EM Guidelines 2010

8/7/2019 EM Guidelines 2010

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EDITORIAL

Disaster medicine reporting: The need for newguidelines and the CONFIDE statementemm_1342 483..487David A Bradt1,2 and Peter Aitken3,41Royal Melbourne Hospital, Melbourne, Victoria, Australia, 2Center for Refugee and Disaster Response,Johns Hopkins Medical Institutions, Baltimore, Maryland, USA, 3Emergency Department, The TownsvilleHospital, and 4Anton Breinl Centre for Public Health and Tropical Medicine, James Cook University,Townsville, Queensland, Australia

This issue of the journal introduces new guidelines forauthors of disaster case reports. This editorial examinesthe drivers and implications of these guidelines.

Government agencies, professional societies, tradeassociations and special interest groups produce vastliterature on various aspects of disasters. Much of thisliterature worldwide is grey print published or webpublished but unobtainable through electronic index-ing services. The electronic information alone is now soextensive that the US National Library of Medicine has

created a Disaster Information Management ResearchCenter to help with national emergency preparednessand response efforts.1 Within the published biomedicalliterature, a recent 30 years review canvassing a rangeof electronically indexed databases found the majorityof event-specific literature indexed in MEDLINE waspublished across a broad spectrum of disciplines. Thetop 10 journals cited are listed in Table 1. 2 Over thelast decade, disaster literature accelerated markedlyprompted by the events of September 11, 2001, at theWorld Trade Center, which yielded the greatest numberof event-specific, peer-reviewed publications to date(686).2 New journals devoted to disasters continue to

emerge with recent ones receiving MEDLINE index-ation before their first full year of publication.

The challenge for the reader keeping up with disasterliterature is therefore daunting. Finding good-qualityevidence within this corpus of literature creates anotherset of hurdles for the reader.

First, the disciplines of medicine, public health anddisaster management differ in origins, definitions,

research paradigms and tools of evidence-based deci-sion making.3,4 In evidence-based medicine, core con-cepts are well known to most physicians. These coreconcepts include population-intervention-comparison-outcome questions, hierarchy of evidence strengthbased upon methods of data acquisition and criteriafor determining adequacy of studies. However, impor-tant questions in disaster medicine are not easily test-able by evidence-based science. Disaster fieldconditions are fluid, data are perishable and compete

with rumour, and security constraints prevail. As aconsequence, controlled studies in disasters are diffi-cult to run. The level of scientific evidence behindmany of our actions in disaster medicine remainsweak. Disaster relief operations continue to relyheavily on eminence-based decisions by parties striv-ing to broker goodwill and consensus.5 Underlyingissues include lack of agency expertise, dyscoordina-tion between agencies in the field, inappropriate proxyindicators, flawed scientific inference and erosion ofthe concept of minimum standards.

Second, the cost-effectiveness of many disaster inter-ventions remains unknown. For example, disaster

medical assistance teams, mobile field hospitals andhospital ships operate in virtually uncharted cost-effectiveness territory. The extensive work of the USNational Institutes of Health, the World Health Organi-zation and the World Bank on cost-effectiveness analy-sis, such as theDisease Control Priorities Project (DCP2),6

is remarkable in part for its lack of external validity indisaster relief operations. Donor governments often

David A Bradt, MD, MPH, FACEM, FAFPHM, FAAEM, DTM&H, Honorary Physician; Peter Aitken, MB BS, FACEM, EMDM, M ClinED, Senior

Staff Specialist, Associate Professor.

doi: 10.1111/j.1742-6723.2010.01342.x Emergency Medicine Australasia (2010) 22, 483487

2010 The AuthorsEMA 2010 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine


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choose options for disaster health interventions based onpolitical criteria for engagement rather than scientific

criteria for lives saved.Third, disaster case reports remain a prominent partof biomedical journal reporting on disasters with a reli-ance on descriptive accounts. Several different types ofreport have emerged in the literature.

Brief case report Rapid epidemiological assessment

Comprehensive case report Comprehensive country profileIn our experience, the most common and least useful isthe brief case report. These are typically written from adonors or intervenors perspective, and are oftenplagued by anecdotal, descriptive, breathless reportingof process ratherthan outcome. This type of reporting, aswell as the field engagement described, has been charac-terized as disaster tourism.7 Dissemination occurs inproportion to the public interest in the event, and esteemof the parent journal, rather than the strength of thescience. This practice creates disaster mythology. Peer-reviewed literature may take years to correct the miscon-

ceptions devolving from particular disasters.810

Nonetheless, there is still a role for duly diligent casereports especially when the science is young. To dothis, there needs to be an appropriate reporting struc-ture that encompasses context, perspective and out-

Table 1. Top 10 journals for peer-reviewed, event-specific

literature by number of publications (19772009) (adapted from2)

Prehospital and Disaster Medicine

Journal of Traumatic Stress

Military Medicine

Psychiatric Services

Journal of the American Medical Association

Lancet

Morbidity and Mortality Weekly Reports

Journal of Nervous and Mental Disease

American Journal of Public Health

Environmental Health Perspectives

Table 2. CONsensus Guidelines on Reports of Field Interventions in Disasters and Emergencies (CONFIDE)

Key components

Introduction

1. State specific objectives of the report.

Context

2. Describe the disaster in terms of type, location, area affected, population affected, damage assessment and epidemiological impact.

3. Describe the donor agency/organization/individuals (intervenors) undertaking the field intervention to include specific goals of

intervention, team membership (disciplines and numbers) and mechanism of accountability to host country health authorities.

Access to the Field

4. Who gave permission to enter the disaster, treat patients, and when were those permissions given?

5. What was the timeline of field intervention? When did the intervenors deploy to the field, when did the deploying team examine

its first patient, and how long did the intervenors stay in the field? Specifically, when did the report authors enter and exit the

field. Use GMT references.

Self Sufficiency and Unmet Needs in the Field

6. How did the deploying medical team secure its food, water, power and medical waste disposal in the field?

7. What translation requirements existed, and how were those requirements addressed?

8. What other providers served the same catchment population as the deploying team?

Data Environment9. Did the deploying team contribute to the initial rapid assessment undertaken by the humanitarian community? If not, why not?

10. Did the deploying team serve as a sentinel reporting site and contribute to the local disease surveillance system? If not, why not?

11. Did the deploying team participate in the local health coordination process? If not, why not?

Patient Care and Epidemiology

12. Using descriptive statistics, characterize all patients treated by the team during the deployment.

13. What standardized case management protocols governed patient care?

14. What referral process occurred for patients needing care beyond that available in the treatment facility?

15. At the departure of the deploying team, to whom were patients at the treatment facility handed over or referred for continuing

care.

Funding

16. Give the source of funding for the intervention, and estimate direct and indirect support costs.

DA Bradt and P Aitken

484 2010 The AuthorsEMA 2010 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine


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Table 3. Case reports: proposed utilities and formats

Type 1: Brief Case Report

report of present practice for epidemiologically unusual disaster or unusual response to it perspective relief agency or disaster victims on the ground

submission time within 4 weeks of acute onset disaster

length 1500 words

recommended structure simple narrative

caveat may be newsworthy in general professional practice but unlikely to be accepted as a case report in specialty journal

Type 2: Rapid Epidemiological Assessment

report of choice for epidemiologically unusual disaster or unusual response

perspective relief sector lead agency or international coordinating agency in the field

submission time within 3 months of acute onset disaster

length 4000 words

recommended structure background sources and methods pre-existing indicators disaster impact current health indicators health sector overview domestic and international response summary of health situation programmatic rationale recommendations

Type 3: Comprehensive Case Report

report of choice for overview of disaster impact, relief and rehabilitation (if applicable); amalgamates data from primary and

secondary sources, and has strong evaluation component that demonstrates scholarship of integration and application

perspective relief sector lead agency or international coordinating agency in the field

submission time within 1 year of disaster

length 4000 words recommended structure mechanism and impact disaster management

initial field response relief operations command and control hazards inventory

morbidity, mortality and disease surveillance recovery process discussion

epidemiological perspective operational perspective

implications for provider groups on future best practices

Type 4: Comprehensive Country Profile report of choice for overview of emergency/disaster experience in country or catchment area

perspective practitioner, donor or host country health authority representative

submission time not applicable

length 4000 words

recommended structure baseline demographic and health status underlying socio-political issues especially affecting current professional practice profiles of selected practices/problems/disasters discussion

local health burden technical issues

Editorial



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comes. There are reasons for optimism. Disaster reliefoperations are becoming increasingly standardized in

management of information as well as interventions.Initial rapid assessments (IRAs), Health ResourcesAvailability Mapping System (HeRAMS) and syndro-mic disease surveillance have long histories of develop-ment led by the World Health Organization. The clustersystem, itself, now has over 30 iterations worldwide.Although field execution is sometimes poor Haiti is arecent example use of standardized data-gatheringtools and inter-agency processes is increasingly seen ascore responsibilities of responders in the health sector.

We also take heart from the systematization of scien-tific reporting requirements undertaken by biomedicalscientists and journal editors. These requirements

inform investigators and authors what information isrequired to ensure readers and reviewers can properlyevaluate a study. For randomized controlled trials,the Consolidated Standards of Reporting Trials(CONSORT) statement emerged in 199611 followed bythe Quality of Reports of Meta-analyses (QUORUM)statement in 1999.12 For observational studies, theStrengthening the Reporting of Observational Studiesin Epidemiology (STROBE) statement emerged in200713 followed by the Meta-analysis of ObservationalStudies in Epidemiology (MOOSE) statement in 2010.14

There have also been efforts, such as the Utstein Tem-

plate,15

to standardize the language of disasters andpromote consistent use of definitions.

In this issue of Emergency Medicine Australasia, wetake the first step in systematizing disaster case reportsby drawing up specific Instructions for Authors coupledwith our CONsensus Guidelines on Reports ofField Interventions in Disasters and Emergencies(CONFIDE). We seek to help authors report on complexissues of disasters. We seek to help the reader makeinformed judgments about these issues by bringing thereader as close as possible to field data. We seek tofoster the work of future scholars undertaking criticalevent analysis, disaster comparisons and translationalresearch. Finally, we seek to engage with other biomedi-cal journal editors in pursuit of best practice standardsfor disaster reporting. To these ends, key components ofthe CONFIDE guidelines are listed in Table 2. Asummary of our case report typology is presented inTable 3. Additional information for authors is posted onthe web.16 For reasons cited above, in the absence ofextremely unusual hazards or compelling epidemiology,the journal is unlikely to publish brief case reports inthe future. Other types of disaster case reports will bewelcomed.

We acknowledge there are many ways to reportscience. Disasters remain a multidisciplinary endeav-

our, and no one owns the truth. Indeed, in disasters ofconflict, the first casualty may be truth itself. However,we believe these guidelines will increase the utility ofcase reports for the reader and other scholars. Improv-ing disaster reporting is merely a first early step. Thereal goal is improving disaster science. We reaffirm toour readers and authors our commitment to thatprocess, our respect for their work and our own willing-ness to learn from their experience.

Competing interests

David A. Bradt: Editorial Board, Emergency MedicineAustralasia. Peter Aitken: Section Editor Disaster Medi-cine, Emergency Medicine Australasia.

References

1. US National Library of Medicine. Disaster Information Manage-ment Research Center. [Cited 1 Sep 2010.] Available from URL:http://disasterinfo.nlm.nih.gov

2. Smith E, Wasiak J, Sen A, Archer F, Burkle FM. Three decades

of disasters: a review of disaster-specific literature from 19772009. Prehosp. Disaster Med. 2009; 24: 30611.

3. Bradt DA. Evidence-based decision-making (part 1): origins andevolution in the health sciences. Prehosp. Disaster Med. 2009; 24:298305.

4. Bradt DA. Evidence-based decision-making (part 2): applicationsin disaster relief operations. Prehosp. Disaster Med. 2009; 24:47992.

5. Adinolfi C, Bassiouni D, Lauritzsen HF, Williams HR. Humani-tarian Response Review. New York and Geneva: United Nations,2005.

6. Laxminarayan R, Mills AJ, Breman JG et al. Advancement ofglobal health: key messages from the Disease Control PrioritiesProject. Lancet2006; 367: 1193208.

7. Roy N, Shah H, Patel V, Coughlin RR. The Gujarat earthquake(2001) experience in a seismically unprepared area: communityhospital medical response. Prehosp. Disaster Med. 2002; 17: 18695.

8. Briggs SM, Schnitzer JJ. Earthquake relief the US medicalresponse in Bam, Iran. N. Engl. J. Med. 2004; 350: 11746.

9. von Schreeb J, Riddez L, Samnegrd H, Rosling H. Foreign FieldHospitals in the Recent Sudden-Onset Disasters in Iran, Haiti,Indonesia, and Pakistan. Prehosp. Disaster Med. 2008; 23: 14451.

10. Motamedi MHK, Saghafinia M, Bafarani AH, Panahi F. A reas-sessment and review of the Bam earthquake five years onward:what was done wrong? Prehosp. Disaster Med. 2009; 24: 45360.

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11. Begg C, Cho M, Eastwood S et al. Improving the quality ofreporting of randomized control trials. JAMA 1996; 276: 6379.

12. Moher D, Cook DJ, Eastwood S et al. Improving the quality ofreports of meta-analyses of randomized controlled trials: theQUOROM statement. Lancet1999; 354: 1896900.

13. von Elm E, Altman DG, Egger M, Pocock SJ, Gtzsche PC,Vandenbroucke JP. The strengthening the reporting of observa-tional studies in epidemiology (STROBE) statement: guidelinesfor reporting observational studies. Lancet 2007; 370: 145357.

14. Stroup DF, Berlin JA, Morton SC et al. Meta-analysis of observa-tional studies in epidemiology: a proposal for reporting. JAMA2000; 283: 200812.

15. Sundnes KO, Birnbaum ML, eds. Health Disaster ManagementGuidelines for Evaluation and Research in the Utstein Style. TheWorld Association for Disaster and Emergency Medicine. [Cited1 Sep 2010.] Available from URL: http://www.wadem.org/guidelines.html

16. Emergency Medicine Australasia. Author Guidelines. [Cited 1Sep 2010.] Available from URL: http://www.wiley.com/bw/submit.asp?ref=1742-6731&site=1

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