Biological emergency response planning plays a critical role in protecting the public from possible devastating results of sudden disease outbreaks. These plans describe the distribution of medical countermeasures across a region using limited resources within a restricted time window. Thus, the ability to determine that such a plan will be feasible, i.e. successfully provide service to affected populations within the time limit, is crucial. Many of the current efforts to validate plans are in the form of live drills and training, but those may not test plan activation at the appropriate scale or with sufficient numbers of participants. Thus, this necessitates the use of computational resources to aid emergency managers and planners in developing and evaluating plans before they must be used. Current emergency response plan generation software packages such as RE-PLAN or RealOpt, provide rate-based validation analyses. However, these types of analysis may neglect details of real-world traffic dynamics. Therefore, this dissertation presents Validating Emergency Response Plan Execution Through Simulation (VERPETS), a novel, computational system for the agent-based simulation of biological emergency response plan activation. This system converts raw road network, population distribution, and emergency response plan data into a format suitable for simulation, and then performs these simulations using SUMO, or Simulations of Urban Mobility, to simulate realistic traffic dynamics. Additionally, high performance computing methodologies were utilized to decrease agent load on simulations and improve performance. Further strategies, such as use of agent scaling and a time limit on simulation execution, were also examined. Experimental results indicate that the time to plan completion, i.e. the time when all individuals of the population have received medication, determined by VERPETS aligned well with current alternate methodologies. It was determined that the dynamic of traffic congestion at the POD itself was one of the major factors affecting the completion time of the plan, and thus allowed for more rapid calculations of plan completion time. Thus, this system provides not only a novel methodology to validate emergency response plans, but also a validation of other current strategies of emergency response plan validation.

OBJECTIVE: Because training in pediatric disaster medicine (PDM) is neither required nor standardized for pediatric residents, we designed and integrated a PDM course into the curriculum of a pediatric residency program and assessed if participation increased participants' knowledge of managing disaster victims. METHODS: We adapted and incorporated a previously studied PDM course into a small-sized pediatric residency program. The curriculum consisted of didactic lectures and experiential learning via simulation with structured debriefing. With IRB approval, the authors conducted a longitudinal series of pretests and posttests to assess knowledge and perceptions. RESULTS: Sixteen eligible residents completed the intervention. Before the course, none of the residents reported experience treating disaster victims. Pairwise comparison of scores revealed a 35% improvement in scores immediately after completing the course (95% confidence interval, 22.73%-47.26%; P < 0.001) and a 23.73% improvement 2 months later (95% confidence interval, 7.12%-40.34%; P < 0.01). CONCLUSIONS: Residents who completed this course increased their knowledge of PDM with moderate retention of knowledge gained. There was a significant increase in perceived ability to manage patients in a disaster situation after this educational intervention and the residents' confidence was preserved 2 months later. This PDM course may be used in future formulation of a standardized curriculum.

Contemporary terrorism is becoming increasingly indiscriminate, and rail bound traffic appears to be vulnerable and at high risk for terrorist attacks. An attack targeting a train or subway system can have enormous implications, both in terms of human suffering and long-term societal consequences. This dissertation aims to analyze how public and private organizations prepare for and respond to crises emanating from terrorism targeting rail bound traffic. It also examines different practices, networks and ideas related to interorganizational collaboration. Contemporary research emphasizes the importance and advantages of collaborative action in crisis management, and the idea of inter-organizational collaboration is also embedded in policy documents and has support among practitioners. Despite this, interorganizational collaboration often turns out to be difficult in practice, and it stands out as a critical factor in many crisis situations. Hence, it is crucial to identify and better understand the challenges associated with interorganizational collaboration in the context of terrorist-induced crises. This dissertation is a contribution to this endeavor. In order to capture the inherent complexity of the topic this dissertation combines and merges literature from three research fields: crisis management research, disaster medicine research and terrorism studies. The dissertation examines international experiences of terrorist attacks directed against rail bound traffic. It identifies the way in which attacks have changed over time and analyzes the main challenges of providing pre-hospital care following a mass-casualty attack. In addition, Sweden is used to provide empirical focus in an analysis of preparedness. Relying on scenario-based interviews with central crisis management actors and actors from rail bound traffic, current preparedness practices for responding to a multi-site terrorist attack on rail bound traffic in Sweden is analyzed. The research shows that both public and private organizations have developed risk awareness about terrorist-induced crises. However, their preparedness practices are characterized by significant variations and substantial uncertainty. Scare resources are a critical factor, and actors find it difficult to invest in preparedness for seldom-occurring crises. This difficulty is accentuated by the fact that no major mass-casualty attack has taken place in Sweden. A terrorist attack differs from a routine event and poses new and different challenges for inter-organizational collaboration. A large number of organizations are supposed to work together under severe time constraints, and their work can be delayed by particular security concerns. It is assumed that rail bound traffic actors engage in collaborative crisis management; however, there appear to be few mechanisms to prepare them, in a systematic way, for managing this particular type of crisis. Among actors, inter-organizational collaboration is understood primarily from a normative view rather than from the point of view of its practical meaning. As a consequence, it is difficult to turn risk awareness and a commitment to working together into actual practical action. In addition, collaboration between different levels in the crisis management system is particularly challenging. This dissertation also identifies a tension between viewing crisis management as an example of policy-as-usual or from a crises-as-exceptions perspective.

Bakgrund: För att upprätthålla en så normal kvalitet på vården som möjligt och minska det psykiska och fysiska lidandet vid stora olyckor och katastrofer måste resurserna ledas och fördelas på ett annat sätt än i sjukvårdens vardagsorganisation. Detta medför en omställning i sättet att bedriva sjukvård på till katastrofmedicinsk metodik. Anestesisjuksköterskan är en viktig del i den katastrofmedicinska beredskapen men hur anestesisjuksköterskan själv uppfattar sin roll är ett sparsamt utforskat område. Syfte: Syftet med denna studie var att beskriva anestesisjuksköterskans uppfattning om sin roll vid stora olyckor och katastrofer. Metod: En kvalitativ metod användes, där 10 semistrukturerade intervjuer med anestesisjuksköterskor har analyserats med en kvalitativ innehållsanalys. Resultat: Efter analys framkom fyra kategorier; vara en del i något större, vara närmast patienten, genom sin profession känna trygghet och medvetenhet och få förutsättningar att fungera i sin roll. Det genomgående temat i anestesisjuksköterskans uppfattningar är att genom sin profession vara en livsviktig nyckelfunktion med vilja att verka i den på bästa sätt. Konklusion: Anestesisjuksköterskan har en betydelsefull och komplex roll i den katastrofmedicinska beredskapsorganisationen men efterfrågar kunskap och utbildning för att kunna verka effektivt och säkert. Den katastrofmedicinska beredskapen måste lyftas och medvetandegöras i verksamheten.

The roles that universities played in the response to the Fukushima nuclear disaster were significant and varied; however, there was limited study on participating graduate students. The purpose of this study was to understand the impact of disaster response on graduate students' personal and academic development. This study examined research questions about the perceived impact on academic and personal identity development. Empowerment, cognitive content engagement, general systems theory, and utilitarianism formed the theoretical foundation. This study used a transcendental phenomenological approach to examine the subjects' experiences in the context of involvement in disaster response. The primary source of data was semiopen interviews with individuals that were publicly recruited graduate students at the time of their involvement in the Fukushima nuclear disaster response; data were triangulated with interviews from faculty supervisors. Analyzing the data resulted in the themes of predisaster normality, proximal impact, stress, perception of foreignness, relationships, breakdowns in relationships, change, new relationships, and religion. Interpreting these themes, it was determined that proximity played a role in the decision to engage in the response effort. Furthermore, identification with victims increased the stress of participants. While the experience was empowering, caution is necessary. Further research is recommended into disaster recovery, the role of interpreters in disaster response, and the role of universities in disaster infrastructure. This information can promote social change by enabling graduate students and gatekeepers to better understand potential outcomes for incorporating graduate students into disaster infrastructure.

Dagens samhälle präglas av globalisering och hög grad av sammankoppling mellan länder och sektorer, vilket även bidrar till sårbarheter. Komplexa risker som präglas av osäkerhet, tvetydighet och konsekvenser med potentialen att få spridningseffekter hotar samhällsviktig verksamhet och därigenom samhällets funktionalitet. Sjukhus är en typ av samhällsviktig verksamhet som behöver upprätthållas för att samhället ska kunna fungera. Skydd av samhällsviktig verksamhet kan uppnås genom en kombination av riskhantering, kontinuitetshantering och incidenthantering. Kontinuitetshantering syftar till att minimera avbrottstider i kritisk verksamhet och tillse att oacceptabla konsekvenser undviks. Internationellt sett har kontinuitetshantering visat sig vara ett effektivt verktyg om det nyttjas korrekt och med rätt kompetens. Det har hittills saknats studier som undersökt hur kontinuitetshantering används på svenska sjukhus, och hur representanter för regionala aktörer som arbetar med kontinuitetshantering ser på verktyget. Syftet med den här studien var därför ”att bidra till en ökad förståelse för implementeringen av kontinuitetshantering på svenska sjukhus, samt synliggöra faktorer som bidrar till respektive hindrar den implementeringen”.Datainsamling skedde genom kvalitativa semistrukturerade intervjuer med fem respondenter med erfarenhet av kontinuitetshantering på svenska sjukhus. Insamlade data bearbetades därefter genom kvalitativ innehållsanalys, och resulterade i två huvudkategorier med två respektive sex underkategorier. Resultatet visar att kontinuitetshantering ses som både ett förhållningssätt och ett verktyg, där målbilden är att genom kontinuitetshantering som verktyg utveckla en plan B för inom sjukhus kritisk verksamhet. Samtidigt ses kontinuitetshantering även som ett förhållningssätt, som präglar den vardagliga verksamheten och i förlängningen har förmåga att bidra till ökad resiliens på svenska sjukhus. Resultatet visar även att risken för att kontinuitetshantering inte ger önskat resultat kan bero på låg kompetens, att underliggande vägledningar upplevs svåra att följa eller att resurser prioriteras till andra arbetsuppgifter.Studiens resultat diskuteras utifrån tidigare vetenskapliga fynd, framgångsfaktorer och hinder för praktisk implementering och även i förhållande till katastrofmedicinsk beredskap, samhällssäkerhet och huruvida kontinuitetshantering kan anses bidra till ökad resiliens på svenska sjukhus. Framtida forskning bör bland annat fokusera ytterligare på det praktiska genomförandet på verksamhetsnivå och lärdomar från störningar där kontinuitetsplaner använts skarpt på svenska sjukhus. / Modern society is largely globalized and different countries as well as sectors are intertwined to a large extent, giving arise to increased vulnerabilities. Complex risk characterized by uncertainty, ambiguity, and consequences with the potential of spill-over effects threaten vital societal functions with the possibility of huge consequences for society. Hospitals are an example of these types of institutions that are critical for a society’s functionality to be upheld. The protection of vital societal functions can be achieved by risk management, business continuity management [BCM] and incident management. BCM aims to minimize disruptions in critical activities and to make sure that unacceptable consequences are avoided. In an international context BCM has been proved efficient when used properly and with the correct competencies in the organization in which it is to be applied. So far, no studies have investigated the usage of BCM in Swedish hospitals, and how the method and concept is viewed by actors on a regional level. Due to this, the aim of this study was to “contribute to knowledge regarding the implementation of business continuity management in Swedish hospitals, as well as map factors promoting and hindering that implementation.”. Data was collected through qualitative semi-structured interviews with five respondents who work with BCM on a regional level in Sweden with a focus on health care. Collected data was analyzed through qualitative content analysis and resulted in two main categories with two and six subcategories respectively. The result shows that BCM is viewed as both an approach and as a tool. As a tool with the goal of creating a plan B for critical operations within a system, as well as an approach to everyday operations within the organization. Together these two viewpoints have the ability of increasing resilience in Swedish hospitals. The result also shows that the risk of BCM not resulting in the aspired outcome might be due to low level of understanding of the concept and method, or that resources needed are prioritized to other areas.The result is discussed from a perspective of past research, as well as practical implementations based on hindering and promoting factors. It is also discussed in relation to disaster medicine, societal safety and how BCM can contribute to increased resilience in Swedish hospitals. Future research should focus on the practical implementation of BCM on an organization’s operative level and lessons learned from real incidents where business continuity plans have been used.

A study to evaluate the level of hospital preparedness to respond to a bioterrorist attack such as smallpox or anthrax, in the western United States (Arizona, California, Idaho, Nevada, Oregon and Washington) was conducted from May to September 2000. A survey questionnaire was mailed to 300 randomly selected hospitals. A telephone survey followed. The data examined the population served, licensed bed capacity, median income of the population served, the geographic location, and the type of facility served. The findings from the 177 hospitals that answered the survey showed that only 28.8% of them had a specific plan in place in the event of a bioterrorist attack to their communities. More hospitals with large bed capacity serving large populations had plans to respond to the event of a bioterrorist attack than those hospitals with small bed capacity, usually serving small rural communities. Although the comparison of hospitals in each of the six western states showed no statistically significant difference between the number of hospitals with a plan to respond to a biological threat, hospitals in California showed the largest percentage of specific plans addressing biological events, followed by hospitals in the state of Washington. When the type of facility was considered, private hospitals more often developed a plan due to high-density population through their area than non-private hospitals, which indicates that bioterrorism plans may be developed when the funds are available. The most frequent answer given for not developing a plan was lack of adequate funding. Findings indicated a need for additional resources directed to hospitals, especially in rural areas. Because this study was conducted before the tragic terrorism events occurred in the United States in the fall of 2001, it may be considered a benchmark for future readiness evaluations of the response to the impact of those events in the Western states. / Graduation date: 2004

Readiness of the urgent reception to mass disasters This thesis is dedicated to the readiness of the urgent reception to mass disasters. It deals with the history, evolution and the current state of the urgent reception, both in the Czech Republic in the first place and in the world. Within the scope of this thesis I focus mainly on the work scope of the urgent receptions in dependence to their structure, equipment and their actual preparedness to deal with mass accidents. I focus besides other things on technical equipment of the urgent receptions, which is in frames of the Czech Republic very heterogeneous, but totally crucial to handle possible mass accident. A very import aspect is the matter of education and further training of the medical employees on all levels. It concerns not only medical positions, but also nurses and auxiliary staff. The question of the conditions severity of the admitted patients, their classification according to these conditions and transparent processing of the information about them cannot be passed over. Furthermore the thesis discusses emergency medicine as a discipline and the direction it should, in my opinion, further be heading in order to improve the functioning of the present system of pre-hospital and hospital emergency care. Urgent receptions in the Czech Republic represent a relatively new thing, which results into certain ambivalence of their concept and structure. Each urgent reception is somehow original and adapted to the requirements of the founder and the local situation. There is one thing the urgent receptions have in common, overload with patients who fall into the competence of practitioners. This is associated with the financial loss-making of these departments within the medical facilities. This, especially in the case of the private hospitals, leads to a reluctance of the founder to invest to the urgent reception. In this thesis I mention legal framework, contingency planning in the Czech Republic, contingency plans, their content purpose and type plan with its importance for solving crisis events. Another plan that is resolved in my thesis and that has crucial importance especially, for urgent receptions is the trauma plan of medical facility whose application into practice in the Czech Republic in many health care facilities is very problematic. And the practice of the trauma plan activation itself is, according to my research, the prerogative of only a very small amount of medical facilities.

Mass accidents and catastrophes do not occur on a daily scale, they occur irregularly and unpredictably and always have devastating consequences that negatively affect the society or nature. They are usually accompanied by a large number of casualties or damage whose removal cannot be managed using usual local means. To cope with such events, it is necessary to have a professionally trained staff in the Integrated Rescue System and an appropriate coordination of rescue and liquidation. In recent years, there has been an increase of such incidents which have resulted in a mass disability of people. The events of recent days have brought a series of terrorist acts, for example in Paris or Brusselles, of suicide bombings that claimed 130 dead and numerous wounded. These acts, which are associated with the current migration crisis on the European continent, cause considerable tension in the society and evoke questions like whether the readiness of IRS to eliminate the consequences of such events is sufficient. Due to these facts, the thesis tries to find out what knowledge the members of the emergency medical service in South Bohemia have on the issue of disaster medicine and mass accidents. The theoretical part of the thesis titled Knowledge of the Members of the Emergency Medical Service in SB on Disaster Medicine and Mass Accidents defines disaster medicine and all tasks and subjects it deals with. It also mentions the Integrated Rescue System including its basic and other components, its powers and organizational structure resulting from the legislation. Furthermore, it describes the security system and planning, specifically crisis and emergency planning, up to the individual partial plans related to this issue. Finally, the thesis deals with the organization of emergencies with a mass disability of people and a detailed procedure of medical emergency regarding the sorting and evacuation of the wounded. The aim of this thesis is to map the knowledge of the members of the emergency medical service in SB, which concern the issue of disaster medicine and mass accidents, where the level of knowledge is later analyzed to confirm or disprove the hypothesis that the knowledge of the SB IRS members corresponds with a normal distribution frequency. The practical part uses a quantitative method based on questionnaires completed anonymously, where 50 questionnaires were selected randomly as a statistical set. The survey focuses on a group of emergency workers in South Bohemia. The meetings with them were organized during previous practical studies. The results of the survey were analyzed using statistical investigation. The statistical investigation used the methods of scaling, measurement of the absolute, relative and cumulative frequency. Later on, the empirical parametres used for non-parametric testing were counted. The results of this pilot study indicate the current state of the knowledge of the SB IRS members on disaster medicine and mass accidents. The thesis will be a beneficial study material for current and future paramedics and students of the field of population protection.

Medical rescue workers are routinely employed in emergency medicine. In emergencies where a large number of people are affected, knowledge of medical disaster practices is necessary. Within a second, the intervening crews should switch to another mode with a different approach to the patients than they use daily. The diploma thesis has set the following goals: to map the level of knowledge of medical rescuers in the field of emergency response with mass health impairment, their personal experience and, last but not least, education and training. Three research questions were asked to reach these objectives. What are the skills of medical rescuers in dealing with emergency health issues with mass health impairment? How do medical rescuers assess incidents with mass health impairment at which they were present and what is their attitude towards training and education in the field of dealing with emergencies with mass health impairment? The research part consists of interviews with two groups of participants: eight medical rescuers of the Medical Rescue Service of the Pardubice Region and the same number of medical rescuers of the Medical Rescue Service of the South Bohemian Region. These interviews supplemented the information provided by the crisis preparedness managers of both medical rescue services. The survey used a qualitative research strategy, conversations were recorded on a dictaphone, then processed into categories, subcategories, tables and evaluated. From the results of the work, a great difference in the knowledge of health rescuers in the field of emergency health problems can be seen. Participants of the South Bohemian Medical Emergency Rescue Service showed shortcomings in both the basic terminology and the solving of extraordinary events in particular, from reporting the situation with a report form to the classification of the disabled. On the contrary, the majority of participants in the Paramedical Rescue Service of the Pardubice Region would be able to file an initial emergency report and categorize and transport patients correctly. On the basis of the evaluated results, this difference in knowledge can be attributed mainly to the frequency and content of the training provided. In the case of South Bohemian participants, we can find the cause in the absence of practical training. The alarming results were noted in the participants' ability to use the START sorting method, from all of the sixteen respondents only one was able to answer there. The elaborated case report of an extraordinary event points to the fact that theoretical shortcomings can subsequently be transferred into practice.