjured bystanders. Those who remain trapped generally require the assistance of specially trained and equipped units from fire, ambulance or police services in order to be safely extricated. Medical members of search and rescue teams are tasked to provide medical care to the victims and medical support to the rescuers. They are not involved in the actual extrication process. Potential hazards to victims and rescuers are numerous, and scene safety is of critical importance. The identification and extrication of victims following a major structural collapse is one of the most physically and emotionally challenging tasks of any rescue operation. The shock of dealing with scenes of carnage and mutilation may render some rescue personnel ineffective. These teams must therefore be trained and prepared to deal with the emotional strains of working in such a demanding environment.

Mental health

It is easy to overlook the mental health needs of affected individuals during the emergency response, when rescue and life-saving interventions receive top priority. Emergency physicians should be aware of the significant psychological impact of disasters on victims, families and rescue personnel. Psychological support is recommended as first-level assistance to disaster-affected communities and personnel.²⁰ Mental health consequences, such as depression, anxiety states and post-traumatic stress syndrome, are well described following disasters and need to be considered when developing the disaster plan. Crisis counselling may play an important role in the overall medical care provided to patients following a disaster. In addition, rescue personnel may well suffer psychological consequences from their own involvement in the disaster response and should therefore be provided with access to appropriate services, including critical incident debriefing.

Mass gatherings

Social and cultural events can result in the gathering of many people in one place at a particular time, sometimes over several days. Common examples include rock concerts, sporting events, fairs and parades. The organization of medical services for mass gatherings is generally designed to address minor medical needs but must also take into consideration medical emergencies, such as cardiac arrests and disaster planning, for incidents such as fire, structural collapse or terrorism. Medical services developed for the mass gathering must be linked to local emergency medical systems. Public health and occupational health regulations, including food safety and environmental health measures, must be observed.

Public health issues in disasters

Public health professionals are involved in all phases of the disaster cycle, and it is important for emergency physicians to understand the role of public health in disaster medicine and disaster management. Epidemiological studies that have identified risk factors for illness and injury following disasters have contributed greatly to disaster planning, mitigation, response and recovery. These investigations have been central to the development of the science of disaster medicine. They have led to key strategies that have been effective in reducing disaster-related morbidity and mortality.

Public health interventions become high priorities following disasters that disrupt the social infrastructure (for instance cyclone, flooding and earthquake), and disasters that result in significant population displacement (such as CEs). Priorities for the affected population include the provision of adequate water quantity and quality, sanitation, food, shelter, infectious disease control and disease surveillance. The role of public health following a mass casualty incident includes injury control, occupational health and safety measures for responders, and injury surveillance.

The interface between emergency medicine and public health becomes increasingly important following technological disasters or terrorist events involving biological, chemical or nuclear agents. The terrorist attacks with anthrax in the USA during 2001 and their aftermath demonstrated the vital importance of key public health tools such as disease surveillance and outbreak investigation and control. Following incidents with chemical or radiological agents, public health officials may be required to provide guidance on issues such as evacuation of the public, mass decontamination and the mass distribution of iodine. Emergency physicians should become more familiar with the skills, roles and responsibilities of their public health colleagues, especially as they relate to disaster management and infectious disease control.

Conclusion

Emergency physicians contribute most significantly to the preparedness and response aspects of disaster management. Emergency physicians should plan and build capacities for disasters based on an assessment of the major risks which their communities face and those which are most likely to result in multiple casualties. These include natural disasters and technological hazards. The increased risks posed by climate change and terrorists require the continuing review and revision of disaster risk-assessment processes and disaster planning. Disasters associated with multiple casualties provide unique challenges to the health and medical communities. Curative medical skills and public health principles are both critical to the comprehensive management of a community affected by a disaster.

Introduction

Provision of high-availability quality medical care is expensive and has been traditionally limited to the very wealthy or to situations of great demand, such as the military in battle. Even today, well-organized emergency medical systems are concentrated in societies sufficiently affluent to spend 5% or more of gross domestic product on health. Some form of rationing is required whenever an expensive resource is coupled with fluctuating demand. Price, queuing and denial are all used in different areas of medicine. Simple application of any of these methods in emergency medicine would not be efficient or equitable, so the majority of emergency medical systems use a triage process to sort patients into a number of queues.

Triage, the sorting of patients on the basis of urgency, is an ongoing process that nevertheless requires formal structures at different points within the continuum of care. In the emergency department (ED) setting, there is considerable evidence that urgency can be assigned reliably and distinctly on a five-level scale and that this categorization is applicable and useful beyond the concept of ‘urgency’ into other aspects of hospital care.

Civilian triage developments

There was certainly some sorting of patients from the moment ‘casual wards’ opened in 19th century hospitals, but the first systematic description in civilian medicine was by E. Richard Weinerman in Baltimore in 1966.² Since that time, there has been a huge growth in emergency medicine as a specialty and a number of workers have undertaken formal investigation of triage, particularly in Australasia. The Australasian experience formed the basis of ED triage development in Canada and the UK, whilst some other jurisdictions have developed systems independently.

Process of triage

The underlying principles of triage are those of equity (or justice) and efficiency. EDs experience potentially overwhelming demand from patients with an enormous range of conditions. Equity demands that the distribution of resources for treatment is fair in the broadest sense. The concept of urgency is well understood by the population who generally accept that it is fair to treat those in the greatest need ahead of those who arrived before them. Efficiency demands that best use is made of available resources. In the setting of ED, cost and resource pressures prevent all demand being satisfied simultaneously. The overall philosophy of ‘doing the greatest good for the greatest number’ requires resource allocation on the basis of need, which in turn requires a process to identify and prioritize the needs of the presenting population.

In the ED, urgency is distinct from severity, prognosis, complexity and casemix, although a correlation exists. Some urgent problems (for example upper airway obstruction) have a poor outcome without rapid intervention but are not severe in the sense of requiring long-term care, other severe problems (for example life-threatening malignancy) may not require any treatment in the ED time frame. Complexity is reflected in the number of interventions such as investigations or consultations required, whereas casemix is an indication of the resources required to provide care.

Triage is an ongoing process that may change in response to alterations in patient status and resource availability, but it is efficient to undertake a formal process once, early in the patient’s encounter, and then review only as necessary. ED triage is normally undertaken by trained nursing staff at the time of arrival, and the assigned urgency is then used to guide treatment order. The overall efficiency and effectiveness of such a system depends not only on the allocated priority but also on the treatment strategy, that is, the way in which the next patient is chosen from the different queues. A more urgent case should wait less time than a less urgent case, but when resources become available to treat the next patient, choice may still be required between a new arrival and a slightly less urgent patient who has already been waiting for some time.

Australasian triage development

The first Australasian description was of the Box Hill Triage Scale by Pink and Brentnall in 1977.³ They used verbal descriptions without time consideration and classified patients into five categories: immediate, urgent, prompt, non-urgent and routine. Fitzgerald modified this scale in 1989,⁴ to produce the Ipswich Triage Scale. This used five colours to categorize patients according to the question: ‘This patient should under optimal circumstances be seen within….’ The five categories were seconds, minutes, an hour, hours and days. Fitzgerald found his triage scale to have good interobserver reliability on formal testing and to be a practical predictor of ED outcome and length of intensive care stay, but a relatively poor predictor of outcome at hospital discharge.

Jelinek⁵ investigated the relationship between the Ipswich Triage Scale and resource use in a stratified sample of 2900 presentations. He observed a strong correlation between triage categorization and overall use of resources in the ED and validated possible funding models. He proposed two possible casemix classifications: urgency and disposition groups (UDGs – 12 groups), and urgency-related groups (URGs – 73 groups) based on urgency, disposition and diagnosis. After trimming for outliers, these were found to account for 47% and 58% of the cost variance in large hospitals.

In 1994, the Australasian College for Emergency Medicine formalized the National Triage Scale (NTS),⁶ derived from the Ipswich Triage Scale. This used colours, names or numerical categories to represent five groups, based on the answer to the question: ‘This patient should wait for medical care no longer than….’ The categories were immediate, 10 min, 30 min, 1 h and 2 h. The definition document also proposed Jelinek’s concept⁵ of performance indicators based on the proportion of patients whose care fell within the desired time threshold, and audit by means of admission rates and sentinel diagnoses. It influenced treatment strategies by indicating the need to achieve performance indicators in a high proportion of patients in every category (higher in the more urgent) and it clearly established the need for EDs to employ systematic, accountable and audited triage processes.

Over the next few years the NTS was widely accepted and recognized by all Australian State Governments as an appropriate measure of access to emergency care. It was also adopted in the performance indicators promulgated by the Australian Council on Healthcare Standards.⁷ Research repeated the findings of Fitzgerald and Jelinek with reference to the new five-point scale and investigated many more of the subtleties of triage scale use.

The Australasian triage scale

The ATS⁸ is the current refinement of the NTS. It has been jointly developed by the Australasian College for Emergency Medicine, emergency nursing organizations and other interested parties. For practical purposes the scale concept itself is unchanged, but the ATS uses numeric classification only, better defines waiting time and includes associated implementation guidelines and educational material, partly derived from work on the NTS in areas such as mental health triage.⁹

The ATS categorizes patients presenting to EDs in response to the question: ‘This patient should wait for medical assessment and treatment no longer than…’ (Table 26.4.1).

Table 26.4.1 ATS categorization of patients presenting to EDs

Other triage scales

The concept of desirable waiting time must include some subjective component but has nevertheless been found to be reliable and reproducible. Achievement of ATS waiting times has proven to be a useful performance indicator but remains a measure of process rather than ED outcome. Concerns have been expressed in some jurisdictions about the medicolegal implications of a time-based threshold which will not always be met, and other systems have taken different approaches in development of their own ED triage systems. Nevertheless, most have developed five-level triage systems along the Australasian model. Major validated triage scales include the following:

Use beyond waiting time

Triage is based on a brief assessment, and an individual triage categorization can reflect only the probability of certain outcomes. Large populations of triaged patients, however, exhibit predictable patterns. There is a very strong, almost linear relationship between triage category and total rate of admission, transfer, or death, ranging from 80–100% in ATS 1 to 0–20% in ATS 5. This pattern is repeated across hospitals of different size and different patient mix.¹³ Admission rates by triage category follow the pattern of overall admission rates in relation to age, giving a flattened U-shaped distribution. The inter-rater reliability studies performed using the Ipswich Triage Scale have been repeated using the NTS/ATS, which has been found to be slightly better.¹⁴ Further, admission rates by triage category have been shown to be constant over time in individual institutions.¹⁵

The NTS/ATS has been extensively studied as a casemix tool. ED outcome (admission/transfer/death versus discharge) accounts for the largest variance in cost, but triage categorization comes a close second, with age third. The mean cost of care for a Category 1 patient is approximately 10 times that of a Category 5 patient. UDGs, described by Jelinek using the Ipswich Triage Scale, have been validated using the NTS by Erwich on 17 819 attendances.^16,17 Age has been included to derive urgency, disposition, and age groups (UDAGs – 32 groups), which account for 51% of the cost variance and are not susceptible to different diagnostic approaches.¹⁴ These studies may not be valid in the era of overcrowding and access block, because staff costs for admitted patients reflect length of time in the ED, which may now be driven by outside factors. Furthermore, the costs for discharged patients are skewed by increased pressure to keep complex patients out of hospital.

Triage categorization is a very strong predictor of ED outcome and a good predictor of utilization of critical care resources. However, it is a relatively poor predictor of outcome at hospital discharge.^18,19 Many patients with chronic or subacute conditions that frequently cause death are triaged to less urgent categories because there is no benefit from earlier treatment within the time scales available in the ED.

Attainment of performance indicators for patients seen within triage thresholds has been shown to be a measure of resource allocation within the ED. A longitudinal comparative study has demonstrated a significant improvement with an increase in ED staff and funding.²⁰

Triage categorization alone is insufficient to direct patients to fast-track services designed for low-complexity patients, but triage staff are appropriate and are able to assess complexity.²¹

Structure and function of a triage system

The exact requirements for triage vary with the role, location and size of the hospital, but effective systems share a number of important features, mostly derived from experience:

Pre-hospital triage

The principle of making best use of available resources to maximize patient outcome remains the basis of triage in any setting. Relatively less therapeutic options are available to pre-hospital providers and patient disposition is generally limited to transport and sometimes choice of hospitals. The initial pre-hospital phase, the travel to the patient, must be undertaken on the basis of minimal information. Allocation of resources through a structured triage system remains important, but data may not be sufficient for a five-level scale, although this is currently being studied in Western Australia. Most pre-hospital systems are strongly protocol-driven and tend towards three- or four-level assessment: rapid response (lights and sirens), immediate response, routine response or no transport.

Introduction

Increasingly over the past few years Australian health professionals, including emergency medicine staff, have responded to refugee crises due to conflict or natural disasters in our region.

Caring for refugees is not a new problem. Since World War II up to 100 000 000 civilians have been forced to flee their homes due to unrest. The major factors that cause people to flee their country, conflict, political repression and persecution, are as old as humanity. In 1573, the term ‘refugee’ was first used for Calvinists fleeing political repression in the Spanish-controlled Netherlands. Refugee numbers are now higher than ever and seem to be relentlessly increasing. The United Nations High Commission for Refugees (UNHCR) is currently responsible for the welfare of some 33 million refugees and other persons of concern (January 2007 figures). These consist mostly of internally displaced persons (refugees inside their country of origin), asylum seekers and recently returned refugees. This equates to about 1:200 persons on the planet. The problem is massive.

The solution to any refugee problem is, ultimately, political and non-medical. Even in the acute phases of refugee movement the most important things are simple, such as food, shelter and clean water. Physicians, however, can play a considerable role, especially if they are adaptable and able to use simple cheap and effective solutions to problems.

This chapter provides an understanding of the issues and possible solutions to the refugee health problem, a bibliography for further reading, an outline of the essential attributes of refugee doctors and links to appropriate organizations for the interested reader.

Responsibility for refugee care

Until the end of the World War I, the response to refugees was from philanthropic sections of the community. The formation of the League of Nations began the process of the international community assuming responsibility for refugees. In 1921 a High Commission for Refugees was established with a mandate to look after refugees fleeing the Russian and Armenian wars. Its first Commissioner was Fridtjof Nansen, who established a special identity document, the ‘Nansen Passport’, as refugees frequently had no means of identification.

In the wake of World War II, the United Nations (UN) established the International Refugee Organization to assist the millions of displaced persons in Europe. Between 1947 and 1951 it helped 1.6 million people, mainly Germans and Austrians.

The modern response to refugees started in 1951 with the establishment of the UNHCR and the Convention Relating to the Status of Refugees, which has the force of law and has been ratified by 120 countries. With some fine-tuning over the years this remains the cornerstone of International Refugee Law. It defines a refugee as:

The UNHCR also encourages countries to receive refugees and to provide them with assistance and protection. One of the major points of the Convention is the principle of ‘non-refoulement’, which means that refugees cannot be forcibly returned to their countries of origin.

Refugee camps

Persons fleeing war or persecution escape in many different ways and may live in host countries in several different arrangements, for instance integration with local community or staying with relatives. The typical image of refugees is of mass movements of populations across borders into temporary accommodations or ‘refugee camps’. It is under these circumstances that refugees are most at risk. Importantly, the populations in refugee camps do not exist in isolation. There are always interactions with the local population, and these may not always be beneficial. Also important are political and ethnic factors within the refugee population. These can lead to tensions or even violence in the camps, as was demonstrated tragically in the post-Rwandan holocaust camps in 1994. Camps themselves can even sustain conflict in some areas, for instance in the West Bank or in the camps on the Thai–Cambodian border, which were used by the Khmer Rouge as refuges from which to carry on a war.

Emergency phase

As a result of a crisis, due to either war or acts of nature, large populations can be displaced from their normal environment. This often results in large numbers of people, with minimal or none of the basic life needs, descending on a region. Where the people congregate is usually where refugee camps evolve. Most population movements into refugee camps occur in third-world countries, which have limited resources to deal with them. Preplanning by aid agencies and governments is, therefore, essential so that humanitarian responses can be quick and coordinated. Considerable expertise in responding to refugee emergencies has been gained and the main priorities are now well recognized. These are outlined below, as per Médecins Sans Frontières (MSF) guidelines.

Post-emergency phase

This phase begins when the basic needs of the population are met (food, shelter, water and so on) and the CMR is less than 1 per day, which is roughly similar to that of the local population. The situation in the post-emergency phase is complex and fluid. Some of the refugees may become quite settled and start to work locally or farm some land. The health and nutritional status of refugees may even surpass those of local population because of large amounts of overseas aid. This may lead to resentment. Complex political issues may arise. Descent back into the emergency phase may occur with an epidemic outbreak or fresh influx of refugees.

In general, however, the post-emergency phase is concerned with consolidation of what has been achieved, preparation for possible new emergencies and sustainability.

There needs to be continuing monitoring of water quality, public health and nutritional status. Healthcare issues in the post-emergency phase are complex. Some of the issues that may need to be addressed include:

Permanent solutions

There are three possible solutions to any refugee situation: repatriation, integration or resettlement in another country.

Repatriation is the preferred option but is often quite complex. First, there needs to be a solution to the problem that caused the refugees to leave initially. This may take years. Persons returning need a lot of extra support in order to rebuild their lives. Some refugees remain in the host countries and integrate into local communities. This was commonplace in African nations but is increasingly difficult, especially when African governments look at the reluctance of affluent Western countries to accept refugees.

The minority of refugees who cannot return are resettled in third (mostly Western) countries. Many countries have quotas and will only admit once a person is assessed by the UNHCR as having a valid claim. In 2001 the number resettled was 100 000. Of these, the USA took 68 500, Canada took 12 200 and Australia received 6500.

Past problems

In the past there have been important problems with the response to a refugee crisis. Often these have their root in poor coordination between the agencies that respond to a particular crisis, which may lead to inappropriate interventions and even frank competition. Often in a dramatic disaster such as an earthquake, which has considerable media coverage, there is a frenzy of intervention as agencies attempt to get their image across to international viewers to assist in fundraising. In the 2001 earthquake in Gujarat province, India, it was estimated that there were as many as 200 different government and non-government agencies in the field. There is no doubt that this has resulted in unnecessary death, most notably in the great lakes region of Africa following the Rwandan genocide.

Innovations in refugee care

Overcoming the problems of lack of planning and coordination has been the major thrust of more recent developments. Importantly, in 1997 it was decided to establish a set of minimum standards and rights to which refugees were entitled. The collaborative project called Sphere involved numerous organizations involved in humanitarian care including Red Cross, MSF and Oxfam. It produced a manual that is available at no cost from the website www.sphere.org. Individual organizations, such as MSF, have several excellent manuals describing in detail the approach to humanitarian emergencies.

The UN in conjunction with other agencies has been refining its disaster response capabilities. Through the Office for the Coordination of Humanitarian Affairs (OCHA) there is now a system of stockpiling supplies, cash reserves and ability for rapid assessment and deployment. The UN works in partnership with several NGOs and the Federation of Red Cross and Red Crescent Societies who have also been developing rapid response field assessment and coordination teams (FACTs). There is now a system of coordination through the Field Coordination Support Section (FCSS) of OCHA and the ability to appoint ‘lead agency’ status to a particular organization.

The Internet and electronic media are also being increasingly used in innovative ways by humanitarian agencies. It is now possible to follow evolving disasters on several websites (e.g. UN affiliated sites, Red Cross sites and MSF sites) and explore what that particular organization is doing. OCHA is also exploring the use of a Virtual Operations Coordination Center, which is an online resource that can be accessed by registered users from various agencies to coordinate their approach to a particular disaster.

Attributes of a refugee doctor

Working under the special conditions imposed by a refugee camp demands special qualities. It is certainly not a glamorous job and often much of what has been learned from training and practice in the West either is not relevant or needs much modification to suit local conditions and resources. In general the main requirements are:

Introduction

An observation ward (OW) is an essential part of a modern emergency department (ED). OWs are a valuable tool in the safe and efficient management of patients and are rapidly being embraced by EDs worldwide. In a 1989 survey it was found that of 44 EDs in major Australian hospitals 50% had beds designated as an OW. A further 25% expressed an intention to establish one.¹ Although there is much local variability, OWs are defined by the following general characteristics:

The primary role of OWs is to provide rapid turnover intensive observation and treatment to patients with suitable medical conditions. This increases efficiency of both the EDs and the hospital overall. OWs have additional benefits, which may include improving patient flow through a busy ED by providing a temporary ‘holding area’ for admissions, temporary accommodation for patients for whom discharge at an antisocial hour would be inappropriate (such as the elderly) or acute situational crises at antisocial hours. They may also function as a ‘safety net’ for patients seen at night by junior medical staff who are uncertain of the diagnosis for review by senior staff in the morning, thus possibly reducing inappropriate discharges.

OW policies and protocols

OWs function well under the umbrella of firm policies and protocols. These of course vary according to the institution, the number of beds in the OW, medical and nursing staff levels and the main perceived functions of the OW in a particular ED. In general, however, the following issues need to be addressed.

Efficiency of patient care

Efficiency is essential if an OW is to maintain rapid patient turnover and treat patients within defined time criteria. This is achieved by a combination of factors:

Staffing

OWs are staffed by ED personnel. As mentioned, a senior doctor is nominated to have responsibility for the ward during each shift. It is preferable to allocate nursing staff from each shift to the OW from the general ED pool of nurses rather than employ nurses only for the OW. This leads to increased flexibility with staffing and demonstrates that the OW is an integral part of the ED. The nursing establishment of an ED needs to take into account commitment to the OW and will need to be increased when it is initially set up. Some units, however, find that a stable, OW-experienced nursing workforce responsible for the ward facilitates greater efficiency. This is a matter for individual units.

Audit and feedback

As with any other medical activity auditing admissions to the OW and monitoring adverse events is important. Results can then be fed back through ED doctors as a quality improvement exercise. Firm key performance indicators for OWs have not been established yet but data worth collecting and analysing might include numbers of OW admissions subsequently admitted under an inpatient team (internationally 10–20% is considered acceptable²), patients discharged who re-present within 48 h, and adverse events and outcomes.

Overall impact of observation wards

OWs are generally well accepted by ED staff who easily see the benefits to efficient functioning of the department. The improved efficiency, however, goes beyond the ED and can affect the hospital as a whole. In a recent study performed in a major Australian ED³ it was found that the introduction of an OW had significant effects on the hospital as a whole. Using diagnostic related grouping (DRG) codes for the most frequently admitted OW patient types a comparison on numbers admitted to OW and inpatient wards was done. Total inpatient days for these groups were also analysed. It was found that the introduction of an OW resulted in a decrease of these patients admitted to the inpatient wards associated with an increase in admissions to the OW. Overall the total numbers of patients increased, but, despite this increase, the total number of bed days decreased. Effectively, more patients were treated using fewer days in hospital, a clear indication of increased efficiency throughout the hospital.

The safety net function in reducing inappropriate discharges and picking up missed diagnoses has an effect on patient well-being as well as potentially reducing litigation and adverse publicity against the hospital. Less tangible results are an increase in staff satisfaction, an increase in patient satisfaction because of fewer days in hospital and an improvement in the public image of the ED within the hospital.

Short-stay medicine

Much of the difference between emergency physicians and their colleagues lies in their approach to a patient or a problem. To some extent, emergency medicine is a method of practice rather than a set of skills and clinical knowledge. A similar comparison can be drawn between standard inpatient wards and an OW. The main difference is in the high-efficiency, rapid turnover, problem-based approach. The ‘technique’ of observation medicine can be applied to situations other than EDs. The examples of chest pain assessment units and toxicology units as an extension of OWs have already been mentioned.

In the increasing drive for efficiency and cost-effectiveness it is likely that more variations on the technique of ‘OW’ medicine will appear. Medical acute assessment units and short-stay wards have already made an appearance in some Australasian hospitals and it is likely that their numbers will increase. What role there will be for emergency physicians in this treatment model remains to be seem, but there is a large potential for at least some expansion of emergency medicine beyond its traditional boundaries with positive effects on both job satisfaction and professional longevity.

Introduction

Wherever human beings gather there are fluctuations in number, and, without outside control, numbers occasionally exceed the efficient maximum for a given purpose. Emergency departments (EDs) are designed largely for ongoing flow of patients rather than gathering, but even in systems designed purely for flow (such as roads) there are peaks and troughs of activity, and occupancy sometimes exceeds the number able to move safely and smoothly.

Overcrowding to the point of dysfunction has gradually become the norm in Australasian EDs since the mid-1990s. The greatest contributing factor has been access block, the inability of patients requiring inpatient admission to access appropriate beds in a timely fashion, a phenomenon which is generally called ‘boarding’ in North America. There has additionally been some increase in demand on EDs in both number and complexity of patients resulting from the enlarging, aging population and the growth in diagnostic and therapeutic choices. This has not been matched by growth in other services, especially outside working hours, increasing the burden on EDs.

Theoretical basis of overcrowding

Queuing theory indicates that the length of a queue and hence the waiting time to treatment is determined by the arrival rate, the treatment rate and the baulk rate (did not wait to be seen rate, which is usually dependent on the length of the queue). An individual patient’s access to emergency care is dependent firstly on the urgency (assuming the patient is triaged to the correct queue), secondly on the number of similar patients already waiting ahead and thirdly on the rate and strategy of treatment. Treatment rate is dependent on staffing and on the number of patients already being treated (occupancy), which determines physical availability of resources and the competing demands on staff. On a daily basis, patient flow is significantly dependent on occupancy because even a small decrease in treatment rate has a cumulative effect: it further increases the number waiting ahead of each new arrival.

EDs can be considered as overcrowded when treatment is dysfunctional, that is the treatment rate is reduced or the treatment quality suffers. This has been termed the ‘cardiac analogy’ model,¹ where ED function is regarded as a starling curve, which increases to a peak but then starts to decrease with overwhelming workload. Some authorities consider that an ED can be purely overcrowded with patients waiting to be seen whilst the treatment function remains optimal, others regard this situation as a ‘surge’ – a subset of disaster medicine, rather than an overcrowding problem.

Definition of overcrowding

The Australasian College for Emergency Medicine (ACEM) defines ED overcrowding² as the situation where ED function is impeded primarily because the number of patients waiting to be seen, undergoing assessment and treatment, or waiting for departure exceeds either the physical or the staffing capacity of the ED. Access block is quantified as the proportion of admissions to hospital, transfers to other hospitals, and deaths that have a total ED time of greater than 8 h.²

The American College of Emergency Physicians defines crowding³ as occurring when the identified need for emergency services exceeds available resources for patient care in the ED, hospital, or both, a definition deliberately closer in spirit to that of disaster medicine. Most research on the subject, however, is concerned with the balance between daily fluctuations and ED occupancy, rather than the response to mass-casualty surges.

‘Crowding’ might be the more descriptive term, but ‘overcrowding’ is in common use, and researchers have used multiple definitions in attempts to quantify the phenomenon. All major recognized definitions incorporate occupancy with patients under treatment, but many also include subjective factors and outcomes such as ambulance bypass, which are not applicable to all EDs.

Retrospectively identified episodes of overcrowding tend to be reliable for research but are of only strategic significance in ED management. Real-time assessments may be correlated with patient service (number of patients waiting correlates well with waiting time for new arrivals) but are only useful if there is a managerial commitment to intervening. Predictive algorithms based on the number being treated suffer from false positives and again are only justified if interventions exist to prevent deterioration in flow.

There are multiple scales proposed and used to define overcrowding:^4,5 EDWIN,⁶ NEDOCS,⁷ READI⁸ and Work score.⁹ Validation studies are difficult and many rely on ambulance diversion as an outcome measure, which is only suitable for multi-ED urban centres. The few Australasian studies have not shown them to be clinically useful in real time.¹⁰

Causes of overcrowding

The single most important factor affecting ED overcrowding is the availability of inpatient beds.^11,12 ED overcrowding is best seen as a marker of whole-of-hospital dysfunction which requires a whole-of-hospital response.^13,14 Bed availability depends not only on the number of physical beds but also on the way the bedstock is managed.

Hospitals providing a local service in areas of significant demographic change, such as a large aging cohort or rapid growth, may experience ED overcrowding simply through the pressure of presenting numbers exceeding appropriate ED changes.

Development of new diagnostic approaches and therapies has contributed to increases in total ED time in some groups. Chest pain ‘rule-out’ protocols using delayed marker measurements and increasing use of computerized tomography (CT) scans for conditions such as abdominal pain are two examples. These are partly mitigated by shorter, protocol-driven care of other conditions, for example routine CT for minor head injury with immediate discharge after a normal result rather than observation.

Results of overcrowding

Adverse effects of hospital overcrowding have been described since the birth of modern medicine,¹⁵ and ED overcrowding had been seen as undesirable since before the recognition of emergency medicine as a specialty.¹⁶ In Australasia, access block was recognized as a quality issue from 1998,¹⁷ first shown to be associated with decreased ED function in 2000¹⁸ and defined by the ACEM from 2002.² Worldwide, properly conducted research started in 2001 and since that time multiple studies in different centres have found an association between overcrowding and reduced access to care, decreased quality measures and lesser outcomes.

Associations between overcrowding and outcomes demonstrated in peer-reviewed studies are shown in the Table 26.7.1 Whilst there is probably some publication bias, there remain no published studies equating overcrowding with improvements in care. The association between overcrowding and poor outcomes is accepted to be causative by most medical authorities.^11,12

Strategies to deal with overcrowding

EDs have an obligation to reduce overcrowding and to mitigate its effects. As noted, any reduction in overcrowding will be largely achieved through whole-of-hospital changes. Long time-series suggest that, in the absence of hospital-wide changes, access block tends to continue to increase even after mitigation efforts within the ED.^39,40

Increases in the number and seniority of ED staff are associated with improvements in process measures^41,42 and are a widely used initial response to overcrowding. Physical rebuilding is used to increase patient care spaces but changes in flow dynamics are highly dependent on the rest of the hospital.⁴³ Analysis of flow and system redesign can allow better use of existing resources.⁴⁴ Deployment of senior medical staff to assist early in the patient’s journey through ED (at triage) reduces total ED time.⁴⁵ None of these responses can be used indefinitely if access block keeps increasing.

Discretionary, low-complexity presentations by patients who might reasonably be managed elsewhere, often incorrectly called ‘GP-type’ patients, constitute a significant number but an insignificant workload in most EDs.^46,47 Such presentations have a short assessment and treatment time and do not need fixed capacity spaces such as resuscitation rooms, so their contribution to occupancy with patients under treatment is low. However, being of lower triage urgency their contribution to the number waiting at any given time is relatively high.

Telephone advice services have not been shown to reduce ED workload in Australasia^48,49 but are highly regarded by the public. Dedicated ED fast-track areas⁵⁰ address the management of low-complexity patients in an efficient manner and thus tend to improve overall waiting time performance and staff and patient satisfaction. Their contribution to reducing occupancy with patients under treatment, and hence improving ambulance offload, is low.

EDs also have a small but significant role in reducing hospital occupancy. Observation medicine within the ED is a useful adjunct or alternative to formal inpatient admission.⁵¹ Multidisciplinary assessment and discharge is effective at reducing representation at least in the elderly.⁵²

Conclusions

Overcrowding has changed the nature of emergency medicine practice. Access block represents a useful simple description of overcrowding because the fundamental issue is the availability of inpatient beds. There is sufficient evidence to convince most authorities that the relationship between overcrowding and worse patient outcomes is causal. Emergency physicians have a role to play in maintaining patient care function in the face of overcrowding, but most of the solutions lie outside the ED.

Introduction

Patient safety, or the freedom from accidental injury due to medical care or from medical error, is increasingly being recognized as a critical consideration in the delivery of acute and emergency healthcare.¹ Several OECD countries have examined the proportion of acute care admissions during which an adverse event (an unexpected medical problem that happens during treatment with a drug or other therapy) is identifiable using a standard medical chart review. They typically report that 1 in 10 admitted patients experiences an adverse event, of which half are considered preventable with the current state of medical knowledge (i.e. are due to medical error).¹ Typically, a third of adverse events lead to moderate, or greater, disability or death.¹ An important consideration for the emergency care of admitted patients is that the day of greatest risk of an adverse event is usually the first day of admission to hospital. This is when knowledge of the patient’s clinical condition is often incomplete, the clinical condition is least stable and when most patients experience the greatest number of procedures and interventions.²

Specific emergency department factors that may compromise patient safety

Safe patient care is challenged by several specific emergency department (ED) factors that include:

Common safety problems encountered in emergency departments

The factors described above interact to create a wide range of risks to patients needing emergency care.⁴ Some of the errors observed in the emergency setting include:

Improving safety in the emergency department

Specific actions to improve patient safety should be undertaken in the context of a comprehensive organizational framework for clinical governance and quality improvement.¹ The development of a programme of safety improvement for an ED should be undertaken methodically, in accordance with existing Australasian and international standards that usually encompass the following process elements:

At all times:

Conclusion

Patients seeking emergency care are at significant risk of harm, in part due to their clinical situation and in part due to the challenges of delivery of emergency care itself. Improving patient safety in the ED requires a systematic approach to risk identification, risk analysis and evaluation and the implementation of safer processes of care. Monitoring is an essential component of patient safety improvement. An open, communicative culture that promotes reporting and minimizes blame supports patient safety improvement.

Introduction and definitions

Medical emergency teams (METs) are composed of doctors and nurses that review acutely unwell hospital ward patients in an attempt to reduce cardiac arrests and other serious adverse events (SAEs). The team should have a number of competencies, including abilities in the following areas:¹

The term ‘rapid response system’ (RRS) has been proposed to represent an entire system that provides both an ‘afferent’ component to identify patient deterioration and an ‘efferent’ component to assess and treat the patient. The most common efferent component is the MET. Other types of review team include the rapid response team (RRT) and critical care outreach team (CCO), which differ in their staff composition, skill set and mechanism of activation.¹ The remainder of this chapter will focus on the MET, which is the predominant team used in hospitals in Australia and New Zealand.

Additional components of the RRS include quality improvement and clinical governance arms, which permit audit and evaluation of SAEs and implementation of hospital-wide strategies to prevent their recurrence.¹

Epidemiology and principles underlying the MET

Several principles underpin the MET and RRS. In summary, SAEs are common in hospitalized patients and these are often preceded by a period of instability of up to 24 h. The MET is summoned to review patients in the early phases of deterioration in an attempt to prevent further deterioration, morbidity and mortality.