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BackgroundAlthough training and education have long been accepted as integral to disaster preparedness, many currently taught practices are neither evidence-based nor standardized. The need for effective evidence-based disaster training of healthcare staff at all levels, including the development of standards and guidelines for training in the multi-disciplinary health response to major events, has been designated by the disaster response community as a high priority. We describe the application of systematic evidence-based consensus building methods to derive educational competencies and objectives in criteria-based preparedness and response relevant to all hospital healthcare workers.MethodsThe conceptual development of cross-cutting competencies incorporated current evidence through a systematic consensus building process with the following steps: (1) review of peer-reviewed literature on relevant content areas and educational theory; (2) structured review of existing competencies, national level courses and published training objectives; (3) synthesis of new cross-cutting competencies; (4) expert panel review; (5) refinement of new competencies and; (6) development of testable terminal objectives for each competency using similar processes covering requisite knowledge, attitudes, and skills.ResultsSeven cross-cutting competencies were developed: (1) Recognize a potential critical event and implement initial actions; (2) Apply the principles of critical event management; (3) Demonstrate critical event safety principles; (4) Understand the institutional emergency operations plan; (5) Demonstrate effective critical event communications; (6) Understand the incident command system and your role in it; (7) Demonstrate the knowledge and skills needed to fulfill your role during a critical event. For each of the cross-cutting competencies, comprehensive terminal objectives are described.ConclusionCross-cutting competencies and objectives developed through a systematic evidence-based consensus building approach may serve as a foundation for future hospital healthcare worker training and education in disaster preparedness and response.

Health care facility surge capacity has received significant planning attention recently, but there is no commonly accepted framework for detailed, phased surge capacity categorization and implementation. This article proposes a taxonomy within surge capacity of conventional capacity (implemented in major mass casualty incidents and representing care as usually provided at the institution), contingency capacity (using adaptations to medical care spaces, staffing constraints, and supply shortages without significant impact on delivered medical care), and crisis capacity (implemented in catastrophic situations with a significant impact on standard of care). Suggested measurements used to gauge a quantifiable component of surge capacity and adaptive strategies for staff and supply challenges are proposed. The use of refined definitions of surge capacity as it relates to space, staffing, and supply concerns during a mass casualty incident may aid phased implementation of surge capacity plans at health care facilities and enhance the consistency of terminology and data collection between facilities and regions.

IMPORTANCESepsis is a common syndrome with substantial morbidity and mortality. A combination of vitamin C, thiamine, and corticosteroids has been proposed as a potential treatment for patients with sepsis.OBJECTIVE To determine whether a combination of vitamin C, thiamine, and hydrocortisone every 6 hours increases ventilator-and vasopressor-free days compared with placebo in patients with sepsis.DESIGN, SETTING, AND PARTICIPANTS Multicenter, randomized, double-blind, adaptive-sample-size, placebo-controlled trial conducted in adult patients with sepsis-induced respiratory and/or cardiovascular dysfunction. Participants were enrolled in the emergency departments or intensive care units at 43 hospitals in the United States between August 2018 and July 2019. After enrollment of 501 participants, funding was withheld, leading to an administrative termination of the trial. All study-related follow-up was completed by January 2020. INTERVENTIONS Participants were randomized to receive intravenous vitamin C (1.5 g), thiamine (100 mg), and hydrocortisone (50 mg) every 6 hours (n = 252) or matching placebo (n = 249) for 96 hours or until discharge from the intensive care unit or death. Participants could be treated with open-label corticosteroids by the clinical team, with study hydrocortisone or matching placebo withheld if the total daily dose was greater or equal to the equivalent of 200 mg of hydrocortisone. MAIN OUTCOMES AND MEASURESThe primary outcome was the number of consecutive ventilator-and vasopressor-free days in the first 30 days following the day of randomization. The key secondary outcome was 30-day mortality. RESULTS Among 501 participants randomized (median age, 62 [interquartile range {IQR}, 50-70] years; 46% female; 30% Black; median Acute Physiology and Chronic Health Evaluation II score, 27 [IQR, 20.8-33.0]; median Sequential Organ Failure Assessment score, 9 [IQR, 7-12]), all completed the trial. Open-label corticosteroids were prescribed to 33% and 32% of the intervention and control groups, respectively. Ventilator-and vasopressor-free days were a median of 25 days (IQR, 0-29 days) in the intervention group and 26 days (IQR, 0-28 days) in the placebo group, with a median difference of −1 day (95% CI, −4 to 2 days; P = .85). Thirty-day mortality was 22% in the intervention group and 24% in the placebo group.CONCLUSIONS AND RELEVANCE Among critically ill patients with sepsis, treatment with vitamin C, thiamine, and hydrocortisone, compared with placebo, did not significantly increase ventilator-and vasopressor-free days within 30 days. However, the trial was terminated early for administrative reasons and may have been underpowered to detect a clinically important difference.

The disposition classification system allows conceptual classification of patients for suitable disposition, including those deemed safe for early discharge home during surges in demand. Clinical criteria allowing real-time categorisation of patients are awaited.

We describe a novel adaptation of the TaqMan PCR assay which potentially allows for highly sensitive detection of any eubacterial species with simultaneous species identification. Our system relies on a unique multiprobe design in which a single set of highly conserved sequences encoded by the 16S rRNA gene serves as the primer pair and is used in combination with both an internal highly conserved sequence, the universal probe, and an internal variable region, the species-specific probe. A pre-PCR ultrafiltration step effectively decontaminates or removes background DNA. The TaqMan system described reliabAly detected 14 common bacterial species with a detection limit of 50 fg. Further, highly sensitive and specific pathogen detection was demonstrated with a prototype species-specific probe designed to detect Staphylococcus aureus. This assay has broad potential in the clinical arena for rapid and specific diagnosis of infectious diseases.Currently, the standard method for diagnosing the presence of bacterial pathogens in clinical samples relies on culture techniques. However, active research is under way using new molecular methods to decrease detection time and increase assay sensitivity. PCR has emerged as the molecular method of choice in achieving these objectives. The utility of PCR and other molecular methods is evidenced by the recent guidelines issued by the NCCLS in 1999 encouraging the use of such methods in clinical laboratories performing bacterial identification assays (11).To detect the presence of any bacterial pathogen in a clinical sample, primers annealing to regions of DNA conserved across a wide range of bacterial genomes have been employed. The design of such universal primers has often focused on the 16S rRNA gene (17). The presence of multiple copies of this gene within the bacterial genome facilitates its amplification by PCR. Further, sufficient sequence variability allows phylogenetic information to be attained for the purposes of microbial identification. However, up to the present, assays which provide for both universal detection and species identification require a second post-PCR processing step, which can be technically cumbersome and slow the time to reporting of results (9, 14).Universal PCR-based bacterial detection systems have also been hampered by contamination issues. High sequence conservation of the DNA region chosen for PCR primer annealing coupled with the immense amplification power of PCR results in the amplification of exceedingly minor bacterial contaminants, leading to false positives. Attempts to decontaminate PCR materials have involved nearly all known methods to destroy DNA, including UV irradiation, 8-MOP treatment, and incubation with various enzymes, such as DNase, restriction enzymes, or both in combination (2, 4). Thus far, none of these methods has been shown to be entirely effective or reproducible.Assessment of bacterial contamination can most reliably be made using real-time detection methods to characterize PCR amplification. Briefly, real-time PCR am...

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