COMPETENCIES FOR AEROMEDICAL EVACUATION PRACTICES IN EMERGENCIES AND DISASTERS: A SCOPING REVIEW

ABSTRACT Objective: to map the competencies developed in training strategies for air transport practices for patients, in the face of emergency situations and disasters involving chemical, biological, radiological and nuclear (CBRN) agents. Method: this is a scoping review structured in accordance with the JBI and Preferred Reporting Items for Systematic reviews and Metanalyses extension for Scoping Reviews recommendations. The study was carried out in five stages: search for sources in 17 databases, an information portal and two repositories of gray literature, using 125 DeCS, MeSH and Emtree descriptors, without temporal and idiomatic clipping; selection; critical reading of the texts selected by two double-blind reviewers; summary of results and presentation of mapped competencies. Results: a total of 878 studies were analyzed, of which 18 composed the sample. In all, 11 competencies were mapped, with emphasis on the technical training domain. Competencies refer especially to technical-scientific knowledge in disaster situations involving CBRN agents and the safety of patients and professionals involved. Conclusion: the operationalization of artifices to improve qualification processes based on competencies proved to be strategic to increase the quality and safety of patient air transport practices. The approach of the sources on specific aspects of the particularities of practices related to emergencies and disasters involving CBRN agents in training/training processes demonstrates the academic effort to promote the reduction of the risk of these events when, in due course, civil and military institutions and their health operators are activated.


INTRODUCTION
Studies on the competencies of nurses in emergencies and disasters have been systematically developed on a global scale.With the aim of formalizing and standardizing what is incumbent upon these professionals and better structuring the education and training processes to work in such situations.Examples are emergencies and natural (floods, floods, landslides, droughts, epidemics, pandemics, infestations/pests, earthquakes and tsunamis), technological emergencies (accidents with explosive, chemical, biological, radiological and nuclear materials, urban fires, rupture of tailings dams, building collapses, oil spills, water contamination and accidents in passenger transport), or social (terrorist attacks, forced migrations, violence and urban chaos, genocide, wars, civil conflicts, ethnic and religious intolerance, poverty extreme and disassistance)disasters 1 .
The complexity, dynamics and demands commonly observed in these events require broad debate with nurses.Timely, the International Council of Nurses has been defending the need to structure specific competencies of nurses by type of disaster, in the understanding that the term "competency" refers to a level of performance that demonstrates the effective application of knowledge, skill and judgment 1 .Thus, we highlighted, in this study, the competencies developed in training strategies for air transport practices for patients in situations of emergencies and disasters involving chemical, biological, radiological and nuclear (CBRN) agents, theme still little explored in health professionals' training curricula.
CBRN events are recognized for their expressive ability to cause harm to human health or cause death.These events transcend the labor dimension, becoming a matter of national security and demand constant improvement in their management 2 .The impacts can be felt in several sectors, such as health and defense, reinforcing the need to develop technologies, contingency plans, public policies and training programs that can prevent future risks as well as prepare the agents and sectors involved to respond better to such events.Amidst these emergencies and disasters, there are also outbreaks, epidemics and pandemics involving biological agents, such as the cases of Influenza A -H1N1 (2009), Ebola (2014 and 2019) and COVID-19 (2020), examples of public health issues that highlighted the need for expanding interdisciplinary collaborations and communications in all aspects of health care 3 .
Commonly, in events of this nature, there is a concern with the safety of professionals and patients during the assistance and transport of victims.Such issues involve technical training and are crucial for serving the population and for patient and professional safety in exposure to CBRN agents 4 .Timely, the Centers for Disease Control and Prevention has developed guidelines for air medical transport regarding the procedures that should be performed on asymptomatic patients who develop symptoms during the flight, particularly when transporting multiple patients at the same time.To this end, a protocol was developed to ensure the safety of air transport for patients and crew members.Guidance applies to flights of any duration and using any type of aircraft 5,6,7 .
Emergencies and disasters involving CBRN agents, in addition to causing victims (sometimes en masse), can result in serious social, environmental and economic damage, as was the case of the event that occurred in the municipality of Goiânia (Brazil) in September 1987, involving cesium-137, considered the greatest radiological disaster in the world that happened outside of nuclear power plants, mobilizing numerous government sectors 7 .
As a response strategy to these situations, patient air transport (PAT) consists of the use of different aircraft, with fixed or rotary wings, used to meet the need for faster transport 8 .Right after an emergency or disaster situation is installed, PAT system's main objective is to save as many lives as possible and provide support to hospitals overwhelmed by the care of multiple victims 9 .

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The development of a multidisciplinary team's competencies is the focus of critical patient transport planning.It is necessary to stabilize clinical priorities, optimize equipment and transmit clinical information clearly 10 .To work in this type of transport, specific knowledge of flight physiology, care for victims, biosecurity, planning and management of actions during the pre-flight, flight and post-flight are required.
Thus, it is important to invest in training strategies for health teams so that the response to a CBRN event is organized more quickly and effectively, thus reducing possible damage and the number of fatalities.It is emphasized, therefore, that excellence in training tends to generate greater flight safety, safety of the team to be transported, savings in time and resources to be mobilized and, above all, quality and adequate assistance for carrying out PAT.
Therefore, the competencies of professionals working in this area involve not only specific care for air removal, but also clinical care with the effects that these CBRN agents can cause in patients and in the operators themselves.Therefore, understanding which competencies should be considered by members of health teams is strategic and necessary.
Considering the above, the study aims to map the competencies developed in training strategies for air transport practices for patients in emergency situations and disasters involving CBRN agents.
It should be noted that a preliminary search was carried out in the MEDLINE (via Pubmed), PROSPERO, Cochrane Database of Systematic Reviews and JBI Evidence Synthesis databases and no other published or ongoing reviews on this topic were identified.It is considered that the findings may contribute for the development of qualifications and training processes guided by the alignment of competencies as a way to support the preparation of human resources in the health area as well as the teaching activities and curriculum review of civil and military institutions that form these resources.

METHODS
This is a structured scope review as proposed by the JBI, with the function of allowing the synthesis of knowledge and mapping of concepts in a given area of research [11][12][13] .The review was organized through the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA -ScR) and the protocol was registered in the Open Science Framework (OSF) at the link https://osf.io/jftzk/.
The following research question was delimited: what are the competencies to be considered in the training of health professionals in air transport practices for patients in emergency situations and disasters involving CBRN agents?Thus, Population, Concept and Context (PCC) acronym elements, indicated for conducting scoping reviews, were defined as follows: P (Population) -health teams (doctors, nurses and nursing technicians); C (Concept) -competencies; and C (Context) -PAT in emergency and disaster situations.In this review, "competency" is understood as the application of knowledge, skills and judgments to act in a complex situation 1 .
From the association of PCC mnemonic elements, the terms were mapped in the controlled vocabularies Health Sciences Descriptors (DeCS), MeSH Medical Subject Headings (MeSH) and Embase Subject Headings (Emtree).It should be noted that terms identified in the titles, abstracts and descriptors of the articles initially identified were also considered.The terms used in database search strategies are described in Chart 1.

Search strategy
The searches were carried out in January 2022 in the databases of the following information and gray literature portals: Regional Portal of the Virtual Health Library (VHL), under the responsibility of the Latin American and Caribbean Center on Health Sciences Information (BIREME), in its main databases: Latin American and Caribbean Literature on Health Sciences (LILACS), Bibliográfico Español em Ciencias (IBECS), Banco de Dados de Enfermagem (BDENF), Coleção Nacional das Fontes de Informação do SUS (ColecionaSUS), DISASTERS and others; at the PubMed Portal and PubMed Central (PMC) of the National Library of Medicine (NLM); at the Scientific Electronic Library Online (Scielo); on the CAPES Journals Portal, through the databases: Elsevier, Embase and Scopus; Clarivate Analytics: Web of Science; Ebsco: Cumulative Index to Nursing and Allied Health Literature (CINAHL); Academic Search Premier; and Epistemonikos: Database of the best Evidence-Based Health Care, information technologies and a network of experts.

Evidence selection
Based on the use of Rayyan application, developed by the Qatar Computing Research Institute (QCRI) to organize review data in a systematic way and blind assessment, two reviewers selected the studies based on the content of titles and abstracts, analyzed individually and simultaneously, maintaining the blinding of the review process.Disagreements were resolved by a third reviewer.
After this first stage, a new selection was carried out, based on a critical reading of full texts, to confirm the pertinence and extract the data of interest.The extraction of these data occurred independently by two reviewers, with the support of an adapted instrument proposed by the JBI.A third researcher analyzed conflicts in the absence of consensus.

RESULTS
A total of 878 studies were located in the databases/repositories, 49 in VHL, 62 in Ebsco, 458 in Embase, 73 in MEDLINE/PubMed, 115 in PMC, one in SciELO, 113 in Scopus, seven in WOS and four by manual search.In the end, 18 studies were selected, of which nine (50%) were extracted from Embase, four (22.2%) by manual search, two (11.1%) from VHL, two (11.1%) from PubMed and one (5.6%)from Ebsco, as shown in the PRISMA-ScR model flowchart (Figure 1).
For the purpose of characterizing the sources, the following information was organized in Chart 2: type of publication, authorship, year, journal, research institution, country of publication, type of institution of the authors (civil, military or government), title and language of origin.
It was found that 14 sources (77.8%) were published in the last ten years and that most authors' institutions of origin, 11 (61.1%), were linked to the civil environment, six (33.3%) to military institutions and one (5.6%) to a government institution.
Among the countries, the United States of America was the one that most published on the subject (six sources, 42.8%).The English language also stood out, with 13 publications (72.2%), followed by Portuguese, with three (16.7%),and Spanish, with two (11.1%).Considering the results, the authors identified four domains and 11 competencies that can be considered in the process of developing training strategies for air transport practices for patients in emergency situations and disasters involving CBRN agents (Chart 3).
Brasil (2014) 17 Kondo et al. (2018) 18 Moya (2007) 13 4. Responds to the specificities of CBRN events through strategically planned interventions, at different levels, offering control of contamination and damage to the health of vulnerable individuals, families and communities.

Domains Competencies Sources
Technical/ educational 7. Plans PAT.
The four domains mapped refer to safety, technical/educational, multidisciplinary work and communication.With regard to competencies, those involving the defense system in CBRN events and the response to the specificities of air transport practices through planned interventions were mapped in seven (38.8%) studies.The competencies that address the use of instruments and equipment that ensure patient and professional safety were highlighted in eight (44.4%)studies.The use of personal protective equipment (PPE) and collective protection equipment (CPE) is extremely important for air medical transport, reducing the risk of team, crew, patients and aircraft contamination.In turn, issues directly related to pre-flight, flight and post-flight, such as the actual planning of air transport practices, were aspects highlighted in nine (50%) publications.The ability to act in different emergency and disaster scenarios was demonstrated in nine (50%) publications.The competencies that refer to continuous training and the development of technical-scientific training that confer quality and safety to professional practice were verified in five sources (27.7%), and this same quantity was demonstrated for the competency to establish good risk communication.

DISCUSSION
The observance of the correct use of PPE and health team safety proved to be relevant for training and periodic simulation exercises for air transport practices for patients in emergency and
In such practices, type A, B or C suits are generally used.Type A suit refers to fully encapsulated equipment, highly resistant to different chemical elements and with an individual autonomous breathing system, aiming at use in a scenario where there is still an unidentified agent, with completely unknown lethality potential.In turn, type B suit has an individual autonomous breathing system, but is not completely sealed, being used in scenarios where CBRN agents are known and pose a risk of contamination by inhalation.Type C suit uses a mask with high filtration potential, not encapsulated, containing a fluid resistant coverall in addition to boots and gloves.Type D involves standard precautions used in an in-hospital environment, which does not necessarily apply to situations involving CBRN agents 20,21 .
A previous study 15 pointed out that health team members should prevent secondary contamination of people affected by such events.This measure can be achieved through the proper use of PPE and the establishment of decontamination and contamination control procedures with the use of detection devices for those affected.
As for the planning of air transport foreseeing the use of materials, care and equipment during pre-flight, flight and post-flight, some studies 15,17,19,[22][23][24][25][26] demonstrate the importance of carrying out air transport in line with victims' clinical needs, regardless of the CBRN agent involved, and maintaining measures that promote team safety.To this end, (re)knowing the specificities and potential clinical effects of the CBRN agents involved allows for a greater possibility of controlling contamination and damage to the health of the people affected 14,15,17,18,22,[27][28][29] .
Competencies related to working relationships between members of air transport teams for patients, especially the ability to integrate multidisciplinary actions and establish effective communication, must be permeated by powerful strategies in order to obtain the best possible response pattern, given the complexity and logistical and care difficulties involved 14,[17][18][19]24 .
It is noteworthy that risk communication within the organization (institution) is strategic in the sense of keeping all members of the health teams involved and informed not only about the organizational guidelines themselves, but also on the most recent data on the event, including its direct and indirect effects that may have an impact on teams' work 24 .
PAT generally reduces the time to access adequate assistance in certain situations involving CBRN agents and may lessen potential risks due to the criticality of some patients residing in inhospitable regions or in a state of lack of assistance.However, potential operational risks must be considered before making a decision for this mode of transport.This involves efficiency and assertiveness in decision-making and knowing how to diagnose and solve problems in the face of dynamic situations of emergencies and CBRN disasters 14,18,30 .
The importance of developing and managing specific knowledge is highlighted with regard to patient care during air transport and patient care management 13,16,18 as well as acting in different scenarios in carrying out emergency care 9,14,[16][17][18]23,24,29,30 .
In addition to the competencies of an operational nature, aspects related to assistance and coordination of care through the appointment of specialists and researchers in such situations are aspects that tend to strengthen local governance regimes, based on the definition of responsibility matrices 14,[16][17][18][19]24 .
The constant training for qualification and for operational maintenance was highlighted in information sources, which pointed out that the benefits of simulated exercises and the training of practices in pre-flight, flight and post-flight allow the teams to be ready to operate in a real situation, which tends to provide a safer flight for everyone involved.Trainings were described as essential so 13/17 that teams can put theoretical knowledge into practice as well as become familiar with the attire and the use of specific PPE in the exercise of their functions, as they can help to correct any discrepancies and procedural deviations and contribute to promoting a flight safety culture, including the observance of standard operating protocols 14,16,18,19,22,30,31 .
Given the above, the framework of identified competencies may positively enhance the organization of training processes for PAT, in the understanding that, when an emergency/disaster situation involving CBRN agents occurs, the fundamental premise that governs the mission of health operators is to save/maintain as many lives as possible.In this sense, systematizing training/qualification practices based on scientific evidence is to remain permanently prepared in favor of better response standards from services dedicated to PAT.
As limitations of this study, we point out the intersection of thematic axes still little explored in the scientific field: PAT in emergency situations and disasters involving CBRN agents.This operation gave us access to a still limited number of information sources, despite the fact that those mapped have addressed specificities that support the review of qualification/training processes on the subject.

CONCLUSION
From the mapping of competencies developed by this study, 11 competencies were identified and categorized, distributed into four domains related to air transport practices for patients in emergency situations and disasters involving CBRN agents.
The mapping indicated that, for PAT to be successful, health professionals need to develop skills and competencies for decision-making, effective risk communication and development of specific technical knowledge related to safe care so that its performance can be as successful as possible, even in the face of the challenges imposed by the complex context of responding to emergencies and disasters involving CBRN agents.
The mapping also identified the importance of investing in qualification/training strategies based on competencies, in order to achieve better standards of practices for transporting patients by air in the face of events of this nature, especially with regard to care quality and safety as well as protection of the members of the health teams involved.
It is noteworthy that the sources do not emphasize competencies related to the psychoemotional preparation of health team members, since air transport practices in emergencies and CBRN disasters commonly demand actions of psychosocial care and mental health of patients and professionals involved.
The operationalization of protocols to improve training processes is revealed in the sources as fundamental to guarantee the effectiveness of these practices.Moreover, competency-based training is expressed as a strategy to ensure knowledge management and the development of skills applicable in such situations.
The alignment of specific competencies has the potential to contribute to the review and improvement of training strategies for such practices in the civil and military spheres, in order to maintain operability for this type of activity.In this regard, this work contributes to the approach of professional performance in an area that is still little explored by nursing, whether in undergraduate or graduate programs, since "disaster nursing" still constitutes, in some countries, a science in the process of being made and made known.
Mapping of domains and competencies for air transport practices for patients in emergency and disaster situations involving CBRN agents.Rio de Janeiro, RJ, Brazil,2022.