Securing the Emergency Department During Terrorism Incidents: Lessons Learned From the Boston Marathon Bombings

Beirut Blast: The Experiences of Acute Care Hospitals

Mass Casualty Incidents recently increased in intensity and frequency at an unprecedented rate globally. On August 4, 2020, a massive blast hit the Port of Beirut severely damaging its healthcare sector. This study aims to provide a comprehensive understanding of the impact of the Beirut blast on acute care hospitals in the Beirut area, with a focus on understanding healthcare professionals' (HCPs) responses and encountered challenges. A qualitative research design method was adopted to evaluate the experiences of HCPs at acute hospitals located within 5 kilometers of the blast epicenter. 9 hospitals participated in the study. 11 semi-structured interviews were conducted with key informant HCPs using a designed interview guide. HCPs reported severe infrastructural damages in their corresponding hospitals, and 2 were completely non-functional post-blast. Other than physical injuries sustained by HCPs, the blast imposed substantial strains on their mental health, exacerbated by the ongoing socio-economic crises in Lebanon. Moreover, the findings revealed critical challenges which hindered hospitals' emergency responses at the level of communication, coordination, and human resources, as well as supplies. Participants urged for the need to conduct proper triage, arrange emergency operating centers, and deploy outdoor treatment tents among others, to effectively respond to future disasters. The Beirut blast overwhelmed the Lebanese healthcare system and challenged its level of emergency preparedness. This generated evidence to address the deficiencies and strengthen the existing hospitals' emergency response plans. Future efforts should include prioritizing hospitals' emergency preparedness to ensure the provision of care at increased capacity following the impact of a large-scale disaster.

Terrorist Attacks Against Emergency Medical Services: Secondary Attacks are an Emerging Risk

INTRODUCTION

Terrorists increasingly aim at so-called soft targets, such as hospitals. However, little is known about terrorist attacks against Emergency Medical Services (EMS).

OBJECTIVE

This study aims to review all documented terrorist attacks against EMS that occurred world-wide from 1970-2019 using the Global Terrorism Database (GTD).

METHODS

Reports of terrorist attacks against EMS were extracted from the GTD from 1970-2019. Data collection included temporal factors, attack and weapon type, number of casualties, and if it was a primary or secondary attack (secondary attack: deliberate attack against the first responders of an initial terrorist attack). Reports were excluded if EMS were not a target or if it was unclear whether they were a target. Chi-square tests were performed to evaluate trends over time.

RESULTS

There were 184 terrorist attacks against EMS, resulting in 748 deaths and 1,239 people injured. Terrorist attacks against EMS significantly increased over the past two decades. The "Middle East & North Africa" was the most frequently affected region with 81 attacks (44.0%) followed by "South Asia" with 41 attacks (22.3%). Bombings and explosions were the most common attack type (85 incidents; 46.2%) followed by armed assaults (68 incidents; 35.3%). Combined prehospital and hospital attacks were first reported in 2005 and occurred seven times. The first secondary attack against EMS dates from 1997, after which an increase was observed from 10 to 39 incidents in the periods 2000-2009 and 2010-2019, respectively.

CONCLUSIONS

This analysis of the GTD, which identified 184 terrorist attacks against EMS over a 50-year period, demonstrates that terrorist attacks against EMS have significantly increased during the years and that secondary attacks are an emerging risk. Bombings and explosions are the most common attack type. Terrorist attacks against EMS are most prevalent in countries with high level of internal conflicts, however, they have also occurred in western countries. These incidents may hold valuable information to prevent future attacks.

Terrorist Attacks against Hospitals: World-Wide Trends and Attack Types

BACKGROUND

Analysts have warned on multiple occasions that hospitals are potential soft targets for terrorist attacks. Such attacks will have far-reaching consequences, including decreased accessibility, possible casualties, and fear among people. The extent, incidence, and characteristics of terrorist attacks against hospitals are unknown. Therefore, the objective of this study was to identify and to characterize terrorist attacks against hospitals reported to the Global Terrorism Database (GTD) over a 50-year period.

METHODS

The GTD was used to search for all terrorist attacks against hospitals from 1970-2019. Analyses were performed on temporal factors, location, attack and weapon type, and number of casualties or hostages. Chi-square tests were performed to evaluate trends over time and differences in attack types per world region.

RESULTS

In total, 454 terrorist attacks against hospitals were identified in 61 different countries. Of these, 78 attacks targeted a specific person within the hospital, about one-half (52.6%) involved medical personnel. There was an increasing trend in yearly number of attacks from 2008 onwards, with a peak in 2014 (n = 41) and 2015 (n = 41). With 179 incidents, the "Middle East & North Africa" was the most heavily hit region of the world, followed by "South Asia" with 125 attacks. Bombings and explosions were the most common attack type (n = 270), followed by 77 armed assaults. Overall, there were 2,746 people injured and 1,631 fatalities. In three incidents, hospitals were identified as secondary targets (deliberate follow-up attack on a hospital after a primary incident elsewhere).

CONCLUSION

This analysis of the GTD identified 454 terrorist attacks against hospitals over a 50-year period. It demonstrates that the threat is real, especially in recent years and in world regions where terrorism is prevalent. The findings of this study may help to create or further improve contingency plans for a scenario wherein the hospital becomes a target of terrorism.

Review of the requirements for effective mass casualty preparedness for trauma systems. A disaster waiting to happen?

Mass casualty incidents (MCIs) are diverse, unpredictable, and increasing in frequency, but preparation is possible and necessary. The nature of MCIs requires a trauma response but also requires effective and tested disaster preparedness planning. From an international perspective, the aims of this narrative review are to describe the key components necessary for optimisation of trauma system preparedness for MCIs, whether trauma systems and centres meet these components and areas for improvement of trauma system response. Many of the principles necessary for response to MCIs are embedded in trauma system design and trauma centre function. These include robust communication networks, established triage systems, and capacity to secure centres from threats to safety and quality of care. However, evidence from the current literature indicates the need to strengthen trauma system preparedness for MCIs through greater trauma leader representation at all levels of disaster preparedness planning, enhanced training of staff and simulated disaster training, expanded surge capacity planning, improved staff management and support during the MCI and in the post-disaster recovery phase, clear provision for the treatment of paediatric patients in disaster plans, and diversified and pre-agreed systems for essential supplies and services continuity. Mass casualty preparedness is a complex, iterative process that requires an integrated, multidisciplinary, and tiered approach. Through effective preparedness planning, trauma systems should be well-placed to deliver an optimal response when faced with MCIs.

Preventing and Mitigating Radiology System Failures: A Guide to Disaster Planning

Disaster planning is a core facet of modern health care practice. Owing to complex infrastructure requirements, radiology departments are vulnerable to system failures that may occur in isolation or during a disaster event when the urgency for and volume of imaging examinations increases. Planning for systems failures helps ensure continuity of service provision and patient care during an adverse event. Hazards to which a radiology department is vulnerable can be identified by applying a systematic approach with recognized tools such as the Hazard, Risk, and Vulnerability Analysis. Potential critical weaknesses within the department are highlighted by the Failure Mode and Effects Analysis tool. Recognizing the potential latent conditions and active failures that may impact systems allows implementation of strategies to prevent failure or to build resilience and mitigate the effects if they happen. Inherent system resilience to an adverse event can be estimated, and the ability of a department to operate during a disaster and the subsequent recovery can be predicted. The main systems at risk in a radiology department are staff, structure, stuff (supplies and/or equipment), and software, although individual issues and solutions within these are department specific. When medical imaging or examination interpretation needs cannot be met in the radiology department, the use of portable imaging modalities and teleradiology can augment the disaster response. All phases of disaster response planning should consider both sustaining operations and the transition back to normal function. Online supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article. Work of the U.S. Government published under an exclusive license with the RSNA.

When disasters strike the emergency department: a case series and narrative review

INTRODUCTION

Emergency departments (EDs) are reasonably well prepared for external disasters, such as natural disasters, mass casualty incidents, and terrorist attacks. However, crises and disasters that emerge and unfold within hospitals appear to be more common than external events. EDs are often affected. Internal hospital crises and disasters (IHCDs) have the potential to endanger patients, staff, and visitors, and to undermine the integrity of the facility as a steward of public health and safety. Furthermore, ED patient safety and logistics may be seriously hampered.

METHODS

Case series of 3 disasters within EDs. Narrative overview of the current IHCD-related literature retrieved from searches of PubMed databases, hand searches, and authoritative texts.

DISCUSSION

The causes of IHCDs are multifaceted and an internal disaster is often the result of a cascade of events. They may or may not be associated with a community-wide event. Examples include fires, floods, power outages, structural damage, information and communication technology (ICT) failures, and cyberattacks. EDs are particularly at-risk. While acute-onset disasters have immediate consequences for acute care services, epidemics and pandemics are threats that can have long-term sequelae.

CONCLUSIONS

Hospitals and their EDs are at-risk for crises and their potential escalation to hospital disasters. Emerging risks due to climate-related emergencies, infectious disease outbreaks, terrorism, and cyberattacks pose particular threats. If a hospital is not prepared for IHCDs, it undermines the capacity of administration and staff to safeguard the safety of patients. Therefore, hospitals and their EDs must check and where necessary enhance their preparedness for these contingencies.

Disaster preparedness should represent an augmentation of the everyday trauma system, but are we prepared?

Background

The increased frequency, geographical spread and the heterogenicity in mass casualty incidents (MCIs) challenge healthcare systems worldwide. Trauma systems constitute the base for disaster preparedness. Norway is sparsely populated, with four regional trauma centers (TCs) and 35 hospitals treating trauma (non-trauma centers (NTCs)). We wanted to assess whether hospitals fill the national trauma system requirements for competence and the degree of awareness of MCI plans.

Methods

We conducted a cross-sectional survey of on-call trauma teams in all 39 hospitals during two time periods: July–August (holiday season (HS)) and September–June (non-holiday season (NHS)). A standardized questionnaire was used to evaluate the MCI preparedness.

Results

A total of 347 trauma team members participated (HS: 173 and NHS: 174). Over 95% of the team members were aware of the MCI plan; half had read the plan during the last 6 months, whereas 63% at the TCs and 74% at NTCs were confident with their MCI role. Trauma team exercises were conducted regularly and 86% had ever participated. Only 63% at the TCs and 53% at the NTCs had participated in an MCI exercise. The proportion of resident surgeons and anesthetists with >4 years’ clinical experience was significantly higher in TCs (88% and 63%) than in NTCs (27% and 17%). All the on-call consultant surgeons were at home, leaving interns in charge at several of the hospitals. All resident surgeons at the TCs were ATLS providers compared with 64% at the NTCs, and almost 90% of the consultant surgeons had participated in advanced trauma surgical courses.

Discussion

Despite increased national focus on disaster preparedness, we identified limited compliance with trauma system requirements concerning competency and training. Strict guidelines to secure immediate notification and early presence of consultants whenever a situation that might turn into an MCI occurs should be a prerequisite.

Level of evidence

Level IV. Study type: cross- sectional.

A scoping review of internal hospital crises and disasters in the Netherlands, 2000-2020

BACKGROUND

Internal hospital crises and disasters (IHCDs) are events that disrupt the routine functioning of a hospital while threatening the well-being of patients and staff. IHCDs may cause hospital closure, evacuations of patients and loss of healthcare capacity. The consequences may be ruinous for local communities. Although IHCDs occur with regularity, information on the frequency and types of these events is scarcely published in the medical literature. However, gray literature and popular media reports are widely available. We therefore conducted a scoping review of these literature sources to identify and characterize the IHCDs that occurred in Dutch hospitals from 2000 to 2020. The aim is to develop a systematic understanding of the frequency of the various types of IHCDs occurring in a prosperous nation such as the Netherlands.

METHODS

A systematic scoping review of news articles retrieved from the LexisNexis database, Google, Google News, PubMed and EMBASE between 2000 and 2020. All articles mentioning the closure of a hospital department in the Netherlands were analyzed.

RESULTS

A total of 134 IHCDs were identified in a 20-year time period. Of these IHCDs, there were 96 (71.6%) emergency department closures, 76 (56.7%) operation room closures, 56 (41.8%) evacuations, 26 (17.9%) reports of injured persons, and 2 (1.5%) reported casualties. Cascading events of multiple failures transpired in 39 (29.1%) IHCDs. The primary causes of IHCDs (as reported) were information and communication technology (ICT) failures, technical failures, fires, power failures, and hazardous material warnings. An average of 6.7 IHCDs occurred per year. From 2000-2009 there were 32 IHCDs, of which one concerned a primary ICT failure. Of the 102 IHCDs between 2010-2019, 32 were primary ICT failures.

CONCLUSIONS

IHCDs occur with some regularity in the Netherlands and have marked effects on hospital critical care departments, particularly emergency departments. Cascading events of multiple failures transpire nearly a third of the time, limiting the ability of a hospital to stave off closure due to failure. Emergency managers should therefore prioritize the risk of ICT failures and cascading events and train hospital staff accordingly.

The current status of disaster preparedness in Canadian trauma centers

Mass casualty incidents (MCIs) put substantial stress on loco-regional resources, and trauma centers are critical to responding to these events. Our previous evaluation of Canadian centers helped to identify several weaknesses in disaster responsiveness. In this analysis, we determined the current state of MCI readiness across Canada and how this has changed over time. A multinational cross-sectional survey-based study on MCI preparedness was performed, including 24 Canadian trauma centers. Surveys were completed anonymously online by representatives of each facility. Responses from Canadian centers were examined and compared to previous findings to assess temporal changes in institutional capacity. Fifteen (63%) trauma centers responded, 100% of which had a disaster committee. Sixty percent had a single all-hazards emergency plan, and 71% performed a practice drill in the last two years. Sixty-two percent had communications systems designed to function during an MCI. Ninety-two percent had a triage system in place, and 54% of centers could monitor surge capacity. Half (54%) reported back-up systems for survival essentials, but the capability for prolonged operation during a disaster was limited. A minority (15%) had a database denoting staff with emergency training, although half (54%) had disaster training programs. Comparison to past data showed an increased prevalence of committees dedicated to disaster preparedness and disaster drills but worsened external stakeholder representation and poor ability to provide a prolonged response to crises. Our results demonstrate that MCI preparedness is a growing focus of Canadian trauma centers, but that there are deficiencies that remain unaddressed. Future efforts should focus on these vulnerabilities to ensure the provision of a robust disaster response. LEVEL OF EVIDENCE: Level 3b (prevalence study, limited population).

Mass Casualty Imaging-Policy, Planning, and Radiology Response to Mass Casualty Incidents

A mass casualty incident (MCI) is an event that generates more patients at one time than locally available resources can manage using routine procedures. By their nature, many of these incidents have no prior notice but result in large numbers of casualties with injuries that range in severity. They can happen anywhere and at any time and regional hospitals and health-care providers have to mount a response quickly and effectively to save as many lives as possible. Radiologists must go from passenger to pilot when it comes to MCI planning. When involved at the hospital-wide planning stage, they can offer valuable expertise on how radiology can improve triage accuracy and at what cost in terms of time and resources and thereby contribute a pragmatic understanding of radiology's role and value during MCIs. By taking ownership of MCI planning in their own departments, radiologists can ensure that the radiology department can respond quickly and effectively to unforeseen emergencies. Well-designed radiology protocols will save lives in an MCI setting.