The importance of considering disaster medicine from a legal perspective has long been recognized. This presentation discusses recent international human rights law/international humanitarian law themes in disaster medicine in Japan and overseas, as well as the possibility of collaboration with related academic societies.

1. Cases of support for foreigners in disaster-affected areas.

J-MIND is the disaster medical interpretation network for the support of foreigners in disaster-affected areas in Japan. It requires a combination of theological backgrounds and a practical foundation in international human rights law to ensure no one is left behind, even in disaster situations.

2. In the process of preparing the Hospital ERU (Emergency Response Unit)

The Japanese Red Cross Society is preparing a Hospital ERU, where we must assume several situations related to international human rights law/international humanitarian law. This process would have many things to do with other GOs and NGOs with similar plans to open emergency hospitals abroad. As disaster medicine in Japan becomes more globalized, coordination in many areas, including international law, will be necessary.

Japan frequently experiences natural disasters, and there is concern about a major earthquake in the Tokyo area, where more than three million people live. The University of Tokyo Hospital is one of the disaster base hospitals in Tokyo, and strengthening disaster response capacity is important. This study aimed to identify the factors associated with staff behavior towards disaster response.

Two different surveys were conducted, a paper-based questionnaire for the departments of the University of Tokyo Hospital (UTH) and an online-based questionnaire for individuals. Eighteen departments in UTH were selected for the paper-based questionnaire because they were considered important in determining hospital functions during a disaster. For the online-based questionnaire, hospital staff were recruited for voluntary participation. Each questionnaire was developed based on the previously reported survey conducted earlier.

Out of 18 departments, 17 departments responded to the survey. There was no significant relationship between the preparedness for disaster and the work content of the section. 338 staff responded to the individual survey. Strong trends were observed in many items related to behavior and knowledge of local conditions and disaster response in hospitals. Some background factors, such as age and profession, were significantly associated with respondents’ behavior and knowledge. Some barriers were observed consistently across sections and individuals. The three main barriers were: lack of leadership, lack of employee engagement, and heavy workload.

This study identified some factors, both in departments and individuals, that may influence behavior towards disaster response in the hospital. Based on these findings, three actions are considered necessary: vision and mission with effective leadership, commitment through education and training, operational efficiency and human resource management.

Further improvement of disaster preparedness in UTH is necessary at the organizational level.

Clarifying the return on investment in disaster management is vitally important for quantifying its value, attracting funding, policy deployment, and eventually promoting this field. The study aimed to consolidate evidence of social return on investment in natural disaster management and to incorporate insights from health perspectives to figure out future directions.

A scoping review was conducted following the PRISMA guidelines, using databases including PubMed and Web of Science. The search strategy employed keywords related to disaster management and cost-benefit analysis. The exclusion criteria encompassed non-English language publications, man-made disasters, and studies in which costs and benefits were not quantified in monetary value.

A literature search was conducted on August 15, 2024, and resulted in identifying 972 documents, of which 46 were selected for further analysis. Additionally, 56 grey literatures were identified, with 14 adopted. A total of 220 disaster management interventions were found, addressing various disasters such as floods, typhoons, and earthquakes. The interventions included hard infrastructure measures, warning systems, and green infrastructure development, encompassing pond maintenance and afforestation. The benefits primarily consisted of the estimated damage that could be avoided. The benefit-cost ratios distributed from approximately zero to over 2000, with a median of 2.30 and quartiles of 1.07 and 5.00. Approximately half of the literature assessed the value of human life by converting the number of deaths into monetary values. The impact on health as a benefit is infrequently taken into account.

The benefit-cost ratios of disaster management are generally high and sometimes very high, with three-quarters exceeding 1 and one-quarter exceeding 5. Furthermore, these benefits are likely underestimated, as the impacts on health are rarely measured. When assessing social return on investment in disaster management, it is considered mandatory to take health into account.

Indonesia’s three research reactors (RSG-GAS in Serpong, TRIGA2000 in Bandung, and the Kartini reactor in Yogyakarta) play a critical role in advancing nuclear research but also pose significant risks, including the release of radioactive materials due to accidents or natural disasters. Despite these risks, preparedness and response mechanisms for nuclear emergencies, particularly in healthcare settings, remain underexplored compared to the country’s established natural disaster management systems.

This field report evaluates the multidisciplinary approach to nuclear disaster preparedness in Indonesia, focusing on the implementation of radiation accident simulation. The Indonesian Ministry of Health coordinated the radiation emergency simulation. It involved key stakeholders, including three National Nuclear Disaster Referral Hospitals (RSUP Fatmawati, RSUP Hasan Sadikin, and RSUP Dr. Sardjito), the Indonesian Nuclear Regulatory Agency (BAPETEN), the National Research and Innovation Agency (BRIN), Public Safety Center 119, and professional organizations. The simulation integrated theoretical and practical components, effectively enhancing participants’ understanding of nuclear emergency management and response. Simulations included pre-hospital treatment at accident sites, ambulance transportation, decontamination procedures, and the preparation of hospital emergency departments. The expert observers evaluated the simulations, but standardized evaluation tools need to be developed. The limited availability of radiation detection devices and personal protective equipment (PPE) was identified as a gap in the infrastructure. There is a need to include BNPB in the simulation, as it is the government agency designated for coordinating disaster management activities in Indonesia.

Multidisciplinary radiation emergency simulations are essential for effectively responding to nuclear emergencies, particularly in medical emergency preparedness and response. While the drills improved knowledge and operational coordination, developing standardized evaluation tools and addressing infrastructure gaps and resource allocation are critical next steps for optimizing preparedness.

This field report investigates the integration of civil-military collaboration in Poland to strengthen emergency medical response frameworks, with a focus on lessons learned from the COVID-19 pandemic and the ongoing Russo-Ukrainian conflict. These crises have exposed gaps in Poland’s emergency preparedness, particularly in coordination and rapid response capacities. By implementing a unified command structure, interoperable data sharing systems, and technology-driven strategies, such as predictive analytics, drone logistics, and digital health management, this report outlines a collaborative model that enhances Poland’s emergency response efficiency.

Key findings emphasize that civil-military collaboration, reinforced by joint training exercises and simulations, leads to faster mobilization, better resource allocation, and improved operational consistency across sectors. This model encourages a proactive approach by establishing communication protocols for real-time data exchange and optimizing readiness through frequent skill-building programs. Additionally, community engagement initiatives foster public awareness and resilience, providing a more comprehensive approach to disaster preparedness.

The significant impact of this integration model is reflected in enhanced responder competencies, a streamlined response framework, and a scalable, adaptable emergency response system that can be tailored to other contexts. The lessons drawn from these efforts serve as a foundation for building a sustainable, technology-enhanced civil-military collaboration that could inform similar emergency response strategies globally.

The October 7, 2023, massacre in Israel was a large, multi-site asymmetric attack with characteristics of both a very large terrorist attack and a conventional armed invasion, where Israel temporarily lost territorial control. Thus, it is a unique event in a Western democracy. Assuta Ashdod is a Level 2 trauma center located 26km from the Gaza Strip, which received 114 patients on October 7th, during which it activated its Mass Casualty Protocol (MCP). This study aimed to explore the experiences of staff working in this environment to inform hospital preparedness efforts in Israel and globally.

A purposeful sample of 18 key staff, including physicians, nurses, security, and orderlies, underwent semi-structured interviews. These were recorded, transcribed, and processed using thematic analysis methodology.

The participants felt well prepared for this event because of recurring, frequent, and immersive MCP drills that had preceded it. Participants mentioned entering a state of mind where they worked mechanically without reflecting on the event itself. The hospital being structurally protected from rocket attacks allowed participants to concentrate on the work without fear of injury. Assuta Ashdod is a relatively small hospital where staff know each other well, and this was recognized as allowing for flexibility and effective communication. Obstacles included a shortage of secretaries for the correct registration and tracing of patients. While paper-based patient files are used during MCP drills, the lack of familiarity with interacting with these during regular work resulted in suboptimal documentation. Some clinicians mentioned a lack of situational awareness as they worked in isolation in a single part of the system throughout MCP activation.

This study has offered insights from staff with practical experience from MCP activation in a major asymmetric attack and has identified several organizational and resilience-related aspects that may inform preparedness efforts in the future.

In May 2023, the Emilia-Romagna Region experienced two unprecedented rainfall episodes, leading to severe flooding and landslides, especially in the Romagna area, its Southernmost part. This study aimed to assess the health response to the May 2023 floods in this area by identifying the main actions undertaken in response to the floods and by highlighting criticalities and lessons learned.

This study was conducted in the context of a collaboration between CRIMEDIM, the Center for Research and Training in Disaster Medicine, Humanitarian Aid and Global Health, and the Romagna Local Healthcare Authority. To achieve the objective, a retrospective qualitative case study design was chosen, and semi-structured interviews were employed to gather in-depth information on the experiences and perspectives of key informants involved in the flood response.

Interviewees consisted of 25 key informants related to the following fields: authorities and public administration, health management, public health, primary care, social services, hospital and emergency care system, communication, and the third sector. The findings highlight the strain on the local health system, including service and infrastructure disruptions. The response strategies have been analyzed and clustered in phases (alert and activation, coordination, communication, identification of vulnerable individuals, evacuation management, surge capacity, health service delivery, logistics, and the role of volunteers), offering a comprehensive overview of local disaster response strategies. Recommendations include enhancing the interoperability of health information systems for disaster management, improving the coordination of evacuations for at-risk populations, improving the capacity to map fragile and vulnerable populations, and strengthening spontaneous volunteers.

This study highlights the importance of collaborations between local health authorities and academia for ongoing evaluations to enhance disaster response and resilience.

Full authorship: Valente Martina, Del Prete Clara, Facci Giulia, Martino Ardigò, Grilli Roberto Giuseppe, Bravi Francesca, Reno Chiara, Ragazzoni Luca

Virtual patients (VPs) have the potential to support military medicine training. Gamification is at least as effective as traditional educational methods and is often more effective for improving knowledge, skills, and satisfaction in health professions education. In military trauma care, where medics must make both medical and tactical decisions, gamified VPs can offer active learning opportunities to better prepare them for providing medical care in austere environments. Despite the potential of VPs to improve military medical training, studies exploring the integration of gamification into VP design are limited.

This study aimed to understand the reasoning and perceptions of Swedish military medics when interacting with VPs, offering insights and recommendations for designing VPs with game elements to support decision-making.

Fourteen military medics from the Swedish Home Guard-National Security Forces participated in a tactical combat care course, engaging with three VP cases simulating military trauma scenarios. Data were collected through think-aloud sessions and semi-structured interviews. The participants’ reasoning processes and perceptions were analyzed using interaction analysis, along with reflexive thematic analysis. A second round of coding identified game elements that could enhance the VP design.

Our analysis indicated that mistakes in VP decisions, followed by feedback, facilitated the military medics’ reflection. The thematic analysis revealed six themes: motivation (“keep on trying”); agency in interaction with VPs; realistic tactical experience; confidence (“I know that the knowledge I have works”); social influence on motivation; and personalized learning. Game elements such as scoring, badges, progress bars, challenges, avatars, and leaderboards were suggested to make the learning experience more enjoyable and increase medics’ confidence.

Overall, the VPs were positively received. Gamification in VP design appears to be a promising approach for military trauma training, encouraging the inclusion of game elements as well as consequences for wrong decisions to support military medics’ training.

Emergency medical technicians (EMTs) often perform patient-handling tasks in emergency settings, posing a high risk of occupational injury. The prevalence of Work-Related Musculoskeletal Disorders (WRMSD) among EMTs has been underestimated due to the lower reporting rate of WRMSD events in Taiwan. This study employed a nationwide safety manual handling survey by integrating the health belief model (HBM) and the transtheoretical model (TTM) to examine behavioral factors influencing the adoption of safety manual handling skills among EMTs.

A cross-sectional study was conducted among frontline EMTs in Taiwan, including full-time and volunteer EMTs from fire departments in Taiwan. Data on individual characteristics, WRMSD experiences, six factors of measuring attitude toward safety handling, and behavioral change stages to adopting safety handling via a questionnaire were analyzed using descriptive statistics and multinomial logistic regression to determine the impact of each factor on adopting safe handling techniques.

A total of 761 participants completed the questionnaire. The lower back was the most frequent WRMSD body part among participants. The most frequent type of patient handling-related injuries was strain/sprain (88.4%). The patient handling-related injuries occurred within 5.3 years after career initiation in 76.9% of participants. The results also indicated that higher perceived benefits and lower perceived barriers increase the odds of being in all TTM stages. The cue to action level was also a predictor for investigating the likelihood of being in each stage of change compared to the reference category.

Promoting the adoption of safety handling skills is a long-term battle in improving occupational health and safety among EMTs. Perceived benefits, perceived barriers, and cues to action may be the critical factors for designing and implementing the interventions in the future. Future interventions should focus on letting EMTs understand the benefits and barriers of conducting safety manual handling and provide clear, real-world guidance.

One Health plays an important role in public health emergencies and pandemic preparedness. Successful public health interventions of infectious disease spread require cooperation of human health, environmental health, and animal health partners. However, One Health is still a new policy initiative in the United States. Few studies have looked at One Health initiatives across U.S. states, and which agencies are involved or excluded from such policy priorities.

To assess scope, primary data was collected from federal and state agencies, ASTHO, and the NCSL. This data was supplemented with elite interviews of state bureaucrat leaders in emergency management and public health to determine whether One Health was an explicitly mentioned policy priority in public health emergency preparedness across states.

Less than a third of US states have/had a One Health Committee or Task Force, many of which have little authority or power to ensure intragovernmental collaboration and cooperation. One-fourth have a division within an agency dedicated to One Health, or they have One Health listed as an official policy priority. Very few states have passed laws or policies that establish official state One Health programs. One Health is most commonly located within a state department of health or public health. Moreover, relationships between emergency management and public health agencies are variable, with little coordination at the subnational level. Formal One Health initiatives are located in environmental health departments or siloed departments within public health. Informal initiatives are coalitions across academic research institutions, nonprofit actors, community organizations, and individual state bureaucratic “policy entrepreneurs”.

While One Health pushes for a collaborative, multisectoral, and transdisciplinary approach, there is little evidence that such initiatives are occurring in practice across US states and localities. Stronger collaborations between emergency management and public health agencies are needed at both the state and local levels.

The Emergency Medical Team (EMT) initiative enhances rapid response to public health emergencies by mobilizing and coordinating national and international medical teams that provide surge capacity. Since the escalation of hostilities in Gaza in October 2023, the local health system has faced severe challenges, including widespread infrastructure damage, critical shortages of medical supplies, and limited access to healthcare. In response, the World Health Organization, upon request from Gaza health authorities, activated the EMT mechanism and established an EMT Coordination Cell to support international deployment. By the end of 2024, 51 national and international EMTs were deployed across Gaza, addressing urgent healthcare needs in trauma care, surgery, maternal and child health, disease outbreak surveillance, non-communicable diseases, and mental health.

A total of 918 international and 242 national personnel delivered over 2.2 million general medical consultations, nearly 37,000 emergency surgeries, and more than 14,000 referrals. Two national EMTs have resumed activities, significantly strengthening local emergency care and specialized surgical capacity. In 2025, EMTs maintain their presence and impact despite major operational constraints, including insecurity, restricted access, and persistent shortages of essential supplies. Current priorities include reinforcing all levels of healthcare, expanding community and home-based services, strengthening disease surveillance, and increasing psychosocial support for both patients and health workers. Operational agility remains critical to respond to evolving needs, including hospital evacuations, displacement, and surges in casualties.

In the realm of trauma response preparation for prehospital teams, the combination of Augmented Reality (AR) and Virtual Reality (VR) with manikin technologies is growing in importance for creating training scenarios that closely mirror potential real-life situations. The study focused on training in airway management and intubation for trauma incidents, based on a Trauma AR-VR simulator involving reserve paramedics of the National EMS service (Magen David Adom) who had not practiced for up to six years, activated during the Israel-Gaza conflict (October 2023). The trauma simulator merges the physical and virtual realms by utilizing a real manikin and instruments outfitted with sensors. This integration enables a precise one-to-one correspondence between the physical and virtual environments.

A quantitative questionnaire was utilized to gauge the influence of AR-VR training on specific psychological and skill-based metrics, including self-efficacy, resilience, medical knowledge, professional competency, confidence in performing intubations, and the perceived quality of the training experience. The methodology entailed administering a pre-training questionnaire, delivering a targeted 30-minute AR-VR training session on airway management techniques, and collecting post-training data through a parallel questionnaire to measure the training’s impact.

Post-training evaluations indicated a significant uptick in all measured areas, with resilience (3.717±0.611 to 4.008±0.665) and intubation confidence (3.541±0.891 to 3.833±0.608) showing particularly robust gains. The high rating (4.438±0.419 on a scale of 5) of the training quality suggests a positive response to the AR-VR integration for the enhancement of medical training.

The application of AR-VR in the training of reserve paramedics demonstrates potential as a key tool for their swift mobilization and efficiency in crisis response. This is particularly valuable for training when quick deployment of personnel is necessary, training resources are diminished, and ‘all hands on deck’ is necessary.

In a world increasingly challenged by disasters and emergencies, practical disaster medicine training is crucial for saving lives and improving response efforts. The Training Disaster Medicine Trainers (TdmT) educational program, launched in 2015 through a partnership between the International Federation of Medical Students’ Associations (IFMSA) and the Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health (CRIMEDIM), aims to enhance the capacity of medical students worldwide. The program provides theoretical knowledge and practical skills in disaster medicine, addressing the growing need for competent leaders in disaster and emergency management, aligning with the Sendai Framework’s goals for disaster risk reduction. TdmT seeks to train a new generation of medical professionals who can effectively contribute to disaster risk management, becoming peer educators in their universities and beyond. The program empowers graduates to serve as trainers and advocates for disaster medicine practices by focusing on knowledge dissemination.

The program is delivered annually, and includes online and residential phases with theoretical lessons and simulations (table-top, computer-based, and full-scale). Covering topics such as triage during mass casualty incidents, pre-hospital and hospital responses, and Chemical, Biological, Radiological, and Nuclear (CBRN) incidents. To date, TdmT has trained 140 graduates worldwide who have implemented disaster medicine training at local, national, and international levels.

Graduates of the TdmT program have successfully established training sessions, workshops, and simulations, enhancing capacity building in disaster medicine and disaster management within their communities. Feedback indicates improved knowledge and confidence among participants, contributing to more effective emergency management practices.

The TdmT program fosters a culture of preparedness and resilience in health systems worldwide. By equipping future leaders and professionals with essential tools and knowledge, TdmT strengthens individual capabilities and enhances disaster response.

On February 3, 2023, a freight train containing 149 train cars operated by Norfolk Southern Railway derailed in East Palestine, Ohio. Eleven of the derailed cars contained hazardous chemicals, including vinyl chloride, ethylene glycol monobutyl ether acetate, 2-ethylhexyl acrylate, isobutylene, n-butyl acrylate, and benzene residue. The Ohio Regional Poison Control Centers received calls from the community and health care providers affected by this incident. On February 6, railroad officials decided to perform a controlled burn with the train cars carrying 115,580 gallons of vinyl chloride due to the rising temperatures, which posed an explosion hazard.

Retrospective case narrative reviews were performed on the phone calls received from the affected community to the Cincinnati Drug and Poison Information Center (DPIC). The cases started in February 2023 and ended in October 2024. Data included the caller location and clinical effects/symptoms from the initial chemical spill, and the controlled burn was entered into a Geographic Information System (GIS).

179 cases were reviewed, with the most common clinical effects/symptoms. The cases were included based on their distance from the derailment, < 1 mile, 5 miles, 20 miles, and > 20 miles radius.

Understanding the health effects of chemical spills in a technological disaster will inform the creation of emergency and disaster management protocols for hospitals and first responders.

During domestic disasters, emergency medical support by nurses includes various forms of assistance, such as participation in DMAT teams, disaster support nurses dispatched by nursing associations, and independent deployment by NGOs and NPOs. Following the Noto Peninsula Earthquake on January 1, 2024, the Health, Medical, and Welfare Coordination Headquarters of Ishikawa Prefecture organized the dispatch of nurses to support medical institutions, social welfare facilities, and evacuation shelters in the disaster-affected areas.

The aim of this study is to identify challenges in coordinating the dispatch of nurses during the Noto Peninsula Earthquake in 2024.

The coordination of nurse dispatch needs was conducted by personnel from Ishikawa Prefecture, the Japan Nursing Association, and the Ishikawa Nursing Association, in collaboration with DMAT staff experienced in nurse dispatch. Unlike previous disasters, where nurses were primarily dispatched to hospitals and evacuation centers, the Noto Peninsula Earthquake required deployment to temporary shelters outside the affected area and to social welfare facilities in the Noto region, where the aging population exceeded 50%. This led to prolonged coordination efforts for long-term dispatch to hospitals and welfare facilities. Information for assessing dispatch needs came from local personnel, municipalities, and systems such as EMIS, D24H, and J-SPEED.

Although the response to the Noto Peninsula Earthquake was confined to a single prefecture, anticipated disasters like the Nankai Trough Earthquake or a direct hit on a metropolitan area would affect multiple prefectures, complicating coordination efforts. The variability in the number, duration, and locations of nurse dispatch depends on the personnel involved in coordination, underscoring the importance of training to manage nurse dispatch effectively in large-scale disasters.

“Outside the Box”

Nurses who have experienced caring for patients with COVID-19 have the potential to identify local and systemic factors that contributed to what helped support the nurses and their ability to provide care and what did not. The three research questions were: 1) What are the experiences of nurses providing care to patients during COVID-19 in community, hospital, and long-term care settings, and how do these experiences impact their professional and personal well-being? 2) How do nurses perceive the effectiveness of organizational strategies, including crisis standards of care, personal protective equipment (PPE) provision, and support for personal preparedness, in supporting their response and practice during the COVID-19 pandemic? 3) What are nurses’ perceptions of the organizational, local, county, state, and federal policies that either support or hinder their ability to effectively respond to the challenges posed by the COVID-19 pandemic?

A qualitative approach was used to interview registered nurses, who had cared for patients with COVID-19 in one of three health care settings (hospitals, long-term and residential care facilities, and community-based or public health response).

Results indicate that most of the nurses felt supported by their immediate supervisor but abandoned by organizational leadership. They experienced challenges with equipment, staffing, emotional support, changing policies, and grief, and felt supported by work colleagues and family.

Healthcare systems were unprepared to respond to a pandemic. The nursing workforce was affected by the lack of preparedness. Preparations for the next pandemic should be underway to address patient care needs and the health and welfare of nurses on the frontline, including maintaining adequate supplies of personal protective equipment, managing a surge of patients, and providing physical and emotional support to nurses and other healthcare workers.

In September 2023, the City of New Orleans became aware of progressive saltwater intrusion up the Mississippi River, the city’s main water source. Saltwater intrusion, a result of global drought conditions and climate change, has increasingly plagued coastal areas globally, causing ill-effects on population health and infrastructure through pipe corrosion, water contamination, and damage to essential appliances. University Medical Center is the largest quaternary hospital New Orleans, a 446-bed hospital serving as the region’s only level 1 trauma center, burn center, and hub for the local medical community. In preparation for possible saltwater intrusion, UMC identified water supply contingency solutions in order to continue patient care throughout the hospital. Reverse Osmosis machines were procured with production capacity up to 1892 L/minute. In addition to tap water filtration, the RO systems are capable of filtering non-potable water supplies including 750,000 gallons (2.84 million L) on-site and an addition 1.5 million gallons (5.69 million L) stored at an off-site location. Finally, an outside vendor was hired to monitor water quality in the hospital and alert hospital administrators once municipal water became substandard. Special considerations were made for services highly reliant on water, including dialysis, dental, laboratory services, sterile processing, pharmacy, and surgery. To continue dialysis services, UMC planned to share capacity with a private service provider (Davita, Inc.) including CRRT machines and storage space for dialysate fluid. The dental team utilized their own water filtration system. A vendor was hired to distribute bottled water as needed. Ultimately, high salinity water never reached the pipes of New Orleans as a result of increased river flow and construction of a sill. However, this overall process serves as a blueprint for rapid expansion of water contingency planning for a major urban hospital.

During the 2016 Kumamoto earthquake, a grade 1–4 evacuation triage (Simple Triage and Rapid Treatment for Neonates, START-Neo) was used to determine the evacuation order at a tertiary neonatal intensive care unit (NICU). However, most newborns are classified as grade 2 or 3, which makes it difficult to determine the order of evacuation. A five-category, 0–12 scale (Neonatal Extrication Triage, NEXT) was developed to reflect the medical care provided. This retrospective observational study investigated whether the use of (i) a triage system (vs. random orders) and (ii) NEXT (vs. START-Neo) improved NICU evacuation efficiency.

NEXT and START-Neo were assessed over 49 days. Given that the evacuation was performed in either ascending or descending order of patient severity, an efficient triage system was defined as one that precisely reflected patient severity. The severity of newborn patients at the time of triage assignment was determined using a Neonatal Therapeutic Intervention Scoring System (NTISS). The Total Evacuation Score (TES) was defined as the time integral of the NTISS scores of newborns waiting for evacuation and remaining within the NICU from the start to the completion of the evacuation. The TES was compared between (i) no triage, (ii) NEXT, and (iii) START-Neo. A computer-based evacuation simulation was conducted using all possible combinations of evacuation orders (NEXT and START-Neo) or randomly extracted combinations (no triage).

Compared to no-triage, both NEXT and START-Neo led to a reduction in TES throughout the study period. NEXT was superior to START-Neo on 34 of 49 days and showed no difference on 10 days.

Triage systems are crucial for improving NICU evacuation efficiency. NEXT, an improved triage system, appears likely to reduce the overall risk of newborns remaining in a damaged NICU before transportation.