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Emergency Department Response to Chemical, Biological, Radiological, Nuclear, and Explosive Events: A Systematic Review

Published online by Cambridge University Press:  31 October 2018

Saydia Razak Open the ORCID record for Saydia Razak [Opens in a new window] ,
Sue Hignett  and
Jo Barnes
Saydia Razak*
Affiliation:
Loughborough Design School, Loughborough University, Leicestershire, UK
Sue Hignett
Affiliation:
Loughborough Design School, Loughborough University, Leicestershire, UK
Jo Barnes
Affiliation:
Loughborough Design School, Loughborough University, Leicestershire, UK
*
Correspondence: Saydia Razak, MSc Loughborough Design School, LDS 2.22 Loughborough University Leicestershire, LE11 3TU, UK E-mail: s.razak@lboro.ac.uk
Rights & Permissions [Opens in a new window]

Abstract

Introduction

A Chemical, Biological, Radiological, Nuclear, and explosive (CBRNe) event is an emergency which can result in injury, illness, or loss of life. The emergency department (ED) as a health system is at the forefront of the CBRNe response with staff acting as first receivers. Emergency departments are under-prepared to respond to CBRNe events - recognizing key factors which underlie the ED CBRNe response is crucial to provide evidence-based knowledge to inform policies and, most importantly, clinical practice.

Problem

Challenges in detection, decontamination, and diagnosis are associated with the ED CBRNe response when faced with self-presenting patients.

Methods

A systematic review was carried out in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). An in-depth search strategy was devised to identify studies which focused on the ED and CBRNe events. The inclusion criteria were stringent in terms of the environment (ED), participants (first receivers), situation (CBRNe response), and actions (detection, decontamination, and diagnosis). Fifteen databases and topic-specific journals were searched. Studies were critically appraised using the Mixed Methods Appraisal Tool (MMAT). Papers were thematically coded and synthesized using NVivo 10 (QSR International Ltd, Melbourne, Australia).

Results

Sixty-seven full-text papers were critically appraised using the MMAT; 70% were included (n = 60) as medium- or high-quality studies. Data were grouped into four themes: preparedness, response, decontamination, and personal protective equipment (PPE) problems.

Discussion

This study has recognized the ED as a system which depends on four key factors - preparedness, response, decontamination, and PPE problems - which highlight challenges, uncertainties, inconsistencies, and obstacles associated with the ED CBRNe response. This review suggests that response planning and preparation should be considered at three levels: organizational (policies and procedures); technological (decontamination, communication, security, clinical care, and treatment); and individual (willingness to respond, PPE, knowledge, and competence). Finally, this study highlighted that there was a void specific to detection and diagnosis of CBRNe exposure on self-presenting patients in the ED.

Conclusion:

The review identified concerns for both knowledge and behaviors which suggests that a systems approach would help understand the ED response to CBRNe events more effectively. The four themes provide an evidence-based summary for the state of science in ED CBRNe response, which can be used to inform future policies and clinical procedures.

RazakS, HignettS, BarnesJ. Emergency Department Response to Chemical, Biological, Radiological, Nuclear, and Explosive Events: A Systematic Review. Prehosp Disaster Med. 2018;33(5):543–549.

Keywords

CBRNedecontaminationdetectiondiagnosisemergency department
Type
Comprehensive Review
Information
Prehospital and Disaster Medicine , Volume 33 , Issue 5 , October 2018 , pp. 543 - 549
Copyright
© World Association for Disaster and Emergency Medicine 2018 

Introduction

Background

Chemical, Biological, Radiological, Nuclear, and explosive (CBRNe) events occur through natural, accidental, and deliberate means.Reference Chilcott and Wyke 1 These events present a threat to human welfare by causing, or having the potential to cause, injury, illness, or loss of life, and they can result in a large number of casualties.

Emergency departments (EDs) have statutory duties and responsibilities to prepare, plan, and respond to CBRNe events adequately. 2 Emergency departments are at the forefront of the CBRNe response and serve as the gateway to the most appropriate care of patients.Reference Whetzel, Walker-Cillo, Chan and Trivett 3 In particular, employees within the ED are often considered a subset of first responders in such incidents.Reference Leiba, Halpern and Priel 4 , Reference Mitchell, Kernohan and Higginson 5 Emergency department staff are termed “first receivers”Reference Koenig 6 and include doctors, nurses, allied health care professionals, and non-clinical staff for initial recognition (receptionists), cordon control (security), and general support (estates/porters) during the CBRNe response.Reference Bland 7

Problem

Patients arrive at the ED by ambulance or self-presentation. If they have been brought in by an ambulance, they receive a medical assessment and care by paramedics while waiting to be allocated an ED cubicle. Patients who self-present are not provided with this assessment or care.Reference Smith, Bouchoucha and Watt 8 This introduces challenges in the ED CBRNe response, particularly in terms of detection of a contaminant on a self-presenting patient at the ED triage or waiting area.Reference Koenig 6 Another associated challenge related to self-presenters and the ED response is decontamination, defined as “the reduction or removal of harmful substances from the body;”Reference Levitin, Siegelson and Dickinson 9 this is an area of ambiguity and is negatively associated with the donning of personal protective equipment (PPE). Finally, the diagnosis of CBRNe-related symptoms is difficult due to the rarity of these events and similarity with other diseases making exposure difficult to diagnose.Reference Mcfee and Leiken 10

Emergency departments are under-prepared to efficiently respond to CBRNe events.Reference Kaji, Langford and Lewis 11 – Reference Kollek 15 Previous research has focused on training, namely doctors and nurses,Reference Mitchell, Kernohan and Higginson 5 , Reference Kotora 16 to overcome unpreparedness. Training as the sole means of enhancing the ED CBRNe response is questionable because obstacles such as short staffing and constant staff turnover arise.Reference Koenig 6 The purpose of this review was to scope the ED CBRNe response with respect to detection, decontamination, and diagnosis of self-presenting patients to identify key factors which can inform future policies and clinical procedures.

Report

Method

The seven-stage framework was used in line with the Preferred Reporting Items for Systems for Systematic Reviews and Meta-Analyses (PRISMA) statement. This provides structured guidance on the development of appropriate research questions, as well as on the eligibility of search criteria, and the identification, selection, retrieval, appraisal, and synthesis of relevant papers according to title and abstract.

Research Question

What is known about the ED CBRNe response with respect to detection, decontamination, and diagnosis of self-presenting patients?

Eligibility

References were screened at the first stage by setting the database parameters to all languages (English abstract), post-2001, world-wide, and any study type.

Search

The search started by scoping and exploring concepts related to the research question. An initial set of keywords was tested in BNI (NHS Evidence; National Institute for Health and Care Excellence; London, UK) and Google Scholar (Google Inc.; Mountain View, California USA) using the string searches in Figure 1. The results were reviewed for relevance, and additional keywords were added from retrieved references. The search was divided into four areas to combine concepts of environment (A), areas of exploration (A+B), context (A+B+C), and types of patients (A+B+C+D):

Figure 1 Example of String Searches.

Abbreviations: CBRNe, chemical, biological, radiological, nuclear, and explosive; ED, emergency department.

  • A.Emergency Department, Accident and Emergency, and Emergency Room.

  • B.Detection, Decontamination, and Diagnosis.

  • C.CBRNe, CBRN, Mass-Casualty Incidents [MCI], and MCI.

  • D.Walking Wounded, Priority 3 (P3; mobile with minor injuries), and Self-Presenters.

The search was run on 15 databases: ProQuest (Ann Arbor, Michigan USA); ASSIA (ProQuest; Ann Arbor, Michigan USA); BNI (NHS Evidence; National Institute for Health and Care Excellence; London, UK); Chemical Database Service (Engineering and Physical Sciences Research Council; Swindon, England); Ergonomics Abstracts (EBSCO Information Services; Ipswich, Massachusetts USA); Google Scholar (Google Inc.; Mountain View, California USA); Health Management Technology (EBSCO; Ipswich, Massachusetts USA); Medline (Ovid SP; US National Library of Medicine, National Institutes of Health; Bethesda, Maryland USA), PsychInfo (EBSCO; Ipswich, Massachusetts USA); Referex (Materials and Mechanical Engineering; Elsevier; Amsterdam, Netherlands); SAE Digital Library (SAE International; Warrendale, Pennsylvania USA); Scopus (Elsevier; Amsterdam, Netherlands); Science Direct (Elsevier; Amsterdam, Netherlands); Toxline (US National Library of Medicine; Bethesda, Maryland USA; and Web of Science (Thomson Reuters; New York, New York USA). Additional searches were run in topic-specific journals (eg, Journal of Breath Research [International Association of Breath Research; Innsbruck, Austria] and Trends in Analytical Chemistry) as shown in Table 1.

Table 1 Search Results

Identification of Relevant Papers (Inclusion/Exclusion)

Papers were included where they reported research in ED (only); ED staff (including surgeons, anesthetists, operational managers, and ED Chiefs); MCI by the intentional release of CBRNe materials, ED triaging; and detection, decontamination, and diagnosis in ED, including donning PPE. Papers were excluded from guidelines, textbooks, and grey literature. Scientific studies of the effects of CBRNe materials (ie, physiological and chemical pathways) were excluded. Psychological or psychosocial effects of CBRNe incidents were excluded. Finally, research reporting on activity in hot zones was excluded.

Selection and Retrieval

The search identified 1,874 papers which were screened by title and abstract and checked for duplication, resulting in 366 papers. Articles that did not adhere to the inclusion criteria were disregarded while simultaneously adding (23) relevant studies through manual citation searches. This resulted in the quality of 67 articles being assessed with the Mixed Methods Appraisal Tool (MMAT).Reference Pluye, Gagnon, Griffiths and Johnson-Lafleur 17

Appraisal

The included papers (n = 67) were appraised using the MMATReference Pluye, Gagnon, Griffiths and Johnson-Lafleur 17 to assign a quality score on a five-point scale from zero to four (100% of criteria met). Seven papers scoring zero or one (<25%) were discarded, as the quality was too poor for inclusion. This resulted in a final number of 60 studies (Figure 2).

Figure 2 PRISMA Flow Diagram of Studies Included in the Systematic Review.

Abbreviations: CBRNe, chemical, biological, radiological, nuclear, and explosive; ED, emergency department; PRISMA, Preferred Reporting Items for Systems for Systematic Reviews and Meta-Analyses.

Synthesis

The residual studies (n = 60) were retained for qualitative synthesis. There were four emerging themes of CBRNe preparedness (n= 38), response (n= 29), decontamination (n= 9), and PPE problems (n= 9). Some papers provided information for more than one theme.

Results

Papers were included from 12 countries: USA, UK, Israel, Canada, Australia, Pakistan, Singapore, Turkey, Ireland, Italy, Norway, and Spain. The methodological quality of the included papers was mostly medium and strong (Supplementary Material; available online only). A quantitative synthesis was not carried out based on the variation in study types, sample populations, study aims, and multi-faceted nature of CBRNe events.

Included papers were coded in Nvivo 10 (QSR International Ltd; Melbourne, Australia) for thematic analysis. Overlapping themes between studies were coded and then grouped into main themes, which highlighted key factors relevant to the research question, as outlined below.

Preparedness

Preparedness was associated with a post-9-11 shift in thinking,Reference Niska and Burt 18 , Reference Timm and Reeves 19 which forced EDs to examine and update their emergency disaster preparedness plans,Reference Masterson, Steffen, Brin, Kordick and Christos 20 such as dividing ED CBRNe preparedness into two domains: departmental and individual.Reference Mitchell, Kernohan and Higginson 5

This systematic review identified the ED as a system and preparedness consisting of three inter-twining levels: organization, technology, and individual (Table 2). With studies reporting research on organizational preparedness to provide timely and high standard care to patients,Reference Mitchell, Kernohan and Higginson 5 , Reference Williams, Walter and Challen 13 , Reference Jasper, Miller, Sweeney, Berg, Feuer and Reganato 21 , Reference Wong, Turner and Boppana 22 particularly emphasizing standardized measures,Reference Kotora 16 , Reference Kollek and Cwinn 23 competencies,Reference Schultz, Koenig, Whiteside and Murray 24 , Reference Djalali, Della Corte and Segond 25 and standardsReference Williams, Walter and Challen 13 for ED CBRNe preparedness.

Table 2 Primary, Secondary, and Tertiary Findings

Abbreviations: CBRNe, chemical, biological, radiological, nuclear, and explosive; ED, emergency department; PPE, personal protective equipment.

a Please see check sheet for ED disaster planners.

Technology-related preparedness both includes and highlights limitations in communication systems to co-ordinate the CBRNe response;Reference Klima, Seiler and Peterson 26 mainly, the unreliability of mobile phones and walkie-talkies due to reception difficulties, particularly when surrounded by certain materials. Additionally, computer-based decision-support systems were anticipated to be overwhelmed due to the surge in patients, resulting in a preference for manual pen-paper methods.Reference Reddy, Paul, Abraham, McNeese, DeFlitch and Yen 27 , Reference Zhu, Abraham and Paul 28 Individual preparedness was associated with the perceptions, perspectives, views, and information needs of first receivers, which affected their capacity to respond to CBRNe events.Reference Becker and Middleton 29 , Reference Considine and Mitchell 30

In addition to communication issues, there was also evidence that EDs lacked preparedness (including capacity) for decontamination, security, appropriate equipment, antidotes, and treatment equipment incapacities.Reference O’Sullivan, Dow and Turner 12 , Reference Wong, Turner and Boppana 22 , Reference Oh, Yong, Ponampalam, Anantharman and Lim 31 , Reference Treat, Williams, Furbee, Manley, Russell and Stamper 32 Furthermore, one study suggested that the limitations in the ED CBRNe response was a reflection of overall hospital preparedness.Reference Kollek 33

Response

Numerous studies reported on individual staff skills or preferences in responding to a CBRNe event, by which, the response was determined by the individual first receivers’ willingness to respond to a CBRNe event. Individual willingness to respond varied based on the type of event, with the majority of first receivers more willing to respond to disasters such as an airplane crash in comparison to radioactive or biological exposure.Reference Masterson 34 , Reference Cone and Cummings 35 Nonetheless, willingness to respond was found to be high for Chemical, Biological, and Radiological (CBR) events amongst ED nurses with post-graduate qualifications; however, this willingness to respond to CBR exposure decreased significantly if the substances were unknown.Reference Considine and Mitchell 30

Studies reported a number of solutions to enhance the ED CBRNe response, including creating surge capacity,Reference Jasper, Miller, Sweeney, Berg, Feuer and Reganato 21 , Reference Waage, Poole and Thorgersen 36 which is the hospital’s ability to accommodate a transient sudden rise in demand for health care following an event.Reference Jasper, Miller, Sweeney, Berg, Feuer and Reganato 21 , Reference Waage, Poole and Thorgersen 36 Implementing specific triage routes (time and sequence for patient management) have been proposed to create surge capacity,Reference Durukan, Ozdemir and Coskun 37 , Reference Raiter, Farfel and Lehavi 38 as well as applying actions such as a decrease in new admissions, discharge of patients earlier, cancelling elective surgeries, organizing daycare for children of staff, and designating victim flow areas.Reference Kaji, Langford and Lewis 11 , Reference Satterthwaite and Atkinson 39 , Reference Shah, Rehman and Sayyed 40 Surge capacity was, however, suggested to be restricted by the failure to fully integrate inter-agency training, planning, and co-ordination.Reference Kaji, Langford and Lewis 11 , Reference Jasper, Miller, Sweeney, Berg, Feuer and Reganato 21 , Reference Waage, Poole and Thorgersen 36

Decontamination

The importance of effective decontamination within the ED was emphasized by a number of studies.Reference Williams, Walter and Challen 13 , Reference Castle 41 , Reference Cohen, Sevdalis, Patel, Taylor, Batrick and Darzi 42 They suggested it was imperative for EDs to have the appropriate facilities, equipment, and capability to respond to CBRNe exposure.

Decontamination challenges related to knowledge and facilities were reported for PPE, clinical waste management, and decontamination timescales.Reference Mitchell, Kernohan and Higginson 5 , Reference Brinker, Gray and Schumacher 43 , Reference Schumacher, Bond, Woodham, Buckingham, Garnham and Brinker 44 Variation existed between studies in terms of having the facilities to physically decontaminate patients. For example, some EDs had designated areas for decontamination,Reference Williams, Walter and Challen 13 , Reference George, Ramsay and Rochester 45 but could not manage a serious chemical incident as a result of lack of equipment. Other studies highlighted a lack of decontamination facilities overall,Reference Kollek and Cwinn 23 , Reference Wetter, Daniell and Treser 46 and some identified factors which restricted capability to decontaminate effectively. These factors included equipmentReference Williams, Walter and Challen 13 , Reference Kotora 16 , Reference George, Ramsay and Rochester 45 and knowledge relating to decontamination procedures. It was reported that decontamination knowledge was flawed in terms of how to carry out decontamination and the associated timescales.Reference Williams, Walter and Challen 13 There was also a lack of knowledge in water flow procedures to prevent cross-contamination, clinical waste management, and the potential of cross-contamination in general.Reference Mitchell, Kernohan and Higginson 5 , Reference George, Ramsay and Rochester 45

Personal Protective Equipment Problems

First receivers were found to hold negative perceptions of PPE, finding it cumbersome; in particular, ED nurses found difficulties in donning PPE with specific limitations including poor suit fit, poor mask fit, claustrophobia, pregnancy, glasses or beard that prevents adequate mask seal, as well as respiratory or cardiovascular illness.Reference Williams, Walter and Challen 13 , Reference Considine and Mitchell 30 , Reference Castle, Bowen and Spencer 47

Several papers identified PPE challenges for routine and life-saving tasks, including inadequate provision,Reference George, Ramsay and Rochester 45 poor fit, and dexterity issues.Reference Williams, Walter and Challen 13 , Reference Considine and Mitchell 30 , Reference Castle, Bowen and Spencer 47 Coping strategies were reported to include substitute equipment while wearing PPE; for example, pre-filled (Aurum) syringes to administer intravenous drugs instead of the traditional glass ampules and syringe method.Reference Castle, Bowen and Spencer 47 Another substitution was using a laryngeal mask airway rather than and endotracheal tube to secure the patients airway, if required.Reference Castle 41 , Reference Flaishon, Sotman, Ben-Abraham, Rudick, Varssano and Weinbroum 48 , Reference Castle, Owen, Hann, Clark, Reeves and Gurney 49

Discussion

This state of science review has systematically searched for and reviewed research on the ED response to a CBRNe event. It has recognized the ED as a system which depends on key factors when responding to such an event. The themes - preparedness, response, decontamination, and PPE problems - were identified as key factors based on research highlighting challenges, uncertainties, inconsistencies, and obstacles associated with the ED CBRNe response.

In line with existing literature, this review highlights that first receivers are under-prepared to respond to a CBRNe event as they would natural disasters,Reference Masterson, Steffen, Brin, Kordick and Christos 20 , Reference Kollek and Cwinn 23 , Reference Considine and Mitchell 30 , Reference Cone and Cummings 35 , Reference Whetzel, Walker-Cillo, Chan and Trivett 50 resulting in the ED being under-prepared to effectively respond overall. An explanation is that the ED is a complex system consisting of organizational, technological, and individual factors, which is further complicated by multifaceted CBRNe events. Although it is suggested that hospitals should implement policies to address the lack of preparedness,Reference Labrague, Hammad and Gloe 51 a means of better understanding the ED as a system is by adopting a systems approach, which accounts for and improves the design of a system and people’s interaction with it, rather than concentrating on an individual part of it.Reference Wilson 52

Further, first receivers display an unwillingness to respond to CBRNe events due to perceived risk, which has previously been associated with invisible hazardsReference Barnett, Thompson and Errett 53 associated with CBRNe events, and an unwillingness of staff to respond,Reference Maxwell 54 resulting in staff shortagesReference Ochi, Tsubokura and Kato 55 compromising an effective response.

Additionally, literature based on response suggested that aspects such as surge capacity would be compromised as a result of limited interagency co-ordination.Reference Jasper, Miller, Sweeney, Berg, Feuer and Reganato 21 , Reference Waage, Poole and Thorgersen 36 A suggested means of creating surge capacity is that of triaging patients efficiently. Effective triage was demonstrated through retrospective studies of explosive events.Reference Satterthwaite and Atkinson 39 , Reference Ashkenazi, Kessel and Khashan 56 , Reference Malik, Hanif and Tariq 57 These studies highlighted varying techniques of triage and how they impacted surge capacity and the care offered to patients. They also demonstrated that experience and expertise were often overcome by the overwhelming surge of patients.

Studies based on decontamination emphasized that it remained an area of ambiguity in the ED CBRNe response,Reference Kotora 16 particularly in terms of providing adequate facilities and equipment to perform decontamination.Reference Williams, Walter and Challen 13 , Reference George, Ramsay and Rochester 45 This disconnect is amplified by the incapability of first receivers to carry out decontamination, resulting from their lack of knowledge on how to carry out decontamination procedures.Reference Mitchell, Kernohan and Higginson 5 , Reference Williams, Walter and Challen 13

Studies identifying PPE problems highlighted the inadequate provision of PPE.Reference Becker and Middleton 29 , Reference George, Ramsay and Rochester 45 This is further complicated by first receivers having limited knowledge about the application of PPE, finding it cumbersome, and having limited dexterity when conducting both routine and life-saving procedures.Reference Williams, Walter and Challen 13 , Reference Considine and Mitchell 30 , Reference Castle, Bowen and Spencer 47 Compensatory-type studies focusing on overcoming PPE problems were prevalent. For example, a recent study which proposed the use of a lighter, size-specific PPE suit,Reference Schumacher, Arlidge, Garnham and Ahmad 58 which overcomes the physical constraints of PPE. The suggestion is that trial and error will continue until both routine and life-saving tasks can be carried out in PPE competently and comfortably.

On a local level, the findings from this review can be used to formulate a check sheet for ED disaster planners in order to enhance planning, preparedness, and response to CBRNe events, as shown in Figure 3. This checklist is entirely based on the literature included in this review. It is likely to have omissions, and should only be used in context of the presenting CBRNe situation combined with up-to-date governmental guidance.

Figure 3 Check Sheet for ED Disaster Planners.

Abbreviations: CBRNe, chemical, biological, radiological, nuclear, and explosive; ED, emergency department; PPE, personal protective equipment.

The findings from this systematic review can further be used to inform CBRNe guidance. For example, in the UK, the Health Protection Agency (HPA; Public Health England; London, UK) 59 has published clinical guidelines on how to respond to CBRNe events in the ED. The HPA guidance explains how to safely clinically recognize, respond, and treat exposure, which is dependent on presenting symptomologies. Mnemonics for rapidly assessing casualties, triaging sieves, guidance on the type of PPE required, as well as useful contacts are provided in this guidance. 59 The link between effective triage and surge capacity highlighted through this review can contribute to revisions of future HPA guidance.

Emergency Preparedness Resilience and Response (EPRR) 60 , 61 is another initiative in the UK providing guidance in CBRNe response. The guidance for self-presenters focuses on chemical exposure 60 and is based on findings from the “Optimization through Research of CHemical Incident Decontamination Systems” (ORCHIDS) 62 project as its empirical framework to better respond to incidents involving hazardous materials. The guidance suggests rapid actions to save lives, known as the Initial Operational Response (IOR) to improve patient outcomes following CBRNe exposure. 63 Findings from this systematic review can inform EPRR guidance to recognize first receivers’ decreased willingness to respond to unknown chemical exposure in comparison to known chemical hazards.Reference Considine and Mitchell 30 Furthermore, in order to implement the IOR, this review emphasizes the need for appropriate facilities, equipment, and capability to carry out decontamination to be ready and available.

With reference to the research question and the challenges of detection, decontamination, and diagnosis, this review found that research investment was being made in decontamination, and the ORCHIDS project adds to this. However, there were no specific studies on the detection or diagnosis of exposure. In terms of the ED responding to self-presenters, this review found that the willingness to respond to CBRNe contaminated casualties’ decreases when the substance is unknown.

Limitations

The majority of the data used in this study were retrospective, event-based data which can be considered to jeopardize the scientific quality and validity of findings.Reference Morelli, Sabbadini and Bortolin 64 However, retrospective event data, particularly in disaster medicine, are the norm. It is suggested that every systematic review faces challenges in terms of the quality of data collected.Reference Morelli, Sabbadini and Bortolin 64 There was also a geographical and publication bias with 20 of the 60 studies conducted in the US. This contributes to an acknowledged bias towards US literature as a point of reference in UK health emergency planning and preparedness evidence.Reference Lee, Booth, Challen, Gardois and Goodacre 65 , Reference Challen, Lee, Booth, Gardois, Woods and Goodacre 66

Conclusion

Understanding the key factors underpinning the dynamic ED system to plan, prepare, and respond to emergencies effectively has major legal, clinical, and moral implications. Emergency department preparedness and response has obstacles, uncertainties, and inconsistencies in addition to the known challenges. The four themes provide an evidence-based summary to inform future CBRNe guidance, policies, and clinical procedures. The themes particularly identify that the ED CBRNe response is limited unless response planning and preparation is considered at three levels: organizational (policies and procedures); technological (decontamination, communication, security, clinical care, and treatment); and individual (willingness to respond, PPE, knowledge, and competence). Further, the complexity of the ED, the multifaceted nature of CBRNe events, combined with the identified concerns from this review, in terms of both knowledge and behaviors, suggest that a systems approach is required to understand the ED CBRNe response in the future.

Supplementary Material

To view supplementary material for this article, please visit https://doi.org/10.1017/S1049023X18000900

Footnotes

Conflicts of interest: none.

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Figure 0

Figure 1 Example of String Searches.Abbreviations: CBRNe, chemical, biological, radiological, nuclear, and explosive; ED, emergency department.

Figure 1

Table 1 Search Results

Figure 2

Figure 2 PRISMA Flow Diagram of Studies Included in the Systematic Review.Abbreviations: CBRNe, chemical, biological, radiological, nuclear, and explosive; ED, emergency department; PRISMA, Preferred Reporting Items for Systems for Systematic Reviews and Meta-Analyses.

Figure 3

Table 2 Primary, Secondary, and Tertiary Findings

Figure 4

Figure 3 Check Sheet for ED Disaster Planners.Abbreviations: CBRNe, chemical, biological, radiological, nuclear, and explosive; ED, emergency department; PPE, personal protective equipment.

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