In 2023, the Committee for Tactical Emergency Casualty Care (C-TECC) issued updated guidelines for the care of pediatric patients who are victims of a high-threat incident such as an active shooter event. C-TECC is a not-for profit coalition that brings together subject matter experts from EMS, fire, law enforcement, government, and emergency medicine to translate military trauma lessons learned into the civilian high-threat prehospital community. The revised pediatric guidelines provide evidence-based or best practice considerations to those individuals and departments that provide operational medical support and that may care for children in this uniquely dangerous and under-resourced prehospital environment.

The evidence base for the care of children in this environment is lacking, and the medical care delivered in the high-threat environment is inconsistent and often not optimized for the care of infants and children. The guidelines are supported from the existing literature base where possible, and where it is not, by consensus as to the current best practices as determined by iterative deliberations among the C-TECC organization.

The guidelines provide patient assessment and management considerations specific to the care of children in three dynamic phases of the high-threat environment: Direct Threat, Indirect Threat, and Evacuation. The guidelines can inform both planning and operations in order to optimize the care of children in this high-risk environment.

The high-threat environment is dynamic and there are competing safety, tactical/operational, and patient care priorities for responders when infants and children are injured. The guidelines provide recommendations on the type of medical and psychological care that should be considered under each phase of threat and establishes the context for them in order the maximize the opportunity for a good outcome for an injured pediatric patient.

In preparation for potential collaboration with international disaster medical response teams, particularly the U.S. DMAT, following a major earthquake in Japan, several challenges related to receiving international teams were identified. This study considers Japan’s approach to receiving international medical teams and identifies and addresses key challenges in receiving international disaster medical response teams, including U.S. DMAT, during major disasters in Japan.

A tabletop exercise, simulating a major earthquake in Japan, was conducted to evaluate Japan’s domestic support and response systems for international disaster medical response teams. The results included:

1. 1. Operational Gaps: Japan’s policy for large-scale disasters lacks specific guidelines on critical areas such as immigration procedures, verification of international medical licenses, logistics for pharmaceuticals, and management of communication and records.

2. 2. Medical Liaison Need: Although the Ministry of Foreign Affairs provides liaison support, there is no plan for specific medical liaisons, highlighting the need to deploy trained DMAT or disaster medical professionals.

3. 3. Logistical Challenges: The U.S. Embassy typically handles transportation and accommodations, but approvals are needed for communication setup, oxygen supplies, and medical resources, underscoring the need for pre-coordinated protocols.

4. 4. US DMAT Exercise Findings: Virtual tabletop exercises with U.S. HHS and ASPR highlighted essential procedural steps for resource and operational alignment in a disaster.

To integrate international disaster medical response teams effectively during major disasters like the anticipated Nankai Trough earthquake, Japan must establish SOPs tailored to these teams, including pre-planned logistical and medical liaison roles. These frameworks not only benefit US DMAT but also serve as a model for supporting other international teams, enhancing Japan’s disaster readiness through global collaboration.

Suburban gas explosions are rare in high-income countries. However, in 2022, a major explosion, presumed due to a gas leak, occurred on Jersey in the Channel Islands. This report details the disaster and assesses the emergency response, emphasizing the unique role local parishes played. The report uses information from local reports and the contributing authors’ experiences.

At 04:00, a blast in southern Jersey destroyed a block of flats. Windows in nearby streets were shattered, displacing 42 residents. Nine people died immediately, with one more succumbing to blast injuries two weeks later. Being a small island with one hospital and limited resources, the island sought assistance from the nearby United Kingdom. Specialist search and rescue teams were deployed alongside equipment from the UK Coast Guard and Royal Air Force. Despite this support, careful planning was needed to prevent the local hospital from becoming overwhelmed.

Jersey is unique in that, since 1311, it has been divided into twelve religious parishes. Each parish holds a distinct community and owns its church, constable, police force, and town hall. After the blast, the parish system was used to systematically provide medical and social care. Within fifteen minutes of the blast, the nearest parish town hall opened as temporary housing for the displaced. It was staffed by general practitioners, nurses, and crews from St. John Ambulance. It served as a hub for medical advice, first aid, and routine medication prescriptions, preventing the local emergency department from becoming overwhelmed. Hospital beds were reserved for critical injuries, while the walking wounded received care within their community.

This report highlights the importance of sustaining secondary services during a disaster and the strategic role management of low-acuity victims plays. It also demonstrates how existing community and religious connections can be leveraged to deliver care effectively and safely during a disaster.

Primary care is the foundation of any health care system. Primary care providers offer public health and individual care for patients in all age groups and respond to acute and chronic health problems with medical and surgical interventions. The principles of primary care are versatile and applicable, and experience shows that primary care is essential in all phases of disasters. It plays a critical role, particularly in restoring affected healthcare systems. Primary care providers are trained to understand illness in the local context. They are flexible to balance limited resources for community and individual care, skills that become critical during a crisis. Proximity in disasters allows primary care to 1) protect families, 2) train local providers, and 3) empower people. These significant roles are hampered by a shortage of skilled primary care providers, both in general and when most needed: in response to a disaster. Even more concerning is the scarcity of competent primary care educators with the experience and skill to walk the walk, talk the talk, and grow the specialty.

There is an adage that says, “The only winner in war is medicine.” Many of the greatest advances in lifesaving were born on the battlefield. Recent prolonged, multi-arena conflicts have fostered real-time learning gleaned from comprehensive data analysis from the point of injury through rehabilitation, strategies for managing mass casualty incidents, and the evolution of triage techniques in complex combat situations. Enhancements in hemorrhage control, volume resuscitation, and pain management for conscious casualties driven by detailed data will be explored. So, too, will the development of a specialized identification unit led by military dentists, which has become a global leader in victim identification technologies. Also on the agenda will be the crucial topic of mental health in combat situations. This presentation will challenge conventional wisdom and provide fresh perspectives on lifesaving techniques under the most demanding circumstances.

Inter-hospital transfers play a critical role in mass casualty events. On October 7, 2023, 3,000 Hamas terrorists invaded Israel from Gaza, killing 1,200 and injuring 1,455, triggering an ongoing military conflict. In routine times, Israel’s smallest hospital, Yoseftal Medical Center (YMC) in Eilat, transfers complex patients to the closest tertiary care hospital, Soroka Medical Center (SMC) in Beer-Sheva. However, this hospital was also closest to Gaza and began receiving injured soldiers. The war initially resulted in a disruption of inter-hospital transfer patterns, where patients routinely transferred from YMC to SMC, were sent to a hospital further away, Hadassah Medical Center Ein Kerem (HMC-EK), in Jerusalem.

The objective of this study is to describe the downstream effects of armed conflict on inter-hospital transfers. Data on patients transferred from YMC to HMC-EK from January 1, 2022 - January 2, 2024, was collected retrospectively from the HMC centralized administrative database. During the study period, all 21 patients transferred from YMC to HMC-EK, arrived after October 7, 2023. The mean age was 61.8 years (± 14.4) and 76.2% were male. Most (n=10, 47.6%) arrived in October with decreasing percentages in November (n=9, 42.9%) and December (n=2, 9.5%). The majority of patients were treated by cardiology specialists (61.9%). During an ongoing military conflict or disaster, hospitals that receive secondary transfers of patients in need of more advanced care than locally available may be overwhelmed. Further studies of the downstream effects of MCEs and disasters on inter-hospital transfers and ED utilization should be conducted to help develop protocols to improve patient care during these events.

Caring for children during mass casualty incidents (MCIs) presents unique challenges that differ significantly from adult care. This presentation addresses the special considerations essential for pediatric patients, emphasizing the distinct injury patterns observed in children and the necessity for age-specific equipment and medications. It is crucial to create an environment that is as appropriate as possible under the given circumstances to mitigate the physical and psychological impacts of the incident on young survivors.

Children’s experiences during MCIs can leave lasting physical and psychological effects, shaping their development. Therefore, clinicians must be equipped with comprehensive knowledge of pediatric medical care, including medication dosing and age-appropriate treatments. Their psychological care should not be forgotten while caring for physical ailments, understanding community resources, and the mental health repercussions associated with traumatic events are important.

A scoping review of the literature was conducted to identify critical themes in pediatric care during MCIs. The analysis revealed five key considerations:

1. Clinician Knowledge and Skills: Training specific to pediatric care in emergency settings is vital for an effective response.

2. Pediatric Supplies: Ensuring the availability of appropriate supplies tailored for pediatric use, including medical devices and sized equipment, is essential for effective treatment.

3. Medications and Vaccines: Understanding pediatric formulations, dosage forms, and countermeasures is crucial to ensure safe and effective pharmacological interventions.

4. Mental Health: Recognizing the mental health impact on children post-MCI is essential for providing holistic care and support.

5. Community Resources: Awareness of local resources can enhance recovery and support for affected children and families.

This presentation advocates for evidence-based training and resources to address the unique needs of pediatric patients during mass casualty incidents, ultimately enhancing their care and recovery.

Children are uniquely vulnerable to chemical, biological, radiological, and nuclear (CBRN) events due to anatomical, physiological, and psychological differences. Current decontamination practices are adapted from adult protocols. This scoping review seeks to evaluate current practices, challenges, and special considerations in pediatric decontamination during CBRN events.

A scoping review was conducted using six databases in accordance with the PRISMA-ScR framework. Studies were eligible if they evaluated decontamination methods involving children (0-18 years) in real or simulated CBRN scenarios. Fourteen studies met the inclusion criteria, and data were thematically analyzed into four domains.

Disrobing is widely recognized as a critical first step in the decontamination process, and 43% of the studies reviewed identified it as such. When done immediately and appropriately, it can remove a significant amount of contaminants, although its effectiveness varies based on how much of the body is covered and the nature of the exposure. Dry decontamination was discussed in 21% of studies, and wet decontamination was the most commonly reported approach, appearing in 93%. Key pediatric challenges included hypothermia, psychological distress, separation from caregivers, and difficulties managing non-ambulatory or special needs populations. Few studies addressed age-specific protocols or long-term psychological impacts. The results are presented in procedural order to reflect the typical sequence of decontamination in CBRN response.

Current decontamination guidelines inadequately address pediatric-specific needs. There is a critical need for standardized, age-appropriate guidelines that integrate caregiver support and psychosocial considerations. A pediatric decontamination algorithm was developed to consolidate current evidence into a practical framework for CBRN mass casualty incidents.

The COVID-19 pandemic had profound impacts across society, including strain on public health and health system resources globally. Given the increasing threat of public health emergencies, it is important to illuminate understandings of public health system resilience. The study objective was to explore public health practitioners’ experiences of the COVID-19 pandemic to better understand factors that contribute to public health system resilience.

The qualitative design included key informant interviews and focus groups conducted at five public health organizations in provinces across Canada at varying sub-national levels. Practitioners in roles related to public health emergency management were recruited to participate. Data were collected from February 2023 to June 2024. Reflexive thematic analysis was then completed to generate descriptive themes.

A sample of N = 70 participants was captured across the focus groups, and N = 34 interviews were completed across the organizations. Analysis identified five themes related to public health system resilience: 1) Prioritize staff wellness as an essential component of a resilient workforce; 2) Identify and map staff assets (strengths, skills, and knowledge) to support purposeful redeployment for future responses; 3) Prioritize and maintain diverse partnerships through proactive engagement to enhance communication and collaboration; 4) Ensure accountability to implement ‘lessons learned’ to support evaluation and future planning and preparedness activities; and 5) Nimble investment and training is essential to diversify and maintain preparedness for future threats.

Public health threats are becoming increasingly frequent and complex for systems to manage. Considering strategies that support system resilience is essential to preparedness. The results of this study demonstrate that workforce capacity, collaboration, learning, and resourcing remain crucial aspects of resilience based on COVID-19 experiences. Future work can integrate COVID-19 pandemic learnings with pre-pandemic perspectives to inform future-oriented resilience strategies.

During disaster response scenarios, pediatric pharmacists’ role becomes increasingly critical, as they bring specialized knowledge and skills essential for the care of children. Given the unique physiological differences between children and adults, accurate medication dosing, appropriate treatment modalities, and adherence to up-to-date evidence-based practices are paramount in pediatric care during emergencies. This presentation will elucidate the vital functions performed by pediatric-trained emergency pharmacists, particularly in high-stress environments where rapid decision-making is crucial.

Key topics will include the pharmacists’ responsibilities in ensuring the safe and effective use of medications tailored to pediatric patients, especially in the face of drug shortages and supply chain disruptions. The presentation will also cover the pharmacist’s role in assessing alternative treatment options, providing education to healthcare teams, and consulting on the appropriateness of various therapeutic strategies to ensure optimal outcomes for children affected by disasters.

Pediatric pharmacists highlight the importance of interdisciplinary collaboration among health care professionals, including physicians, nurses, and emergency responders. They serve as essential resources in developing and implementing pediatric-specific protocols and guidelines during crises.

This presentation aims to reinforce the necessity of incorporating pediatric pharmacists into disaster response planning and operations, ultimately enhancing the quality of care provided to vulnerable pediatric populations during emergencies. It showcases real-world examples and case studies and will highlight the need to advocate for the recognition of pediatric pharmacists as integral members of disaster response teams, ensuring that the unique needs of children are met with expertise and precision amidst challenging circumstances.

Extreme heat is an increasing health threat for older adults in the United States. Older adults are more likely than younger people to experience health effects during extreme heat events, often because of age-related physiological changes and social factors. The goal of this study was to understand experiences of extreme heat among older adults, including perceptions of current health risks and concerns about the impact of climate change on future generations.

Data were analyzed from the August 2024 National Poll on Healthy Aging, a recurring nationally representative survey of community-dwelling adults aged 50 and older. Respondents were asked about experiences with and concerns about climate change and health, particularly extreme heat. Descriptive statistics characterized participants’ extreme heat experiences and levels of concern about the impact of climate change on health.

Of 3,463 respondents, 62.6% (n = 2,168, 95% CI 60.6 - 64.6) reported experiencing an extreme heat event in the past two years. 27.0% (n = 923, 95% CI 25.8 - 28.2) reported feeling very concerned about the effects of extreme heat on their health. Concerns were highest among those living in the Southern region of the United States (33% n = 1,091; 95% CI 30.1 - 35.9). Only 6% of the sample reported that their health care provider had discussed preparedness actions for climate-related health emergencies with them (95% CI 5.3 - 6.7). Overall, 42.7% (95% CI 39.9 - 45.6) reported feeling very concerned about the effects of climate change on the health of future generations.

A significant proportion of older individuals in this study reported experiencing extreme heat events and expressed heightened concern for their health with these events. Few older adults reported receiving guidance from their healthcare providers on preparing for such events. Respondents also reported high levels of concern about the impacts of climate change on future generations.

In recent years, ASEAN has increasingly recognized the importance of adopting the One Health approach. The launch of the ASEAN One Health Network (AOHN) in June 2024, alongside the development of the ASEAN One Health Joint Plan of Action (ASEAN OH-JPA), represents significant steps toward enhancing preparedness for Public Health Emergencies (PHE) and disaster events among ASEAN Member States (AMS). To effectively address these challenges, it is essential to leverage existing governance capacities and resources through collaborative efforts. A comprehensive understanding of ASEAN’s objectives is crucial for the successful implementation of the Network in bolstering future PHE preparedness. This report, derived from a policy brief, aimed to elucidate ASEAN’s intentions and prioritize its strategic initiatives.

This policy brief was developed based on the experts’ insights, qualitative data from responses from 10 AMS, and literature review studies. The three presenting experts were academicians, researchers, and practitioners. After the presentation session, one key question was given to the AMS: “How will your country or our region adapt for better future preparation?” and “What is ASEAN’s role in the future preparation of PHE responses?”

The key messages and recommendations include (1) strengthening the integration of the ASEAN Coordinating Council and related platforms and networks for PHE and natural disaster management, (2) promoting regional knowledge management within the One Health Approach, and (3) initiating capacity-building efforts through collaborative drills for PHE and Public Health in Disasters.

As a conclusion, the insights and frameworks presented by the speakers have inspired ten AMS to further clarify the One Health network within ASEAN (AOHN), emphasizing the need for improved technical capacity building through collaborative drills, as well as enhancing information-sharing mechanisms and coordination for the implementation of One Health among the ten AMS in the context of the ASEAN OH-JPA.

The ability of a healthcare entity to serve its community during and after a disaster begins with a foundational indicator: remaining operational. This factor is facilitated by a business continuity plan in the health service sector, which can be labeled as a health service continuity plan. It is defined as the capability of an organization to continue the delivery of services at acceptable predefined levels following a disruptive incident. An all-hazards approach to emergency preparedness and business continuity planning will allow for flexibility in addressing different types of hazards, but it can also define the specific needs of certain hazards. The objectives for continuity of operations include ensuring the safety of personnel, the performance of the institution’s essential functions, protection of assets, minimizing damages and losses, reducing disruptions in operations, and achieving an orderly recovery from an incident. It also includes identifying relocation sites, as well as ensuring that operational and managerial requirements are met before a disaster strikes. The focus in business continuity planning is on the mission-critical functions. This is done by examining the organization’s core mandate and whether these functions are vital to delivering services even during emergencies. The goal is to make health systems more resilient to the impact of public health emergencies.

Implementing One Health initiatives in middle-income countries in Southeast Asia is crucial for improving public health outcomes in the region. One Health is a holistic approach that recognizes the interconnectedness of human, animal, and environmental health. Many challenges are faced regarding public health emergency cases, cross-border collaboration and coordination, integrated surveillance, risk communication, and community engagement.

The authors facilitated a seminar and tabletop exercise among ASEAN member states to elaborate on best practices and lessons learned from international cooperation and international organizations in implementing one health. From the selected partners, such as the quadripartite (WHO-FAO-WOAH-UNEP), UKHSA, and GIZ, try to elaborate on more possibilities to link the global policy, such as frameworks and global instruments to be adopted and implemented in the regional, national, and sub-national context.

Results:

1. Periodic one health situation analysis, respectively in each AMS, to identify and update the key stakeholders and other relevant stakeholders implementing One Health.

2. Select and adapt the massive one-health tools developed by the Quadripartite and ASEAN to optimize the scope needed in the country.

3. Enhancing academic role to ensure the quality of tools, scientific evidence, and conducting more research and implementing activities.

The Launching of the ASEAN One Health Network (AOHN) and the Development of the ASEAN One Health Joint Plan of Action (ASEAN OH-JPA) provide a concrete work plan for One Health implementation. Elaborate on best practices and lessons learned from international cooperation and/or international organizations in implementing One Health, giving an understanding that a country’s One Health situation is crucial for designing the agenda and mapping a country’s needs and priorities. Moreover, through shared experiences, challenges, and opportunities was expected that be identified.

Child care centers are vital hubs for monitoring pediatric respiratory and gastrointestinal illness transmission. The Michigan Child Care Related Infections Surveillance Program (MCRISP), established in 2013, is a key component of local public health surveillance. MCRISP captures symptoms often missed by traditional hospital and clinic-based biosurveillance. Child care providers (CCPs) submit illness reports, enabling enhanced local illness surveillance and improving communication through visual dashboards. MCRISP is a free-to-use and novel community-based biosurveillance and research tool.

MCRISP collected daily illness reports from ~25 centers in Washtenaw County, Michigan, focusing on gastroenteritis, respiratory infections, and rashes. CCPs enter non-identifiable data categorized into four age groups: 0-12 months (infant), 13-35 months (toddler), 36-59 months (preschool), and 60 months and older (kindergarten/1st grade). Data from 2013 to 2024 were analyzed using descriptive statistics. Reports from October 1, 2014, to September 30, 2024, were classified by symptoms and diagnoses into Gastrointestinal (GI), Respiratory, Rash, and Other illnesses. Seasonal trends and epidemic curves were evaluated based on illness counts to identify patterns and outbreaks.

Over 22,000 reports were analyzed across ten seasons. Preschool-aged children (35-59 months) were the highest reporting group (13,612 cases). Respiratory illnesses were most prevalent (16,568 reports), with viral cases comprising 10,521. GI illnesses accounted for 4,923 reports, while rashes totaled 1,392 cases. Certain respiratory conditions, typically treated with antibiotics, were reported 1,092 times. Confirmed or suspected COVID-19 cases based on symptomatic children with positive family members totaled 578 cases (2020 to 2024). MCRISP’s early detection provided critical lead time for public health responses. MCRISP was leveraged for two national viral respiratory pathogen studies (influenza and COVID).

Marking a decade of surveillance, MCRISP serves as an effective and novel platform for data collection and dissemination. MCRISP models community-based surveillance and provides an innovative tool for research, essential for moving public health preparedness forward.

The activation of volunteer first responders (VFR) near out-of-hospital cardiac arrests is recommended by current guidelines. Advanced smartphone alerting systems (SAS) alert registered medical professionals who are able to arrive at the scene before emergency services. In addition, these systems could potentially inform, dispatch, and enable VFR to provide quick, accurate reports during major incidents or disasters. This study evaluates the potential of using SAS for major incidents by retrospectively examining performance criteria of the “Region of Lifesavers” system.

In this retrospective study, the “Region of Lifesavers” system was analyzed in August 2024 in the Freiburg region (1,531 km², 493,036 population). The analysis focused on the number, profession, and availability (acceptance, distance) of VFR. Descriptive analysis of the system’s operation data was conducted using Microsoft Excel Business (v2408). The study was approved by the Ethics Committee Freiburg (No: 23-1450-S1).

A total of 1,657 VFR were registered in the system, equipped with basic medical equipment. Their affiliations were: EMS (663), hospital staff (381), medical students (114), firefighters (103), police with medical qualification (90), mountain rescue (57), physicians (53), admins (13), and others/unknown (183). Of the 127 alerts, 89 (70%) were accepted by at least one VFR. On average, 20 VFR were in the pre-alert area within five kilometers of the scene. The median airline distance from VFR to the scene was 628 m (IQR 1042 m, N = 156).

The study demonstrates adequate availability and geographical coverage of VFR with professional qualifications. The high alert acceptance rate indicates a strong willingness to participate in operations. With further technological advancements, the system could play a promising role in supporting the management of major incidents in the future. Appropriate app features should be designed and developed to facilitate subsequent practical testing.

Sudden cardiac arrest (SCA) can occur during running events, and immediate and effective CPR significantly improves survival. Training race participants in basic life support (BLS) could potentially increase survival chances during these events. Online learning may improve access to BLS training by reducing instructor, travel, and organizational costs. While online video training alone may not fully replicate in-person learning, this study explores a refined online training model with online platform feedback. This study aimed to compare CPR performance, knowledge, and confidence scores in traditional onsite training vs. self-training video with learning feedback as an alternative method for teaching BLS.

Runners were invited into the study and selected between two BLS training methods:traditional face-to-face training (F2F) or self-training videos and online learning feedback (VDO). CPR training dummies were sent to parks and running groups for the VDO group to use. Both groups were evaluated for CPR performance by certified BLS instructors. Knowledge and confidence scores in BLS were collected by questionnaire and compared before and after training.

161 participants were in the VDO group and 577 in the F2F group. 88.2% and 93.2% of VDO and F2F groups achieved BLS competency (p value=0.25). Knowledge and confidence scores increased significantly in both groups. Although increased, the increase in scores for knowledge in the VDO group had an odds ratio of 0.5 (95% CI: 0.34, 0.74, p-value of 0.001), and in having confidence for assisting unconscious patients an odds ratio of 0.33 (95% CI: 0.22, 0.5, p-value of <0.001), compared to the F2F group.

Self-training videos with learning feedback achieved competent BLS skills in 88% of runners and improved knowledge and confidence in performing basic life support, but to a lesser extent than onsite training. Such a method could potentially be used to increase BLS training in runners.

Emergency Department (ED) and Emergency Medical Services (EMS) workers are regularly exposed to undifferentiated patients during daily work activities. Patient encounters often occur before the full elucidation of the patient’s symptoms. As such, it may be supposed that ED and EMS workers are regularly exposed to respiratory illnesses and pathogens prior to clinicians being aware of the risk of exposure. This review sought to assess the literature about the masking behaviors of EMS and ED workers.

A literature review was conducted using key terms to look at ED and EMS populations. Terms focused on papers with respiratory surveillance data and masking behaviors. Papers written in English were included. 577 papers were included per the search terms, and nine were eligible for data extraction.

Eight papers from 2020-2022 focused on the COVID-19 pandemic. One paper from 2015 studied MERS exposure in an ED. Three papers focused on EMS, while the remaining six focused on ED workers. Six papers were a one time survey and not longitudinal, and two were retrospective chart reviews. Only one paper had weekly surveys assessing behaviors. Data were heterogeneous, and masking behaviors varied widely from no masks worn to full personal protective equipment (PPE) worn. In the final presentation, masking rates, a PRISMA diagram, and an evaluation of the strength of evidence will be included.

There is limited data about longitudinal masking and PPE behavior among EMS and ED workers. One time surveys limit assessing true masking behaviors. The majority of papers collected data during the height of the COVID-19 pandemic (2020-2022), therefore, further research must be conducted to look at changes in masking behaviors, symptoms, and sick leave as COVID-19 rates fluctuate, change, and coexist with other respiratory illnesses.

Growing dependence on digital systems for operations increases the risks for healthcare during downtime events. Cyberattacks typically result in hospitals needing to use downtime procedures for multiple weeks, severely compromising patient safety and care. The 2024 Crowdstrike global failure event provided an opportunity to assess the adequacy of current downtime training and procedures.

Our hospital system administered two surveys: one before the CrowdStrike failure as part of efforts to establish priorities to improve hospital downtime readiness and the other as part of the evaluation process after the CrowdStrike outage. Both surveys included multiple-choice and open-ended questions. The downtime readiness survey was administered in December 2023 and included 64 questions. The post-outage survey had 27 questions and was administered in July 2024.

The vulnerabilities identified in the 2023 survey were highly predictive of the primary issues reported in the post outage survey. The downtime readiness survey showed that all departments had downtime plans, but only 77% had tested them. The post-outage survey documented major challenges in paper charting, handoffs without digital systems, and reconciliation of data during recovery, as well as difficulties with rapidly transitioning to downtime procedures as the event began. Only 78% of departments had printed copies of necessary downtime forms on hand at the beginning of the event, and 48% had enough to operate for more than 2 days. Only 44% and 33% of departments reported having a backup for departmental and interdepartmental communication, respectively, during downtime. Positively, 79% of respondents felt they had access to sufficient information during the event.

Our surveys describe priority areas of focus in the development of standardized policies, staff training, specialized response resources, and communication tools to improve digital downtime preparedness and response. Further work is needed to identify barriers to the adoption of recommended potential solutions.