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Health Disaster Management: Guidelines for Evaluation and Research in the Utstein Style: A Short Introduction
A report by Knut Ole Sundnes, MD; Marvin L. Birnbaum, MD, PhD. President of World Association for Disaster and Emergency Medicine; Editor-in-Chief of Prehospital and Disaster Medicine.
The objective of this presentation is to draw attention to newly developed disaster research strategies that in their wake, are likely to result in shifts of currently accepted policies and paradigms. Such shifts will have relevance for health-care personnel, bureaucrats, politicians, and the industry of health-care and public health. The Problem Disasters are described as a mismatch between resources and tasks, whether caused by unavoidable natural events or by avoidable, man-made events. Disability, loss of human lives, crops, fertile land, seeds, production equipment, infrastructure, and intangible losses all contribute to the short- and long-term consequences of disasters. Overall, for every person killed in a disaster, 750 are affected. During the natural a disasters from 19661990, 975-billion people were affected: 1.35 million were killed. For complex emergencies, the figures are worse. In Rwanda during 1993-94), >800,000 were killed. The total damage resulting from similar events, differs significantly between the developing and the developed world, as does the ratio between the numbers of those affected and killed. This inequity has the potential to help to reveal some of the unknowns as pertinent questions arise and are researched systematically. Unfortunately, such research has not been recognized in an institutionalized fashion, partly as it has been considered to be an unethical competitor for scarce resources and partly because appropriate techniques have not been legitimized medically. Consequently, much of the work has been based on intuition, not necessarily rooted in understanding and knowledge. The lack of needed techniques has been appreciated for decades and is mirrored in disaster documents: reports from the last 3-4 years focus on the same mistakes and shortcomings as did reports from 2030 years ago.1,2

Solution
To meet the demands for structured disaster research, the TFQCDM developed mechanisms for evaluating interventions applied during disasters, but also for prevention of future disasters and/or mitigation of the damage from future events. They suggest how the effects of interventions can be evaluated including their efficiency, benefits derived, and costs. Although the prime focus has been the health aspects of disasters, generic guidelines were created that can be applied to development and long-term assistance.

Task Force for Quality Control of Disaster Medicine (TFQCDM) / World Association for Disaster and Emergency Medicine (WADEM/) Global Health 2002

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These structured mechanisms (Guidelines and Templates) have been designed to improve external validity of the findings through identification of similar findings from multiple studies, and comprise four pillars of the table of research: 1. Conceptual framework; 2. Template with defined chronological phases and functions; 3. Application of scientific methods; 4. Tools for developing and maintaining baseline inventories.

Pillar 1. Conceptual Framework Newer definitions have been proposed because of confusion created by the broad use of older definitions. The evolution of a common language across the multiple disciplines associated with disasters will enhance communication and help prevent duplication of efforts by parties.

A generic formula has been devised to facilitate the distinction between risk, hazard, vulnerability, mitigation, and management:
PD = (RH)(Hman + Hnat)( Vnat + a1 +a2 + b1 + b2 )

Where: PD=the probability that an event will inflict damage on a ociety at risk; H=hazard; =a function of the relationship between all of the variables; RH=risk that an event that may result in damage; Hman= human component responsible for the hazard; Hnat= natural hazard; Vnat=natural vulnerability; a1 =vulnerability augmentation; a2 =vulnerability mitigation; b1 =counter-productive management; and b2 =productive management or alleviation. The ultimate objective of disaster management is to bring probability that damage will occur as close to zero as is possible. This can be achieved by bringing the net value of any of the brackets to zero. As part of the development of a society, man-made hazards are imposed on the society, but are accepted because the risk associated with the hazard is perceived to be very small (e.g., nuclear power plants. hydroelectric dams). The probability of damage occurring will be zero if the facilities are not built; or approaches zero if effective preventive measures are mandated. However, the main focus has been aimed at reduction of vulnerability by increasing preparedness and/or the absorbing capacity for when the hazard becomes an event. This can be achieved by implementing mitigating measures (a2 ) or through productive management ( b2 ). Thus, use of this formula facilitates identification of those interventions that will be most effective in reducing the probability that damage will happen: it provides a rough, pathophysiologic framework for evaluation.

Task Force for Quality Control of Disaster Medicine (TFQCDM) / World Association for Disaster and Emergency Medicine (WADEM/) Global Health 2002

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The Templates Three Templates (A, B and C) contain the structure for the study of disasters (Figure 1). The first Template (A) relates to Pillar 2. The second provides structure and guidelines for the conduct of such studies, and the third structure and guidelines for their design. Templates B and C comprise Pillar 3.

Pillar 2. Template A: Disaster Elements

For analysis purposes, it is essential to partition a disaster into simple, recognizable, and welldefined phases that together comprise an algorithm defined by the properties of the respective phase and not by time (hours, days, etc.) For example, some of the elements included in Phase 2 (Event) of an earthquake can be compared to those in Phase 2 of a drought, even when the drought lasted for years and the earthquake for 2090 seconds.
1. Pre-Event Statusthe Point of Reference and serves as the baseline to identify damage to the society affected. It also is necessary for evaluation of the effectiveness of responses, since the endpoint for management of a disaster is when the pre-event situation for the societal function(s) being evaluated has been reconstructed. 2. Eventthe release of uncontrolled energy described by type, onset, intensity, magnitude, duration, and the area and population impacted, using standardized, universally accepted indicators. These descriptors are essential for comparing the effects of similar events on the same or different regions and/or societies. 3. Insult (Damage Assessment) comprehensive inventory of the functional status of each societal function must be conducted as soon after and during events regardless of rate of onset and duration, using the same indicators as used for the pre-event inventory. Identification of factors that render the damage caused by similar events or similar magnitude is essential for understanding disasters. 4. Disturbances in Health Status This phase focuses on the changes resulting specifically in the medical care and public health functions, and generically can be adapted to study the damage to other specific functions as well. 5. Needs AssessmentsThe structure provided should facilitate the further development of validated, standardized, needs assessment tools. Performance of needs assessments are complicated by confusion between real needs, perceived needs, assessed needs, and demands.3 However, it is not possible to evaluate any intervention without first knowing the need(s) that the intervention addressed. Needs Assessment must not be confused with Damage Assessments. 6. Responsesinclude not only immediate responses during the acute phase of a sudden onset event, but all aid and assistance provided until the disaster endsthe Disaster Critical Control Point (DCCP) is the time at which the available supplies balance all of the needs of the function or sub-function being evaluated. Identification of DCCP depends on correct, ongoing needs assessment, and is crucial to avoid oversupply. Aid always is significant: response that is not needed is counter-productive. 7. Changes in Health Statusthe outcome from the intervention(s) being studied, and are defined by comparing the current health status of the affected population with that before the intervention being studied was implemented. Changes could be documented by a change in a disaster health severity score or by changes in the elements of health. Since a society never is static, the concept of what the Best Outcome Without Assistance
Task Force for Quality Control of Disaster Medicine (TFQCDM) / World Association for Disaster and Emergency Medicine (WADEM/) Global Health 2002

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(BOWA) should be included when assessing the effects of any intervention. Thus, not only must the preevent baseline be assessed, but also the direction the status was going prior to the event. As the use of these Guideline evolve, ways to incorporate BOWA will be identified. Currently, the points of reference still will be the immediate pre-event inventory. 8. Restoration of Health Status When the pre-event status has been attained for the aspect of health being studied, that aspect of the disaster for the affected population is terminated. Improvement beyond the Pre-event status is development.

Pillar 3. Scientific methods: Templates B and C: Disaster science cannot provide randomized, controlled, experimental trials. However, adaptation of techniques used in the study of the social sciences has expanded the capabilities for learning about disasters. Templates B and C outline the steps for the performance of studies related to situations that do not lend themselves to use of experimental techniques. Template B consists of eight sections: A) Identification of the Problem(s); B) Design Research Project; C) Data Collection; D) Analysis of the Data; E) Comparisons; F) Conclusions; G) Recommendations; and H) Feedback. Section B, Design of a Project, is detailed in Template C: 1) Formulation of the question(s)/hypotheses; 2) Validation of the question(s); 3) Identification of what needs to be evaluated; 4) Selection of indicators; 5) Determining the most appropriate methodology; 6) Identification or construction of data collection instruments; 7) Validation of data collection instruments; 8) Plan for data collection; 9) Organizing and training the research team; 10) Construction of the sampling plan; 11) Selection of methods for analysis; and 12) Implementation.

Pillar 4. Inventory: Basic Societal Functions The Guidelines and their Templates are dependent upon inventories of Societal Elements of Function. Such inventories, in addition to serving as baselines from which to judge change, provide valuable information about vulnerability and preparedness, and information for formulation of external responses. Fourteen Basic Societal Functions (BSF) have been identified, all linked together by Coordination and Control function provided by the respective governments based on the triangle of responsibility: Mandate, Power, and Resources (Figure 2): 1) Medical; 2) Public health; 3) Sanitation and water supplies; 4) Shelter and clothing; 5) Food; 6) Energy supplies; 7) Search and rescue; 8) Public works and engineering; 9) Environment; 10) Logistics and transport; 11) Security; 12) Communications; 13) Economy; and 14) Education. The format emphasizes the interdependence of all societal functions upon one another. Failure to recognize this interdependence often results in unrealistic approaches to disaster. Each functional element contains many sub-elements. To describe changes in a BSF indicators for each of the societal functions and their respective sub-functions must be developed. Indicators may be numerically or qualitatively described. The concept of functional and critical thresholds has been developed. Thresholds have utility in defining the functional status of a BSF, and require selection and use of the most appropriate indicators of function.

Task Force for Quality Control of Disaster Medicine (TFQCDM) / World Association for Disaster and Emergency Medicine (WADEM/) Global Health 2002

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Future The Guidelines a dynamic document, and will be refined into a working methodology and operational manual.. Decisions as to modifications and refinement of the Guidelines should be the responsibility of the TFQCDM through consensus congresses conducted at intervals of no longer than five years.

Conclusions

The overall objective for the use of the Guidelines and Templates is to attenuate or eliminate the damage from disasters through institutionalized, evidence-based competence building. This could result from the elimination of hazards, decreasing the risks for the actuation of the hazard, augmenting the absorbing capacity of the society and environment at risk, and proper and effective disaster management, depending on which combination of activities prove more feasible or/and more cost-beneficial to the society at risk. The Guidelines open for comparison of otherwise quite dissimilar events. They provide a conceptual framework to address the need for standardized definitions, descriptors, and indicators, provide a structure for conducting and reporting disaster research, and summarize techniques that can be applied to the study of disasters. They provide the first referral standard for the evaluation and research into medical efforts that are part of disasters.

The full document will be available as a Supplement to PDM. See also <http//:pdm.medicine.wisc.edu> and <http//:wadem.medicine.wisc.edu>

Acknowledgement This work was supported in part by grants from the Laerdal Foundation for Acute Medicine, the Royal Norwegian Ministry of Foreign Affairs, , the Swedish National Board on Health and Welfare; the Swedish International Development Agency (SIDA); and the Nordic Council. This work would not have been possible without the indirect support of the Joint Medical Command of the Norwegian Defense Forces.

References

1.

2.

Pan American Health Organization/World health organization: Evaluation of Preparedness and Response to hurricanes George and Mitch: Conclusions and Recommendations. Prehosp Disast Med 1999;12:53-65. HRH Prince Sadruddin Aga Khan: Improving the Disaster Management Capability of the United Nations. United Nations Management & Decision-Making Project UNA-USA United Nations Association of the United States of America, January 1987
Rubin M, Heuvelmans JHA, Tomic-Cica A, Birnbaum ML: Health-related relief in the former Yugoslavia: Needs, demands, and supplies. Prehospital and Disaster Medicine 2000; 15(1):1-11.

3.

Task Force for Quality Control of Disaster Medicine (TFQCDM) / World Association for Disaster and Emergency Medicine (WADEM/) Global Health 2002

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A: Medical Elements in a Disaster


1. Pre-event Health Status

B: Evaluation/Research

C: Project Design

Prospective

A.A. Identification of a problem Identification of Question(s)


2. Event B. Design Research Project 3. Insult
Damage= (H nat+Hman)(Vnat +a1 +a2 +b 1+b 2)

1. Formulate Question/Hypothesis

2. Validate Question
3. Identify What Needs to Be Evaluated 4. Choose Indicators and Measures of Effectiveness 5. Determine Most Appropriate Methodology C. Data Collection

Retrospective

4. Disturbances in Health Status


Damage

6. Identify/Construct Data Collection Instruments D. Analysis of Data 7. Validate Collection Instruments 8. Plan for Data Collection E. Comparisons 9. Organize/Train Research Teams 10. Construct Sampling Plan F. Conclusions 11. Select Methods for Data Analysis 12. Do It G. Recommendations

I. Change 5. Needs Assessments

6. Responses

7. Changes in Health Status

8. Restored Health Status H. Feedback

Figure 1Templates for the Evaluation and Research on Responses to Disasters

Task Force for Quality Control of Disaster Medicine (TFQCDM) / World Association for Disaster and Emergency Medicine (WADEM/) Global Health 2002

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Medical

my ono Ec
Security Co mm uni cat ion s

Pu blic He alth
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Shelter/Clothing

Coordination and Control Resources Power


Culture/Language Geography/Climate

rt spo ran T / s istic Log

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Mandate

En erg y

Figure 2Basic elements of societal functions linked by Coordination and Control

Sundnes/Birnbaum- Utstein Disaster Research Templates/TFQCDM/WADEM/ Page 7 of 7

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