Development of National Standardized All-Hazard Disaster Core Competencies for Acute Care Physicians, Nurses, and EMS Professionals

DISASTER MEDICINE/CONCEPTS

Development of National Standardized All-Hazard Disaster Core Competencies for Acute Care Physicians, Nurses, and EMS Professionals Carl H. Schultz, MD, Kristi L. Koenig, MD, Mary Whiteside, PhD, Rick Murray, EMT-P, for the National Standardized All-Hazard Disaster Core Competencies Task Force From the Center for Disaster Medical Sciences, Department of Emergency Medicine, University of California Irvine School of Medicine, Orange, CA (Schultz, Koenig); and the American College of Emergency Physicians, Irving, TX (Whiteside, Murray).

The training of medical personnel to provide care for disaster victims is a priority for the physician community, the federal government, and society as a whole. Course development for such training guided by well-accepted standardized core competencies is lacking, however. This project identified a set of core competencies and performance objectives based on the knowledge, skills, and attitudes required by the specific target audience (emergency department nurses, emergency physicians, and out-of-hospital emergency medical services personnel) to ensure they can treat the injuries and illnesses experienced by victims of disasters regardless of cause. The core competencies provide a blueprint for the development or refinement of disaster training courses. This expert consensus project, supported by a grant from the Robert Wood Johnson Foundation, incorporated an all-hazard, comprehensive emergency management approach addressing every type of disaster to minimize the effect on the public’s health. An instructional systems design process was used to guide the development of audienceappropriate competencies and performance objectives. Participants, representing multiple academic and provider organizations, used a modified Delphi approach to achieve consensus on recommendations. A framework of 19 content categories (domains), 19 core competencies, and more than 90 performance objectives was developed for acute medical care personnel to address the requirements of effective all-hazards disaster response. Creating disaster curricula and training based on the core competencies and performance objectives identified in this article will ensure that acute medical care personnel are prepared to treat patients and address associated ramifications/ consequences during any catastrophic event. [Ann Emerg Med. 2012;59:196-208.] A podcast for this article is available at www.annemergmed.com. 0196-0644/$-see front matter Copyright © 2012 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2011.09.003

INTRODUCTION Since the tragedy of September 11, 2001, a vast number of medical disaster response education and training courses have appeared. Many were developed and taught in the absence of accepted standards to validate the content and objectives being presented. For some products, the course designers created the training instruction first and then later developed the competencies and curricula to support the training, which is just the opposite of how effective instruction is implemented. Despite some attempts to craft competency standards, there are currently no comprehensive, widely endorsed consensus requirements for all-hazards disaster medical education and training, either for medical professionals in general or for individual groups. Creation of broadly recognized standard core competencies to support development of disaster response education and training courses for general health care providers and specific health care professionals will help to ensure that medical personnel are truly prepared to care for victims of mass casualty events. 196 Annals of Emergency Medicine

Although preliminary work has occurred identifying broadbased competencies for all health professionals involved in disaster response, there is still a need to define the specific knowledge, skills, and attitudes that must be mastered by specialized professionals. Standardized core competencies for acute care medical personnel— emergency department (ED) nurses, emergency physicians, and out-of-hospital emergency medical services (EMS) personnel—are needed to ensure that effective emergency medical response can be provided efficiently during all types of disasters. Such competencies and associated performance objectives provide a blueprint for the development of all-hazard disaster curricula and training courses to meet the needs of this target audience. The current education and training for these professionals do not adequately address the unique and complex situations that occur in disasters. Most of these individuals are not familiar with topics such as disaster triage, the incident command system, and the needs of special populations that arise during catastrophic events. In 2001, Waeckerle et al,1 under contract to the US Department of Volume , .  : March 

Schultz et al Health and Human Services Office of Emergency Preparedness, published extensive recommendations focusing on objectives, content, and competencies for training of these acute care medical personnel to care for victims of nuclear, biological, or chemical incidents. Hick et al2 published training guidelines for health care facility decontamination teams after a review of existing courses. However, these documents, as well as additional similar publications, did not promulgate competencies for the other areas of an all-hazards disaster response. An article published by Subbarao et al3 did create disaster core competencies, but they are designed for a general medical audience. As such, they are not comprehensive and therefore do not effectively address the needs of acute medical care personnel. To resolve this situation, the Robert Wood Johnson Foundation contracted with the Emergency Medicine Foundation to identify national standardized core competencies and associated performance objectives so acute care medical personnel can effectively prepare for, respond to, and recover from all types of disasters and mass casualty events. The Robert Wood Johnson Foundation President’s Staff Grant to the Emergency Medicine Foundation supported creation of an expert task force to determine (1) the knowledge and skills ED nurses, emergency physicians, and out-of-hospital EMS personnel need to effectively recognize and treat acute injuries and illnesses that may occur during disaster events; and (2) the barriers to, and solutions for, attaining the necessary knowledge and skills. In addition, the grant required documentation and dissemination of the core competencies developed by the task force.

MATERIALS AND METHODS To create comprehensive disaster core competencies specifically for acute care medical professionals, the Emergency Medicine Foundation contracted with the American College of Emergency Physicians to convene a stakeholder task force of individuals from multiple professional organizations representing the target audience. (See the Appendix for list of organizations and participants.) An individual representing the American College of Surgeons Committee on Trauma also participated on the task force. The American College of Surgeons Committee on Trauma has made substantial contributions to the specialty of disaster medicine and their interest, support, and expertise enhanced the strength of the resulting recommendations. An instructional systems design approach was used to guide the development of audienceappropriate competencies and performance objectives.4-6 Instructional systems design consists of 5 phases: analysis, design, development, implementation, and evaluations. Often referred to by the acronym ADDIE, instructional design is a systematic framework or guideline for creating strong, effective instructional experiences. The outcome of the overall process is to produce instruction that closes identified learning gaps. This project focused on identifying the learning needs, design objectives, and competencies that would guide the development of effective performance solutions. Facilitated discussions and Volume , .  : March 

Disaster Core Competencies for Acute Care Medical Personnel nominative group techniques were used for consensus building. Two in-person stakeholder meetings were held in Dallas, TX. Between these meetings, several rounds of e-mail communication and conference calls occurred among the participants of smaller working groups. In the first meeting, participants initially discussed the target audience and training goal for the project. The relevant characteristics and needs of the target audience group (ED nurses, emergency physicians, and out-of-hospital EMS professionals) as related to effective disaster response training were reviewed. Stakeholders also discussed the differences and similarities that would affect all-hazard disaster training requirements, including job responsibilities, levels of education, current training opportunities, and motivation. After describing the target audience, a training goal was developed to guide the development of core competencies. A training goal is a broad statement that describes a desired solution and helps identify the parameters or boundaries of the content. Next, group members created a list of all potential content categories or domains that might qualify for inclusion as competencies. Candidate topics were drawn from journals, textbooks, and training documents unique to each of the 3 participating specialties. Even work from other countries, such as the European Master in Disaster Medicine, was included. Task force members did not specify formal identification of these references. Many relied on peer-reviewed material within their own specialty. Some of the works were even authored by task force members. It was thought that a more efficient use of time would be to select participants with significant knowledge and experience within their specialty rather than create a reading list that all must review. However, when a participant relied on a specific publication to support a position, all task force members were able to review this material and decide its relevance for themselves. Using a modified Delphi technique, content categories were then sorted into 2 groups: those thought to be essential and those considered important but not critical. Categories that remained on the essential list would become the core competencies. Categories not selected for the essential list but considered important were recorded for future evaluation by others and are listed in Appendix E1 (available online at http:// www.annemergmed.com). Unanimous agreement was sought during the sorting process. When disagreement occurred, debate and discussion ensued until either consensus was reached or the number of participants dissenting was reduced to 1 or 2. Task force leaders did not identify an a priori number of competencies on which members must agree. Rather, discussion and evaluation occurred until the group was satisfied with the list of essential topics. These became the 19 content domains. It was agreed that these would cover requirements of the target audience to meet the training goal. A competency worksheet was developed to facilitate the development of competencies and performance objectives. The worksheet required that each content category be defined to clarify the intent of the category. Then, for each defined category, a specific competency was created. Annals of Emergency Medicine 197

Disaster Core Competencies for Acute Care Medical Personnel According to the instructional design approach used for this project, competencies were defined as a set of behaviors that encompassed the knowledge, skills, and personal attributes that are critical to successful work accomplishment. For each competency, 1 or more performance objectives were required. Performance objectives are specific statements describing the changes learners are expected to achieve for a particular competency. A worksheet defining performance objectives and providing a step-by-step approach to well-written (specific, measurable, and achievable) objectives was used. The performance objectives serve as benchmarks toward mastery of the associated competency. Before adjourning of the first meeting, 3 groups were created from within the task force, each containing at least 1 physician, nurse (RN), and emergency medical technician (EMT). The 19 core competencies were evenly divided between the 3 groups, so each group was assigned either 6 or 7 competencies. Each group was charged with creating definitions, descriptions, and performance objectives for each assigned core competency during the following 2 months. Stakeholder working groups clarified and revised the competencies and related performance objectives during this period. The groups used e-mail and conference calls to complete their respective tasks. In the second meeting, the entire task force reviewed the work products from the 3 groups. Those in attendance reached consensus on further revisions and additions to these documents, resulting in the final product. Throughout the process, a specialist in the development of educational material was present, providing guidance and consultation to the task force leaders and members. This ensured consistent adherence to sound competency development principles. As part of the instructional analysis, stakeholders identified barriers and challenges related to all-hazard training. Recognition of these situations and concerns improved the potential for successful implementation of the core competencies.

RESULTS Target Audience The primary target audience for the core competencies developed in this project is defined as acute care medical professionals—ED nurses, emergency physicians, and out-ofhospital EMS personnel. A secondary audience was identified as nursing, medical, and EMS students and medical residents. Two caveats related to the target audience definition were discussed: (1) this audience is large and varied in terms of resources, funding, access to training, and types of disasters that might be encountered; and (2) not everyone in the target audience is located in large urban areas or cities. Training Goal The following training goal was developed as a guide to focus the competency development on a specific audience and outcome: “Ensure acute care medical personnel have the competencies (knowledge, attitudes, and skills) to care for 198 Annals of Emergency Medicine

Schultz et al patients and address associated ramifications/consequences during any disaster.” Content Categories/Core Competencies/Performance Objectives The stakeholders identified 19 content categories (domains), 19 core competencies, and 93 performance objectives relevant to acute care medical professionals (Table 1). The categories cover the requirements for an effective all-hazard disaster response by individuals in the target audience. Each of the primary content categories was clarified by a succinct definition. The competency statements delineate the level of knowledge, skills, and attitudes that must be mastered to meet the training goal. The core competencies also provide a flexible framework into which new disaster-related issues, knowledge, and skills can be inserted to ensure that courses/curricula remain current. The performance objectives reflect the expert knowledge and experience of the stakeholders and their professional organizations and provide the necessary content details and performance measures to facilitate course or curricula development. Because all-hazard disaster training for acute care medical professionals should be designed at the performance or application level, objectives require the learners to use information or perform tasks as they would in their work environment. Barriers/Solutions During discussions, the task force identified multiple barriers limiting access to disaster training for acute medical care professionals once competencies are created. These included the following: ● lack of time and space in current training programs to accommodate an expanded disaster curricula ● limited time for professionals to attend training courses ● multiple competing courses or training options outside of disaster medicine ● lack of funding to support disaster course development and professional training ● an interest by federal agencies to fund mostly terrorismrelated projects, with less emphasis on comprehensive disaster training ● a sense of complacency about the current level of training options Stakeholders suggested the following solutions to address the barriers that could impede development and delivery of competency-based all-hazard disaster training: ● Focus on how competency-based training is different from other offerings: Competency-based education and training focuses on what learners are supposed to do, not just what they should learn. In other words, competency-based education emphasizes the knowledge, skills, and attitudes that correlate directly with the ability to perform a specific job. Competencies are measurable against accepted benchmarks and can be improved with training and development. Competency-based education clearly identifies requirements Volume , .  : March 

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Table 1. Final recommendations for core competencies, organized into 19 domains, with definitions and measurable performance objectives. All-Hazard Disaster Core Competencies for Acute Care Medical Professionals: ED Nurses and Physicians and Out-of-Hospital EMS Domain

Definition

Core Competency

Performance Objectives

1. Nomenclature

Terminology and professional vocabulary associated with disaster medicine

Comprehend orders, tasks, requests, conversations, and other forms of communication, including professional vocabulary, related to all-hazard preparedness and response

2. IMS (NRF, NIMS, ICS)

Purpose, structure, responsibilities, organization, span of control, and unified command (NRF, NIMS, ICS)

Demonstrate an ability to follow and work within an IMS

3. Recognition, notification, initiation, and data collection

Process of recognition, situational awareness and assessment, notification/activation of needed resources and the disaster plan, and data collection after the event

Recognize a disaster is in progress, assess and report the situation, initiate the disaster plan, notify the appropriate persons/ agencies, and identify important data for inclusion in postevent report

Define terminology/vocabulary necessary for effective professional communication during a disaster, including, but not limited to, the following: ● IMS; NRF, NIMS, and ICS ● span of control ● surge capability, surge capacity ● disasters defined by functional effect rather than cause (eg, environmental/natural, manmade) ● multiple/mass casualty incident ● situation assessment ● standard terminology associated with commonly used regional terms ● volunteer ● casualty ● continuum of care ● joint information center Given a disaster scenario, distinguish between the 4 temporal phases of emergency management (mitigation, preparedness, response, and recovery) Delineate the basic IMS structure, including command and general staff positions Explain the function and interaction of the NRF and the NIMS List functional responsibilities for each of the general staff positions in IMS List functional responsibilities for each of the command staff positions in IMS Explain the term “span of control” as it relates to IMS Explain the term “unified command” as it relates to IMS Explain how the IMS structure expands and contracts to fit the needs of an event Explain how communication flows within the IMS structure. Explain why plain language is important in an event governed by the IMS List the primary benefits of the IMS Explain how to recognize a disaster, including the importance of situational awareness and considering each of the following: ● a high-level description of the event ● environmental and geographic factors ● potential hazards to self and others in immediate vicinity ● need for immediate, additional, or specialized resources Summarize and describe the process of a proper situational evaluation (ie, assess the event) Describe the process for local/regional/ federal disaster agency notification List 3 steps required to activate a local disaster plan After the disaster, identify important data/information that should be included in a postevent report

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Table 1. Continued. All-Hazard Disaster Core Competencies for Acute Care Medical Professionals: ED Nurses and Physicians and Out-of-Hospital EMS Domain

Definition

Core Competency

4. Communication (inter/intra-agency, media)

Principles, devices, and need for bidirectional communication in sharing and disseminating information during a disaster

Communicate effectively and efficiently within and among agencies, as well as with the media, during any disaster

5. Resource management

Material acquisition and distribution in disasters

Manage supplies, pharmaceuticals, equipment, and other resources for an effective response

6. Volunteer management (invited/spontaneous or convergent)

Deploying, delegating appropriate tasks, and supervising volunteers

Manage, supervise, and appropriately use volunteers

7. GO- and NGOsponsored response teams

Purposes and capabilities of GO- and NGO-sponsored response teams

Use the resources provided by GOs and NGOs effectively (such as DMAT, USAR, MRC, and the Red Cross)

8. Public health and safety

Health and safety of patients, bystanders, and medical personnel, including risks associated with disasters

Prevent and mitigate risks to self and others

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Performance Objectives Distinguish between interagency/intra-agency (bidirectional) communication Explain the role/function of a joint information center List 3 key principles for effective communication Define and give an example of an effective communication/radio protocol Identify alternative methods of communication (eg, runners, walkie-talkies, ham radio) and list the pros and cons for each method or device Discuss the importance of media management (eg, controlling media, using media effectively) Identify 3 principles of crisis and emergency risk communication and explain their importance Describe the management of local and regional resources and how to call for additional pharmaceuticals and supplies Describe the change in patient management, given disaster-associated increased resource demand and decreased resource supply over time Formulate a management plan in a situation, without an influx of additional resources Explain the need for mutual aid and interoperability, including memorandums of understanding Explain why emergency credentialing of volunteers is important Identify appropriate tasks that can be delegated to volunteers according to their skills/licensure level Describe the process of deploying volunteers to appropriate task(s) or mission(s) Define the basic functions of GO- and NGOsponsored response teams (such as DMAT, USAR, MRC, and the Red Cross) Explain the limitations of GO and NGO resources Describe situations in which GO and NGO teams may be deployed Identify common components of and precautions for scene safety for patients, bystanders, and medical personnel Describe the process by which the working personnel will be routinely evaluated for medical or psychological fitness related to the event List environmental and topographic factors that will affect scene safety List appropriate hygienic practices—such as hand washing, covering a cough—for all personnel, victims, and bystanders List factors necessary for the provision of a safe, clean, and structurally sound area for medical care

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Table 1. Continued. All-Hazard Disaster Core Competencies for Acute Care Medical Professionals: ED Nurses and Physicians and Out-of-Hospital EMS Domain

Definition

Core Competency

9. Patient triage

Sorting patients according to care demands, considering available resources

Prioritize patients to maximize survivability

10. Surge capacity/capability

Health care facilities’/ systems’ abilities to rapidly expand operations to manage increased demand

Participate in a process that secures adequate personnel, supplies, equipment, and space for patient care

11. Patient identification and tracking

Seamlessly tracking patients through the continuum of disaster care

Use recordkeeping processes to ensure continuity of patient information

12. Transportation

The movement of patients throughout the continuum of care

Facilitate or perform patient transport effectively and safely during a disaster

13. Decontamination

Removal or neutralization of a contaminating substance, such as chemical, biological, radioactive, blood/ body fluids, or other hazardous material

Decontaminate patients or staff, following appropriate procedures

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Performance Objectives Demonstrate the appropriate donning, doffing, and disposal of level C PPE List the indications for use of PPE List common limitations and troubleshooting techniques for PPE Describe the process of establishing a perimeter to provide patients, medical personnel, and supplies with adequate protection Explain the difference between the objectives of conventional triage and disaster triage Discuss the operational advantages and disadvantages of common triage practices Define the benefits of a scalable triage process relative to patient outcomes, the EMS system, and the health care system Demonstrate the use of a mass-casualty triage protocol Explain the difference between surge capacity and capability Identify and define the 3 components of surge capacity (3-Ss: staff, stuff, structure) Describe the capabilities and limitations of the response system Describe the functions of alternate care sites Explain the importance of maintaining patient medical records (past, current, and developing) through the patient care continuum Describe important components of patient identification and medical information tracking practices (ie, patient identifiers, inpatient records, transfer destination) Describe the safe and efficient transportation of patients List common challenges associated with patient transportation during a disaster Identify requirements of patients with special or unique transportation needs Identify need for decontamination Explain the need for PPE and protection of staff performing decontamination Describe environmental and privacy factors that effect decontamination List necessary equipment for decontamination List the necessary requirements and specifications for a patient holding area for use before decontamination Sort patients according to those capable of self-decontamination versus those needing assistance Describe the method for containing and tracking personal/contaminated items Identify and perform all steps necessary for decontamination, including rewarming, reclothing, and retriage

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Table 1. Continued. All-Hazard Disaster Core Competencies for Acute Care Medical Professionals: ED Nurses and Physicians and Out-of-Hospital EMS Domain

Definition

Core Competency

Performance Objectives

14. Clinical considerations

Clinical treatment of specific injuries or illnesses that commonly occur during a disaster

Manage patients with presentations that commonly occur during specific types of disasters, eg, environmental illnesses; burns; blast and crush injuries; nuclear, biologic, and chemical exposure

15. Special-needs populations

Groups whose needs are not fully addressed by traditional services, including but not limited to people with functional disabilities, people with mental illness, non-English speaking people, the elderly, and children

Manage patients within each special-needs population, as appropriate, according to their specific psychosocial, medical, cultural, age, and logistic needs

16. Evacuation

Moving or relocating individuals to a safe area

Perform evacuation, as needed, using preevent evacuation plans and maintaining essential medical information with each patient

17. Critical thinking/ situational awareness

Perception of environmental elements within a given time and space and projection of the change in the status of these elements in the near future

Synthesize information and formulate new plans in an everchanging environment

Recognize the most common patient presentations that occur during specific types of disasters Recognize the types of additional equipment, medications, and treatment modalities that may be needed to provide care for the most common illnesses and injuries during specific types of disasters Identify potential threats with medical implications in response area List and apply the principles for managing patients with the most common victim presentations, eg, environmental illnesses; burns; blast and crush injuries; nuclear, biologic, and chemical exposures Explain how to adapt treatment under austere conditions with limited resources Discuss the implication of underlying chronic medical conditions (ie, congestive heart failure, renal failure) on treatment of unique disaster-related illnesses/injuries List special-needs populations that might be encountered in a disaster situation Describe potential age, cultural, ethnic, and belief differences that may require modifying treatment plans Identify unique medical conditions related to each special-needs population and describe the additional equipment, supplies, and management strategies (including patient transfer) necessary to manage patients in each group Identify situations that require evacuation Identify need for and reasons to shelter in place Identify differences and techniques for immediate versus gradual or delayed evacuation For health care facility evacuation, explain how to keep essential medical information with patients Explain how to track patient location after evacuation Describe event(s) in which awareness of changing situations and environments results in modification of plans and actions Given a series of changing situations, demonstrate how to integrate and react to new information Explain the need for assuming leadership duties as needed Integrate nonmedical factors that influence decisions (dangerous environments, human behaviors, political issues) Describe procedures for evidence preservation

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Table 1. Continued. All-Hazard Disaster Core Competencies for Acute Care Medical Professionals: ED Nurses and Physicians and Out-of-Hospital EMS Domain

Definition

Core Competency

18. Ethical principles and challenges

Rules or standards governing the conduct (including actions and motives) of those acting as independent individuals or as members of a profession

Apply basic principles of medical ethics to disaster situations

19. Psychosocial issues

Influences of human behavior on disaster management

Respond appropriately to stress- induced and other behaviors in patients, responders, and others during a disaster

Performance Objectives List the basic principles of medical ethics as they apply to disaster situations Describe a strategy for allocating scarce resources in an ethical manner to optimize population outcomes during triage and treatment Discuss important considerations in the provision of palliative care Explain how shifting the focus of patient care from individual to population outcomes changes patient management in resource-scarce environments Provide defensible solutions to a series of ethical dilemmas arising in a disaster Identify other human behaviors that put individuals at risk during a disaster (eg, refusing vaccinations, refusing to evacuate) Identify common human stress reactions during a disaster List the acute and long-term consequences of exposure to austere or overwhelming situations Recognize the need for psychological first aid for responders, patients, and other victims List the appropriate steps for requesting psychological first aid for responders, patients, and other victims

NRF, National Response Framework; NIMS, National Incident Management System; ICS, Incident Command System; IMS, incident management system; PPE, personal protective equipment; GO, governmental organization; NGO, nongovernmental organization; DMAT, disaster medical assistance team; USAR, urban search and rescue team; MRC, medical reserve corps.

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for various levels of functional job performance and is based on a participant’s ability to demonstrate the attainment or mastery of those requirements. Emphasize concepts, not just skills, eg, triage: Disaster environments may be complex and evolve over time. Simple application of skills may therefore be inadequate for optimizing outcomes. Competent practitioners must learn to perform or apply requisite skills in a variety of circumstances. Learning overarching principles or concepts related to specific skills will enable practitioners to adapt to differing challenges and to perform within a variety of expected and unexpected situations. Emphasize nomenclature: Use of a standardized nomenclature that is clear to everyone involved in managing a disaster is essential to avoid miscommunication and inappropriate application of limited resources. Modular course design/self-paced/Web delivered: Dividing educational/training materials into modules that can be accomplished in a shorter period would facilitate delivery of these competencies to a busy professional audience. In addition, self-paced and Web-delivered approaches would

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provide adult professionals a learning environment that is adaptable to their personal situations. Provide continuing educational credit/continuing medical education/continuing education units: Offering educational credit to professional audiences places value on the course offerings and provides an incentive for achievement. Designate courses as required by appropriate agencies/groups: When appropriate agencies or groups require specific courses or experiences, then the competencies will be integrated as part of specific training programs. Deliver as preconference activity, especially to introduce the course, to excite interest: As competency-based materials are developed, they could be offered as workshops or seminars before professional conferences. This would introduce the materials to a broad audience and increase motivation and interest.

DISCUSSION The essential role of acute care medical personnel during any type of disaster or large-scale emergency accentuates the need for standardized all-hazard disaster training. Comprehensive core Annals of Emergency Medicine 203

Disaster Core Competencies for Acute Care Medical Personnel competencies provide a blueprint for the design and development of courses and curricula to prepare this audience to respond effectively. Using this set of standardized core competencies to train the target audience should result in an understanding of the demands and requirements for each professional group and heighten the importance of collaboration and cooperation. The integration of the 3 disciplines was an important part of the process that made these efforts unique. Emergency care is often delivered by a team, with medicine, nursing, and EMS each playing unique but interlocking roles. The care delivered by each group cannot be provided in a vacuum but is sometimes interdependent on what treatment the other has provided, is providing, or will provide. The belief is that this kind of collaboration builds a stronger basis for training when competencies are cross-referenced. As an example, the specific knowledge and skills required to care for crush injury victims after an earthquake will be different for EMTs, nurses, and physicians. However, they all must have competency within their specialty to manage crush injury victims. As such, the competencies must be the same for each. Core competencies developed during this project focused specifically on acute care medical personnel. Other existing core competencies for disaster preparedness addressed broad, general health care audiences. The competencies established here examined existing content to refine the specific knowledge, skills, and attitudes required by emergency physicians, nurses, and EMS professionals in responding to disaster situations. Table 2 demonstrates the relationship between one set of existing domains and the domains and competencies created during this project. Instructional Strategies The core competencies and the associated performance objectives provide the content blueprint for creation of allhazard training courses. An important element of instructional design methodology is to ensure that the instructional strategies used to teach the content match the performance objectives and meet the identified training needs. As courses or curricula are created, objectives should be examined, as well as audience characteristics, barriers, existing materials, and potential training formats. Instructional strategy suggestions made by the stakeholders include the following: ● Use a blended learning approach, eg, reading materials, online presentations, live instructor-led skill sessions: Blended learning refers to mixing different educational environments. By using a variety of different learning modalities, course designers can provide learners and instructors with a more effective environment according to the objectives being taught and the characteristics of the learners. An approach using instructor-led scenario-based sessions and online, self-based learning would be effective because the competencies include both knowledge objectives and performance objectives. ● Use distance learning, eg, Web-based learning modules: Because the target audiences are working professionals, the use of techniques allowing access to parts of the training as a 204 Annals of Emergency Medicine

Schultz et al self-paced and self-scheduled delivery would allow broader participation. Even though Web-based modules could be used for many objectives, it is more difficult to create an online learning experience for performance-based instruction than for competencies such as terminology. ● Integrate realistic scenarios or exercises to enhance interactivity: Realistic scenarios would be effective techniques for performance-level learning that requires learners to experience how specific disasters might evolve over time. ● Apply active learning techniques effective with the learning style of the target audience: Consideration for the learning styles of the target audience is a basic building block of effective instruction. When training is designed for professional adults, characteristics such as background experience, limited time, desire for immediate results, and application to their actual environments should be a priority. ● Teach the target audience together, but account for their differences, eg, the advanced cardiac life support model: The 3 target audience groups (physicians, nurses, EMTs) may have different learning needs that should be taken into consideration when a course or learning experience is designed. For example, there may be differences among the groups in reading level, attention span, or level of background knowledge and experience. However, in a real disaster setting, collaboration and communication among these groups become paramount. Course designers should incorporate a variety of techniques to minimize differences and emphasize teamwork. Another fundamental component of developing effective training materials is to create a formal plan for evaluating both the learners and the course. This would entail writing and validating plans for assessing mastery of the core competencies, as well as completing pilot tests and collecting summative evaluation information when the course is delivered. To address concerns related to instructional quality and credibility, the stakeholders recommended investigating a collaborative effort, for example, partnering with appropriate professional organizations, and following the model used in the development of the American College of Emergency Physicians/Centers for Disease Control and Prevention Blast Injury Project.7 Subsequent Objectives Task force members identified 3 additional objectives after completion of the project. The first objective was approval of the core competencies as a standard for the development of all-hazard disaster curricula and training courses for acute care medical professionals by each of their respective professional organizations. The second objective was wide dissemination of the core competency list to all professional organizations and other interested groups. The third objective was to disseminate this information by publishing articles and presenting at conferences. Once the core competencies are disseminated and adopted as standards, curricula and courses can be developed. Ultimately, after creating and implementing such instruction to acute care medical personnel, it will be possible to measure the outcomes of the Volume , .  : March 

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Table 2. Relationship between one set of existing domains and the domains and competencies created during this project.* Core Competencies for All Health Professionals in a Disaster: A Consensus-Based Educational Framework and Competency Set for the Discipline of Disaster Medicine and Public Health Preparedness3 Domain 1. Preparation and planning

2. Detection and communication

3. Incident management and support systems

Core Competency 1.1 Demonstrate proficiency in the use of an all-hazards framework for disaster planning and mitigation. 1.2 Demonstrate proficiency in addressing health-related needs, values, and perspectives of all ages and populations in regional, community, and institutional disaster plans 2.1 Demonstrate proficiency in the detection of and immediate response to a disaster or public health emergency 2.2 Demonstrate proficiency in the use of information and communication systems in a disaster or public health emergency 2.3 Demonstrate proficiency in addressing cultural, ethnic, religious, linguistic, socioeconomic, and special health-related needs of all ages and populations in regional, community, and institutional emergency communication systems 3.1 Demonstrate proficiency in the initiation deployment and coordination of national regional, state, local, and institutional incident command and emergency operations systems 3.2 Demonstrate proficiency in the mobilization and coordination of disaster support services. 3.3 Demonstrate proficiency in the provision of health system surge capacity for the management of mass casualties in a disaster or public health emergency

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All-Hazard Disaster Core Competencies for Acute Care Medical Professionals: ED Nurses, Emergency Physicians, and Out-of-Hospital EMS: RWJ/Emergency Medicine Foundation Grant Consensus Project Domain

Core Competency

1. Nomenclature 2. IMS (NRF, NIMS, ICS)

1.1 Comprehend orders, tasks, requests, conversations, and other forms of communication, including professional vocabulary, related to all-hazard preparedness and response 2.1 Demonstrate an ability to follow and work within an IMS

3. Recognition, notification, initiation, and data collection

3.1 Recognize a disaster is in progress, assess and report the situation, initiate the disaster plan, notify the appropriate persons/agencies, and identify important data for inclusion in postevent report

4. Communication (inter/ intra-agency, media) 5. Resource management 6. Volunteer management (invited/spontaneous or convergent) 7. GO- and NGO-sponsored response teams 10. Surge capacity/capability 11. Patient identification and tracking 12. Transportation 13. Decontamination 15. Special needs populations 19. Psychosocial issues

4.1 Communicate effectively and efficiently within and among agencies, as well as with the media, during any disaster 5.1 Manage supplies, pharmaceuticals, equipment, and other resources for an effective response 6.1 Manage, supervise, and appropriately use volunteers 7.1 Use the resources provided by GOs and NGOs effectively (such as DMAT, USAR, MRC, and the Red Cross) 10.1 Participate in a process that secures adequate personnel, supplies, equipment and space for patient care 11.1 Use recordkeeping processes to ensure continuity of patient information 12.1 Facilitate or perform patient transport effectively and safely during a disaster 13.1 Decontaminate patients or staff, following appropriate procedures 15.1 Manage patients within each special-needs population, as appropriate, according to their specific psychosocial, medical, cultural, age, and logistic needs

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Table 2. Continued. Core Competencies for All Health Professionals in a Disaster: A Consensus-Based Educational Framework and Competency Set for the Discipline of Disaster Medicine and Public Health Preparedness3 Domain

Core Competency

All-Hazard Disaster Core Competencies for Acute Care Medical Professionals: ED Nurses, Emergency Physicians, and Out-of-Hospital EMS: RWJ/Emergency Medicine Foundation Grant Consensus Project Domain

Core Competency 19.1 Respond appropriately to stress- induced and other behaviors in patients, responders, and others during a disaster

4. Security and safety

5. Clinical/public health assessment and intervention

6. Contingency, continuity, and recovery

4.1 Demonstrate proficiency in the prevention and mitigation of health, safety, and security risks to yourself and others in a disaster or public health emergency 4.2 Demonstrate proficiency in the selection and use of personal protective equipment at a disaster scene or receiving facility 4.3 Demonstrate proficiency in victim decontamination at a disaster scene or receiving facility 5.1 Demonstrate proficiency in the use of triage systems in a disaster or public health emergency 5.2 Demonstrate proficiency in the clinical assessment and management of injuries, illnesses, and metal health conditions manifested by all ages and populations in a disaster or public health situation 5.3 Demonstrate proficiency in the management of mass fatalities in a disaster or public health situation 5.4 Demonstrate proficiency in public health interventions to protect the health of all ages, populations, and communities affected by a disaster or public health emergency 6.1 Demonstrate proficiency in the application of contingency interventions for all ages, populations, institutions, and communities affected by a disaster or public health emergency 6.2 Demonstrate proficiency in the application of recovery solutions for all ages, populations, institutions, and communities affected by a disaster or public health emergency

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14. Clinical Considerations 9. Patient triage

14.1 Manage patients with presentations that commonly occur during specific types of disasters, eg, environmental illnesses, burns, blast and crush injuries, and nuclear, biologic, and chemical exposure 9.1 Prioritize patients to maximize survivability

16. Evacuation 17. Critical thinking/situational awareness

16.1 Perform evacuation, as needed, using pre-event evacuation plans and maintaining essential medical information with each patient 17.1 Synthesize information and formulate new plans in an ever-changing environment

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Table 2. Continued. Core Competencies for All Health Professionals in a Disaster: A Consensus-Based Educational Framework and Competency Set for the Discipline of Disaster Medicine and Public Health Preparedness3 Domain 7. Public health law and ethics

All-Hazard Disaster Core Competencies for Acute Care Medical Professionals: ED Nurses, Emergency Physicians, and Out-of-Hospital EMS: RWJ/Emergency Medicine Foundation Grant Consensus Project

Core Competency

Domain

Core Competency

7.1 Demonstrate proficiency in the application of moral and ethical principles and policies for ensuring access to and availability of health services for all ages, populations, and communities affected by a disaster or public health emergency 7.2 Demonstrate proficiency in the application of laws and regulations to protect the health and safety of ages, populations, and communities affected by a disaster or public health emergency

8. Public health and safety 18. Ethical principles and challenges

8.1 Prevent and mitigate risks to self and others 18.1 Apply basic principles of medical ethics to disaster situations

*This example serves as a crosswalk between an existing training system’s approach and the current recommendations. It will be most useful for persons who are developing education and training to give a better understanding of how to apply the methodology used in this project. For those interested only in the final product, Table 1 should be sufficient.

training process. Possible strategies to assess efficacy could include measuring the performance of course participants during an actual disaster scenario or assessment of knowledge and skill retention some time after attending a training course. A national standardized set of core competencies for all-hazard disaster training of acute care medical personnel will meet the needs of large, diverse audiences. Training based on standardized competencies will ensure that acute care medical professionals practice, demonstrate, and maintain the knowledge and skills required for effective response to disaster-related emergencies. The core competencies and associated performance objectives presented here provide a flexible framework that can be adapted for local and changing training needs. The desired outcome expressed by the stakeholders is that this material become a national standard for training acute care medical professionals. Supervising editor: Kathy J. Rinnert, MD, MPH Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The project was funded by a grant from the Robert Wood Johnson Foundation. Publication dates: Received for publication January 27, 2011. Revision received August 25, 2011. Accepted for publication September 6, 2011. Available online October 7, 2011.

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Address for correspondence: Carl H. Schultz, MD, E-mail [email protected].

REFERENCES 1. Waeckerle JF, Seamans S, Whiteside M, et al, on behalf of the Task Force of Health Care and Emergency Services Professionals on Preparedness for Nuclear, Biological, and Chemical Incidents. Executive summary: developing objectives, content, and competencies for the training of emergency medical technicians, emergency physicians, and emergency nurses to care for casualties resulting from nuclear, biological, or chemical (NBC) incidents. Ann Emerg Med. 2001;37:587-601. 2. Hick JL, Penn P, Hanfling D, et al. Establishing and training health care facility decontamination teams. Ann Emerg Med. 2003;42: 381-390. 3. Subbarao I, Lyznicki JM, Hsu EB, et al. A competency-based educational framework and competency set for the discipline of disaster medicine and public health preparedness. Disaster Med Public Health Preparedness. 2008;2:57-68. 4. Merrill MD. Instructional Design Theory. Englewood Cliffs, NJ: Educational Technology Publications; 1994. 5. Clark RC. Developing Technical Training: A Structured Approach for Developing Classroom and Computer-based Instructional Materials. 3rd ed. Pfeiffer; San Francisco, CA: 2007. 6. Moore MG, Kearsley G. Distance Education: A Systems View. Belmont, CA: Wadsworth Publishing Co; 1996. 7. American College of Emergency Physicians. Bombings: injury patterns and care. 2007. Available at: http://www.acep.org/ blastinjury/. Accessed August 4, 2011.

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APPENDIX Members, National Standardized All-Hazard Disaster Core Competencies Task Force. American Academy of Pediatrics (AAP) Craig Huang, MD American College of Emergency Physicians Carl H. Schultz, MD (Task Force Chair) Ramon W. Johnson, MD (American College of Emergency Physicians Board Liaison) American College of Surgeons (ACS) Leonard J. Weireter, MD Content Consultant Kris Powell, RN Department of Homeland Security/Office of Health Affairs Kathryn H. Brinsfield, MD, MPH Emergency Nurses Association (ENA) Andrew Galvin, ACNP, MSN, CEN National Association of EMS Educators (NAEMSE) Robert Waddell, BS, BA National Association of EMS Physicians (NAEMSP) Jullette Saussy, MD Kathy J. Rinnert, MD, MPH National Association of Emergency Medical Technicians (NAEMT) Connie Meyer, RN, Paramedic National Association of State EMS Officials (NASEMSO) Maxie Bishop, RN, LP

Schultz et al Society for Academic Emergency Medicine (SAEM) Kristi L. Koenig, MD American College of Emergency Physicians staff Rick Murray, EMT-P Director of EMS and Disaster Preparedness Department Mary Whiteside, PhD Educational Development Consultant Denise Fechner, ADM Assistant, EMS and Disaster Preparedness Department

INVITED PARTICIPANTS American College of Emergency Physicians Jonathan L. Burstein, MD American Public Health Association (APHA) Georges C. Benjamin, MD Society of Critical Care Medicine (SCCM) James Geiling, MD

FEDERAL PARTNERS Centers for Disease Control and Prevention/Division of Injury Response (CDC) Rick C. Hunt, MD Department of Health and Human Services: Preparedness and Emergency Operations Kevin Yeskey, MD National Highway Traffic Safety Administration (NHTSA) Office of EMS Drew Dawson, Director

IMAGES IN EMERGENCY MEDICINE (continued from p. 176)

DIAGNOSIS: Phlegmasia cerulea dolens. Vascular surgery was urgently consulted for concern about acute arterial or venous occlusion, and a heparin bolus was initiated. Bedside ultrasonography showed a large venous thrombus from the level of the common femoral to popliteal vein (Figure 2). The common femoral artery showed patent Doppler flow (Figure 3). The patient was taken urgently to the operating room for venous thrombectomy. Fasciotomies were also performed, given concern for compartment syndrome. After skin grafting and an uncomplicated hospital course, the patient was discharged home, receiving warfarin with close follow-up. This is a rare variation of venous thrombosis caused by massive iliofemoral thrombosis that leads to significant venous congestion and subsequently compromised arterial circulation. Malignancy is the most common underlying condition.1 Other causes include postoperative state, diabetes, previous deep venous thrombosis, and hypercoagulability.2 Treatment options include conservative management with systemic high-dose heparin versus thrombolysis or surgical thrombectomy.3 REFERENCES 1. Weaver FA, Meacham PW, Adkins RB, et al. Phlegmasia cerulea dolens: therapeutic considerations. South Med J. 1988; 81:306-312. 2. Hood DB, Weaver FA, Modrall JG, et al. Advances in the treatment of phlegmasia cerulea dolens. Am J Surg. 1993;166: 206-210. 3. Chopra A. Thrombophlebitis and occlusive arterial disease. Emergency Medicine: A Comprehensive Study Guide. 6th ed. Tintinalli JE, Kelen GD, Stapczynski JS, eds. New York: McGraw-Hill, 2004:409-418.

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APPENDIX E1 Secondary (“important, but not critical”) content category topics. Resource tracking Debriefing Tactical vs strategic vs operational Outcomes: What do we want from this Cultural Geography (hospital) Capacity determinations vs capability determinations Continuity of operations Critical incident stress debriefing/patients, staff, bystanders Quarantine; isolation Crime scene management, forensics, identify evidence Prophylaxis and other protective measures (vaccines) Surveillance Fatality management Family notifications Pets/animal populations/veterinary medicine/surveillance Legal/legislature/regulatory Search and rescue (hospital)

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Disaster myths, misconceptions, mistakes, lessons learned Role in the emergency operations plan and the partners’ roles (hospital incident command system) Realities, how long it takes decisions to be made, supplies to arrive Nonmedical influences, eg, crowd pressures, psychosocial, political factors Cultural competencies: Seeing how something is viewed from other perspectives Patient history/medications Internally displaced persons Licensure/regulatory Repatriation/separation of families Tribal and territories Resource tracking Role of nonmedical personnel Information security/cyber security International communications Emerging technology

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