Planning for major burns incidents by implementing an accelerated Delphi technique

Advancing the scientific study of prehospital mass casualty response through a Translational Science process: the T1 scoping literature review stage

PURPOSE

The European Union Horizon 2020 research and innovation funding program awarded the NIGHTINGALE grant to develop a toolkit to support first responders engaged in prehospital (PH) mass casualty incident (MCI) response. To reach the projects' objectives, the NIGHTINGALE consortium used a Translational Science (TS) process. The present work is the first TS stage (T1) aimed to extract data relevant for the subsequent modified Delphi study (T2) statements.

METHODS

The authors were divided into three work groups (WGs) MCI Triage, PH Life Support and Damage Control (PHLSDC), and PH Processes (PHP). Each WG conducted simultaneous literature searches following the PRISMA extension for scoping reviews. Relevant data were extracted from the included articles and indexed using pre-identified PH MCI response themes and subthemes.

RESULTS

The initial search yielded 925 total references to be considered for title and abstract review (MCI Triage 311, PHLSDC 329, PHP 285), then 483 articles for full reference review (MCI Triage 111, PHLSDC 216, PHP 156), and finally 152 articles for the database extraction process (MCI Triage 27, PHLSDC 37, PHP 88). Most frequent subthemes and novel concepts have been identified as a basis for the elaboration of draft statements for the T2 modified Delphi study.

CONCLUSION

The three simultaneous scoping reviews allowed the extraction of relevant PH MCI subthemes and novel concepts that will enable the NIGHTINGALE consortium to create scientifically anchored statements in the T2 modified Delphi study.

European Burns Association guidelines for the management of burn mass casualty incidents within a European response plan

BACKGROUND

A European response plan to burn mass casualty incidents has been jointly developed by the European Commission and the European Burn Association. Upon request for assistance by an affected country, the plan outlines a mechanism for coordinated international assistance, aiming to alleviate the burden of care in the affected country and to offer adequate specialized care to all patients who can benefit from it. To that aim, Burn Assessment Teams are deployed to assess and triage patients. Their transportation priority recommendations are used to distribute outnumbering burn casualties to foreign burn centers. Following an appropriate medical evacuation, these casualties receive specialized care in those facilities.

METHODS

The European Burns Association's disaster committee developed medical-organizational guidelines to support this European plan. The experts identified fields of interest, defined questions to be addressed, performed relevant literature searches, and added their expertise in burn disaster preparedness and response. Due to the lack of high-level evidence in the available literature, recommendations and specially designed implementation tools were provided from expert opinion. The European Burns Association officially endorsed the draft recommendations in 2019, and the final full text was approved by the EBA executive committee in 2022.

RECOMMENDATIONS

The resulting 46 recommendations address four fields. Field 1 underlines the need for national preparedness plans and the necessary core items within such plans, including coordination and integration with an international response. Field 2 describes Burn Assessment Teams' roles, composition, training requirements, and reporting goals. Field 3 addresses the goals of specialized in-hospital triage, appropriate severity criteria, and their effects on priorities and triage. Finally, field 4 covers medical evacuations, including their timing and organization, the composition of evacuation teams and their assets, preparation, and the principles of en route care.

Mobile Burn Disaster Response Teams: A Scoping Review

The resources needed to deliver modern burn care may be overwhelmed by mass casualty disasters. In 2021, the World Health Organization (WHO) recommended that countries prepare teams of deployable burn experts to assist with responding to a mass casualty disaster. The aim of this scoping review was to identify existing literature regarding burn mobile response team organization, describe the reported effectiveness of these teams, identify challenges in adopting the WHO recommendations, and consider how the recommendations may be reconsidered. We conducted a scoping review of all literature types published up to January 2022. Searches of MEDLINE, EMBASE, Scopus, and CINAHL databases were conducted to identify reports informing or reporting the use of mobile burn care specialty teams that respond to events resulting in multiple burn-injured victims, including pediatric victims and military response to civilian events. Of 6132 identified reports, 26 publications were reviewed. Three types of mobile burn response teams were identified: (1) teams organized by burn care networks, (2) government-organized medical disaster teams with burn-specific experts, and (3) the U.S. Army Burn Flight Team. Teams have responded to events such as terrorist attacks by providing specialized burn supplies and personnel. These teams have demonstrated expert triage and stabilization advantages but are limited by the number of deployable specialists. Although the WHO recommends increasing the number of mobile burn response teams available around the world, few countries have implemented this recommendation. A hybrid model where responders on scene communicate with burn center experts to manage triage may address these challenges.

A Scoping Review of the Essential Components of Emergency Medical Response Systems for Mass Casualty Incidents

OBJECTIVE

Emergency medical (EM) response systems require extensive coordination, particularly during mass casualty incidents (MCIs). The recognition of preparedness gaps and contextual priorities to MCI response capacity in low- and middle-income countries (LMICs) can be better understood through the components of EM reponse systems. This study aims to delineate essential components and provide a framework for effective emergency medical response to MCIs.

METHODS

A scoping review was conducted using 4 databases. Title and abstract screening was followed by full-text review. Thematic analysis was conducted to identify themes pertaining to the essential components and integration of EM response systems.

RESULTS

Of 20,456 screened citations, 181 articles were included in the analysis. Seven major and 40 sub-themes emerged from the content analysis as the essential components and supportive elements of MCI medical response. The essential components of MCI response were integrated into a framework demonstrating interrelated connections between essential and supportive elements.

CONCLUSIONS

Definitions of essential components of EM response to MCIs vary considerably. Most literature pertaining to MCI response originates from high income countries with far fewer reports from LMICs. Integration of essential components is needed in different geopolitical and economic contexts to ensure an effective MCI emergency medical response.

An International Expert Delphi Study to Determine Research Needs in Major Incident Management

Objective

To collate the opinions of experts and to reach consensus about the research priorities in the management of major incidents.

Design

A three-round e-Delphi study was conducted using an international panel of experts drawn from active researchers and active educators in major incident management. General areas for consideration were derived from the literature analysis undertaken as part of the overall project.

Results

Experts generated 221 statements in 11 topic areas in the first round. Fifty-one of these statements reached consensus in Round 2. A further 23 statements reached consensus in Round 3, leaving 147 statements that did not reach consensus.

Conclusions

An international expert panel reached consensus on 74 topics of research priority in major incidents management. The strongest themes within these topics were education and training, planning, and communication.

Mackway-Jones K, Carley S. An international expert Delphi study to determine research needs in major incident management. Prehosp Disaster Med. 2012;27(4):1-8.

KAMEDO Report 89: Terrorist Attack in Bali, 2002

On 12 October 2002, two bombs exploded on the island of Bali in Indonesia, destroying two bars in the tourist district of the holiday resort Kuta Beach. The explosions killed 202 people from 21 different countries, and >300 people were injured. A team of observers conducted structured and unstructured interviews, and lessons learned from the experience were identified. This report summarizes various elements of the response including: (1) prehospital care; (2) coordination; (3) hospital response; and (4) Australia's efforts in air evacuation.

Burns Assessment Team as Part of Burn Disaster Response

With a huge, climactically hostile catchment area, limited retrieval options and finite resources at the only adult burns unit in South Australia, this paper discusses the case for the establishment and maintenance of a Burns Assessment Team in South Australia. The composition and role of the team and its relationship with other retrieval services, the primary care unit, and the proposed National Burn Coordinator also are discussed.

Mass casualty incidents with multiple burn victims: rationale for a Swiss burn plan

INTRODUCTION

Mass casualty incidents involving victims with severe burns pose difficult and unique problems for both rescue teams and hospitals. This paper presents an analysis of the published reports with the aim of proposing a rational model for burn rescue and hospital referral for Switzerland.

METHODS

Literature review including systematic searches of PubMed/Medline, reference textbooks and journals as well as landmark articles.

RESULTS

Since hospitals have limited surge capacities in the event of burn disasters, a special approach to both prehospital and hospital management of these victims is required. Specialized rescue and care can be adequately met and at all levels of needs by deploying mobile burn teams to the scene. These burn teams can bring needed skills and enhance the efficiency of the classical disaster response teams. Burn teams assist with both primary and secondary triage, contribute to initial patient management and offer advice to non-specialized designated hospitals that provide acute care for burn patients with Total Burn Surface Area (TBSA) <20-30%. The main components required for successful deployments of mobile burn teams include socio-economic feasibility, streamlined logistical implementation as well as partnership coordination with other agencies including subsidiary military resources.

CONCLUSIONS

Disaster preparedness plans involving burn specialists dispatched from a referral burn center can upgrade and significantly improve prehospital rescue outcome, initial resuscitation care and help prevent an overload to hospital surge capacities in case of multiple burn victims. This is the rationale behind the ongoing development and implementation of the Swiss burn plan.

Quality assessment of clinical practice guidelines for adaptation in burn injury

OBJECTIVES

A number of clinical practice guidelines (CPGs) are available for managing burn injury patients but clinical practice is highly variable. We report the first steps to trans-contextual adaptation of international burn CPGs to local settings.

METHODS

Key clinical topics and questions to be covered in the final guideline were defined and prioritized. Systematic search between 1990 and 2008 retrieved 546 citations, of which 24 were CPGs on the general and intensive care of burn patients. Assessment of the clinical content of CPGs was carried out. Methodological quality of CPGs was evaluated using the AGREE instrument.

RESULTS

Of the 24 CPGs evaluated, 10 (42%) were evidence-based. All major burn topics were covered by at least one CPG, but no single CPG addressed all areas important in terms of outcomes. According to the AGREE criteria, 2 CPGs (8%) were strongly recommended, 14 with provisos or alterations (58%) and the rest were not recommended for adaptation.

CONCLUSIONS

Although existing CPGs for the management of burn may accurately reflect agreed clinical practice, most performed poorly when evaluated for methodological quality. Future CPG efforts addressing these methodological shortcomings would add substantially to the improved management of burned patients.

A Delphi-based consensus study into planning for biological incidents

OBJECTIVE

Biological incidents present a significant threat to health services in the UK. The objective of this study was to achieve consensus in all phases of biological incident planning and response.

METHODS

A three-round Delphi study was conducted using a panel of 23 experts from specialities involved in the management of biological incidents. The consensus and non-consensus outcomes from the Delphi study were subsequently presented for discussion in four syndicate groups at a one-day consensus conference funded by the Health Protection Agency.

RESULTS

The results of each syndicate group discussion were presented at a subsequent plenary session at the end of the conference. Further iteration of both the consensus and the non-consensus outcomes of the Delphi study resulted in the endorsement, modification, integration or rejection of individual statements. 125 consensus statements were produced.

CONCLUSIONS

The 125 synopsis consensus statements that all phases of biological incident planning and response. These can be used to inform policy decisions and translated into practical guidance for emergency planners and first responders at local, regional and national levels.

Categorization of major and minor complications in the treatment of patients with resectable rectal cancer using short-term pre-operative radiotherapy and total mesorectal excision: a Delphi round

BACKGROUND

To properly balance the benefit (reduction of local recurrence) of short-term pre-operative radiotherapy for resectable rectal cancer against its harm (complications), a consensus concerning the severity of complications is required. The aim of this study was to reach consensus regarding major and minor complications after short-term radiotherapy followed by total mesorectal excision in the treatment of rectal carcinoma, using the Delphi technique.

METHODS

A Delphi round was performed in cooperation with 21 colo-rectal surgeons from the Netherlands, United Kingdom and Sweden. The key-question was: 'Which of the predefined complications, caused or substantially aggravated by radiotherapy, are so important (major) that they might lead to the decision to abandon short-term pre-operative radiotherapy (5 x 5Gy) when treating patients with resectable rectal cancer (T1-3N0-2M0)?'

RESULTS

After three rounds, consensus was reached for 37 (68%) of 54 complications of which 13 were considered major and 24 considered minor. The following complications were considered to be major: mortality, anastomotic leakage managed by relaparotomy, anastomotic leakage resulting in persisting fistula, postoperative haemorrhage managed by relaparotomy, intra-abdominal abscess without healing tendency, sepsis, pulmonary embolism, myocardial infarction, compartment syndrome of the lower legs, long-term incontinence for solid stool, long-term problems with voiding, pelvic fracture with persisting pain, and neuropathy with persisting pain (legs). Three of 17 complications without consensus showed a tendency to be considered as major: perineal wound dehiscence managed by surgical treatment, small bowel obstruction leading to relaparotomy and long-term incontinence for liquid stool.

CONCLUSION

The 13 major and three 'accepted as major' complications can be used to properly balance the benefit and harm of short-term pre-operative radiotherapy in resectable rectal cancer. This may eventually lead to improved treatment strategies for these patients.

Planning for chemical incidents by implementing a Delphi based consensus study

This paper provides a practical approach to the difficulties surrounding planning for chemical incidents, based upon the results of a Delphi based consensus study. It is intended to offer advice, which can be implemented at regional and local prehospital and hospital level. The phases of the response that are covered include preparation, management of the incident, delivery of medical support during the incident, and recovery and support after the incident.

Delphi based consensus study into planning for chemical incidents

OBJECTIVE

To achieve consensus in all phases of chemical incident planning and response.

DESIGN

A three round Delphi study was conducted using a panel of 39 experts from specialties involved in the management of chemical incidents. Areas that did not reach consensus in the Delphi study were presented as synopsis statements for discussion in four syndicate groups at a conference hosted by the Department of Health Emergency Planning Co-ordination Unit.

RESULTS

A total of 183 of 322 statements had reached consensus upon completion of the Delphi study. This represented 56.8% of the total number of statements. Of these, 148 reached consensus at >94% and 35 reached consensus at >89%. The results of the process are presented as a series of synopsis consensus statements that cover all phases of chemical incident planning and response.

CONCLUSIONS

The use of a Delphi study and subsequent syndicate group discussions achieved consensus in aspects of all phases of chemical incident planning and response that can be translated into practical guidance for use at regional prehospital and hospital level. Additionally, areas of non-consensus have been identified where further work is required.