Despite the increasing risk of disasters and health crises worldwide, we are failing to equip the new generation of health care workers with basic education and training in disaster medicine and global public health. Unfortunately, the teaching of disaster medicine is underrepresented in several countries worldwide.

Understand the role of education and training as integral components of disaster preparedness.

Recognize the fundamentals of adult learning and competency-based education and training.

Discover the general principles of education and training in disaster medicine.

Explore the state of the art of simulation-based training in disaster medicine.

The aim of this paper is to outline the steps taken to develop an operational checklist to assess primary healthcare (PHC) all-hazards disaster preparedness. It then describes a study testing the applicability of the checklist.

A PHC approach is an essential foundation for health emergency and disaster risk management (H-EDRM) because it can prevent and mitigate risks prior to disasters and support an effective response and recovery, thereby contributing to communities’ and countries’ resilience across the continuum of the disaster cycle. This approach is in line with the H-EDRM framework, published by the World Health Organization (WHO) in 2019, which emphasizes a whole-of-health system approach in disaster management and highlights the importance of integrating PHC into countries’ H-EDRM. Nevertheless, literature focusing on how to practically integrate PHC into disaster management, both at the facility and at the policy level, is in its infancy. As of yet, there is no standardized, validated way to assess the specific characteristics that render PHC prepared for disasters nor a method to evaluate its role in H-EDRM.

The checklist was developed through an iterative process that leveraged academic literature and expert consultations at different stages of the elaboration process. It was then used to assess primary care facilities in a province in Italy.

The checklist offers a practical instrument for assessing and enhancing PHC disaster preparedness and for improving planning, coordination, and funding allocation. The study identified three critical areas for improvement in the province’s PHC disaster preparedness. First, primary care teams should be more interdisciplinary. Second, primary care services should be more thoroughly integrated into the broader health system. Third, there is a notable lack of awareness of H-EDRM principles among PHC professionals. In the future, the checklist can be elaborated into a weighted tool to be more broadly applicable.

Effective response to a mass-casualty incident (MCI) entails the activation of hospital MCI plans. Unfortunately, there are no tools available in the literature to support hospital responders in predicting the proper level of MCI plan activation. This manuscript describes the scientific-based approach used to develop, test, and validate the PEMAAF score (Proximity, Event, Multitude, Overcrowding, Temporary Ward Reduction Capacity, Time Shift Slot [Prossimità, Evento, Moltitudine, Affollamento, Accorpamento, Fascia Oraria], a tool able to predict the required level of hospital MCI plan activation and to facilitate a coordinated activation of a multi-hospital network.

Three study phases were performed within the Metropolitan City of Milan, Italy: (1) retrospective analysis of past MCI after action reports (AARs); (2) PEMAAF score development; and (3) PEMAAF score validation. The validation phase entailed a multi-step process including two retrospective analyses of past MCIs using the score, a focus group discussion (FGD), and a prospective simulation-based study. Sensitivity and specificity of the score were analyzed using a regression model, Spearman’s Rho test, and receiver operating characteristic/ROC analysis curves.

Results of the retrospective analysis and FGD were used to refine the PEMAAF score, which included six items–Proximity, Event, Multitude, Emergency Department (ED) Overcrowding, Temporary Ward Reduction Capacity, and Time Shift Slot–allowing for the identification of three priority levels (score of 5-6: green alert; score of 7-9: yellow alert; and score of 10-12: red alert). When prospectively analyzed, the PEMAAF score determined most frequent hospital MCI plan activation (>10) during night and holiday shifts, with a score of 11 being associated with a higher sensitivity system and a score of 12 with higher specificity.

The PEMAAF score allowed for a balanced and adequately distributed response in case of MCI, prompting hospital MCI plan activation according to real needs, taking into consideration the whole hospital response network.

In 2019, the World Health Organization (WHO) published the Health Emergency and Disaster Risk Management (H-EDRM) framework detailing how effective management of disasters, including mass-casualty incidents (MCIs), can be achieved through a whole-of-health system approach where each level of the health care system is involved in all phases of the disaster cycle. In light of this, a primary health care (PHC) approach can contribute to reducing negative health outcomes of disasters, since it encompasses the critical roles that primary care services can play during crises. Hospitals can divert non-severe MCI victims to primary care services by applying reverse triage (RT), thereby preventing hospital overloading and ensuring continuity of care for those who do not require hospital services during the incident.

This study explores the topic by reviewing the literature published on early discharge of MCI victims through RT criteria and existing referral pathways to primary care services.

A scoping literature review was performed and a total of ten studies were analyzed.

The results showed that integrating primary care facilities into disaster management (DM) through the use of RT may be an effective strategy to create surge during MCIs, provided that clear referral protocols exist between hospitals and primary care services to ensure continuity of care. Furthermore, adequate training should be provided to primary care professionals to be prepared and be able to provide quality care to MCI victims.

The results of this current review can serve as groundwork upon which to design further research studies or to help devise strategies and policies for the integration of PHC in MCI management.

Team dynamics and nontechnical skills in general are crucial for emergency medical teams (EMT). No study has ever examined these important issues during a real mission in the field. This study aimed to better investigate team dynamics and nontechnical skills for EMTs; it tried to understand if a real mission, when the people are obliged to work together for the first time, without a prior specific training focused on teamwork, is enough or not to work as an effective team in the field.

The study is designed as a pre-test/post-test survey study, and it collected data from 51 people deployed to Mozambique in 2019. Three indexes (the self-efficacy (SE), the teamwork (TW), and the overall team’s performance (TW12)) were calculated as the average value of the rating given by all the participants. Open text feedback was also collected.

A positive trend was observed comparing the “post” data to the “pre” data, but results did not show a statistical significance, with the only exception of stratified analyses showing a P-value less than 0.05 for SE and TW12 for some categories.

According to the study findings, humanitarian workers feel good but not at their best; training programs focused on team dynamics can be really useful to improve self-confidence of people leaving for a mission.

A Mass Casualty Incident response (MCI) full scale exercise (FSEx) assures MCI first responder (FR) competencies. Simulation and serious gaming platforms (Simulation) have been considered to achieve and maintain FR competencies. The translational science (TS) T0 question was asked: how can FRs achieve similar MCI competencies as a FSEx through the use of MCI simulation exercises?

T1 stage (Scoping Review): PRISMA-ScR was conducted to develop statements for the T2 stage modified Delphi (mD) study. 1320 reference titles and abstracts were reviewed with 215 full articles progressing for full review leading to 97 undergoing data extraction.

T2 stage (mD study): Selected experts were presented with 27 statements derived from T1 data with instruction to rank each statement on a 7-point linear numeric scale, where 1 = disagree and 7 = agree. Consensus amongst experts was defined as a standard deviation ≤ 1.0.

After 3 mD rounds, 19 statements attained consensus and 8 did not attain consensus.

MCI simulation exercises can be developed to achieve similar competencies as FSEx by incorporating the 19 statements that attained consensus through the TS stages of a scoping review (T1) and mD study (T2), and continuing to T3 implementation, and then T4 evaluation stages.

In response to the global upward trend of humanitarian emergencies, the humanitarian health workforce has grown substantially in the last decades. Still, humanitarian education and training programs are limited in availability, geographical locations, and teaching methods, and are too expensive for local respondents. To address these gaps, an e-learning tool for humanitarian public health has been developed and evaluated.

Action research was used to develop the e-Learning tool. Rapid prototyping–a modified analysis, design, development, implementation, and evaluation (ADDIE) model, was used to identify the content and instructional design. This iterative process involved consultations and feedback from public health and disaster medicine instructors and students at different levels and training programs from within and outside CRIMEDIM. Qualitative data were analyzed using thematic analysis. Quantitative data were appropriately summarized. Pre/post-test change in knowledge score was tested with paired t-test.

Although different levels of training are needed, targeting health professionals at the entry-level in the humanitarian field is identified as a priority. Scenario-based e-Simulation covers health needs assessment, essential health services, communicable diseases standards, and the health system was developed and evaluated. Trainees were highly satisfied by the clear objectives, the realism of the simulated scenarios, quizzes, and interactivity. In the 1-7 numerical scale, the median for overall experience satisfaction was 6.3 (IQR=5.3-7, N=35). The mean of the post-test score was 7.71, which was significantly higher than the mean of the pre-test score of 5.88. The large effect size of 1.179 indicates the training effectiveness. Poor internet was identified as a potential barrier to delivering the training.

This participatory study resulted in the development of effective Scenario-based e-Simulation. Offline mode of training will be adapted for trainees with poor internet connection settings. Successful factors in instructional design will be used to inform the development of advanced training in the field.

The Novel Integrated Toolkit for Enhanced Pre-Hospital Life Support and Triage in Challenging and Large Emergencies (NIGHTINGALE) project was awarded to a consortium to design an innovative toolkit featuring different technological solutions for prehospital mass casualty incident (MCI) response. Translational science (T) methodology was undertaken to develop evidence-based guidelines for MCI response.

The consortium was divided into three work groups (WGs) MCI Triage, Prehospital Life Support and Damage Control and Prehospital Processes. Each WG previously collected data through the project T1 scoping review stage to provide the foundation for the initial T2 modified Delphi draft statements to present to WG internal focus groups for content and NIGHTINGALE study objectives. Their refined statements proceeded to WG specific external focus groups for further editing to be clear and concise for the following modified Delphi consensus rounds. Final WG statements were presented to modified Delphi experts for their consensus using the STAT59 platform with instruction to rank each statement on a seven-point linear numeric scale, where 1 = disagree and 7 = agree. Consensus amongst experts was defined as a standard deviation ≤1.0.

After three modified Delphi rounds, 18 of 24 statements attained consensus by the MCI Triage experts, eight of 25 by the Prehospital and Life Support and Damage Control experts, and 23 of 28 by the Prehospital Processes experts.

The three work groups will utilize consensus statements during the NIGHTINGALE project T3 phase to create evidence-based MCI response guidelines.

Migration and forced displacement are reshaping the globe today. More people are being displaced by conflicts and natural disasters than ever before, and climate change is playing a pivotal role as a contributing factor for migration and conflict.

While there is a growing literature regarding provision of care for migrants in hosting countries there is no evidence on the use of the surge capacity model to support preparedness, readiness, and response to migration crisis by local health services, or medical teams.

A scoping review with a narrative summary relevant to disaster medicine, looking at two major migration routes (Central/Eastern Mediterranean and South/Central America) was performed to determine if the surge capacity model has been applied by medical teams responding to migration crises, and how this has affected the adaptation of health services.

Preliminary analysis demonstrates variations on the use of the term “surge capacity”, and the imperative need to better define its application when preparing to or responding to any type of disaster, here specifically migration crisis. Thus far, there is no evidence on the use of the surge capacity model for the conformation of national/international medical teams when responding to this type of crises, and its relation to the adaptation of health services. This is particularly relevant, as the surge capacity model can support building and/or strengthening the capacity and capability of national and international medical teams.

There is an imperative need to design a conceptual framework based on the surge capacity model for the conformation of fit-for-purpose medical teams, that ensures preparedness, readiness, and appropriate response to migration crises guaranteeing adaptation of health services depending on context needs, and that defines skills and competencies of the responders. Additionally, this provides a conducive platform for operational research activities to foster evidence coming from the field.

Sierra Leone, one of the countries with the highest maternal and perinatal mortality in the world, launched its first National Emergency Medical Service (NEMS) in 2018. We carried out a countrywide assessment to analyze NEMS operational times for obstetric emergencies with access to timely essential surgery within 2 hours. Moreover, we evaluated the relationship between operational times and maternal and perinatal mortality.

We collected prehospital data of 6,387 obstetric emergency referrals from primary health units to hospital facilities between June 2019 and May 2020 and we estimated the proportion of referrals with a prehospital time (PT) within 2 hours. The association between PT and mortality was investigated using Poisson regression models for binary data.

At the national level, the proportion of emergency obstetric referrals with a PT within 2 hours was 58.5% (95% CI 56.9% to 60.1%) during the rainy season and 61.4% (95% CI 59.5% to 63.2%) during the dry season. Results were substantially different between districts, with the capital city of Freetown reporting more than 90% of referrals within the benchmark and some rural districts less than 40%. Risk of maternal death at 60, 120, and 180 min of PT was 1.8%, 3.8%, and 4.3%, respectively. Corresponding figures for perinatal mortality were 16%, 18%, and 25%.

NEMS operational times for obstetric emergencies in Sierra Leone vary greatly and referral transports in rural areas struggle to reach essential surgery within two hours. Maternal and perinatal risk of death increased concurrently with operational times, even beyond the two-hour target, therefore, any reduction of the time to reach the hospital may translate into improved patient outcomes.

In 2019, the World Health Organization published the Health Emergency and Disaster Risk Management (H-EDRM) framework, detailing how all actors in the health system can contribute to reducing negative health outcomes of emergencies and disasters, including mass casualty incidents (MCI). The H-EDRM framework’s whole-of-health-system approach stresses the need for each level of healthcare systems to be involved in all phases of the disaster cycle, particularly preparedness and response. This approach highlights the critical role that lower levels of care, including primary healthcare, can play during MCI, demonstrating the need to integrate these into countries’ disaster plans. Nevertheless, countries’ disaster management plans have historically focused on hospitals and few recommendations exist for how to practically proceed with such an integration. This study explores what has been published on the topic of reverse triage (RT), namely the process used by healthcare workers (HCWs) to determine which patients can safely be discharged to lower levels of care, resulting in increased surge capacity at hospitals. The objective of this work is to collect evidence around existing criteria, tools or referral pathways used by HCWs during MCI, ultimately integrating lower levels of care in MCI management.

A systematic literature review was performed and a total of 12 studies were analyzed.

Literature focusing on RT towards lower levels of care during MCI is scant and limited to few case studies. There is no standardized tool or guidelines for how to perform RT and existing referral pathways are described in only isolated case studies.

Published evidence on RT criteria is limited. The results of the current review can serve as groundwork upon which to design further research studies. It can be used to help devise strategies and policies for the integration of lower levels of care during MCI.

Hospitals around the world need to be safe and prepared to face disasters, being these man-made or caused by natural hazards. The Hospital Safety Index (HSI) is a tool developed by the World Health Organization (WHO) that allows access to the level of preparedness of hospitals; it is the most widely used instrument of its kind. Although the HSI is frequently used by hospitals and healthcare facilities around the world, scientific literature on its application in real life is scarce and qualitative studies are absent. By adopting a qualitative methodology, this study aims to investigate the use of the HSI to assess disaster preparedness in hospitals and healthcare facilities, identify challenges and facilitators of the HSI use, and devise recommendations for future adaptations of the tool.

A retrospective qualitative study employing semi-structured online interviews was conducted to gather opinions and perspectives of professionals using the HSI to assess disaster preparedness. Participants were recruited by contacting via email the authors of scientific publications on the use of the HSI.

In total, nine people from three different countries (Serbia, Sri Lanka, and Indonesia) and having different professional backgrounds agreed to participate in this study. They shared the reasons for their choice of using the HSI, against other tools, as well as the steps taken before and during data collection. Strengths and weaknesses of the HSI were identified and authors reported the challenges they encountered in the preparatory phase and during data collection. Modifications of the tool and recommendations for the future were proposed targeting both researchers and hospital managers.

As far as the authors know, this is the first qualitative study examining the methodological implications of using the HSI and providing practical recommendations that can advance the HSI tool and foster its use for disaster preparedness assessments worldwide.

The European Union Horizon 2020 research and innovation funding program awarded the NIGHTINGALE grant to develop a toolkit to support first responders engaged in prehospital (PH) mass casualty incident (MCI) response. To reach the projects’ objectives, the NIGHTINGALE consortium adapted the Translational Science (TS) process. The aim of this study is to perform the first TS (T1) phase PRISMA scoping review to extract data that will be used to guide the creation of the initial evidence-based second TS phase (T2) modified Delphi statements for a subsequent study.

The consortium was divided into three work groups (WGs) MCI triage, Prehospital Life Support and Damage Control (PHLSDC) and Prehospital Processes (PHP). Each WG conducted simultaneous literature searches following the PRISMA extension for scoping review with a common research strategy sharing MCI related search terms and then terms specific for each WG. Final included articles went through data extraction based on identified themes and sub-themes from PH MCI response literature to be used to create the future statements.

The initial search yielded 925 total references to be considered for a title and abstract review (PH Triage 311, PHLSDC 329, PHP 285), then 483 articles for a full reference review (MCI Triage 111, PHLSDC 216, PHP 156) and 155 articles for the database extraction process (MCI Triage 27, PHLSDC 38, PHP 90).

The progression of the study of prehospital MCI response enabled NIGHTINGALE partners to methodically obtain information that will contribute to each WG’s creation of initial T2 modified Delphi statements.

With the publication of the Health Emergency and Disaster Risk Management (H-EDRM) Framework in 2019, the World Health Organization (WHO) emphasized the need for disaster preparedness in all sectors of the health system, including primary health care (PHC). PHC disaster preparedness plays a crucial role in guaranteeing continuity of care and responding to the health needs of vulnerable populations during disasters. While this is universally acknowledged as an important component of disaster management (DM), there is still a severe paucity of scholarship addressing how to practically ensure that a PHC system is prepared for disasters. The objective of this study is to propose a new framework that describes key characteristics for PHC disaster preparedness and lays the groundwork to deliver operational recommendations to assess and improve PHC disaster preparedness.

A systematic literature review including the following online scientific databases was performed: Cochrane Library, Embase, Medline, National Library of Medicine, PubMed, Scopus, and Web of Science. Gray literature was also found by searching in: Trove, Mednar, and OpenGray. A total of 145 records were analyzed.

Twenty-five characteristics that contribute to a well-prepared PHC system were identified and categorized according to the WHO Health System Building Blocks to form a new PHC disaster preparedness framework.

The findings will contribute to the elaboration of a set of guidelines for PHC systems to follow in order to assess and boost their disaster preparedness. This will hopefully help to raise awareness among international policymakers and health practitioners on the importance to design interventions that integrate PHC into overall DM strategies, as well as to assess the preparedness of PHC systems in different political, developmental, and cultural contexts. The proposed framework is currently being used by our research group as groundwork for the creation of an assessment tool for evaluating all-hazards preparedness at the PHC level.

In 2018 Sierra Leone, a country highly prone to disasters, launched its first National Emergency Medical Service (NEMS) aiming to strengthen the provision of essential health services to the population with the long-term goal of creating a resilient health system able to effectively respond to and recover from emergencies. The Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health (CRIMEDIM), together with the Italian NGO Doctors with Africa (CUAMM), under the supervision of the Ministry of Health and Sanitation (MoHS), developed a prehospital Disaster Training Package (DTP) delivered to all NEMS personnel to boost the prehospital management of mass-casualty incidents (MCIs) and outbreaks.

The DTP was designed following the six-step approach to curriculum and training development with the ultimate goal of creating a workforce comprising qualified emergency responders with specific professional competencies to respond to outbreaks and MCIs. The DTP included a first phase in which NEMS local trainers underwent a training-of-trainers (ToT) course, enabling them to deliver cascade trainings to 16 district ambulance supervisors, 441 paramedics, 441 ambulance drivers, and 36 operators working in the NEMS operation center.

Starting on July 19, 2021, the ToT course was delivered to the seven national trainers. All trainers successfully passed the final examination and achieved high scores in the practical sessions, demonstrating active participation, commitment to the project, and good awareness. Following the ToT course, the series of cascade trainings started on August 2, 2021, delivered by the just-trained national trainers under the direct supervision of the two training managers.

The NEMS’ DTP is the very first Disaster Medicine training course delivered to prehospital healthcare providers in Sierra Leone. The authors believe that the provision of the DTP to all NEMS personnel has the potential to improve Disaster Medicine culture among health professionals in the Country.