Master of Science / Department of Industrial & Manufacturing Systems Engineering / Malgorzata J. Rys / Emergency department (ED) overcrowding is a nationwide problem affecting the safety and preparedness of our health care system. Many hospital EDs face significant short and intense surges in demand on a daily basis. However, the surge in demand during disaster event is not short and intense, but it is a sustained one. In order to meet this sudden surge as defined above, hospital EDs need to be more prepared and efficient to cater to increased volume of demand involving huge uncertainties. This thesis looks at the creation and use of discrete event simulation modeling using ARENA 10.0 software. In this thesis, an attempt is made to show how the different arrival patterns and time durations for which victims keep arriving affect the EDs ability to treat the patients. It is shown, how the model can be used to estimate additional resources that would be required to accommodate additional patients within the ED. Various shapes of arrival distributions were tested for different time durations. It was found that the arrival distribution with parameters (3, 4), (3, 3), (4, 2) and (2, 4) did not challenge the institutional capacity. In other words, the hospital was able to treat all the patients without compromising the quality of care up to 24 hours. However, distribution with parameter (3, 2), (2, 2), (3, 1), (1, 2), (2, 3), (2, 1), (1, 4), (1, 3), (1, 1) and (0.5, 2) did affect the system performance. Under these distributions, there was at least one patient who was either dead, LWBS or diverted. This indicates the immediacy with which victims arriving under these distributions overwhelmed the limited resources Our aim was to study, how many more resources would the ED need in order to have zero critical expire, zero Left without Being Seen (LWBS) and zero patients diverted. Arrival distribution (1, 2) was randomly selected to study this objective and it was found that for a 24 hours of simulation run time, an additional of two full trauma resources were required in order to have zero critical expire in trauma rooms area and additional of five ED beds and three nurses were required in treatment area for patients with moderate severity to have zero LWBS. With these additional resources, the ED was also able to treat all the non disaster related patients thereby having zero patients diverted. The same procedure can be used to determine the number of additional resources ED would require to treat all the victims arriving with the rest of the arrival distribution for different time periods. The simulation model built would help the emergency planners to better allocate and utilize the limited ED resources in order to treat maximum possible patients. It also helps estimate the number of additional resources that would be required in a particular scenario.

In this thesis, we explore three critical emergency logistics problems faced by healthcare and humanitarian relief service providers for short-term post-disaster management. In the first manuscript, we investigate various integration mechanisms (fully integrated horizontal-vertical, horizontal, and vertical resource sharing mechanisms) following a natural disaster for a multi-type whole blood-derived platelets, multi-patient logistics network. The goal is to reduce the amount of shortage and wastage of multi-blood-group of platelets in the response phase of relief logistics operations. To solve the logistics model for a large scale problem, we develop a hybrid exact solution approach involving an augmented epsilon-constraint and Lagrangian relaxation algorithms and demonstrate the model's applicability for a case study of an earthquake. Due to uncertainty in the number of injuries needing multi-type blood-derived platelets, we apply a robust optimization version of the proposed model which captures the expected performance of the system. The results show that the performance of the platelets logistics network under coordinated and integrated mechanisms better control the level of shortage and wastage compared with that of a non-integrated network. In the second manuscript, we propose a two-stage casualty evacuation model that involves routing of patients with different injury levels during wildfires. The first stage deals with field hospital selection and the second stage determines the number of patients that can be transferred to the selected hospitals or shelters via different routes of the evacuation network. The goal of this model is to reduce the evacuation response time, which ultimately increase the number of evacuated people from evacuation assembly points under limited time windows. To solve the model for large-scale problems, we develop a two-step meta-heuristic algorithm. To consider multiple sources of uncertainty, a flexible robust approach considering the worst-case and expected performance of the system simultaneously is applied to handle any realization of the uncertain parameters. The results show that the fully coordinated evacuation model in which the vehicles can freely pick up and off-board the patients at different locations and are allowed to start their next operations without being forced to return to the departure point (evacuation assembly points) outperforms the non-coordinated and non-integrated evacuation models in terms of number of evacuated patients. In the third manuscript, we propose an integrated transportation and hospital capacity model to optimize the assignment of relevant medical resources to multi-level-injury patients in the time of a MCI. We develop a finite-horizon MDP to efficiently allocate resources and hospital capacities to injured people in a dynamic fashion under limited time horizon. We solve this model using the linear programming approach to ADP, and by developing a two-phase heuristics based on column generation algorithm. The results show better policies can be derived for allocating limited resources (i.e., vehicles) and hospital capacities to the injured people compared with the benchmark. Each paper makes a worthwhile contribution to the humanitarian relief operations literature and can help relief and healthcare providers optimize resource and service logistics by applying the proposed integration and coordination mechanisms.

The diploma thesis analyzes the topic of preparedness of individual regional and training centers of medical rescue service providers and employees of such organizations for cases of emergencies with mass casualties. In order to collect the data required for the empirical part of the diploma thesis, I prepared two questionnaires: one was a qualitative research aimed only at managers of educational and training centres of individual regional medical rescue services. The other questionnaire was used for a quantitative research, in the form of an anonymous non-standardized questionnaire, which was prepared for employees of medical rescue service. The evaluation of the results of the questionnaire surveys has shown that in spite of the usually appropriate conditions secured by the medical rescue service providers and in spite of the relatively frequent trainings, the knowledge of individual employees in this field is not sufficient. Based on the results acquired it is obvious that individual educational and training centres of medical rescue service providers should pay more attention to the professional training of their employees on this issue. These results will be, upon request, presented to the representatives of individual educational and training centres, and should be used to make the preparation of their employees for cases of emergencies with mass casualties more effective.

<p>För att kunna erbjuda god och lättillgänglig hälso- och sjukvård vid stora olyckor och katastrofer krävs en katastrofberedskap grundad på planläggning, utbildning och övning. Sjukvårdens särskilda beredskap måste kunna hantera såväl den "lilla vardagsolyckan" som den stora olyckan eller katastrofen. Syftet med denna studie var att undersöka hur enhetschefer och distriktssköterskor vid primärvården i två kommuner i Jämtlands län upplevde sig förberedda inför en katastrof eller en stor olycka där utryckning krävdes utanför vårdinrättningar till olycksplats. Syftet var även att undersöka hur katastrofberedskap prioriteras av enhetschefer. En intervjustudie har genomförts med tre enhetschefer och fem distriktssköterskor. Intervjuerna har analyserats med kvalitativ innehållsanalys. Utifrån analysen skapades två<strong> </strong>kategorier: ”känsla av säkerhet”<strong> </strong>och ”organisation” samt fyra underkategorier ”beredskap”, ”prioritet”, ”förmåga” och<strong> </strong>”kunskap”. Huvudfyndet var att samtliga intervjudeltagare önskade ha övningar för att känna sig mer förberedd vid en stor olycka. I dagsläget övades det inte alls på katastrofberedskap.</p> / <p>In order to provide good and accessible healthcare in case of emergencies and disasters, an emergency plan based on planning, training and practice is required. Special care must be prepared to deal with both the ”small everyday accident” but also the major accident and disaster. The purpose of this study was to examine how unit managers and districtnurses in primary care in two municipalities in Jämtland county experience themselves prepared in case of a disaster or a major accident which requires emergency care facilities outside the unit. The aim was also to examine how emergency preparedness is a priority for the unit managers. An interview study has been carried out with three unitmanagers and five districtnurses. The interviews were analyzed with qualitative content analysis. Based on the analysis two categories were created: 'feeling of security "and" organization "and four sub-categories of" security "," priority "," ability "and" knowledge ". Major findings was that all the interview participants wished to have exercises to feel more prepared for a major accident. For the time being, no practice in disaster preparedness is carried out.</p>

För att kunna erbjuda god och lättillgänglig hälso- och sjukvård vid stora olyckor och katastrofer krävs en katastrofberedskap grundad på planläggning, utbildning och övning. Sjukvårdens särskilda beredskap måste kunna hantera såväl den "lilla vardagsolyckan" som den stora olyckan eller katastrofen. Syftet med denna studie var att undersöka hur enhetschefer och distriktssköterskor vid primärvården i två kommuner i Jämtlands län upplevde sig förberedda inför en katastrof eller en stor olycka där utryckning krävdes utanför vårdinrättningar till olycksplats. Syftet var även att undersöka hur katastrofberedskap prioriteras av enhetschefer. En intervjustudie har genomförts med tre enhetschefer och fem distriktssköterskor. Intervjuerna har analyserats med kvalitativ innehållsanalys. Utifrån analysen skapades två kategorier: ”känsla av säkerhet” och ”organisation” samt fyra underkategorier ”beredskap”, ”prioritet”, ”förmåga” och ”kunskap”. Huvudfyndet var att samtliga intervjudeltagare önskade ha övningar för att känna sig mer förberedd vid en stor olycka. I dagsläget övades det inte alls på katastrofberedskap. / In order to provide good and accessible healthcare in case of emergencies and disasters, an emergency plan based on planning, training and practice is required. Special care must be prepared to deal with both the ”small everyday accident” but also the major accident and disaster. The purpose of this study was to examine how unit managers and districtnurses in primary care in two municipalities in Jämtland county experience themselves prepared in case of a disaster or a major accident which requires emergency care facilities outside the unit. The aim was also to examine how emergency preparedness is a priority for the unit managers. An interview study has been carried out with three unitmanagers and five districtnurses. The interviews were analyzed with qualitative content analysis. Based on the analysis two categories were created: 'feeling of security "and" organization "and four sub-categories of" security "," priority "," ability "and" knowledge ". Major findings was that all the interview participants wished to have exercises to feel more prepared for a major accident. For the time being, no practice in disaster preparedness is carried out.

In 2011 and 2012, dramatic changes were made to the health care reform in the Czech Republic. As a consequence, almost the complete legislation related to traumatological planning was changed. This reform primarily introduced two new types of operating divisions; a department of emergency preparedness, as for the emergency medical service providers, and a contact point, from the aspect of emergency inpatient care providers. Emergency preparedness primarily processes a concept of the traumatological plan for the emergency medical service and introduces potential changes. The contact point, as a department of the emergency inpatient care with continuous operation, receives calls from the emergency medical service, especially in the event of emergencies and crisis situations. The given Master's Diploma Thesis entitled "Cooperation of the Trauma Centre of the Hospital České Budějovice and Medical Operation Center of the Emergency Medical Service of the South Bohemian Region in the Event of Mass-Casualty Incident" develops a key issue of the interconnection of traumatological plans established by health service providers within the South Bohemian Region and the level of their cooperation. Then the work analyses three mass-casualty incidents which happened in the past within the area and the level of involvement and cooperation of the aforementioned departments, i.e. the Hospital's trauma centre and Medical Operation Centre upon the Medical Emergency Centre of the Region of South Bohemia. The Diploma Thesis proceeds from the qualitative research which is divided into two parts. The first one defines the V1 research question specifying the role of the Traumatological Plan of the South Bohemian health care during the cooperation with the trauma centre under the Hospital České Budějovice and medical operation centre of the Medical Emergency Service of the South Bohemian Region in the event of a mass-casualty incident. By using a comparative method, which assessed the three traumatological plans, the level of cooperation did not exceed more than 20 % owing to the fact that the Traumatological Plan of the South Bohemian health care is out-dated. As a consequence, the answer to the V1 research question was following: The role of the Traumatological Plan of the South Bohemian health care with the cooperation of the trauma centre under the Hospital České Budějovice and Medical operation centre of the Medical Emergency Service of the South Bohemian Region in the event of a mass-casualty incident is insignificant. The second part develops the V2 research question: whether the failure in communication between the aforementioned trauma centre and medical operation centre could have any impact on the injured in the event of a mass-casualty incident. The qualitative research with the use of a method of analysis implemented during the previous mass-casualty incidents and interviews with four operators working for the medical operation centre and four doctors working at the accident, emergency and plastic surgery department provided the second answer to the V2 research question: Failure in communication between the two aforementioned departments could have a significant impact on the injured in the event of a mass-casualty incident. In the end, the thesis refers to the dramatic difference between the ideal traumatological planning and the current situation pointing out the Traumatological Plan of the South Bohemian healthcare which has not been updated for three and a half years since the reform. The given work also describes the issue of the ideal solution to the establishment of contact points in hospitals and compares it with the current situation at the Hospital České Budějovice where the contact point was established only in order to comply with the legislation, i.e. the contact point is based in the operating centre of medical transport.

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.

The goal of this thesis was to analyze processes of the Emergency Medical Dispatch Center of the Emergency Medical Service of the Pilsen Region (ZOS ZZS Pk) when dealing with a mass casualty incident. The theoretical part of the thesis provides basic information relevant to the Pilsen Region, the Emergency Medical Service of the Pilsen Region, basic information on operations and general work processes of an emergency medical dispatch center during a normal work regime, and specific activities performed when dealing with a mass casualty incident. The research part of this thesis analyses activities and processes of an emergency medical dispatch center as described in the Mutual Mission Types Manual for Integrated Rescue System forces while at a mutual incident - Activities of Integrated Rescue System Forces at a Mass Casualty Incident (STČ 09/IZS). Further on the thesis evaluates activities of the ZOS ZZS Pk taken while dealing with two mass casualty incidents. These were a bus accident nearby Rokycany town in 2013 and a two trains collision nearby Horažďovice town in 2015. In order to make the analysis of readiness of the ZOS ZZS Pk to deal with mass casualty incidents more complex, SWOT analysis was added to the results. Based on the results of the STČ 09/IZS-manual analysis and of the SWOT analysis, suggestions for new manuals were made, that should make all the actions taken by employees of the ZOS ZZS Pk while dealing with a mass casualty incident more efficient and more effective. The goal of this thesis: to analyze activities of the ZOS ZZS Pk while dealing with a mass casualty incident, and to create suggestions of which inadequacies to remove and how to make operations of the ZOS ZZS Pk more efficient and more effective when dealing with mass casualty incidents; has therefore been fulfilled. The main outcome of the thesis are the final recommendations for making operations of the ZOS ZZS Pk more efficient and more effective when dealing with a mass casualty incident.

Syfte: Att kartlägga triagekunskap hos kliniskt verksam ambulanspersonal i en masskadesituation med patientfall från MACSIM. Metod: Studien är en kvantitativtvärsnittsstudie som baseras på en webenkät med 84 respondenter som arbetar inom ambulansverksamheten. Enkäten innehöll slutna bakgrundsfrågor och ett kunskapstest med 30 patientfall som bygger på simuleringsverktyget MACSIM. All data bearbetades med analytiskoch deskriptiv statistik. Resultat: Studien resulterade i totalt 2520 triageringar, inklusive 924 triageringar av barn. Resultatet visar total korrekt triage (66,8 %), undertriage (17,9 %) och övertriage (15,2 %) samt triage av barn som visar korrekt triage (72,7 %), undertriage (8,4 %) och övertriage (18,8 %). Studien visar signifikanta och icke signifikanta skillnader i ovanstående triageresultat beroende på bakgrundsfaktorer. Konklusion: Det framkommertydligt i denna studie att ambulanspersonal är i behov av mer utbildning i hur man triagerar enligt sållningstriage vid en masskadesituation. Sållningstriage är tänkt att vara ett enkelt tillvägagångssätt under det första triaget vid en masskadesituation. Trots detta var det bara ett fåtal av deltagarna som hade en acceptabel nivå av såväl korrekt triage som undertriage.Däremot visar det totala resultatet en acceptabel nivå av övertriage. / Aim: The aim of this study is to identify triage knowledge of clinically active ambulance personnel in a mass casualty incident (MCI) with patient cases from MACSIM. Method: The study is a quantitative, cross-sectional study based on a digital survey with 84 respondents working in the prehospital organization. The survey included closed background questions and a knowledge test with 30 patient cases based on the simulation tool, MACSIM. All data were processed with analytical and descriptive statistics. Results: The study resulted in total of 2520 triages, including 924 triages of children. Results showed a total correct triage (66,8 %), undertriage (17,9 %) and overtriage (15,2 %) and triage of children showing correct triage (72.7%), undertriage (8.4%) and overtriage (18.8%). The study shows significant and nonsignificant differences in the above triage results depending on the background factors.Conclusion: It stands clear in this study that ambulance personnel need more education in how to triage according to MCI triage. MCI triage is supposed to be an easy approach during the first triage in an MCI. Even so, only a small number of the participants had an acceptable level of correct triage as well as undertriage. However, the overall result showed an acceptable level of overtriage.

This dissertation investigates the value of deep reinforcement learning (DRL) within an agent-based model (ABM) of a large open-air venue. The intent is to reduce civilian casualties in an active shooting incident (ASI). There has been a steady increase of ASIs in the United States of America for over 20 years, and some of the most casualty-producing events have been in open spaces and open-air venues. More research should be conducted within the field to help discover policies that can mitigate the threat of a shooter in extremis. This study uses the concept of dynamic signage, controlled by a DRL policy, to guide civilians away from the threat and toward a safe exit in the modeled environment. It was found that a well-trained DRL policy can significantly reduce civilian casualties as compared to baseline scenarios. Further, the DRL policy can assist decision makers in determining how many signs to use in an environment and where to place them. Finally, research using DRL in the ASI space can yield systems and policies that will help reduce the impact of active shooters during an incident.