Embracing uncertainty in mass casualty incidents

Uncertainty is the defining state of the first minutes and hours of a mass casualty event, yet decisions must be taken and actions must happen before the picture is complete. To move forwards in face of uncertainty, we must acknowledge that there will be insufficient information for us to be comfortable in our decisions and actions. We discuss here a range of solutions that allow us to tolerate, even flourish, in the midst of uncertainty.

Learning from terrorist mass casualty incidents: a global survey

BACKGROUND

Reports published directly after terrorist mass casualty incidents frequently fail to capture difficulties that may have been encountered. An anonymised consensus-based platform may enable discussion and collaboration on the challenges faced. Our aim was to identify where to focus improvement for future responses.

METHODS

We conducted a mixed methods study by email of clinicians' experiences of leading during terrorist mass casualty incidents. An initial survey identified features that worked well, or failed to, during terrorist mass casualty incidents plus ongoing challenges and changes that were implemented as a result. A follow-up, quantitative survey measured agreement between responses within each of the themes using a Likert scale.

RESULTS

Thirty-three participants responded from 22 hospitals that had received casualties from a terrorist incident, representing 17 cities in low-middle, middle and high income countries. The first survey identified themes of sufficient (sometimes abundant) human resource, although coordination of staff was a challenge. Difficulties highlighted were communication, security, and management of blast injuries. The most frequently implemented changes were education on specific injuries, revising future plans and preparatory exercises. Persisting challenges were lack of time allocated to training and psychological well-being. The follow-up survey recorded highest agreement amongst correspondents on the need for re-triage at hospital (90% agreement), coordination roles (85% agreement), flexibility (100% agreement), and large-scale exercises (95% agreement).

CONCLUSION

This survey collates international experience gained from clinicians managing terrorist mass casualty incidents. The organisation of human response, rather than consumption of physical supplies, emerged as the main finding. NHSH Clinical Effectiveness Unit project registration number: 2020/21-036.

Refining mass casualty plans with simulation-based iterative learning

BACKGROUND

Preparatory, written plans for mass casualty incidents are designed to help hospitals deliver an effective response. However, addressing the frequently observed mismatch between planning and delivery of effective responses to mass casualty incidents is a key challenge. We aimed to use simulation-based iterative learning to bridge this gap.

METHODS

We used Normalisation Process Theory as the framework for iterative learning from mass casualty incident simulations. Five small-scale 'focused response' simulations generated learning points that were fed into two large-scale whole-hospital response simulations. Debrief notes were used to improve the written plans iteratively. Anonymised individual online staff surveys tracked learning. The primary outcome was system safety and latent errors identified from group debriefs. The secondary outcomes were the proportion of completed surveys, confirmation of reporting location, and respective roles for mass casualty incidents.

RESULTS

Seven simulation exercises involving more than 700 staff and multidisciplinary responses were completed with debriefs. Usual emergency care was not affected by simulations. Each simulation identified latent errors and system safety issues, including overly complex processes, utilisation of space, and the need for clarifying roles. After the second whole hospital simulation, participants were more likely to return completed surveys (odds ratio=2.7; 95% confidence interval [CI], 1.7-4.3). Repeated exercises resulted in respondents being more likely to know where to report (odds ratio=4.3; 95% CI, 2.5-7.3) and their respective roles (odds ratio=3.7; 95% CI, 2.2-6.1) after a simulated mass casualty incident was declared.

CONCLUSION

Simulation exercises are a useful tool to improve mass casualty incident plans iteratively and continuously through hospital-wide engagement of staff.

A Decade of Damage Control Resuscitation: New Transfusion Practice, New Survivors, New Directions

OBJECTIVE

The aim of this study was to identify the effects of recent innovations in trauma major hemorrhage management on outcome and transfusion practice, and to determine the contemporary timings and patterns of death.

BACKGROUND

The last 10 years have seen a research-led change in hemorrhage management to damage control resuscitation (DCR), focused on the prevention and treatment of trauma-induced coagulopathy.

METHODS

A 10-year retrospective analysis of prospectively collected data of trauma patients who activated the Major Trauma Centre's major hemorrhage protocol (MHP) and received at least 1 unit of red blood cell transfusions (RBC).

RESULTS

A total of 1169 trauma patients activated the MHP and received at least 1 unit of RBC, with similar injury and admission physiology characteristics over the decade. Overall mortality declined from 45% in 2008 to 27% in 2017, whereas median RBC transfusion rates dropped from 12 to 4 units (massive transfusion rates from 68% to 24%). The proportion of deaths within 24 hours halved (33%-16%), principally with a fall in mortality between 3 and 24 hours (30%-6%). Survivors are now more likely to be discharged to their own home (57%-73%). Exsanguination is still the principal cause of early deaths, and the mortality associated with massive transfusion remains high (48%). Late deaths are now split between those due to traumatic brain injury (52%) and multiple organ dysfunction (45%).

CONCLUSIONS

There have been remarkable reductions in mortality after major trauma hemorrhage in recent years. Mortality rates continue to be high and there remain important opportunities for further improvements in these patients.

Paediatric major incident simulation and the number of discharges achieved using a major incident rapid discharge protocol in a major trauma centre: a retrospective study

OBJECTIVES

Hospitals have the responsibility of creating, testing and maintaining major incident (MI) plans. Plans emphasise readiness for acceptance of casualties, though often they neglect discharge planning and care for existing inpatients to make room for the sudden influx.After collaboration and design of a discharge policy for a paediatric MI, we aimed to establish the number of beds made available (primary outcome) to assess potential surge and patient flow. We hypothesised that prompt patient discharge would improve overall departmental flow. Flow is vital for sick patients awaiting admission, for those requiring theatre and also to keep the emergency department clear for ongoing admissions.

METHOD AND SETTING

A simulated MI was declared at a London major trauma centre. Five paediatric priority 1 and 15 priority 2 and priority 3 patients were admitted. Using live bed boards, staff initiated discharge plans, and audits were conducted based on hospital bed occupancy and discharge capacity. The patients identified as dischargable were identified and folllowed up for 7 days.

RESULTS

Twenty-nine ward beds were created (42% of the total capacity). Handwritten summaries just took 13.3% of the time that electronic summaries took for the same patients by the same doctor. In-hospital transfers allowed five critically injured children into paediatric intensive care unit (PICU), and creation of a satellite PICU allowed for an additional six more if needed.

CONCLUSION

We increased level 3 capacity threefold and created 40% extra capacity for ward patients. A formalised plan helped with speed and efficiency of safe discharge during an MI. Carbon copy handwritten discharge letters allowed tracking and saved time. Robust follow-up procedures must be in place for any patients discharged.