Background
The increase in disasters that has been occurring world-wide has highlighted that Emergency Medicine (EM) physicians are at the forefront of the management of these crises. Whether one is a new graduate, working solo on a night shift when a chemical exposure occurs at a local industrial site, or a seasoned EM physician working the day of a horrific terrorist event, the ability to immediately recall and apply the core content and principles of Disaster Medicine (DM) is an essential component of EM practice. As passengers expect airline pilots to be prepared for rare, but possible, inflight emergencies, so do communities trust and expect EM physicians to be prepared for these low-frequency, high-acuity events. Emergency Medicine program directors have recently indicated disaster-preparedness is one of the most frequently listed components that they want to add to their curricula.Reference Katzer, Cabanas and Martin-Gill 1 However, gaps exist between desire, need, and time.
The Accreditation Council for Graduate Medical Education (ACGME; Chicago, Illinois USA) residency program requirements for EM have minimal recommendations for education in DM, with no clear standard or guidelines for training programs on how to address this broad topic. 2 A 2017 survey of United States EM residency directors indicates that while most training programs include some level of DM education, there is a wide variation in content, methodologies, and dedicated hours.Reference Sarin, Cattamanchi and Alqahtani 3 For this reason, many DM leaders have long recommended the development of a common set of core competencies in DM to be required of trainees that will help standardize training and practice in the field. In a study published in 2012, a consensus document addressed the need for basic educational competencies in DM across all fields, and produced a list of core competencies for medical personnel.Reference Schultz, Koenig and Whiteside 4 Despite this growing political and educational interest in DM, there is no indication that these educational goals are currently being met in the field of EM.
The goal of this study was to define and prioritize DM core competencies for EM residency programs through the consensus opinion of experts, including EM professional organization representatives.
Methods
Investigators utilized a modified, two-round Delphi methodology to generate a recommended core curriculum of DM educational topics for EM residencies. The Delphi method is particularly well-suited for curriculum development, needs assessments, research agendas, and other projects where group consensus is required.Reference Linstone and Turoff 5 – Reference Phillips, Lewis and McEvoy 7 This process included virtual meetings and offline work with a survey to establish initial priorities for the project, followed by an in-person consensus panel. There was subsequent modification of learning objectives at the in-person meeting based on group consensus, followed by a re-prioritization of these objectives.
The initial steps included a literature review for peer-reviewed articles in PubMed (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA) and Hollis (Harvard University; Cambridge, Massachusetts USA) for educational competencies in DM for various health care specialties. The articles were then provided to a core group of seven experts for review and classification of relevance. Expert reviewers were also asked to add additional articles for consideration. The experts were chosen for their established DM expertise in the prehospital, hospital, or policy setting and their history of current or prior practice and engagement with EM training programs in the United States. Given the focus of the study, experts who had not worked with EM training programs in the United States were excluded from participations. Expert panelists participating in this study are listed in Table 1. Articles were scored on their relevancy for review using a binary score of “include” (one point) and “exclude” (zero points) as being pertinent to EM resident education. Those that were scored for inclusion by a majority of the seven reviewers were used to build the competency list (Table 2). The educational content outlined in these articles was compiled and condensed where there were redundant educational objectives outlined by two of the authors. Forty competencies with specific teaching objectives were identified from these articles and shared with the core team of ten independent experts and representatives from the Society of Academic Emergency Medicine (SAEM; Des Plaines, Illinois USA), American Council of Emergency Physicians (ACEP; Irving, Texas USA), Council of Emergency Medicine Residency Directors (CORD; Irving, Texas USA), and the National Association of Emergency Medical Services Physicians (NAEMSP; Overland Park, Kansas USA) via online survey (Survey Monkey; San Mateo, California USA). Participants were asked to prioritize these competencies using a Likert scale of one (not a priority) to five (essential priority) for each competency. They were instructed to rate the competencies specifically based on the applicability and necessity of them being added to an EM residency curriculum, with the goal that participants highly recommend all residencies teach topics with a rating of four out of five, or higher.
Demographics of Expert Panel
Abbreviations: ACEP, American Council of Emergency Physicians; CORD, Council of Emergency Medicine Residency Directors; NAEMSP, National Association of Emergency Medical Services Physicians; SAEM, Society of Academic Emergency Medicine.
a Also served as expert reviewer of literature search.
Published Literature Used to Inform Development of Disaster Medicine Competencies
Following this online survey, this national expert consensus panel convened to review and confirm rankings of competencies, in addition to clarify wording of objectives for each competency. During this meeting, voting was kept anonymous and investigators utilized controlled opinion feedback. Each category was discussed in full before moving on to the next. The facilitators first displayed the questions for each and then the array of submitted responses. Each participant was invited to advocate vocally for their choice of best answer among the possible choices presented. An anonymous vote was then conducted using Poll Everywhere (San Francisco, California USA), an audience response system that allows participants to answer in anonymity. The results were then shown to the group and participants were again allowed to further advocate and reflect on the results. A final vote was then conducted, and results were displayed.
After the meeting, five teams of two expert reviewers were each assigned eight competencies to edit and review for consistency in wording and inclusion of any critical missing educational components that were discussed at the consensus meeting. There was then an open session for edits and feedback on all 40 newly revised educational categories by the full expert working group. Following this review of the edited 40 competencies, they were shared with the core team of independent experts and representatives to re-prioritize via an online survey, again using a Likert scale of one (not a priority) to five (essential priority) for each competency. For equally ranked items in this second round of review, the expert panel was iteratively queried as to proper scoring using a secure group email. Final rankings of tied items were assigned based on scoring order selected by a majority of participants.
Results
All ten experts completed the prioritization survey and nine of them participated in the consensus conference during the first modified Delphi round. All ten participants engaged in detailed editing and review of the competencies prior to re-evaluation. Nine of the participants engaged in the second prioritization survey, and all ten participated in the final ranking in the second modified Delphi round. Table 3 compares competency rankings after the first round of prioritization, based on teaching objectives found in the literature, to the second re-prioritization round, after expert-panel-generated amendments were made to these teaching objectives.
Prioritization of Disaster Medicine Competencies after Delphi Rounds
Abbreviations: MCI, mass-casualty incident; NGO, non-governmental organization; PPE, personal protective equipment.
The 40 competencies were ranked, with the goal that panelists highly recommend all residencies teach topics with a rating of four out of five, or higher. Competencies and associated scoring are listed in Table 4. There were 12 topics with a rating score of four (high priority) or higher, with 28 remaining topics ranked based on priority to address in an EM residency program.
Final Ranking of Disaster Medicine Educational Competencies for Emergency Medicine Residencies
Abbreviations: MCI, mass-casualty incident; NGO, non-governmental organization; PPE, personal protective equipment.
The DM topics recommended for inclusion in EM residency training included: patient triage in disasters, surge capacity, introduction to disaster nomenclature, blast injuries, hospital disaster mitigation, preparedness, planning and response, hospital response to chemical mass-casualty incident (MCI), decontamination indications and issues, trauma MCI, disaster exercises and training, biological agents, personal protective equipment, and hospital response to radiation MCI, and all are listed with detailed teaching objectives in Table 5 (also Appendix 1; available online only). There is a heavy emphasis on key disaster concepts surrounding hospital-based emergency management, chemical-biological-radiological-nuclear explosives (CBRNE) events, and trauma.
Essential and High-Priority Disaster Medicine Educational Competencies for Emergency Medicine Residencies
Abbreviations: CBRNE, chemical-biological-radiological-nuclear explosives; ED, emergency department; EMS, Emergency Medical Services; HVA, Hazard Vulnerability Analysis; ICU, intensive care unit; MCI, mass-casualty incident; OR, operating room; PACU, post-anesthesia care unit; PPE, personal protective equipment.
Discussion
This study created focused, definable competencies in DM as determined by an expert panel, allowing EM residencies to add the highest value content to their curriculum. While each residency program currently has a variety of resources that allow for differing teaching modalities and depth of exploration of DM topics, the most commonly taught competencies are patient triage and decontamination, both listed as high-priority topics in this review.Reference Sarin, Cattamanchi and Alqahtani 3 While there are many education programs and curricula developed for medical practioners,Reference Waeckerle, Seamans and Whiteside 8 – Reference Subbarao, Lyznicki and Hsu 15 a 2016 review of training opportunities indicates that there is not a standard, all-hazards DM training curriculum available for EM physicians who are not seeking to be expert-level practictioners.Reference Hansoti, Kellogg and Aberle 16 This prioritized curriculum will allow residencies to focus on the most high-yield topics, ensuring EM residents across all programs are being prepared to the same standards and facilitating their designation as hospital leaders during disasters when the need arises.
The specific topics were developed for EM residencies with the knowledge that some content in these categories is already covered in the EM model,Reference Counselman, Babu and Edens 17 though not always within the construct of DM-based scenarios. Expert panelists noted that many of the highest priority topics are already being taught across EM, including management of blast injuries; chemical, biological, and radiation events; as well as mass-casualty management from trauma. With disasters resulting from multiple etiologies occurring with increasing frequency, including mass shootings and terrorist-based events,Reference Guha-Sapir, Hoyois and Wallemacq 18 , 19 training to manage a sudden influx of casualties to the hospital from no-notice events is critical.
There are numerous studies addressing novel methods of teaching DM content and improving learners’ retention of knowledge, including virtual reality and online gaming systems.Reference Curtis, Trang and Chason 20 , Reference Ngo, Schertzer and Harter 21 However, gaps in the literature remain regarding how to select specific topics within DM that are best addressed with these new methods, and how to best use these education strategies in conjunction with other, older techniques. The targeted teaching objectives developed by the expert panel serve as a platform to best benefit physician learners, ultimately leading to improved outcomes for affected patient populations.
While the expert panel focused on prioritizing content, it did not address how to teach the content. Future research involving both this expert panel, as well as a larger working group of residency educators, should build a standard approach to delivering this material, as well as assessments for measuring competency for programs with limited resources in the areas of DM. These findings will be shared via organizational representatives with each professional society for endorsement as investigators progress to the next step of detailed curriculum development.
Limitations
The group of panelists reviewing content did so over approximately 1.5 years. Investigators’ initial work occurred in early 2016 with the first consensus conference in May 2016. Review and editing of content by expert teams continued with an open period of edits by the entire group of experts in early 2017. The last Delphi round took place in the summer of 2017, with final re-rankings and discussion in January of 2018. While this may have created some lack of familiarity with the competencies over time, it allowed the experts to review the content with a fresh perspective each time. Current disaster events may have biased how experts prioritized content between rounds. For example, in the fall of 2017, a group of the experts were deployed as part of response to the hurricane season, while another group was heavily involved in developing a conference focused on urban terrorist events. During this same period, others were advising on the Hepatitis A outbreak in California. Ideally, this variety of priorities held by the panelists helped prevent bias in the overall scoring of curriculum components, but this may also potentially have affected the final rank list versus how it might have appeared six months earlier. In addition, the review process and second modified Delphi round was not done in-person due to lack of scheduling feasibility. The expert team members have international reputations as leaders in the field, but they are all based in and primarily practice in the US, as investigators were targeting the US training environment. This did prevent other outside viewpoints which might have influenced the editing of content or prioritization of teaching points.
Conclusion
Table 4 summarizes the prioritized expert ranking of DM topics for inclusion in the US EM residency core curriculum. The content included in the appendix specifies teaching objectives for all 40 teaching points. While the details of standardized assessment and teaching methodology are being developed, EM residency program faculty are encouraged to make use of this content to build upon their own existing DM curricula to help train the next generations of DM leaders and responders.
Conflicts of interest/financial support
This study was partially funded by the Department of Emergency Medicine, Brigham and Women’s Hospital (Boston, Massachusetts USA). All authors have no conflicts of interest to disclose. Previous presentation at the Society of Academic Emergency Meeting Annual Meeting 2018; Indianapolis, Indiana USA.
Supplementary Material
To view supplementary material for this article, please visit https://doi.org/10.1017/S1049023X19004746
