OBJECTIVES This systematic review sought to identify the best available evidence regarding strategies for allocating scarce resources during mass casualty events (MCEs). Specifically, the review addresses the following questions: (1) What strategies are available to policymakers to optimize the allocation of scarce resources during MCEs? (2) What strategies are available to providers to optimize the allocation of scarce resources during MCEs? (3) What are the public's key perceptions and concerns regarding the implementation of strategies to allocate scarce resources during MCEs? (4) What methods are available to engage providers in discussions regarding the development and implementation of strategies to allocate scarce resources during MCEs? DATA SOURCES We searched Medline, Scopus, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Global Health, Web of Science®, and the Cochrane Database of Systematic Reviews from 1990 through 2011. To identify relevant non-peer-reviewed reports, we searched the New York Academy of Medicine's Grey Literature Report. We also reviewed relevant State and Federal plans, peer-reviewed reports and papers by nongovernmental organizations, and consensus statements published by professional societies. We included both English- and foreign-language studies. REVIEW METHODS Our review included studies that evaluated tested strategies in real-world MCEs as well as strategies tested in drills, exercises, or computer simulations, all of which included a comparison group. We reviewed separately studies that lacked a comparison group but nonetheless evaluated promising strategies. We also identified consensus recommendations developed by professional societies or government panels. We reviewed existing State plans to examine the current state of planning for scarce resource allocation during MCEs. Two investigators independently reviewed each article, abstracted data, and assessed study quality. RESULTS We considered 5,716 reports for this comparative effectiveness review (CER); we ultimately included 170 in the review. Twenty-seven studies focus on strategies for policymakers. Among this group were studies that examined various ways to distribute biological countermeasures more efficiently during a bioterror attack or influenza pandemic. They provided modest evidence that the way these systems are organized influences the speed of distribution. The review includes 119 studies that address strategies for providers. A number of these studies provided evidence suggesting that commonly used triage systems do not perform consistently in actual MCEs. The number of high-quality studies addressing other specific strategies was insufficient to support firm conclusions about their effectiveness. Only 10 studies included strategies that consider the public's perspective. However, these studies were consistent in their findings. In particular, the public believes that resource allocation guidelines should be simple and consistent across health care facilities but should allow facilities some flexibility to make allocation decisions based on the specific demand and supply situation. The public also believes that a successful allocation system should balance the goals of ensuring the functioning of society, saving the greatest number of people, protecting the most vulnerable people, reducing deaths and hospitalizations, and treating people fairly and equitably. The remaining 14 studies provided strategies for engaging providers in discussions about allocating and managing scarce medical resources. These studies did not identify one engagement approach as clearly superior; however, they consistently noted the importance of a broad, inclusive, and systematic engagement process. CONCLUSIONS Scientific research to identify the most effective adaptive strategies to implement during MCEs is an emerging area. While it remains unclear which of the many options available to policymakers and providers will be most effective, ongoing efforts to develop a focused, well-organized program of applied research should help to identify the optimal methods, techniques, and technologies to strengthen our nation's capacity to respond to MCEs.

Allocation of scarce resources during mass casualty events.

The hospitalisation and management of patients at the end-of-life by emergency medical services is presenting a challenge to our society as the majority of people approaching death explicitly state that they want to die at home and the transition from acute care to palliation is difficult. In addition, the escalating costs of providing care at the end-of-life in acute hospitals are unsustainable. Hospitals in general and emergency departments in particular cannot always provide the best care for patients approaching end-of-life. The main objectives of this paper are to review the existing literature in order to assess the evidence for managing patients dying in the emergency department, and to identify areas of improvement such as supporting different models of care and evaluating those models with health services research. The paper identified six main areas where there is lack of research and/or suboptimal policy implementation. These include uncertainty of treatment in the emergency department; quality of life issues, costs, ethical and social issues, interaction between ED and other health services, and strategies for out of hospital care. The paper concludes with some areas for policy development and future research.

/pdf/a-literature-review-on-care-at-the-end-of-life-in-the-2gocpjtlln.pdf

A Literature Review on Care at the End-of-Life in the Emergency Department

Eine Patientenverfugung (PV) ist nach dem sog. Patientenverfugungsgesetz vom 01.09.2009 unter bestimmten Bedingungen – auch fur arztliche und nichtarztliche Mitarbeiter des Rettungsdienstes – formal rechtlich bindend. Doch sind diese Bedingungen in Notfallsituationen derzeit nur selten erfullt, sodass das Rettungspersonal auch bei Vorliegen einer PV meist in Unkenntnis des (mutmaslichen) Patientenwillens entscheiden muss. Dies fuhrt regelmasig zu Unsicherheit und Konflikten und belastet alle Beteiligten erheblich. Verschiedene internationale und deutsche Modellprojekte haben gezeigt, dass regionale Initiativen zum Advance Care Planning in Verbindung mit arztlich (mit)verantworteten Notfallbogen tief greifende Strukturveranderungen bewirken konnen, durch die Patientenverfugungen im Rettungsdienst regelmasig grose Relevanz erhalten. Grundlegend sind eine professionelle Gesprachsbegleitung zur Entwicklung der personlichen PV und ein regionales System zur Beachtung solcherart entstandener PV. Dieses System muss alle an der Betreuung chronisch kranker, multimorbider und in ihrer Mobilitat eingeschrankter Menschen beteiligten Berufsgruppen und Versorgungsebenen einbeziehen. Darauf aufbauend konnen Rettungsdienstmitarbeiter dem einer PV zugrunde liegenden Gesprachs- und Entscheidungsprozess vertrauen. Damit konnen sie guten Gewissens den prazisen Festlegungen eines regional eingefuhrten Notfallbogens wie der „Hausarztlichen Anordnung fur den Notfall“ (HAnNo) folgen.

Patientenverfügungen im Rettungsdienst (Teil 2)

Introduction. The aim of our study was to investigate challenges faced by emergency physicians (EPs) who provide prehospital emergency care to patients with advanced incurable diseases and family caregivers in their familiar home environment. Methods. Qualitative study using semistructured interviews with open-ended questions to collect data from 24 EPs. Data were analyzed using qualitative content analysis. Results. We identified nine categories of challenges: structural conditions of prehospital emergency care, medical documentation and orders, finding optimal patient-centered therapy, uncertainty about legal consequences, challenges at the individual (EP) level, challenges at the emergency team level, family caregiver’s emotions, coping and understanding of patient’s illness, patient’s wishes, coping and understanding of patient’s illness, and social, cultural, and religious background of patients and families. EPs strengthened that the integrations of specialized prehospital palliative care services improved emergency care by providing resources to patients and family caregivers, enhancing the quality and availability of medical documentation and accessibility of aftercare in emergencies. Areas of improvement that were identified were to promote emergency physicians’ knowledge and skills in palliative care, communication, and family caregiver support by education and training. Furthermore, structures for better care on-site, thorough medical documentation, and specialized palliative care emergency facilities in hospital and prehospital care were requested. Conclusion. Prehospital emergency care in patients with advanced incurable diseases in their familiar home environment may be improved by training EPs in palliative care, communication, and caregiver support competences. Results underline the importance of collaborative specialized palliative care and prehospital emergency care.

/pdf/challenges-faced-by-prehospital-emergency-physicians-44hd3y3it1.pdf

Challenges Faced by Prehospital Emergency Physicians Providing Emergency Care to Patients with Advanced Incurable Diseases

Patients with complex medical problems and acute life-threatening diseases deserve a physician with the capability of rapid decision making. Despite an emergency scenario with several unknown or uncertain variables an individual therapeutic plan needs to be defined for each patient. In order to achieve this goal the physician must define medical indications for each form of treatment. Secondly, the patients declared intentions must be respected concerning the previously defined medical indications; however, very often the patients' will is not known. It is very difficult to define an individual treatment plan especially if the patient is not able to adequately communicate. In these situations a custodian is helpful to find out the patients declared intentions towards the current medical situation. If there is no advance directive, family members often have to act as surrogates to find out what therapy goal is best for the individual patient. The patients' autonomy is a very highly respected ethical priority even when the ability for the otherwise usual practice of shared decision-making between physician and patient is compromised. Therefore, in order to do justice to this demanding situation it is necessary to deal with the characteristics of the physician-patient-relatives relationship in emergency medicine.

Patientenwille und Akutmedizin

Background At the end of life acute exacerbations of medical symptoms (e.g. dyspnea) in palliative care patients often result in emergency medical services being alerted. The goals of this study were to discuss cooperation between emergency medical and palliative care structures to optimize the quality of care in emergencies involving palliative care patients. Methods For data collection an open discussion of the main topics by experts in palliative and emergency medical care was employed. Main outcome measures and recommendations included responses regarding current practices related to expert opinions and international literature sources. Results As the essential points of consensus the following recommendations for optimization of care were named: (1) integration of palliative care in the emergency medicine curricula for pre-hospital emergency physicians and paramedics, (2) development of outpatient palliative care, (3) integration of palliative care teams into emergency medical structures, (4) cooperation between palliative and emergency medical care, (5) integration of crisis intervention into outpatient palliative emergency medical care, (6) provision of emergency plans and emergency medical boxes, (7) provision of palliative crisis cards and do not attempt resuscitation (DNAR) orders, (8) psychosocial aspects concerning palliative emergencies and (9) definition of palliative patients and their special situation by the physician responsible for prior treatment. Conclusions Prehospital emergency physicians are confronted with emergencies in palliative care patients every day. In the treatment of these emergencies there are potentially serious conflicts due to the different therapeutic concepts of palliative medical care and emergency medical services. This study demonstrates that there is a need for regulated criteria for the therapy of palliative patients and patients at the end of life in emergency situations. Overall, more clinical investigations concerning end-of-life care and unresponsive palliative care patients in emergency medical situations are necessary.

[Palliative care and end-of-life patients in emergency situations. Recommendations on optimization of out-patient care].

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[Palliative care and end-of-life patients in emergency situations. Recommendations on optimization of out-patient care].