Structured analysis, evaluation and report of the emergency response to a terrorist attack in Wuerzburg, Germany using a new template of standardised quality indicators

Retrospective charts for reporting, analysing, and evaluating disaster emergency response: a systematic review

OBJECTIVE

Given the frequency of disasters worldwide, there is growing demand for efficient and effective emergency responses. One challenge is to design suitable retrospective charts to enable knowledge to be gained from disasters. This study provides comprehensive understanding of published retrospective chart review templates for designing and updating retrospective research.

METHODS

We conducted a systematic review and text analysis of peer-reviewed articles and grey literature on retrospective chart review templates for reporting, analysing, and evaluating emergency responses. The search was performed on PubMed, Cochrane, and Web of Science and pre-identified government and non-government organizational and professional association websites to find papers published before July 1, 2022. Items and categories were grouped and organised using visual text analysis. The study is registered in PROSPERO (374,928).

RESULTS

Four index groups, 12 guidelines, and 14 report formats (or data collection templates) from 21 peer-reviewed articles and 9 grey literature papers were eligible. Retrospective tools were generally designed based on group consensus. One guideline and one report format were designed for the entire health system, 23 studies focused on emergency systems, while the others focused on hospitals. Five papers focused specific incident types, including chemical, biological, radiological, nuclear, mass burning, and mass paediatric casualties. Ten papers stated the location where the tools were used. The text analysis included 123 categories and 1210 specific items; large heterogeneity was observed.

CONCLUSION

Existing retrospective chart review templates for emergency response are heterogeneous, varying in type, hierarchy, and theoretical basis. The design of comprehensive, standard, and practicable retrospective charts requires an emergency response paradigm, baseline for outcomes, robust information acquisition, and among-region cooperation.

Communication failure in the prehospital response to major terrorist attacks: lessons learned and future directions

INTRODUCTION

Communication is key in efficient disaster management. However, in many major incidents, prehospital communication failure led to insufficient upscaling, safety concerns for the emergency responders, logistical problems and inefficient disaster management.

METHODS

A review of medical reports and news articles of mass-casualty terrorist attacks was performed using PubMed-archived and (non-)governmental reports. The terrorist attacks in Tokyo 1995, Oklahoma 1995, Omagh 1998, New York 2001, Myyr-manni 2002, Istanbul 2003, Madrid 2004, London 2005, Oslo/Utøya 2011, Boston 2013, Paris 2015, Berlin 2016, Brussels 2016, Wuerzburg 2016, Manchester 2017, London 2017 were included.

RESULTS

In all mass-casualty terrorist attacks, communication failure was reported. Some failures had significant impact on casualty numbers. Outdated communication equipment, overwhelmed communication services, failure due to damaged infrastructure by the terrorist attack itself, and lack of training were the major issues. Communication failures were most commonly observed in both attacks between 1995-2009 and 2011-2017.

DISCUSSION

Communication failure was reported in all mass-casualty terrorist incidents. In several cases, communication between the different responding actors was poor or non-existing. Malfunctioning of (outdated) telecommunication services, inadequate training in the use of communication devices, unfortunate damage of telecommunication network infrastructure were also worrisome.

CONCLUSION

Despite reports of lessons learned in previous EMS responses, communication failures were still reported in most recent terrorist attacks. Governments should provide sufficient resources to equip hospitals, emergency departments, and ambulance services with (back-up) communication systems and invest in training. A European registration system is warranted. We provide proposals for improvement.

The Epidemiological Profile of Multiple Casualty Incidents in Northern Spain: 2014-2020

OBJECTIVE

To describe the epidemiological profile of multiple casualty incidents (MCI) and contribute to the better understanding of their impacts in Northern Spain.

METHOD

Retrospective, population-based observational study of MCI between 2014 and 2020 in 5 autonomous communities (Aragón, Castilla y León, Galicia, the Basque Country and Principado de Asturias) that participated in the MCI Database of Northern Spain. Inclusion criteria was any incident with 4 or more patients needing ambulance mobilization. A total of 54 variables were collected. This study presents the most relevant results.

RESULTS

There were 253 MCI. Of these, 79.8% were road traffic accidents, 12.3% fires or explosions, 2.0% poisonings and 5.9% defined as others. Monthly average was 2.9 (SD = 0.35; EEM = 15.90), average of victims by MCI was 6.8 (CI95% 6.16 - 7.60). There were significantly (P < 0.05) more victims in 3 types of MCI (fires, poisonings, and others). We saw 37.7% of MCI involved 4 victims, 18.8% 5 victims, and 37.9% more than 5. Mean response time was 30.8 minutes (95% CI 28.6 - 33.1), longer in maritime incidents. A total of 67% (95% CI 64.5 - 69.5) of victims were mild.

CONCLUSIONS

Road traffic accidents are the most frequent MCI and minor injuries predominate. More than 50% of the MCI have 5 or fewer patients. Fires had significantly more mild patients and significantly more resources deployed. Maritime incidents had a significantly longer response time.

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.

[Further developments in disaster control: goal, strategy and tactic using the example of the 2021 flood disaster in the Ahr valley]

Objectives

In July 2021, the Medical Task Force 47 was deployed to the flood disaster in western Germany as part of the cross-regional disaster relief system. With the aim of deriving possible improvements in disaster management, it was scientifically evaluated. The focus of this study was the strategy to build up and to maintain a responsive and efficient rescue system.

Materials and methods

After defining an evaluation process, an interdisciplinary panel of experts reviewed operational documents and relevant concepts of the Bavarian Red Cross. Based on these, strategies and tactics were developed to achieve predefined goals.

Results

The performance of the emergency units could be increased by modern vehicles and equipment (eBikes, drones, all-terrain vehicles). To improve the response capability, new rapid response groups could be required that can take over the function of an advance command and can process mission assignments in impassable terrain autonomously. These could be integrated and synchronized into regional and cross-regional disaster relief.

Conclusion

In future, it could be difficult for Germany's largely volunteer-organised disaster management to safely deploy the multitude of possible state-of-the-art resources in the highly complex environment of a disaster. Partial professionalization by full-time command and control staff could be one solution for this problem.

Lessons learned from terror attacks: thematic priorities and development since 2001-results from a systematic review

Purpose

The threat of national and international terrorism remains high. Preparation is the key requirement for the resilience of hospitals and out-of-hospital rescue forces. The scientific evidence for defining medical and tactical strategies often feeds on the analysis of real incidents and the lessons learned derived from them. This systematic review of the literature aims to identify and systematically report lessons learned from terrorist attacks since 2001.

Methods

PubMed was used as a database using predefined search strategies and eligibility criteria. All countries that are part of the Organization for Economic Cooperation and Development (OECD) were included. The time frame was set between 2001 and 2018.

Results

Finally 68 articles were included in the review. From these, 616 lessons learned were extracted and summarized into 15 categories. The data shows that despite the difference in attacks, countries, and casualties involved, many of the lessons learned are similar. We also found that the pattern of lessons learned is repeated continuously over the time period studied.

Conclusions

The lessons from terrorist attacks since 2001 follow a certain pattern and remained constant over time. Therefore, it seems to be more accurate to talk about lessons identified rather than lessons learned. To save as many victims as possible, protect rescue forces from harm, and to prepare hospitals at the best possible level it is important to implement the lessons identified in training and preparation.

[Safety aspects, emergency preparedness and hazard prevention in hospitals concerning mass casualty incidents (MCI)/terror-related MCI : Prospects on future challenges based on survey results from the 3rd emergency conference of the DGU]

Hintergrund

Weltweite terroristische Aktivitäten seit „9/11“ und folgend auch im europäischen Raum haben im Rahmen der Bewertung von kritischer Infrastruktur in Deutschland zu einem Umdenken auch hinsichtlich der Sicherheit an und in Kliniken geführt.

Ziel der Arbeit

Die vorliegende Publikation befasst sich mit der Bewertung vorliegender Konzepte zu Themen wie „Alarmierung“, „Sicherheit“, „Kommunikation“ und „Vorbereitung“ im vorgenannten Kontext.

Material und Methoden

Anhand einer Literatursichtung sowie einer Umfrage unter den Teilnehmern*innen der 3. Notfallkonferenz der DGU (Deutsche Gesellschaft für Unfallchirurgie) werden diese Thematik und die aktuell vorliegende Situation weiter analysiert und vorgestellt.

Ergebnisse

Die gewonnenen Daten verdeutlichen, dass ein Großteil der Kliniken zwar über eine Krankenhausalarm- und Einsatzplanung verfügt, jedoch die Frequenz der Aktualisierungen und die innerklinische Kommunikation zur Steigerung der Wahrnehmung eine deutliche Streuung zeigen.

Weiterhin verdeutlichen die Ergebnisse eine Heterogenität der vorliegenden innerklinischen Alarmierungskonzepte sowie einen Mangel an Sicherheitskonzepten und Kooperationen mit Sicherheits- und Wachdiensten. Zudem zeigt sich, dass die Thematik einer möglichen CBRN(chemical, biological, radiological, nuclear)-Bedrohung in der Risikoanalyse noch nicht adäquat wahrgenommen wird bzw. umgesetzt ist.

Diskussion

Zusammenfassend scheint die latente Bedrohung durch terroristische Aktivitäten dazu geführt zu haben, dass sich deutsche Kliniken in der Bewertung als kritische Infrastruktur mit der Thematik „Krankenhausalarm- und Einsatzplanung“ auseinandergesetzt und diese überwiegend auch umgesetzt haben. Allerdings zeigt sich für die nachgeordneten Bereiche und die aus der Alarmplanung ableitbaren Konsequenzen noch nicht die nötige Stringenz, um letztendlich adäquate Reaktionen in diesen besonderen Szenarien im Hinblick auf die Sicherheit in und an deutschen Kliniken zu gewährleisten.

Multiagency programs with police as a partner for reducing radicalisation to violence

Background

Multiagency responses to reduce radicalisation often involve collaborations between police, government, nongovernment, business and/or community organisations. The complexities of radicalisation suggest it is impossible for any single agency to address the problem alone. Police-involved multiagency partnerships may disrupt pathways from radicalisation to violence by addressing multiple risk factors in a coordinated manner.

Objectives

1.Synthesise evidence on the effectiveness of police-involved multiagency interventions on radicalisation or multiagency collaboration 2.Qualitatively synthesise information about how the intervention works (mechanisms), intervention context (moderators), implementation factors and economic considerations.

Search Methods

Terrorism-related terms were used to search the Global Policing Database, terrorism/counterterrorism websites and repositories, and relevant journals for published and unpublished evaluations conducted 2002-2018. The search was conducted November 2019. Expert consultation, reference harvesting and forward citation searching was conducted November 2020.

Selection Criteria

Eligible studies needed to report an intervention where police partnered with at least one other agency and explicitly aimed to address terrorism, violent extremism or radicalisation. Objective 1 eligible outcomes included violent extremism, radicalisation and/or terrorism, and multiagency collaboration. Only impact evaluations using experimental or robust quasi-experimental designs were eligible. Objective 2 placed no limits on outcomes. Studies needed to report an empirical assessment of an eligible intervention and provide data on mechanisms, moderators, implementation or economic considerations.

Data Collection and Analysis

The search identified 7384 records. Systematic screening identified 181 studies, of which five were eligible for Objective 1 and 26 for Objective 2. Effectiveness studies could not be meta-analysed, so were summarised and effect size data reported. Studies for Objective 2 were narratively synthesised by mechanisms, moderators, implementation, and economic considerations. Risk of bias was assessed using ROBINS-I, EPHPP, EMMIE and CASP checklists.

Results

One study examined the impact on vulnerability to radicalisation, using a quasi-experimental matched comparison group design and surveys of volunteers (n = 191). Effects were small to medium and, aside from one item, favoured the intervention. Four studies examined the impact on the nature and quality of multiagency collaboration, using regression models and surveys of practitioners. Interventions included: alignment with national counterterrorism guidelines (n = 272); number of counterterrorism partnerships (n = 294); influence of, or receipt of, homeland security grants (n = 350, n = 208). Study findings were mixed. Of the 181 studies that examined mechanisms, moderators, implementation, and economic considerations, only 26 studies rigorously examined mechanisms (k = 1), moderators (k = 1), implementation factors (k = 21) or economic factors (k = 4).All included studies contained high risk of bias and/or methodological issues, substantially reducing confidence in the findings.

Authors' Conclusions

A limited number of effectiveness studies were identified, and none evaluated the impact on at-risk or radicalised individuals. More investment needs to be made in robust evaluation across a broader range of interventions.Qualitative synthesis suggests that collaboration may be enhanced when partners take time to build trust and shared goals, staff are not overburdened with administration, there are strong privacy provisions for intelligence sharing, and there is ongoing support and training.

[Prehospital and In-hospital Concepts for Disaster Response and Preparedness]

Disaster medicine faces complex challenges and will play an increasing role in the future. Disaster medicine is dominated by a phased imbalance of available and required resources. Various factors, such as a possible hazard for the rescue forces, inaccessible terrain or even destroyed infrastructure increase the complexity enormously. For casualties, this can mean a concentration of medical care on life-threatening conditions. The primary goal of emergency planning is to ensure standard or contingency care and to avoid crisis care.Hospitals and the preclinical emergency organizations must prepare for possible major emergencies or disasters. Easy-to-understand and just as easy to apply emergency plans are an important prerequisite for successful emergency management. These plans can only be guiding structures; the adaptation to the actual circumstances of the incident and the situation-adapted interpretation of the plans is the responsibility of the operational commanders. A clear leadership structure is essential for both preclinical and clinical operations. In this article, we describe important basic principles of disaster medicine mission planning and management.

Pre-hospital emergency response to terrorist attacks: A scoping review

Background:

Terrorist incidents are on the rise in the world, and many countries have been involved so far. Unfortunately, many innocent people fall victim to such incidents every year. The pre-hospital emergency, as one of the most important organs in the management and service of the victims, plays a vital role in these events.

Objectives:

This scoping review aimed to evaluate the performance and preparedness of the pre-hospital emergency in the world for such Terrorist incidents.

Methods:

In order to access the documents and scientific evidence relevant to the purpose of our research, selected keywords were searched in PubMed, Scopus, and Web of Science databases. Finally, we collected the required information through a pre-designed data extraction form that designed based on the purpose of this study.

Results:

The initial search, with the specified search strategies, resulted into 794 documents (263, 488, and 43 documents from PubMed, Scopus, and Web of Science databases, respectively). Finally, eight papers were selected through the full text of the selected articles, three of which were qualitative and three were quantitative, and two were mix-methods (qualitative/quantitative). Our findings show that published papers have so far emphasized four main axes, namely, preparation, training and practice, effective communication, and the proper triage and transmission of these four axes.

Conclusion:

A few studies have been done in this area and more studies should be done in different areas and sectors, and given that terrorist incidents are on rise and the pre-hospital emergency organization as one of the most important organizations is not well prepared to respond these events although it has a vital role to play, they need to be more prepared to effectively manage these incidents.

[Terror awareness of 5th year medical students in the Mannheim reformed curriculum medicine plus]

BACKGROUND

The treatment of gunshot wounds and wounds caused by explosive devices as used in terrorist attacks is not currently an issue for education in most medical faculties; however, because of the increasing number of terrorist attacks in Germany and Europe this is becoming more important. The aim of this study was to evaluate the knowledge of dealing with and treatment of patients as victims of terrorist attacks of 5th year medical students at the Mannheim Medical Faculty of Heidelberg University prior to and after a specific seminar.

METHODS

All students offered to participate voluntarily. Before the seminar a questionnaire with six questions about previous knowledge on terror awareness was distributed. After the seminar another almost identical questionnaire with six questions was distributed and completed by the students.

RESULTS

A total of 97 medical students agreed to take part in the study of whom 53 were female. The mean age was 25.4 years (SD 2.75 years). After the seminar the students wanted to statistically significantly intensify the topic and believed that hospitals should be prepared for the treatment of victims of terrorism.

CONCLUSION

With the seminar "Military Medicine", which was held as part of the Mannheim reformed curriculum of medicine (MaReCuM plus) in the 5th year, the interest of medical students could be significantly increased. This study could show for the first time that terrorist attacks and the resulting injuries have significant relevance for medical students. Consideration of this topic in all medical school curricula would be justified.

Emergency response to terrorist attacks: results of the federal-conducted evaluation process in Germany

Purpose

Rescue missions during terrorist attacks are extremely challenging for all rescue forces (police as well as non-police forces) involved. To improve the quality and safety of the rescue missions during an active killing event, it is obligatory to adapt common rescue mission goals and strategies.

Methods

After the recent attacks in Europe, the Federal Office of Civil Protection and Disaster Assistance started an evaluation process on behalf of the Federal Ministry of the Interior and the Federal Ministry of Health. This was done to identify weaknesses, lessons learned and to formulate new adapted guidelines.

Results

The presented bullet point recommendations summarise the basic and most important results of the ongoing evaluation process for the Federal Republic of Germany. The safety of all the rescue forces and survival of the greatest possible number of casualties are the priority goals. Furthermore, the preservation and re-establishment of the socio-political integrity are the overarching goals of the management of active killing events. Strategic incident priorities are to stop the killing and to save as much lives as possible. The early identification and prioritised transportation of casualties with life-threatening non-controllable bleeding are major tasks and the shortest possible on-scene time is an important requirement with respect to safety issues.

Conclusion

With respect to hazard prevention tactics within Germany, we attributed the highest priority impact to the bullet points. The focus of the process has now shifted to intense work about possible solutions for the identified deficits and implementation strategies of such solutions during mass killing incidents.

[Advanced medical post within hospitals as possible tactical instrument for handling mass casualty incidents]

BACKGROUND

An important instrument for handling mass casualty incidents in preclinical settings is the use of an advanced medical post. In certain circumstances, however, the establishment of such an advanced medical post on or close to the incident site is impossible. Terrorist attacks are a prime example for this. The highest priority for hospitals during mass casualty incidents is to adjust the treatment capacity to the acute rise in demand and to sustain its functionality throughout the duration of the incident. By establishing an advanced medical post within hospitals during certain types of mass casualty incidents these aims could potentially be accomplished.

AIMS

The aims of this pilot study were to test the practicability of the establishment of an advanced medical post within a university hospital and to identify potential problems. The results provide the foundation of a generalized concept, which will then be integrated into the hospital emergency plans.

METHODS

After the formation of a multiprofessional expert committee, different areas within the hospital were evaluated based on spatial and tactical considerations. Predefined questions were assessed and harmonized with respect to organization, vehicle management, communication, leadership and patient transport through the means of a practice run.

RESULTS

The establishment and operation of an advanced medical post within the hospital were easily possible. The consequent deployment of section leaders enabled the smooth coordination of transport and an unobstructed simulated patient flow. The management of the treatment area by a senior emergency physician and a senior emergency medical service officer in close cooperation with the operational hospital lead proved to be a useful concept. Technical problems with communication within the hospital were resolved by using wireless phones and the installation of a digital radio repeater.

DISCUSSION

During acute scenarios with only short prior notice, the authors prefer concepts that supplement the normal hospital operation through additional staff and material. In circumstances with prior notice of more than 60 min an advanced intrahospital advanced medical post, staffed by civil protection units, could be a concept that enables the absorption of the first patient arrivals within the first hour of a mass casualty incident without disturbing the functionality of hospitals to any great extent. Further practice runs are, however, necessary to further develop and adjust this concept to real-life circumstances.