To identify and describe patterns and challenges in communication in sudden-onset major incidents.

Systematic scoping review according to Joanna Briggs Institute and PRISMA-ScR guidelines. Data sources included Cochrane Library, EMBASE, PubMed/MEDLINE, Scopus, SweMed+, Web of Science, and Google Scholar. Non-indexed literature was searched as well. The included literature went through data extraction and quality appraisal as per pre-registered protocol.

The scoping review comprised 32 papers from different sources. Communication breakdown was reported in 25 (78.1%) of the included papers. Inter-authority communication challenges were reported in 18 (56.3%) of the papers. System overload and incompatibility was described in 9 papers (28.1%). Study design was clearly described in 30 papers (93.8%).

The pattern in major incident communication is reflected by frequent breakdowns with potential and actual consequences for patient survival and outcome. The challenges in communication are predominantly inter-authority communication, system overload and incompatibility, and insufficient pre-incident planning and guidelines.

Major incidents (MIs) put great demands on the medical response to effectively organize and redistribute resources and personnel, in prehospital care as well as hospital care, and coordinating functions. Studies indicate that regular training and well-established contingency plans are vital for the medical response to MIs. Previous assessments have concluded that Swedish disaster preparedness requires improved organization and coordination. There is currently no method to easily follow-up the preparedness work of the prehospital medical response organizations for MIs in Sweden.

The aim of the study was to assess qualifications and training requirements for central individual roles, to examine frequency and focus of training and simulation, as well as to examine current regional routines for MIs in Sweden. The aim was also to identify, to evaluate, and to investigate areas for improvement in prehospital health care preparedness for MIs in Sweden.

Descriptive comparative study of Sweden’s prehospital organization, planning, education, and training for MIs through a web-based survey sent to all 21 regions in Sweden. The survey included 64 questions and was based on national legislation and guidelines for preparedness and previous investigations of real MIs.

A total of 37 answers to the survey were collected representing 17/21 regions (80.9%) from which Regional Management Individuals (RMIs) were selected from 15 regions and used as representative primary responses. The initial routines regarding alarm and establishment of management functions were mainly in-line with national guidelines. Staffing and qualification requirements for certain leadership roles differed substantially between regions. The requirements for the health care staff’s knowledge of the contingency plan were generally low and routines for follow-up were often lacking. The frequency of exercises in certain areas were deficient.

The results of the study showed several potential areas for improvement within the prehospital emergency medical preparedness for MIs in Sweden. Methodology and adherence of national guidelines for medical response preparedness differ between regions in Sweden, which motivates recurring assessments. It is possible to use a well-prepared questionnaire study to follow-up and to examine parts of the regional prehospital preparedness work and organization for MIs.

Mass-casualty incidents (MCIs) and disasters are characterized by a high heterogeneity of effects and may pose important logistic challenges that could hamper the emergency rescue operations.

The main objective of this study was to establish the most frequent logistic challenges (red flags) observed in a series of Italian disasters with a problem-based approach and to verify if the 80-20 rule of the Pareto principle is respected.

A series of 138 major events from 1944 through 2020 with a Disaster Severity Score (DSS) ≥ four and five or more victims were analyzed for the presence of twelve pre-determined red flags.

A Pareto graph was built considering the most frequently observed red flags, and eventual correlations between the number of red flags and the components of the DSS were investigated.

Eight out of twelve red flags covered 80% of the events, therefore not respecting the 80-20 rule; the number of red flags showed a low positive correlation with most of the components of the DSS score. The Pareto analysis showed that potential hazards, casualty nest area > 2.5km2, number of victims over 50, evacuation noria over 20km, number of nests > five, need for extrication, complex access to victims, and complex nest development were the most frequently observed red flags.

Logistic problems observed in MCIs and disaster scenarios do not follow the 80-20 Pareto rule; this demands for careful and early evaluation of different logistic red flags to appropriately tailor the rescue response.

Scientific reporting on major incidents, mass-casualty incidents (MCIs), and disasters is challenging and made difficult by the nature of the medical response. Many obstacles might explain why there are few and primarily non-heterogenous published articles available. This study examines the process of scientific reporting through first-hand experiences from authors of published reports. It aims to identify learning points and challenges that are important to address to mitigate and improve scientific reporting after major incidents.

This was a qualitative study design using semi-structured interviews. Participants were selected based on a comprehensive literature search. Ten researchers, who had published reports on major incidents, MCIs, or disasters from 2013-2018 were included, of both genders, from eight countries on three continents. The researchers reported on large fires, terrorist attacks, shootings, complex road accidents, transportation accidents, and earthquakes.

The interview was themed around initiation, workload, data collection, guidelines/templates, and motivation factors for reporting. The most challenging aspects of the reporting process proved to be a lack of dedicated time, difficulties concerning data collection, and structuring the report. Most researchers had no prior experience in reporting on major incidents. Guidelines and templates were often chosen based on how easily accessible and user-friendly they were.

There are few articles presenting first-hand experience from the process of scientific reporting on major incidents, MCIs, and disasters. This study presents motivation factors, challenges during reporting, and factors that affected the researchers’ choice of reporting tools such as guidelines and templates. This study shows that the structural tools available for gathering data and writing scientific reports need to be more widely promoted to improve systematic reporting in Emergency and Disaster Medicine. Through gathering, comparing, and analyzing data, knowledge can be acquired to strengthen and improve responses to future major incidents. This study indicates that transparency and willingness to share information are requisite for forming a successful scientific report.

Unacceptable practices of health care providers during disasters have been observed because they work outside the scope of their daily practices and have inadequate training. A greater need for the involvement of health professionals in disaster management has been noted in Saudi Arabia. This study evaluates the efficacy of a training course in prehospital major incident management for health care providers in Saudi Arabia.

An interactive course for general principles in prehospital major incident management was developed with domains and core competencies. The course was designed according to the local context and was based on international standards. It was piloted over four days at the Officers Club of the Ministry of Interior (Riyadh, Saudi Arabia) and was sponsored by Mohammed Bin Naif Medical Center, King Fahd Security College in Riyadh, Saudi Arabia. The participants (n=29) were from different disciplines from main government health facilities in Riyadh. They completed a pre-test and a post-test.

The overall score was 55.1% on the pre-test and 68.4% on the post-test (Wilcoxon test for paired samples, P <.05). Three out of the four domains had significant difference between pre- and post-test results, as well as the overall total knowledge.

Conducting inter-disciplinary and competency-based disaster medicine courses for health care providers can augment appropriate disaster preparedness for major incidents in Saudi Arabia.

BajowNA, AlAssafWI, CluntunAA. Course in Prehospital Major Incidents Management for Health Care Providers in Saudi Arabia. Prehosp Disaster Med. 2018;33(6):587–595.

Major-incident triage ensures effective emergency care and utilization of resources. Prehospital emergency care providers are often the first medical professionals to arrive at any major incident and should be competent in primary triage. However, various factors (including level of training) influence their triage performance.

The aim of this study was to determine the difference in major-incident triage performance between different training levels of prehospital emergency care providers in South Africa utilizing the Triage Sieve algorithm.

This was a cross-sectional study involving differently trained prehospital providers: Advanced Life Support (ALS); Intermediate Life Support (ILS); and Basic Life Support (BLS). Participants wrote a validated 20-question pre-test before completing major-incident training. Two post-tests were also completed: a 20-question written test and a three-question face-to-face evaluation. Outcomes measured were triage accuracy and duration of triage. The effect of level of training, gender, age, previous major-incident training, and duration of service were determined.

A total of 129 prehospital providers participated. The mean age was 33.4 years and 65 (50.4%) were male. Most (n=87; 67.4%) were BLS providers. The overall correct triage score pre-training was 53.9% (95% CI, 51.98 to 55.83), over-triage 31.4% (95% CI, 29.66 to 33.2), and under-triage 13.8% (95% CI, 12.55 to 12.22). Post-training, the overall correct triage score increased to 63.6% (95% CI, 61.72 to 65.44), over-triage decreased to 17.9% (95% CI, 16.47 to 19.43), and under-triage increased to 17.8% (95% CI, 16.40 to 19.36). The ALS providers had both the highest likelihood of a correct triage score post-training (odds ratio 1.21; 95% CI, 0.96-1.53) and the shortest duration of triage (median three seconds, interquartile range two to seven seconds; P=.034). Participants with prior major-incident training performed better (P=.001).

Accuracy of major-incident triage across all levels of prehospital providers in South Africa is less than optimal with non-significant differences post-major-incident training. Prior major-incident training played a significant role in triage accuracy indicating that training should be an ongoing process. Although ALS providers were the quickest to complete triage, this difference was not clinically significant. The BLS and ILS providers with major-incident training can thus be utilized for primary major-incident triage allowing ALS providers to focus on more clinical roles.

AlenyoAN, SmithWP, McCaulM, Van HovingDJ. A Comparison Between Differently Skilled Prehospital Emergency Care Providers in Major-Incident Triage in South Africa. Prehosp Disaster Med. 2018;33(6):575–580.

The transfer of experiences gained after prehospital medical responses to major incidents has largely been nonsystematic, and better-structured reporting methods have been advocated. A consensus-based template was recently created and implemented as an open-access website. This qualitative study assessed the feasibility of using the template and reporting site.

Informants who had used or who had been asked to use the template were interviewed. The semi-structured interviews were transcribed verbatim, and the transcripts were analyzed by using an inductive approach based on grounded theory methodology.

The major theme identified was a need for “defining purpose” as explained by the minor themes “relevance,” “scope,” “resources,” and “usefulness.” Informants reported that the template content needed to be revised and that the scope and rationale behind each question should be conveyed to the user. Resources necessary for reporting and clarity regarding the aim and outcome also need to be communicated to users and policy-makers. The interface between informants and the template is critical.

Informants considered the template and website useful but reported that the workload exceeded their expectations. Despite pilot testing of the template before implementation, early revision of the template is recommended. (Disaster Med Public Health Preparedness. 2017;11:403–406)

Disaster triage is the allocation of limited medical resources in order to optimize patient outcome. There are several studies showing the poor use of triage tagging, but there are few studies that have investigated the reasons behind this. The aim of this study was to explore ambulance personnel attitude towards, and experiences of, practicing triage tagging during day-to-day management of trauma patients, as well as in major incidents (MIs).

A mixed method design was used. The first part of the study was in the form of a web-survey of attitudes answered by ambulance personnel. The question explored was: Is it likely that systems that are not used in everyday practice will be used during MIs? Two identical web-based surveys were conducted, before and after implementing a new strategy for triage tagging. This strategy consisted of a time-limited triage routine where ambulance services assigned triage category and applied triage tags in day-to-day trauma incidents in order to improve field triage. The second part comprised three focus group interviews (FGIs) in order to provide a deeper insight into the attitudes towards, and experience of, the use of triage tags. Data were analyzed using qualitative content analysis.

The overall finding was the need for daily routine when failure in practice. Analysis of the web-survey revealed three changes: ambulance personnel were more prone to use tags in minor accidents, the sort scoring system was considered to be more valuable, but it also was more time consuming after the intervention. In the analysis of FGIs, four categories emerged that describe the construction of the overall category: perceived usability, daily routine, documentation, and need for organizational strategies.

Triage is part of the foundation of ambulance skills, but even so, ambulance personnel seldom use this in routine practice. They fully understand the benefit of accurate triage decisions, and also that the use of a triage algorithm and color coded tags is intended to make it easier and more secure to perform triage. However, despite the knowledge and understanding of these benefits, sparse incidents and infrequent exercises lead to ambulance personnel’s uncertainty concerning the use of triage tagging during a MI and will therefore, most likely, avoid using them.

RådestadM, Lennquist MontánK, RüterA, CastrénM, SvenssonL, GrythD, FossumB. Attitudes Towards and Experience of the Use of Triage Tags in Major Incidents: A Mixed Method Study. Prehosp Disaster Med. 2016;31(4):376–385.

Health registers have been established in the United Kingdom (UK) and elsewhere following mass exposure to novel agents or known agents, but there is no consensus on the criteria for establishing such registers.

This study aimed to develop a decision framework to assess the need for establishing a health register for major chemical, biological, radiological, and nuclear (CBRN) incidents.

The study comprised three stages. In the first stage, the study team prepared a list of potential criteria that may be used to assess the need for setting up a health register based on literature review and personal experiences in previous incidents. In the second stage, the potential criteria were evaluated in two Delphi rounds involving experts and key decision makers from the UK Health Protection Agency (HPA) and academic organizations. In the final stage, the criteria were converted into a decision framework, and its utility was tested using four fictional scenarios.

A total of 11 statements were proposed by the study group. These criteria were revised following feedback from 16 experts in the first Delphi round. All 11 statements achieved consensus at the end of the second Delphi round. Pilot testing of the agreed criteria on four fictional scenarios confirmed validity and reliability for use in the decision process.

A decision framework to assess the need for setting up a health register after a major incident was agreed upon and tested using fictional scenarios. Further areas of work for practical implementation of the criteria and related planning for systems and protocols have been identified.

ParanthamanK, CatchpoleM, SimpsonJ, MorrisJ, MuirheadCR, LeonardiGS. Development of a Decision Framework for Establishing a Health Register Following a Major Incident. Prehosp Disaster Med. 2012;27(6):1-7.

The decision to declare a major incident (MI) is not one to be taken lightly, but a delay in doing so may have dire consequences. The aim of this study was to ascertain what factors make specialists from a variety of pro-fessional backgrounds in the United Kingdom determine from an initial visu-al assessment of a scene that a MI should be declared.

Participants were presented with three different scenarios, which were presented pictorially. Their responses were noted.

One hundred seventy-eight professionals took part in this study. For Scenario 1 (a road traffic incident), 101 (57%) declared a MI. For a coach rollover in Scenario 2, a MI was declared by 82 (46%) people, and a MI was declared by 156 (87%) for a rail crash in Scenario 3.

Forty-six participants had attended a MI previously.The results for declar-ing a MI in this group were: (1) Scenario 1, 25 (54%); (2) Scenario 2, 25 (54%); and (3) Scenario 3, 44 (96%). Of this group, 44 had previously had training before experiencing the MI. Those who had >10 years of service in emergency services were more likely to declare a MI in Scenario 2 and 3.

The main problem with the existing system is the interpreta-tion and subjective nature of the word “major”. Specialists incorporate many individual factors into using the word. Future research should focus on the development of a system tied to more objective analysis.

International mass gatherings can cause great challenges to local healthcare system and emergency medical services (EMS). Traditionally, planning has been based on retrospective reports of previous events, but there still is a need for prospective studies in order to make the process more evidence-based. The aim of this study was to analyze the success of medical preparedness, ambulance patient characteristics, emergency care, and the use of pre-hospital resources during the 2005 World Championship Games in Athletics in Helsinki, Finland.

The study was a prospective, observational study conducted within the Helsinki EMS. Data from all emergency calls at the sport venues and Games village between 05 and 14 August 2005 were collected. Data from the organizations responsible for the health care and first aid of spectators and accredited persons (e.g., athletes, coaches, the press, very important persons and personnel working in the Games area) also were collected. The Institutional Review Board of Helsinki University Central Hospital approved the study plan.

A total of 479,000 persons visited the Games. The ambulance call incidence at the Olympic Stadium was 0.50 per 10,000 people and 0.7 per 10,000 when the Games Village was included. The overall need for ambulance transportation to the emergency department was 0.52 per 10,000. No patients needed cardiopulmonary resuscitation or other immediate, life-saving procedures on-site. First aid was provided to 554 spectators (0.17per 10,000 people). The three medical organizations cared for 1,586 patients of which 25 (1.6%) were transported to a hospital by an ambulance. The number of patients needing transportation and the overall patient loadfor the healthcare system was well-anticipated. Accredited persons sought health care a total of 1,009 times.The number of patients treated was associated closely with the number of spectators (p = 0.05). The number of ambulance calls in the city increased 5.9 % as compared to the corresponding time period in the five previous years.

The medical preparedness and resources for the Games proved to be sufficient. The EMS personnel were able to provide quality emergency care. This prospective study provided new, detailed data for the medical aspects of mass gatherings and confirmed many previous observations.