Authors
- Adams, Lavonne Associate Professor, PhD, RN, CCRN
- Smith, Lisa
- Weeks, Susan
Abstract
Review question/objective: What is the effectiveness of multidisciplinary team response to mass casualty disasters upon the resolution of immediate needs and the support perceived by survivors of mass casualty disasters? The objectives of this review are to identify the effectiveness of multidisciplinary team response on;
1) the resolution of immediate needs, and;
2) the support perceived among survivors of mass casualty disasters.
Background: When mass casualty disasters occur, multiple response systems are activated to mitigate the negative consequences of the disaster and to support survivors.1-5 Disaster literature includes descriptions of responses to varied events such as the 1983 Ash Wednesday Bushfires in Australia,1 Hurricanes Katrina and Rita in the United States,2 large-scale accidents in Norway,3 and the 2004 Asian Tsunami.4,5
In addition to their own physical and/or psychological trauma, disaster survivors are often dealing with the loss of their family members and friends. The needs of these survivors are immense, and one technique that can be used by response organizations is the formation and deployment of multidisciplinary response teams.4,5 These teams are typically composed of individuals trained to respond to and provide referrals for the physical health, mental health, and financial needs of disaster survivors.3,4 In addition, teams such as those utilized by the American Red Cross since 1995 also include individuals trained to respond to the spiritual needs of disaster survivors (S. Stanley, personal communication, May 22, 2011).
The third author of this systematic review was involved in the development of the multidisciplinary response team design used by a national disaster response entity. This team format was first composed following the bombing of the Alfred P. Murrah Federal Building in Oklahoma City, Oklahoma, U.S.A. in April of 1995.6 The team format was formalized and became known as an Integrated Care Team (ICT) when used to respond to survivors of the World Trade Center incident in New York, New York, U.S.A. on September 11, 2001. Since that time, the ICT structure has been used for other mass casualty disaster responses, although no studies related to its effectiveness have yet been located. Although the ICT format has been viewed as a successful method of intervention, the format was less effective when used to respond to two large tornadoes which occurred in the U.S. states of Alabama and Missouri during the spring of 2011. (S. Stanley, personal communication, May 22, 2011).
This review will focus on the target population of survivors of mass casualty disasters. Although each disaster is unique, there are commonalities in the needs of individuals, families, and communities surviving disasters which result in mass casualties. The effect of the type of disaster on team effectiveness, resolution of immediate needs, and support perceived has not been studied in the literature reviewed.
The term "Integrated Care Team" is used by at least one International Red Cross/Red Crescent entity; however, the authors have not yet located other disaster response organization that uses this specific term. While the ICT is familiar to disaster responders within the United States, it may not be commonly used in other countries. Therefore, the term "multidisciplinary response team" has been used in the title and study objectives for this review. The term is used to indicate a team of individuals representing various disciplines who are trained to respond to disasters. Disciplines represented in a multidisciplinary response team may include physical health professionals (nurses, physicians, etc.), mental health professionals (psychologists, social workers, etc.), and individuals trained to respond to the financial needs of disaster survivors. The individuals in the latter category may or may not be credentialed professionals. Another function that is sometimes included in the multidisciplinary response to disasters is that of spiritual care. The authors have not yet located any studies in the international literature related to the ICT format, so the focus of the search for relevant literature will be on the multidisciplinary response team.
It is often difficult to measure the outcomes of disaster response systems. This can be particularly true when evaluating the response to the complex emotional needs of individuals, families, and communities impacted by a mass casualty disaster. Despite the difficulties of outcome measurement, it is important to evaluate the effectiveness of response modalities. Two possible measures of response effectiveness are the resolution of immediate needs and the extent to which disaster survivors perceive they have been supported by the response team.2, 7
Although careful planning, protocol and procedure writing, team member selection, training, and practice are suggested as key factors in providing effective response to disasters,8 a consistent definition of team effectiveness has not yet been located. Team effectiveness has been defined by measurement of participants' perception of received benefits, 7 and through study of efficacy, efficiency, and cost-effectiveness of early intervention activities.13
Multiple articles have been published describing team response to disasters.1,9-14 While many articles focus on the broad topic of disaster response, some authors have addressed specific methods used by specific disaster response organizations.15 It is acknowledged that the quality and effectiveness of disaster response programs can be difficult to assess.16 Regardless of this difficulty, a few descriptive studies have been published assessing the effectiveness of disaster response teams.2,3,7 The reviewers have not yet located any RCTs or quasi-experimental studies, however, we believe it is important to uncover all literature on the topic. Therefore, this review includes a detailed search strategy designed to discover all relevant literature.
Multidisciplinary teams are used throughout various healthcare settings, and numerous articles have discussed the functioning of these teams.4,17,18,19 It is recognized that multidisciplinary teams are impacted upon by multiple challenges including historical, political, economic, and social factors.20 Methodological challenges are also acknowledged as problematic in researching the impact of multidisciplinary teams.21
Despite the prevalence of research on the multidisciplinary healthcare teams, the functioning of multidisciplinary response teams has been less frequently evaluated. Much of the published literature related to multidisciplinary disaster response teams has focused on the training of the team members,22 variations in the team size,23 and barriers to eliciting feedback from disaster survivors.24 Additional topics found in the literature describing multidisciplinary disaster response teams include the use of support networks used to bolster multidisciplinary disaster response teams5 and the types of disasters to which teams have been deployed.25 It has also been recognized that disaster response services must be tailored to the diverse needs of each unique community.26 Very little international literature on multidisciplinary response teams has been found to date, however, the reviewers are hopeful that this systematic review will uncover additional sources.
Disaster-related literature indicates the need for standardized methods for needs assessment to be developed4 and for multidisciplinary collaboration to be explored and tested.4,8 Articles describing individual studies and the experiences of teams responding to individual disasters are prominent in the literature. Less is known, however, in a synthesized format about the effectiveness of a multidisciplinary disaster response team's work. This review will therefore synthesize the literature that is available on the effectiveness of these specialized teams. This systematic review will be useful to guide future planning, deployment, and evaluation of these multidisciplinary teams which comprise an essential element of disaster response following mass casualty disasters.
A preliminary search of Joanna Briggs Institute Library of Systematic Reviews, Cochrane Library of Systematic Reviews, DARE, PROSPERO, Medline, CINAHL, and EMBASE has been performed for existing systematic reviews on this topic. The authors of the review were unable to locate a systematic review synthesizing evidence on the effectiveness of multidisciplinary response teams intervening with survivors of mass casualty disasters.
Two JBI review protocols related to disasters were located, both involving qualitative evidence. One review protocol relates to nurses' experiences of ethical preparedness for catastrophic public health emergencies and health care disasters.27 The other review protocol relates to nurses' experiences of responding to a health care disaster.28
Article Content
Inclusion criteria
Types of participants
This review will consider studies that include survivors of mass casualty disasters. Survivors of all ages and in all settings will be included.
Types of intervention(s)
This review will consider studies that evaluate the effectiveness of multidisciplinary response teams focused on the well-being of survivors of mass casualty disasters.
Types of outcomes
This review will consider studies that include the following outcome measures:
1) the resolution of immediate needs and/or
2) the support perceived among survivors of mass casualty disasters.
For clarity of outcomes measurements in the review we present the following explanations: The resolution of immediate needs refers to maintenance of health,3 prevention of psychopathologic outcomes,3 normalization of reactions,2,7 increased coping skills,2,7 and reducing stigma of help-seeking behavior.2,7 The support perceived refers to the degree to which encounters with the team achieved resolution of immediate needs.2,7 Disaster literature tends to describe outcomes in varied manners rather than consistent measurements. Because of this, it may be necessary to translate outcomes in any study into a dichotomous ("yes" or "no") scale. While this approach is not ideal, it may be the only way to move forward with this particular topic. The authors believe that the importance of synthesizing any available evidence on this topic warrants this approach.
Types of studies
This review will consider both experimental and epidemiological study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental, before and after studies, prospective and retrospective cohort studies, case control studies and analytical cross sectional studies for inclusion. The reviewers have not yet located any studies of this nature; however, we believe that it is important to try to uncover any literature related to this topic and therefore include them in our search for this systematic review. This review will also consider descriptive epidemiological study designs including case series, individual case reports and descriptive cross sectional studies for inclusion. Thus far, descriptive studies related to mental health 2, 7, 16, 26 and anecdotal reports or after-action plans4,5,12,23 have been located; we are hopeful that this systematic review will uncover additional sources.
Search strategy
The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE, CINAHL, PsycINFO, EMBASE, and SocIndex will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Studies published in English will be considered for inclusion in this review. Studies published between 1995 and 2012 will be considered for inclusion in this review. The dates of inclusion were selected because the integrated care team approach utilized by the American Red Cross was first formalized following the bombing of the Alfred P. Murrah Federal Building in Oklahoma City, Oklahoma, USA in April 1995.
The databases to be searched include:
PubMed (MEDLINE)
CINAHL
SOCIndex
EMBASE
PsycINFO
The search for unpublished studies will include:
MEDNAR
Initial keywords to be used will be:
Multidisciplinary response team
Disaster response
Integrated care team
Disaster response team
Red Cross team
Red Crescent team
All studies identified during the database search will be assessed for relevance to the review based on the information provided in the title, abstract, and descriptor/MeSH terms. A full report will be retrieved for all studies that meet the inclusion criteria. Studies identified from reference list searches will be assessed for relevance based on the study title.
Assessment of methodological quality
Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.
Data collection
Data will be extracted from papers included in the review using the standardized data extraction tool from JBI-MAStARI (Appendix II). The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Data will be extracted by two reviewers working independently. The author of primary studies will be contacted for missing information or to clarify unclear data.
Data synthesis
Quantitative data will, where possible, be pooled in statistical meta-analysis using JBI-MAStARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and also explored using subgroup analyses based on the different study designs included in this review. Where statistical pooling is not possible the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.
Conflicts of interest
Although two of the reviewers (Dr. Weeks and Dr. Adams) have participated in ICT work or evaluation, the reviewers do not believe this participation will bias the review. Therefore, we are not aware of any conflict of interest in conducting this review.
Acknowledgements
The reviewers would like to acknowledge Dr. Sharon Stanley, Chief Nursing Officer of the American Red Cross and Dr. Susan Hassmiller, Senior Advisor for Nursing of the Robert Wood Johnson Foundation for the inspiration to undertake and complete this review.
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Appendix I: Appraisal instruments
Appendix II: Data extraction instruments
MAStARI data extraction instrument[Context Link]
Keywords: multidisciplinary response team; disaster response; integrated care team; disaster response team; Red Cross team; Red Crescent team