Die Rolle des Krankenhauses bei Bedrohungslagen

[Terror attacks : Recommendations for cooperation between police, hospitals and non-police security services]

BACKGROUND

The risk of terrorist attacks in the Federal Republic of Germany is present and is currently increasing. Publicly funded acute care hospitals and their owners are involved in disaster control as part of their remit and are responsible for taking comprehensive precautions to ensure their operational capability in the event of disasters. This mandate must also be ensured in the event of terrorist attacks and amok incidents. For this purpose, an optimal cooperation between preclinical and clinical care is indispensable.

AIM

Recommended actions for collaboration between nonclinical and clinical planning to manage a mass casualty incident in terrorist life-threatening response situations are presented.

MATERIAL AND METHODS

The Inter-Hospital Security Conference Baden-Württemberg (IHSC BW) is an association of representatives of acute hospitals in Baden-Württemberg, the Ministry of the Interior, Digitalization and Migration Baden-Württemberg, the Ministry of Social Affairs and Integration Baden-Württemberg, the State Police Headquarters Baden-Württemberg and the Baden-Württemberg Hospital Association. From 2018 to 2020, the IHSC BW developed recommendations for action on cooperation between police, hospitals and non-police emergency response. The recommendations for action were agreed by the group members in 6 working sessions and initialled in two subsequent video conferences. A recommendation was considered adopted when the IHSC BW plenary assembly finally gave its approval with an absolute majority.

RESULTS AND DISCUSSION

Competence-based interface solutions for a smooth cooperation between prehospital and hospital management in the care of patients who have become victims of a terrorist attack are to be demanded. For preliminary planning, the establishment of a local safety conference at the county disaster control authority level with the following participants is recommended: disaster control authority, fire department, regional police headquarters, chief emergency physician, rescue services and disaster control officers of affected clinics. It is recommended to set up a joint command and situation center (CSC), where management personnel from the police, rescue service, fire department and disaster control can meet to organize the handling of the incident jointly, competently and without loss of time. From this CSC, a liaison officer should then provide the clinics with information at regular intervals. Exercises should take place regularly. Cross-organizational exercises are particularly important, and this is one of the tasks of the local safety conference.

Education and training as a key enabler of successful patient care in mass-casualty terrorist incidents

BACKGROUND AND PURPOSE

The increase in terrorist attacks with sometimes devastating numbers of victims has become a reality in Europe and has led to a fundamental change in thinking and a reorientation in many fields including health policy. The purpose of this original work was to improve the preparedness of hospitals and to provide recommendations for training.

MATERIAL AND METHODS

We conducted a retrospective literature search based on the Global Terrorism Database (GTD) for the period 2000 to 2017. Using defined search strategies, we were able to identify 203 articles. We grouped relevant findings into main categories with 47 statements and recommendations on education and training. In addition, we included data from a prospective questionnaire-based survey on this topic that we conducted at the 3rd Emergency Conference of the German Trauma Society (DGU) in 2019.

RESULTS

Our systematic review identified recurrent statements and recommendations. A key recommendation was that regular training should take place on scenarios that should be as realistic as possible and should include all hospital staff. Military expertise and competence in the management of gunshot and blast injuries should be integrated. In addition, medical leaders from German hospitals considered current surgical education and training to be insufficient for preparing junior surgeons to manage patients who have sustained severe injuries by terrorist events.

CONCLUSION

A number of recommendations and lessons learned on education and training were repeatedly identified. They should be included in hospital preparations for mass-casualty terrorist incidents. There appear to be deficits in current surgical training which may be offset by establishing courses and exercises.

[Hospital disaster planning in south-western Germany. A survey of 214 clinics]

Background

Due to legal regulations in Germany, public acute and emergency (A&E) hospitals-along with responsible authorities, emergency medical services, and other institutions such as the state medical associations-are committed to participate in civil protection. This participation includes the need to create and update emergency plans for external and internal crises and to take part in disaster drills. In fact, so far there is only little literature to prove whether and to what extent hospitals fulfill their obligations on this topic.

Objectives

Using a standardized survey, the state of emergency planning in hospitals in Baden-Wuerttemberg was evaluated.

Materials and methods

Based on a listing provided by the Hospital Society of Baden-Wuerttemberg (BWKG), all 214 hospitals in Baden-Wuerttemberg were identified. The standardized questionnaire inquired about specific characteristics of the emergency plan, the availability and knowledge of this plan by the hospital workforce and other local institutions that take part in civil protection and, finally, participation in disaster drills were queried.

Results

Of the 214 hospitals in Baden-Wuerttemberg, 135 (63%) provided information using the questionnaire. Except for one hospital, all other clinics indicated having a special emergency plan ready. In most cases (79.3%), both external (e.g., mass casualty incidents) and internal (e.g., fire, failure of technical equipment) crises are covered. In the vast majority of cases (94%), the hospitals also indicated that they regularly update their emergency plan, whereby the frequency of updates varied markedly. Three quarters of the hospitals said that they also regularly simulate the use of the emergency plan in disaster drills. In two thirds of the cases, external forces such as emergency medical services or the fire department also take part in these drills along with the hospitals themselves. In some cases, knowledge gained from the drills was incorporated into the emergency plan or led to improvements in staff training.

Conclusions

The willingness of public hospitals to establish comprehensive disaster planning and to take part in related drills seems to have improved noticeably in recent years. However, there is still the need for improvement in keeping the concepts up to date at some hospitals. Especially smaller hospitals showed deficits in emergency planning, particularly concerning preparedness for internal crises, resulting from failure of technical equipment. More regular drills should be used to test existing concepts and to familiarize employees with the processes on a routine basis.

Terrorist incidents: strategic treatment objectives, tactical diagnostic procedures and the estimated need of blood and clotting products

BACKGROUND

Terrorism-related incidents that are associated with mass casualties (mass-casualty terrorist incidents) are a medical and organisational challenge for every hospital because of the special injury patterns involved, the time of the incident, the development of the situation, the initial lack of information, the number of injured, and the number of uninjured survivors who self-refer to a hospital.

METHODS

The Terror and Disaster Surgical Care (TDSC®) - Course was developed in order to address mass-casualty terrorist incidents and to provide surgeons with the specialist medical and surgical knowledge and skills required for these special situations. The focus of the TDSC® course is on how to provide surgical care and how to deploy scarce resources in a particular tactical situation in such a way that the number of survivors is maximised.

RESULTS

The effective management of such a tactical situation must be based on priorities and first and foremost requires the standardised sorting and categorisation of the injured at the hospital. The aim of triage, or the sorting of the injured, is to immediately identify patients with life-threatening injuries in environments with strained resources. The medical management of mass-casualty terrorist incidents requires tactical abbreviated surgical care (TASC) teams that have the skills needed to perform a primary survey and to provide care for casualties who need immediate surgery (triage category 1-T1). Initial fluid therapy should be restrictive (permissive hypotension) unless contraindicated. Clotting products are replaced in a standardised manner on the basis of patient requirements, which are calculated using rapidly available surrogates (blood gas analysis). Blood products can be administered or kept available depending on risks and triage categories. The highest priority should be given to the identification and management of haemodynamically unstable patients who require immediate surgery for injuries associated with bleeding into body cavities (T1 + +).

CONCLUSION

The recommendations and approaches described here should be considered as proposals for hospitals to develop standards or modify well-established standards that enable them to prepare themselves successfully for situations (e.g. mass-casualty terrorist or shooter incidents) in which their resources are temporarily overwhelmed.

[ATLS® and TDSC®: how it fits together : A treatment concept for mass casualty and terrorist-related mass casualty situations, life-threatening and special scenarios]

Terrorist-related mass casualty incidents represent a medical and organizational challenge for all hospitals. The main reasons are the special patterns of injuries, the onset and development of the scenario, the lack of information at the beginning, the overall number of casualties and the number of uninjured but involved patients presenting at the hospital.Due to these circumstances and the high percentage of penetrating injuries with a permanent risk of uncontrollable bleeding and other life-threatening complications, a strategic and tactical initial surgical care is necessary.For these special terrorist-related mass casualty (MasCal) situations, the Terror and Disaster Surgical Care (TDSC®) course was developed and imparts special medical and surgical knowledge as well as a scenario-based training in surgical decision-making. The TDSC® course focusses on the scenario-related provision of surgical care and distribution of the limited resources to enable survival for as many patients as possible.To improve individualized trauma care course formats, such as the Advanced Trauma Life Support (ATLS®) were established and are nowadays widespread in Germany. It could be shown that standardized approaches and algorithm-based treatment could improve the outcome of trauma victims. Faced with the present day permanent risk of a possible terrorist-related MasCal situation, the question arises how and to what extent elements and principles of both course formats (TDSC® and ATLS®) could be used to improve and organize the initial care in a terrorist-linked MasCal incident.For the first time it is shown that the key elements of both courses (primary survey of the ATLS® and the TDSC® principles: categorization, prioritization, disposition and realization) could be established and integratively used to structure the initial intrahospital medical and surgical care.

[Terrorist attack training exercise-What can be learned? : Baden-Württemberg counterterrorism exercise (BWTEX)]

BACKGROUND

There is a risk of terror attacks in the Federal Republic of Germany, which might increase in the future. A timely comprehensive strategy for treatment and care of a large number of casualties helps minimize chaos and improve the outcome of patients. Adequate training is vital for successful implementation of an emergency plan. Therefore, the effectiveness of training should be assessed and evaluated; however, data collection capabilities for training events are extremely limited, so that publications on the topic are almost impossible to find.

OBJECTIVE

This study aimed to collect data from a simulated terrorist attack in order to draw conclusions from a clinical point of view concerning the improvement of preclinical and clinical management, taking interface problems into consideration.

MATERIAL AND METHODS

On 19 October 2019 the Ministry of the Interior, Digitalization and Migration of Baden-Württemberg conducted a large-scale simulation of a terrorist attack in the city center of Constance, called the Baden-Württemberg counterterrorism exercise (BWTEX). The simulation included an explosion of a car bomb as well as the use of firearms by terrorists. The large scale of the simulation with the high number of participants in combination with close cooperation between military and civil forces was unprecedented. The police force, the armed forces, civil protection forces, air rescue teams and staff from Constance, Friedrichshafen and Sigmaringen regional hospitals in southwest Germany worked together to treat simulated injuries to victims of the attack. The following parameters were recorded when the injured patients arrived at the hospital: prehospital triage time, prehospital triage score, initial treatment and quality of documentation on site as well as triage time, triage score, injury severity scale (ISS) score based on the specified injury pattern, treatment, and quality of documentation on hospital arrival.

RESULTS

Out of a total of 84 "injured patients" 55 were admitted to hospital and 80% were triaged at the scene. Injured patients of triage category 1 (TK1 red: life-threatening injury, immediate treatment) arrived at the hospital 198 ± 50 min after the attack, injured patients of triage category 2 (TK2 yellow: severely injured, urgent treatment) after 131 ± 44 min and injured patients of triage category 3 (TK3 green: slightly injured, non-urgent treatment) arrived after 157 ± 46 min. There was no significant difference in terms of arrival time at the hospital between the triage scores (r = 0.2) or between the ISS scores (r = 0.43). The authors assume that approximately 44% of TK1 patients would have died due to avoidable time delays. Prehospital medical documentation was insufficient in 78% and insufficient in 65% in the hospitals.

CONCLUSION

A mass casualty incident resulting from a terrorist attack differs greatly from a conventional mass casualty incident. The scene of the attack has to be evacuated as quickly as possible, which means that a large number of patients arrive untreated at the nearest hospitals. The setting up of treatment facilities in city centers and areas close to the city seems to be counterproductive because the time delay may result in higher mortality rates of victims. The particularities of mass casualties caused by a terrorist attack have to be incorporated into terrorist attack training.