Education, training and technological innovation, key components of the ESTES-NIGHTINGALE project cooperation for Mass Casualty Incident preparedness in Europe

A national study of in-hospital preparedness for Mass Casualty Incidents and disasters

PURPOSE

The current geopolitical situation and climate changes accentuate the importance of health preparedness. The aim was to examine the in-hospital preparedness for Mass Casualty Incidents (MCI) and Major Incidents (MI) on a national level.

METHOD

A web-based, cross-sectional study of in-hospital preparedness for MCI/MI in Norway. All hospitals with trauma function were included with 3 defined representatives, excluding hospitals without trauma function. The survey consisted of 63 questions covering: MCI/MI organisation, education, plans, Surge Capacity, triage and supply management.

RESULTS

The study had a response rate of 97/112 (87%), representing 35/38 (92%) of the included hospitals. Contingency responsible respondents (CRR) reported that 27/34 (80%) of the hospitals had a contingency responsible function/role and 29/34 (85%) had a Disaster Preparedness Committee. Among CRR, formal MCI/MI education 5/34 (15%) and MCI/MI training 9/34 (26%) was completed. Further, 87/97 (90%) had an all-hazard contingency plan. MCI/MI exercise within the last 2 years was reported by 63/97 (65%). Surge Capacity was assessed within the last 5 years at 6/35 (17%) of the hospitals. MCI/MI material storage was reported by 56/97 (58%).

CONCLUSION

Many key aspects of contingency work were found to be well-established. MCI/MI education and training for roles/functions was missing in most hospitals. Areas of improvement detected included Surge Capacity and emergency storage. The results suggest a need for national minimum standards and requirements. National in-hospital MCI/MI preparedness could be monitored by a web-based survey, providing information of pan-European relevance.

Key performance indicators and benchmarks in MCI prehospital response using technological tools: a qualitative study assessing the perception of practitioners and tool developers

PURPOSE

The aim of this study is to investigate the opinions and perspectives of The Novel Integrated Toolkit for Enhanced Prehospital Life Support and Triage in Challenging and Large Emergencies (NIGHTINGALE) end-users and tool developers regarding Key Performance Indicators (KPIs) and benchmarks that assess the prehospital response to Mass Casualty Incidents (MCIs) enhanced by the NIT-MR.

METHODS

A qualitative study employing focus group discussions was conducted to collect opinions and perspectives of end-users and tool developers regarding KPIs and benchmarks in MCI response using the NIT-MR. The criteria considered for the selection and distribution of participants within the groups was the nature of their involvement within the NIGHTINGALE project and their familiarity with the tools to be discussed.

RESULTS

Thirty-one participants from different countries were included. Four themes emerged during data analysis which are: definition/explanation is the personal understanding of participants of the term KPI, process of KPI development and relationship with User Requirements is the decision process for assigning KPIs to user requirements, benchmarking is the mental process of associating a benchmark to a KPI or for developing a benchmark, and technical/medical gap is the gap of understanding between each sides' fields.

CONCLUSION

This study emphasized the need for a structured approach to using KPIs and bridging the gap between technological and medical worlds, taking the NIGHTINGALE project, funded by the European Union, which aims to develop a technological toolkit for first responders in mass casualty incidents as an example. These insights are crucial for enhancing disaster response.

Factors affecting the accuracy of prehospital triage application and prehospital scene time in simulated mass casualty incidents

BACKGROUND

The contemporary management of mass casualty incidents (MCIs) relies on the effective application of predetermined, dedicated response plans based on current best evidence. Currently, there is limited evidence regarding the factors influencing the accuracy of first responders (FRs) in applying the START protocol and the associated prehospital times during the response to MCIs. The objective of this study was to investigate factors affecting FRs' accuracy in performing prehospital triage in a series of simulated mass casualty exercises. Secondly, we assessed factors affecting triage-to-scene exit time in the same series of exercises.

METHODS

This retrospective study focused on simulated casualties in a series of simulated MCIs Full Scale Exercises. START triage was the triage method of choice. For each Full-Scale Exercise (FSEx), collected data included exercise and casualty-related information, simulated casualty vital parameters, simulated casualty anatomic lesions, scenario management times, and responder experience.

RESULTS

Among the 1090 casualties included in the primary analysis, 912 (83.6%) were correctly triaged, 137 (12.6%) were overtriaged, and 41 (3.7%) were undertriaged. The multinomial regression model indicated that increasing heart rate (RRR = 1.012, p = 0.008), H-AIS (RRR = 1.532, p < 0.001), and thorax AIS (T-AIS) (RRR = 1.344, p = 0.007), and lower ISS (RRR = 0.957, p = 0.042) were independently associated with overtriage. Undertriage was significantly associated with increasing systolic blood pressure (RRR = 1.013, p = 0.005), AVPU class (RRR = 3.104 per class increase), and A-AIS (RRR = 1.290, p = 0.035). The model investigating the factors associated with triage-to-scene departure time showed that the assigned prehospital triage code red (TR = 0.841, p = 0.002), expert providers (TR = 0.909, p = 0.015), and higher peripheral oxygen saturation (TR = 0.998, p < 0.001) were associated with a reduction in triage-to-scene departure time. Conversely, increasing ISS was associated with a longer triage-to-scene departure time (TR = 1.004, 0.017).

CONCLUSIONS

Understanding the predictors influencing triage and scene management decision-making by healthcare professionals responding to a mass casualty may facilitate the development of tailored training pathways regarding mass casualty triage and scene management.

Evaluation of urological and gynecological surgeons as force multipliers for mass casualty trauma care

BACKGROUND

The clinical demands of mass casualty events strain even the most well-equipped trauma centers and are especially challenging in resource-limited rural, remote, or austere environments. Gynecologists and urologists care for patients with pelvic and abdominal injuries, but the extent to which they are able to serve as "force multipliers" for trauma care is unclear. This study examined the abilities of urologists and gynecologists to perform 32 trauma procedures after mentored training by expert trauma educators to inform the potential for these specialists to independently care for trauma patients.

METHODS

Urological (6), gynecological surgeons (6), senior (postgraduate year 5) general surgery residents (6), and non-trauma-trained general surgeons (8) completed a rigorous trauma training program (Advanced Surgical Skills Exposure in Trauma Plus). All participants were assessed in their trauma knowledge and surgical abilities performing 32 trauma procedures before/after mentored training by expert trauma surgeons. Performance benchmarks were set for knowledge (80%) and independent accurate completion of all procedural components within a realistic time window (90%).

RESULTS

General surgery participants demonstrated greater trauma knowledge than gynecologists and urologists; however, none of the specialties reached the 80% benchmark. Before training, general surgery, and urology participants outperformed gynecologists for overall procedural abilities. After training, only general surgeons met the 90% benchmark. Post hoc analysis revealed no differences between the groups performing most pelvic and abdominal procedures; however, knowledge associated with decision making and judgment in the provision of trauma care was significantly below the benchmark for gynecologists and urologists, even after training.

CONCLUSION

For physiologically stable patients with traumatic injuries to the abdomen, pelvis, or retroperitoneum, these specialists might be able to provide appropriate care; however, they would best benefit trauma patients in the capacity of highly skilled assisting surgeons to trauma specialists. These specialists should not be considered for solo resuscitative surgical care.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Exploring medical first responders' perceptions of mass casualty incident scenario training: a qualitative study on learning conditions and recommendations for improvement

OBJECTIVE

Despite participating in scenario training, many medical first responders (MFRs) perceive themselves as inadequately prepared to respond to mass casualty incidents (MCIs). The objective of this study was to conduct a comprehensive examination of traditional MCI scenario training methods, focusing on their inherent strengths and limitations. An investigation into the perceptions of MFRs who had participated in MCI scenario training was carried out to identify potential areas for improvement and provide recommendations for refining MCI training protocols.

DESIGN

Qualitative inductive approach using semistructured interviews that took place between October 2021 and February 2022. Data were analysed with qualitative content analysis.

SETTING

MCI scenario training involving four organisations (three emergency medical services and one search-and-rescue organisation) tasked with responding to MCIs, collectively representing four European Union countries.

PARTICIPANTS

27 MFRs (17 emergency medical services personnel and 10 search-and-rescue volunteers) were recruited to participate in the study.

RESULTS

Two categories and seven associated subcategories (shown in parentheses) were identified as influencing the learning outcomes for MFRs: Training in a context mirroring real-world incidents (conducting incident scene risk assessment, realistic representation in casualties, incorporating scenario variety into the curriculum, interagency collaboration, role alignment when training incident site management) and use of a pedagogical framework (allowing for mistakes, the importance of post-training evaluation).

CONCLUSIONS

This study reaffirms the value of traditional MCI scenario training and identifies areas for enhancement, advocating for realistic scenarios, interagency collaboration, improved incident site management skills and thorough post-training evaluation. It suggests a shift in MCI training conceptualisation and delivery. The potential of virtual reality technologies as a valuable addition to training methods is explored, with a note on the need for further research to ascertain the long-term effectiveness of these technologies. However, the selection of a training method should consider programme goals, target population and resources.

Trauma systems in high socioeconomic index countries in 2050

Considerable political, structural, environmental and epidemiological change will affect high socioeconomic index (SDI) countries over the next 25 years. These changes will impact healthcare provision and consequently trauma systems. This review attempts to anticipate the potential impact on trauma systems and how they could adapt to meet the changing priorities. The first section describes possible epidemiological trajectories. A second section exposes existing governance and funding challenges, how these can be met, and the need to incorporate data and information science into a learning and adaptive trauma system. The last section suggests an international harmonization of trauma education to improve care standards, optimize immediate and long-term patient needs and enhance disaster preparedness and crisis resilience. By demonstrating their capacity for adaptation, trauma systems can play a leading role in the transformation of care systems to tackle future health challenges.

Artificial intelligence in emergency medicine. A systematic literature review

Motivation and objective: Emergency medicine is becoming a popular application area for artificial intelligence methods but remains less investigated than other healthcare branches. The need for time-sensitive decision-making on the basis of high data volumes makes the use of quantitative technologies inevitable. However, the specifics of healthcare regulations impose strict requirements for such applications. Published contributions cover separate parts of emergency medicine and use disparate data and algorithms. This study aims to systematize the relevant contributions, investigate the main obstacles to artificial intelligence applications in emergency medicine, and propose directions for further studies.

METHODS

The contributions selection process was conducted with systematic electronic databases querying and filtering with respect to established exclusion criteria. Among the 380 papers gathered from IEEE Xplore, ACM Digital Library, Springer Library, ScienceDirect, and Nature databases 116 were considered to be a part of the survey. The main features of the selected papers are the focus on emergency medicine and the use of machine learning or deep learning algorithms.

FINDINGS AND DISCUSSION

The selected papers were classified into two branches: diagnostics-specific and triage-specific. The former ones are focused on either diagnosis prediction or decision support. The latter covers such applications as mortality, outcome, admission prediction, condition severity estimation, and urgent care prediction. The observed contributions are highly specialized within a single disease or medical operation and often use privately collected retrospective data, making them incomparable. These and other issues can be addressed by creating an end-to-end solution based on human-machine interaction.

CONCLUSION

Artificial intelligence applications are finding their place in emergency medicine, while most of the corresponding studies remain isolated and lack higher generalization and more sophisticated methodology, which can be a matter of forthcoming improvements.

Determining surgical surge capacity with a hybrid simulation exercise

Background

To help test and improve surgical surge capacity, mass casualty incident (MCI) exercises generate valuable information. Both large scale table-top exercises (TTX) and full-scale exercises (FSX) have limitations if you want to test an organisation's capability and structure. A hybrid exercise incorporating the advantages of TTX and FSX is a possible way forward, but is no standardised exercise method, yet. This study aims at evaluating the exercise results to determine the feasibility of a hybrid TTX/FSX exercise for an organization's capability and structure.

Methods

A hybrid MCI simulation using moulaged figurants and simulation cards was designed, where the emergency department of a level 1 trauma centre receives 103 casualties over 4 h. After registration and triage, all casualties are expected to be resuscitated in real time and are transferred for further treatment inside the hospital (radiology, operating theatres, intensive care unit (ICU)/postop and wards). When reaching operation theatre, ICU or ward, figurants are replaced by simulation cards. Observers ensured that those procedures performed were adequate and adhered to realistic times. Use of resources (materials, drugs etc.) were registered. Primary endpoint was average time spent in the emergency department, from time of arrival, to transfer out. Secondary endpoints were related to patient flow and avoidable fatalities.

Results

The hospital managed to deal with the flow of patients without collapse of existing systems. Operating theatres as well as ICU and ward beds were available at the end of the exercise. Several details in the hospital response were observed that had not been noticed during previous TTX.

Conclusion

FSX have a valuable role in training, equipping, exercising, and evaluating MCI management. Hybrid simulations combining both FSX and TTX may optimise resource utilisation and allow more frequent exercises with similar organisational benefit.