Regarding pandemics or bioterrorism incidents, prompt and secure distribution of vaccines and prophylactic antibiotics is crucial. Open Points of Dispensing (PODs) are established to serve the public, and their effectiveness depends on the internal spatial layout and operational workflow design. However, studies on systematic classifications of open POD configurations and comprehensive syntheses of strategies for enhancing operational efficiency are lacking.

This scoping review aimed to classify open POD layout types used for vaccine and antibiotic distribution and to consolidate strategies that improve efficiency across various workflow stations.

A scoping review was conducted following the PRISMA-ScR guidelines. A comprehensive literature search was conducted across PubMed, Embase, and Web of Science databases, spanning from January 2001 through July 2025. The search strategy involved incorporating keyword combinations related to “points of dispensing,” “mass vaccination,” “mass prophylaxis,” and specific pathogens such as anthrax, influenza, and COVID-19. Extracted data included the POD layout typologies, process designs, and efficiency metrics. The findings were synthesized using a narrative approach.

Nineteen studies met the inclusion criteria and were analyzed. Vaccine PODs were classified into four primary layouts, namely station-based sequential-flow, cell-based, fixed-seat service, and pop-up PODs. Antibiotic PODs were categorized into two types, namely sequential processing and selective-expedited processing. Each layout exhibited unique operational characteristics, including sequential versus integrated clinical stations (for vaccine PODs) and standard versus expedited dispensing lines (for antibiotic PODs). Efficiency enhancement strategies across workflow stations included task integration, use of digital tools, simplification of documentation, optimization of medication preparation, and staffing adjustments guided by simulation modeling.

This review provides a systematic classification of open POD layouts and summarizes the strategies for improving efficiency across workflow stations. The derived insights offer practical guidance for planning and operating PODs in future public health emergency responses.

Out-of-hospital cardiac arrest (OHCA) remains a major cause of mortality world-wide. Early bystander cardiopulmonary resuscitation (CPR) is a critical determinant of survival; however, many witnessed arrests are managed by untrained laypersons. Dispatcher-assisted CPR (DA-CPR) increases bystander intervention rates, but telephone-based guidance limits real-time assessment of compression quality. Video-assisted CPR (V-CPR) may overcome these limitations by enabling visual feedback and demonstration-based guidance.

The aim of this study was to evaluate whether video call-assisted dispatcher guidance incorporating simultaneous real-time demonstration improves CPR performance quality compared with voice call-assisted guidance in untrained laypersons during a simulated adult OHCA scenario.

This prospective, randomized, single-blind, manikin-based trial included 85 university students without prior CPR training. Participants were randomized to telephone-assisted CPR (T-CPR; n = 40) or video-assisted CPR (V-CPR; n = 45). All participants performed standardized hands-only CPR for five minutes following dispatcher instructions. In the V-CPR group, the dispatcher simultaneously demonstrated CPR on a manikin during the video call. The primary outcome was the composite CPR Quality Score generated by the manikin feedback system. Secondary exploratory outcomes included compression depth, compression rate, interruption time, and Emergency Medical Services (EMS)-related time intervals. Robust regression analysis adjusted for age, sex, dominant hand, height, and weight was performed.

The mean age of participants was 20.13 (SD = 1.81) years, and 54.1% were female. The CPR Quality Score was significantly higher in the V-CPR group than in the T-CPR group (median difference −47; 95% CI, −60 to −36; P < .001). The V-CPR group demonstrated greater mean compression depth, higher proportions of compressions within recommended rate and depth ranges, and shorter interruption times between compressions. The T-CPR group showed shorter time from case recognition to EMS call, while the interval from dispatcher contact to CPR initiation was similar between groups. In multivariable robust regression analysis, allocation to the V-CPR group remained independently associated with higher CPR Quality Score and improved compression performance metrics.

Video call-assisted dispatcher guidance incorporating simultaneous real-time visual demonstration significantly improves CPR quality in untrained lay rescuers compared with voice-only guidance. These findings suggest that structured visual modeling integrated into DA-CPR systems may enhance bystander resuscitation performance and help bridge gaps in community CPR training.

Appropriate, evidence-based care of traumatically injured patients in the prehospital setting is essential to saving lives and yielding better outcomes. There exists mixed evidence on the outcome differences between ambulance and helicopter prehospital transport, and on the effects of transport time on outcomes. The purpose of this paper is to examine these in patients presenting to an urban Level-1 trauma center.

A retrospective analysis was conducted with three years of patient information from a trauma registry maintained by a Level-1 trauma center in St. Louis, Missouri (USA). Propensity matching was used to compare helicopter versus ground ambulance outcomes, while regression analysis was used to investigate transport time.

After propensity matching to injury severity, helicopter transport was associated with improved prehospital survival (OR = 4.1; [95% CI, 1.2-21]; P = 0.02), though no difference in in-hospital survival (OR = 0.9; [95% CI, 0.4-1.8]; P = 0.71), intensive care unit (ICU) stay (difference = 0.8 days; [95% CI, -0.9-2.5]; P = 0.36), or hospital length-of-stay (difference = 51 hours; [95% CI, -7-109]; P = 0.08). Decreased transport time was not associated with increased survival (P = 0.31), but when transport times were less than 30 minutes, further reductions were significantly associated with shorter hospital stays (r2 = 0.02; P = 0.05) and fewer ICU days (r2 = 0.02; P = 0.05).

Decreased injury to hospital arrival time and increased use of helicopter transport in specific situations may improve patient outcomes; this indicates the need for prospective studies.

The Emergency Paramedic Act (EPA; Notfallsanitätergesetz), implemented in 2014, expanded the legal authority of German paramedics to independently perform defined invasive and pharmacological interventions under specific conditions. However, real-world implementation of these competencies within the physician-based German Emergency Medical Services (EMS) system remains insufficiently described.

The aim of this study was to evaluate the frequency, type, temporal development, and regional variation of invasive and pharmacological/therapeutic interventions performed independently by paramedics over a six-year period.

A retrospective, descriptive multicenter analysis of digital EMS documentation was conducted across three districts in Saxony, Germany, from January 1, 2019 through December 31, 2024. All missions were screened (n = 197,842). Paramedic-led missions without physician presence were included; physician-attended missions and non-emergency interfacility transports were excluded. Interventions were classified according to the 2024 Federal Association of Medical Directors of EMS competency catalogue. Frequencies were analyzed by year and district. Temporal trends were assessed using the Mann–Kendall test, and regional differences were explored using one-way ANOVA with Tukey HSD post hoc testing. All inferential analyses were exploratory.

Of 197,842 missions, 156,417 (79.1%) were paramedic-led without physician presence. Invasive procedures occurred in 7.6% of missions and were predominantly peripheral intravenous (IV) access (5.7%). Advanced airway management and intraosseous (IO) access were rare (<0.1%). Pharmacological/therapeutic administrations occurred in 11.3% of missions and increased from 9.4% in 2019 to 12.1% in 2024 (Mann–Kendall test), whereas overall invasive procedure rates remained stable.

Ten years after implementation of the EPA, invasive and pharmacological interventions performed independently by German paramedics remain relatively infrequent and largely confined to basic measures. Advanced procedures are rarely applied, reflecting continued structural characteristics of the physician-based EMS model.

Nurses often serve as the initial responders in cases of cardiac arrest, making cardiopulmonary resuscitation (CPR) competence essential to effective resuscitation. It is therefore important for nursing students to possess sufficient CPR knowledge and skills for future clinical practice.

The aim of this study was to examine whether CPR post-qualification training is needed in maintaining knowledge and skills and if face-to-face or online training is more effective as an educational method in preserving CPR knowledge and skills in nursing students.

A three-group, parallel randomized-controlled, single-blind design was used. The participants were 133 nursing students, randomly assigned to the face-to-face group (n = 43), the e-learning group (n = 43), and the control group (n = 47). Before randomization, all participants (n = 133) successfully completed the European Resuscitation Council (ERC) standard five-hour Basic Life Support/Automated External Defibrillation (BLS/AED) course (t0) and a questionnaire based on the 2021 ERC Guidelines to assess their knowledge. Six months later, Group A received face-to-face training, Group B received e-learning training, and Group C had no intervention. Six months after interventions, all participants (n = 133) were re-assessed on the same questionnaire, and they were given the same scenario of cardiopulmonary arrest that was used during the initial BLS course to assess the skills that they retained (t1) with the use of the ERC CPR/AED 11-item checklist. The collected data were analyzed with inferential “among group” analysis involving Kruskal-Wallis’s and Pearson’s Chi-Squared test and inferential “within group” analysis including Wilcoxon’s Signed-Rank and McNemar’s test. Multiple linear regression was used for adjusting demographic characteristics.

Based on pairwise differences between independent groups, both intervention groups presented higher scores in knowledge at t1 (P < 0.001) and in skills at t1 (P < 0.001) compared to the control group. Moreover, both training methods demonstrated comparable effectiveness. Based on comparisons between paired groups, there was also a statistically significant decrease in the Skill Score in the control group after one year (P < 0.001). Most skills were notably higher, primarily in the e-learning group, and to a lesser extent in the face-to-face group. In specific, intervention groups demonstrated statistically significant improvement in nine of the eleven assessed skills (all P < 0.05).

The current study showed that post-qualification training is needed to retain CPR knowledge and skills of nursing students, and that face-to-face and e-learning training had similar outcomes.

Prehospital electrocardiogram teletransmission (E-ECG) enables early cardiac diagnosis and triage in the field. This study assessed its diagnostic and operational impact in a real-world Emergency Medical Service (EMS) in Marseille, France.

A retrospective, single-center observational study including adults ≥18 years who underwent E-ECG acquisition by Marseille first responders from January 1 through September 15, 2023 was conducted. Electronically transmitted prehospital ECGs were transmitted via Schiller devices to medical regulators. Patients with trauma, pediatric age, pregnancy, training cases, uninterpretable ECGs, or incomplete files were excluded. The main outcome was the proportion of acute ECG abnormalities (signs of ischemia, rhythm, or conduction disorders).

Secondary outcomes included reinforcement requests, patient orientation, and transport mode.

Among 425 included patients (Median age: 56 years [IQR 40–72]; 61% male), 21.9 % (n = 93) presented abnormal ECGs, including 2.1% with ST-elevation myocardial infarction (STEMI). Transmission results led to management changes in 11.5% of cases (n = 49): 8.2% required additional medical reinforcement and 3.3% underwent direct cardiology triage without medical reinforcement. Technical issues occurred in 15.8% of transmissions (n = 67).

Prehospital ECG teletransmission allowed early detection of cardiac abnormalities and was associated with changes in patient management in a subset of cases. Its integration in emergency workflows could enhance triage, optimize cardiology routing, and strengthen coordination between field teams and regulation centers.

During the coronavirus disease 2019 (COVID-19) pandemic, emergency departments (EDs) faced unprecedented operational stress compounded by mandatory testing requirements that directly influenced patient flow and length-of-stay (LOS). Two testing modalities were central to pandemic ED operations: (1) rapid point-of-care lateral flow assays (LFAs), which return results in minutes but depend on frontline ED personnel and space, and (2) laboratory-based polymerase chain reaction (PCR), which requires sample transport and centralized processing but functions independently of ED capacity. Whether the relative performance of these modalities remains robust under varying ED operational pressures is unclear.

This retrospective observational study analyzed 31,737 COVID-19 testing encounters (11,098 LFA; 20,639 PCR) during the 11-month dual-testing period (May 2022–March 2023) at a high-volume tertiary ED, when both modalities were concurrently deployed. Propensity score matching (PSM; 1:1 nearest-neighbor, caliper 0.5 SD) generated 8,492 well-balanced LFA–PCR pairs. Turnaround time (TAT) was evaluated as an operational stress indicator modifying the association between testing modality and ED LOS. Variability analyses assessed performance stability under differing capacity levels.

Overall, LFA was associated with longer LOS than PCR (median 8.3 versus 5.8 hours; P < 0.001). Under low-stress conditions (TAT ≤30 minutes), this difference was modest (median difference 1.5 hours; 95% CI, 0.80 to 2.07). As TAT increased, modality performance diverged substantially. At TAT >90 minutes, LOS difference increased to 3.6 hours (95% CI, 2.85 to 4.42). Threshold inflection occurred between 60–90 minutes. Lateral flow assays exhibited higher operational variability (CV ratio 2.09; 95% CI, 1.25 to 3.12), with the greatest instability during high-volume periods, while PCR performance remained comparatively stable across stress levels. Stratified analyses were exploratory; confidence intervals were not adjusted for multiplicity.

Turnaround time and its variability serve as actionable, real-time indicators of ED system capacity. Lateral flow assay performance degrades progressively under operational strain due to its reliance on frontline ED resources, whereas PCR—supported by external laboratory infrastructure—maintains more stable throughput. Capacity-contingent, adaptive testing strategies that shift toward PCR as TAT rises may enhance ED resilience, reduce LOS, and support more predictable patient flow during future outbreaks and surge conditions.

The provision of instant telephone pre-arrival instructions (PAI) on first aid to laypeople by emergency services’ telecommunicators for conditions beyond cardiac arrest, such as trauma or acute coronary syndrome, is practiced by emergency services around the world and is recognized by some prehospital systems as a standard of care. However, to the best of the authors’ knowledge, no attempts have been made to date to systematically summarize the related research evidence.

The aim of this study was to systematically map and analyze published quantitative research on telecommunicator-assisted first aid (TAFA) for medical emergencies other than cardiac arrest.

Peer-reviewed journal papers reporting original quantitative data on experimental or real-world applications of TAFA were identified through PubMed, Scopus, and Google Scholar. Studies focusing solely on cardiac arrest management (cardiopulmonary resuscitation [CPR] or automated external defibrillation) were excluded. A scoping review of eligible papers was conducted in accordance with the PRISMA-ScR guidance.

Twenty-two studies published from 2000 through 2024 met inclusion criteria. First authors represented nine high-income countries. The studies investigated hypothetical or actual application of TAFA for anaphylaxis, chest pain or myocardial infarction, stroke, trauma, bleeding, childbirth, foreign body airway obstruction, opioid overdose, and respiratory arrest; four studies did not specify the type of emergency. Eight studies (36.4%) analyzed real Emergency Medical Services (EMS) call data, another eight (36.4%) were simulation-based, five (22.7%) used surveys, and one (4.5%) represented a cost-effectiveness analysis. The studies described existing TAFA practices, evaluated expectations and perceptions of the service by the public, demonstrated the feasibility of experimental techniques, including video communication, and identified areas for future investigations and interventions. Along with some beneficial effects of TAFA, several studies have demonstrated downsides of the practice, including suboptimal dispatcher adherence to pre-arrival protocols. The relationships between the real-world application of TAFA and patient outcomes are unclear.

According to the review of quantitative research, non-resuscitative TAFA remains an under-explored area of prehospital medicine. Considering the paucity and the inconclusiveness of available evidence, significantly more research is required to better understand its effects and practical implications. The evidence map generated by this scoping review may assist the professional community in advancing the development of non-resuscitative TAFA.

Dispatcher-guided cardiopulmonary resuscitation (CPR) via video calls represents an important shift from purely verbal instruction to real-time visual modeling for untrained bystanders during out-of-hospital cardiac arrest. This approach may improve compression depth, rhythm, overall CPR quality, and reduce interruptions.

Its implementation remains challenging because voice calls may be faster, whereas video guidance requires stable connectivity, smartphone access, digital literacy, appropriate camera positioning, and trained dispatchers. Moreover, simulation findings among young university students may not reflect real emergency conditions.

Video-assisted CPR should be developed as a hybrid, equitable, low-bandwidth intervention and tested pragmatically across diverse emergency systems.

Traditional lecture-based learning (LBL) is often insufficient for cultivating the practical decision-making skills required in high-stakes environments like Emergency Medical Response (EMR). While game-based learning (GBL) offers an immersive alternative, it can lack immediate expert guidance. This study addresses this gap by exploring the integration of generative Artificial Intelligence (AI) as an “intelligent tutor” within GBL. The objective was to evaluate and compare the effectiveness of LBL, GBL, and generative AI-powered game-based learning (AI-GBL) on medical students’ knowledge acquisition, retention, learning motivation, and cognitive load in an EMR course.

A retrospective, comparative study was conducted with 86 medical students from three consecutive cohorts (2022-2024), each exposed to one of the three teaching modalities (n = 29 LBL, n = 28 GBL, n = 29 AI-GBL). Knowledge was assessed via pre-test, post-test, and final-test scores with a maximum score of 10 points. Student feedback was collected for learning motivation, cognitive load, and technology acceptance.

For immediate knowledge acquisition, both GBL (mean difference = 1.124/10 points; 95% CI [0.297, 1.952]; P = 0.008) and AI-GBL (mean difference = 0.897/10 points; 95% CI [0.076, 1.717]; P = 0.033) significantly outperformed LBL. For delayed knowledge retention, the AI-GBL group demonstrated significantly superior retention compared to both the GBL group (mean difference = 0.689 points; unadjusted 95% CI [0.080, 1.299]) and the LBL group (mean difference = 1.310 points; unadjusted 95% CI [0.706, 1.915]). The AI-GBL group also reported significantly lower cognitive load than the GBL group (mean difference = −0.273 points; unadjusted 95% CI [−0.456, −0.090]). Finally, students perceived the AI-powered approach as significantly more useful than the standard game-based approach (mean difference = 0.513 points; unadjusted 95% CI [0.137, 0.889]).

The AI-enhanced GBL model for EMR training improves knowledge acquisition and retention while reducing cognitive load, representing a promising approach for developing proficiency in complex, high-stakes medical competencies.

Clinical decision support (CDS) tools have been demonstrated to improve patient care and outcomes yet remain under-utilized in many clinical domains, including en route care.

This study evaluated whether a decision-tree CDS tool integrated within the government-created Battlefield Assisted Trauma Distributed Observation Kit (BATDOK; AFRL) clinical care software improves adherence to Joint Trauma System (JTS) guidelines for severe traumatic brain injury (TBI).

In a randomized crossover simulation of military clinicians (N = 24), paired participants managed a patient with elevated intracranial pressure (ICP) using either usual care (UC) or BATDOK with TBI CDS in a simulated fixed-wing air transport mission. Outcomes included completion of critical actions by simulation conclusion, time to completion of critical actions, adherence to tiered interventions as outlined in JTS Clinical Practice Guideline (CPG), and user evaluations of the CDS tool using the validated instrument, System Usability Scale (SUS).

There were no significant differences in the primary outcome, percentage of critical items completed. Teams completed a median 83.3% of the critical items in the UC scenario, compared to 91.7% in the CDS scenario (P = 0.58; median difference 4.2%, 95% CI of the difference -8.1% to 16.4%). The mean SUS score for the CDS platform was 77.6 (SD = 16.0), which is associated with a “good” usability rating. Most participants rated the CDS platform favorably on every item of the SUS.

The BATDOK with TBI CDS did not statistically increase completion of critical tasks in this initial evaluation of usability. However, these data suggest that BATDOK enhanced with CDS improved tiered guideline-concordant sequencing of ICP interventions outlined by the JTS CPG and was favorably rated by users, suggesting feasibility for operational integration.

Survival after out-of-hospital cardiac arrest (OHCA) depends on the immediate provision of high-quality bystander cardiopulmonary resuscitation (CPR) during the prehospital phase. In many community settings, repeated training opportunities are not guaranteed, making early attainment of guideline-consistent CPR skills during a single training exposure particularly important.

This study evaluated whether a scalable, feedback-enabled CPR training model was associated with earlier attainment of guideline-recommended chest compression metrics compared with conventional instruction.

A quasi-experimental study was conducted among medical students who received CPR instruction during two consecutive teaching periods (2014-2015, conventional instruction [CONV]; 2016-2017, simplified feedback-enabled kit [SIM]). Overall CPR performance was assessed at three pre-defined time points: pre-Basic Life Support (BLS), immediate post-BLS, and delayed follow-up (two-to-twelve months post-BLS). The primary outcome was attainment of the target compression rate (100-120 compressions/minute). Mixed-effects regression models were used to account for repeated measurements and to evaluate group × assessment interactions.

A total of 334 students were included: 171 in the CONV group and 163 in the SIM group. At the pre-BLS assessment, students in the SIM group demonstrated higher odds of achieving the target compression rate (odds ratio [OR], 3.49; 95% confidence interval [CI], 2.13–5.71), target compression depth (OR, 2.65; 95% CI, 1.24–5.64), and complete chest recoil (OR, 1.71; 95% CI, 1.05–2.78). Mixed-effects modeling demonstrated that the between-group difference in target compression rate changed over time, with convergence observed at delayed follow-up.

A scalable, feedback-enabled CPR training model was associated with earlier attainment of guideline-consistent chest compression performance. These findings may support further evaluation of scalable feedback-enabled approaches in community-based or resource-limited training environments where repeated CPR instruction may not be feasible.

Hemorrhagic shock represents a major cause of preventable mortality following trauma. Identifying shock early on the scene is critical for survival, particularly within resource-limited settings like Thailand, where prehospital blood products are unavailable. Although several scoring tools exist, uncertainty remains regarding which tool offers the optimal diagnostic accuracy for predicting massive transfusion (MT) and early death in this specific setting.

This research aimed to compare the predictive performance of five prehospital scoring tools – Shock Index (SI), Reverse Shock Index multiplied by Glasgow Coma Scale (rSIG), National Early Warning Score (NEWS), Assessment of Blood Consumption (ABC), and Revised Assessment of Bleeding and Transfusion (RABT) – for predicting MT and 24-hour mortality.

This retrospective prognostic accuracy study included adult trauma patients transported by Emergency Medical Services (EMS) to a university-affiliated Level 1 Trauma Center in Bangkok from January 2019 through December 2024. The primary endpoint was MT; the secondary endpoint was 24-hour mortality. Area Under the Receiver Operating Characteristics (AUROCs) assessed discrimination and the DeLong test compared performance among scores.

A total of 584 eligible patients were included, of whom 63 (10.8%) required MT. The NEWS demonstrated the highest discriminatory power for MT (AUROC 0.84; 95% CI, 0.79–0.90), followed by rSIG (AUROC 0.83; 95% CI, 0.76–0.90) and SI (AUROC 0.78; 95% CI, 0.72–0.86). In contrast, trauma-specific scores showed lower performance, with AUROCs of 0.69 for ABC and 0.74 for RABT. For 24-hour mortality, NEWS and rSIG demonstrated excellent discrimination (AUROCs of 0.93 and 0.91, respectively). At a cut-off of four or higher, NEWS showed a sensitivity of 81.0% for MT, while rSIG ≤ 16 provided a balanced sensitivity of 74.6% and specificity of 88.5%.

Both NEWS and rSIG predicted MT and 24-hour mortality more accurately than ABC and RABT. These tools may support early pre-arrival notification and blood bank preparation without delaying rapid transport.

Pediatric patients present distinct developmental, psychosocial, and clinical challenges during high-consequence infectious disease (HCID) transport. Despite these differences, national biocontainment transport systems have historically been designed around adult patients, resulting in limited pediatric-specific guidance and operational experience.

The aim of this study was to describe pediatric-specific observations from the inaugural deployment of the US Department of Health and Human Services’ (HHS) Portable Biocontainment Unit (PBCU) during a national full-scale exercise and to identify considerations relevant to pediatric-inclusive HCID transport.

A qualitative, observational evaluation was conducted during the 2025 Tranquil Passport Full-Scale Exercise. Data sources included structured interviews with pediatric actors and caregivers, evaluator observations, and facilitated multi-disciplinary debriefings. Pediatric participants simulated biocontainment transport scenarios within the PBCU across multiple sites and phases of care.

Pediatric transport within the PBCU required advance planning to address developmental, psychosocial, and physiologic needs distinct from adult care. Pediatric participants frequently described confusion or anxiety related to noise, vibration, movement, and the appearance of personnel in personal protective equipment (PPE). Communication challenges associated with masked voices were reported. Caregiver separation due to infection-control requirements was consistently described as stressful. Clinical teams identified benefits of pediatric-specific medication dosing guides and essential medication sets within the confined biocontainment environment.

This inaugural deployment of the PBCU with pediatric participants identified key operational and psychosocial considerations relevant to pediatric-inclusive HCID transport. Findings supported the need for deliberate integration of pediatric-specific planning, communication strategies, and resources within biocontainment transport systems. These observations may also inform pediatric HCID transport planning in international settings where similar challenges are encountered.

Large-scale medical surges (whether arising from mass-casualty incidents [MCIs], pandemic disease, or wartime casualty repatriation) can rapidly overwhelm traditional hospital capacity. Alternate care facilities (ACFs) have been used to decompress hospital systems, yet prior configurations such as convention centers exhibit significant clinical and patient-experience limitations.

This paper describes the development, proof-of-concept validation, and operational framework of the Hotel2Hospital (H2H) Conversion Guidebook, a comprehensive resource enabling hospital emergency management professionals to rapidly convert a suitable hotel into a functional ACF capable of providing hospital-level care.

The H2H Guidebook was developed by Team Colorado, comprising emergency, hospitalist, and virtual medicine physicians, emergency management professionals, medical subject matter experts, architects, engineers, and regulatory specialists from the University of Colorado Hospital (UCH) and All Clear Emergency Management Group, funded under a Defense Health Agency (DHA) National Disaster Medical System (NDMS) Capability Pilot. The framework was informed by operational experience from COVID-19 ACF deployments in Colorado (USA). A proof-of-concept exercise conducted in 2025 at the Hyatt Regency Denver–Aurora Conference Center physically converted portions of a hotel into functional hospital spaces and validated clinical workflows through multi-disciplinary “Day-in-the-Life” simulations.

The proof-of-concept demonstrated that hotels can be successfully converted to provide general Med-Surg and intensive care unit (ICU)-level capacity within four weeks. Key advantages over traditional ACFs included private patient rooms capable of a high level of infection prevention measures, individual heating, ventilation, and air conditioning (HVAC) control, in-room bathrooms with showers, and existing hotel infrastructure supportive of hospital operations while being comprehensive enough to provide full Med-Surg and most ICU-level care. Clinical services including laboratory point-of-care testing, portable radiology, pharmacy, respiratory therapy, telehealth/virtual ICU, and electronic medical record (EMR) integration in the “live” environment were all demonstrated as operationally feasible. A wireless mesh network with cellular, cable, and satellite capabilities was successfully deployed to provide seamless information technology (IT) connectivity with UCH.

Hotel conversion represents a viable, scalable ACF strategy for prolonged medical surge events. The H2H Conversion Guidebook provides a structured, reproducible framework addressing activation, operations, and demobilization. Hospital emergency management professionals, public health agencies, and defense medical planners should consider incorporating the H2H model into sustained surge capacity planning.

Conflict brings excess and changing demands to local civilian health care resources. While conflict-related needs are often easily identifiable, in the aftermath of disaster or conflict, health care systems may struggle to identify changing needs, and humanitarian actors may initiate responses targeted to traumatic injuries while facing different operational realities.

This study aims to quantify the immediate changes in, and short-term trends of, Emergency Department (ED) patient profiles following a break in conflict, informing humanitarian intervention and the prioritization of local health care resources in future contexts.

A single center, retrospective Interrupted Time Series (ITS) analysis was undertaken comprising of every patient attendance to the Nasser Medical Complex (Gaza Strip) ED from September 1, 2025 through November 30, 2025, inclusive, to evaluate the impact of the ceasefire on October 10, 2025. Binomial and negative binomial regression was used, adjusting for day-of-week confounding, with Newey–West robust standard errors. Coefficients were exponentiated to Incidence Rate Ratios for interpretation as the percentage change in the relevant presentations numbers or trend and were presented with 95% Confidence Intervals (95%CI).

There were 107,631 presentations over the study period, a median of 1,217 (IQR 1,120-1,291) per day prior to, and 1,202 per day (IQR 1,083-1,356) following, the ceasefire. There was no significant step-change in total presentation to the ED following ceasefire, but thereafter, relative to the pre-ceasefire trajectory, attendances experienced a sustained decrease of two percent per day (95%CI, 1.0% to 2.0% reduction; P < 0.001).

There were observed changes to the profile of attendances by diagnostic group, with step-change reductions in trauma admissions, gastrointestinal, and pediatric presentations. There were daily trend reductions for multiple diagnostic groups, including traumatic injuries discharged from the ED, respiratory infections, gastrointestinal presentations, and other medical emergencies.

This study demonstrates that the implementation of a ceasefire has the potential to change presentation patterns to a civilian ED in a conflict area. While there was no step-change following the ceasefire, there was a reversal of the previous trend of rising daily presentations. It should be noted that most presentations both before and after the ceasefire were for non-traumatic events. These findings highlight the need to continue support and resource for the non-traumatic workload of emergency care during crises, a pattern described in other contexts.