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Introduction and Objective: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.Methods: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.Results: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.Conclusion and Relevance: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.

Background: Triage of victims in mass casualty incidents (MCI) is crucial in prioritizing care and allocating resources1. Triage skills are important to be evaluated for training and better preparedness. Using clinical vignettes is a well-known approach to evaluate clinicians’ knowledge and decision-making2. This study aims to evaluate preparedness of emergency residents and fellows to triage victims of MCI. Methods: Emergency Medicine (EM) residents and fellows at Hamad General Hospital, Emergency Department (HGH-ED) were invited to the study. Each participant filled a questionnaire followed by triaging of 15 vignette-based victims of MCI. Descriptive statistics elaborated on participants’ training and relevant exposures (Table 1). It also showed the degree of agreement in their triage results and rates of under-triage and over-triage. Cohen's kappa coefficient showed inter-rater agreement and internal consistency in triage results. Results: Participants included 63 emergency trainees, 27 residents, and 36 fellows. Only 28.3% (n = 17) of them participated in an MCI drill over the past two years. 51.7% (n = 31) attended training on triage in MCI. 73.3% (n = 44) indicated that they have rarely or never triaged victims in a real MCI or a drill. Only 3.3% (n = 2) perceived themselves as highly confident in triaging victims of MCI. A total of 904 triage outcomes resulted from this exercise (Table 2). The overall rate of agreement among the triage outcomes is 73% (660 times in 904 triage outcomes). The rate of over-triage was 36.8% and 23% under-triage. Conclusion: Better triage results was associated with previous triage training. The rate of over-triage was as the literature recommends. However, the rate of under triage was alarmingly higher than the literature recommendation as < 5%3. The higher rate of under-triage imposes a risk of missing seriously injured victims, which may lead to higher mortality or poor patients’ outcomes. Further training and exercises may be the key to saving more lives and resources.

Introduction Diverse decision-making is needed in managing mass casualty incidents (MCIs), by emergency medical services (EMS). The aim of the study was to review consensus among international experts concerning policies of EMS management during MCIs. Methods Applicability of 21 EMS policies was tested through a 2-cycle modified e-Delphi process, in which 38 multi-disciplinary experts from 10 countries participated. Threshold for approving proposed solutions was defined as consensus of >80%. Policies that did not achieve the targeted consensus were reviewed to detect variability according to respondents' origin country. Results 16 policies were endorsed in the first cycle including collaboration between ambulance service providers; implementing a unified mode of operation; preparing criteria for ground versus aerial evacuation; and, developing support systems for caregivers exposed to violence. An additional policy which proposed that senior EMS officers should not necessarily act as on-site MCI commanders was endorsed in the second cycle. Demographic breakdown of views concerning non-consensual policies revealed differences according to countries of origin. Assigning ambulances to off-duty team members was highly endorsed by experts from Israel and South Africa and strongly rejected by European respondents. Avoiding entry to risk areas until declared safe was endorsed by European, Asian and Oceanic experts, but rejected by Israeli, South African and North American experts. Conclusions Despite uniqueness of countries and EMS agencies, solutions to most dilemmas were applicable to all organizations, regardless of location or affiliation. Cultural diversity was found concerning readiness to implement military-civilian collaboration in MCIs and a rigid separation between work-leisure responsibilities.

Study/Objective: The objective of this research is to document and evaluate the technical and educational needs for the emergency response system in Pristina, Kosovo. This is a current work in prog ...

Introduction: Head nurses at emergency departments often assume responsibility for managing the initial response to a major incident, and to create surge capacity. Training is essential to enable these nurses to perform an effective disaster response. Evaluating the effects of such training is however complicated as real skill only can be demonstrated during a real major incident. Self-efficacy has been proposed as an alternative measure of training effectiveness. Purpose: The aim of this study was to examine if short, small-scale computer-based simulation exercises could improve head emergency nurses general and specific self-efficacy and initial incident management skills. Method: A within-group pretest-posttest design was used to examine 13 head nurses general and specific self efficacy before and after an intervention consisting of three short computer based simulation exercises during a 1-h session. Management skills were assessed using the computer simulation tool DigEmergo. Results: The exercises increased the head nurses general self-efficacy but not their specific self-efficacy. After completing the first two exercises they also exhibited improved management skills as indicated by shorter time to treatment for both trauma and in-hospital patients. Conclusion: This study indicates that short computer based simulation exercises provide opportunities for head nurses to improve management skills and increase their general self-efficacy. Funding Agencies|Swedish Civil Contingencies Agency (MSB) [2011-4957]

Background. Training of medical professionals is important to improve care during mass-causality events. Therefore, it is essential to extend knowledge on how to design valid and usable simulation-based training environments. Purpose. This article investigates how distributed cognition and simulation theory concepts can guide design of simulation-based training environments. We present the design and user evaluation of DigEmergo, a simulator for training and assessing emergency medicine management. Design approach. A prior Distributed Cognition in Teamwork (DiCoT) analysis of the Emergo Train System (ETS) guided the design process. The design objective of DigEmergo was to be useful, usable, retain distributed cognition features of ETS, and strengthen validity and output reliability. Evaluation. Eight expert ETS instructors participated in a formative system evaluation. The Technology Assessment Model (TAM) questionnaire was used to measure usefulness and ease of use. Observations and post-test interviews were conducted to contextualize the measures. Results. The results showed that DigEmergo was perceived as somewhat to quite useful and somewhat easy to use. Overall, expert users considered DigEmergo promising and successful in retaining core ETS features. Conclusions. The study indicates that a design methodology based on distributed cognition and simulation theory can be successfully combined to guide simulator (re)design and strengthen simulator validity.

Introduction: In mass-casualty situations, communications and information management to improve situational awareness is a major challenge for responders. In this study, the feasibility of a prototype system that utilizes commercially available, low-cost components, including Radio Frequency Identification (RFID) and mobile phone technology, was tested in two simulated mass-casualty incidents.Methods: The feasibility and the direct benefits of the system were evaluated in two simulated mass-casualty situations: one in Finland involving a passenger ship accident resulting in multiple drowning/hypothermia patients, and another at a major airport in Sweden using an aircraft crash scenario. Both simulations involved multiple agencies and functioned as test settings for comparing the disaster management’s situational awareness with and without using the RFID-based system. Triage documentation was done using both an RFID-based system, which automatically sent the data to the Medical Command, and a traditional method using paper triage tags. The situational awareness was measured by comparing the availability of up-to date information at different points in the care chain using both systems.Results: Information regarding the numbers and status or triage classification of the casualties was available approximately one hour earlier using the RFID system compared to the data obtained using the traditional method.Conclusions: The tested prototype system was quick, stable, and easy to use, and proved to work seamlessly even in harsh field conditions. It surpassed the paper-based system in all respects except simplicity of use. It also improved the general view of the mass-casualty situations, and enhanced medical emergency readiness in a multi-organizational medical setting. The tested technology is feasible in a mass-casualty incident; further development and testing should take place.

Organizations involved in disaster response often have a defined operative level of management (command and control) that can take the overall decisions regarding the mobilization and distribution of resources and distribution of casualties. This level of management can be referred to as strategic management. The aim of this pilot study was to show the possibility, in simulation exercises, to relate decisions made regarding resources to patient outcome.The simulation system used measures to determine if lifesaving interventions are performed in time or not in relation to patient outcome. Evaluation was made with sets of performance indicators as templates and all management groups were evaluated not only as to how the decisions were made (management skills), but also how staff work was performed (staff procedure skills).Owing to inadequate response and insufficient distribution of patients to hospitals, 11 'patients' died in the simulated incident, a fire at a football stand with subsequent collapse. The strategic level of management received 16 points out of a possible 22 according to a predesigned template of performance indicators.The pilot study demonstrated the possibility to, in simulation exercises, relate decisions made regarding resources to patient outcome. This training technique could possibly lead to increased knowledge in what decisions are crucial to make in an early phase to minimize mortality and morbidity.

Health care organizations employ simulation-based team training (SBTT) to improve skill, communication and coordination in a broad range of critical care contexts. Quantitative approaches, such as team performance measurements, are predominantly used to measure SBTTs effectiveness. However, a practical evaluation method that examines how this approach supports cognition and teamwork is missing. We have applied Distributed Cognition for Teamwork (DiCoT), a method for analysing cognition and collaboration aspects of work settings, with the purpose of assessing the methodology's usefulness for evaluating SBTTs. In a case study, we observed and analysed four Emergo Train System® simulation exercises where medical professionals trained emergency response routines. The study suggests that DiCoT is an applicable and learnable tool for determining key distributed cognition attributes of SBTTs that are of importance for the simulation validity of training environments. Moreover, we discuss and exemplify how DiCoT supports design of SBTTs with a focus on transfer and validity characteristics. Practitioner Summary: In this study, we have evaluated a method to assess simulation-based team training environments from a cognitive ergonomics perspective. Using a case study, we analysed Distributed Cognition for Teamwork (DiCoT) by applying it to the Emergo Train System®. We conclude that DiCoT is useful for SBTT evaluation and simulator (re)design. Funding agencies: Swedish Civil Contingencies Agency; Swedish Governmental Agency for Innovation Systems (VINNOVA)

Introduction:An important issue in disaster medicine is the establishment of standards that can be used as a template for evaluation. With the establishment of standards, the ability to compare results will improve, both within and between different organizations involved in disaster management.Objective:Performance indicators were developed for testing in simulations exercises with the purpose of evaluating the skills of hospital management groups. The objective of this study is to demonstrate how these indicators can be used to create numerically expressed results that can be compared.Methods:Three different management groups were tested in standardized simulation exercises. The testing took place according to the organization's own disaster plan and within their own facilities. Trained observers used a predesigned protocol of performance indicators as a template for the evaluation.Results:The management group that scored lowest in management skills also scored lowest in staff skills.Conclusion:The use of performance indicators for evaluating the management skills of hospital groups can provide comparable results in testing situations and could provide a new tool for quality improvement of evaluations of real incidents and disasters.

The aim of the study was to evaluate the Swedish medical systems response to a mass casualty burn incident in a rural area with a focus on national coordination of burn care. Data were collected from two simulations of a mass casualty incident with burns in a rural area in the mid portion of Sweden close to the Norwegian border, based on a large inventory of emergency resources available in this area as well as regional hospitals, university hospitals and burn centres in Sweden and abroad. The simulation system Emergo Train System(®) (ETS) was used and risk for preventable death and complications were used as outcome measures: simulation I, 18.5% (n=13) preventable deaths and 15.5% (n=11) preventable complications; simulation II, 11.4% (n=8) preventable deaths and 11.4% (n=8) preventable complications. The last T1 patient was evacuated after 7h in simulation I, compared with 5h in simulation II. Better national coordination of burn care and more timely distribution based on the experience from the first simulation, and possibly a learning effect, led to a better patient outcome in simulation II. The experience using a system that combines both process and outcome indicators can create important results that may support disaster planning.

Introdution:Large, functional, disaster exercises are expensive to plan and execute, and often are difficult to evaluate objectively. Command and control in disaster medicine organizations can benefit from objective results from disaster exercises to identify areas that must be improved.Objective:The objective of this pilot study was to examine if it is possible to use performance indicators for documentation and evaluation of medical command and control in a full-scale major incident exercise at two levels: (1) local level (scene of the incident and hospital); and (2) strategic level of command and control. Staff procedure skills also were evaluated.Methods:Trained observers were placed in each of the three command and control locations. These observers recorded and scored the performance of command and control using templates of performance indicators. The observers scored the level of performance by awarding 2, 1, or 0 points according to the template and evaluated content and timing of decisions. Results from 11 performance indicators were recorded at each template and scores >11 were considered as acceptable.Results:Prehospital command and control had the lowest score. This also was expressed by problems at the scene of the incident. The scores in management and staff skills were at the strategic level 15 and 17, respectively; and at the hospital level, 17 and 21, respectively.Conclusions:It is possible to use performance indicators in a full-scale, major incident exercise for evaluation of medical command and control. The results could be used to compare similar exercises and evaluate real incidents in the future.

Background Although disaster simulation trainings were widely used to test hospital disaster plans and train medical staff, the teaching performance of the instructors in disaster medicine training has never been evaluated. The aim of this study was to determine whether the performance indicators for measuring educational skill in disaster medicine training could indicate issues that needed improvement. Methods The educational skills of 15 groups attending disaster medicine instructor courses were evaluated using 13 measurable performance indicators. The results of each indicator were scored at 0, 1 or 2 according to the teaching performance. Results The total summed scores ranged from 17 to 26 with a mean of 22.67. Three indicators: 'Design', 'Goal' and 'Target group' received the maximum scores. Indicators concerning running exercises had significantly lower scores as compared to others. Conclusion Performance indicators could point out the weakness area of instructors' educational skills. Performance indicators can be used effectively for pedagogic purposes.

IntroductionOn 11 June 2009, an Influenza A (H1N1) pandemic was declared by the World Health Organization (WHO). The Major Medical Incident Regional Command and Control Protocol in the County Council of Östergötland, Sweden was activated. After vaccinations were competed, it was decided that the operation should be evaluated in a retrospective study. This study aims to increase knowledge regarding regional management of a pandemic flu.MethodsAll protocols from regional command meetings were studied together with central data regarding, logistics, vaccination site reports, incident reports, and all written correspondence between involved departments. Information from results of a questionnaire that was distributed to all vaccination site managers were summarized and studied. In addition, an interview was performed with the chief of medical operations.ResultsOut of the approximately 426,000 inhabitants of the county, a total of 224,780 (53%) were vaccinated during a five and a half month period. The mean pace was 1,246 vaccinated per day (range 0–9643). Regional command had 41 recorded meetings resulting in a collected number of about 740 working hours. Three hundred sixty-six employees were involved in the vaccination, working 38,741 hours. Twenty-eight safety and 52 security incidents were reported. Uncertainty about vaccine delivery and keeping the public's interest were reported to be of concern for the management.DiscussionEven with the large scale of the operation, there were only a few security and safety issues. Although the goal of vaccinating 75–80% of the inhabitants was not reached, it could be assumed that the pandemic was dampened. Given the public's high initial interest, it could be considered that vaccination should not start until a large number of doses have been delivered.ConclusionThe medical incident command structure and protocol successfully can be adapted to a mass vaccination event. Information from the Östergötland County Council operation yielded significant experience for future mass vaccinations.

IntroductionDisaster medicine is a young discipline and there is a need for the development of methods for evaluation and research. This includes full-scale disaster exercises that are quite costly. Within each organization these exercises are seldom conducted. If there was a standardized concept on how to conduct as well as evaluate these exercises, this could lead to better knowledge and cost effectiveness. The aim of this study was to increase awareness of the possibility to develop and conduct full-scale exercises in different settings using performance indicators combined with indicators related to patient outcome serving as a basis for comparison and evaluation process.MethodsTwo full-scale exercises in different organizations were studied. Identical panorama with the same number and type of casualties was used. Sets of performance indicators combined with indicators for unfavorable patient outcome, according to the Emergo Train System®, were recorded as well as all transportation times and the patient distribution to selected hospitals. Qualified observers scored the results on predetermined locations; on the scene, hospital and strategic command and control.ResultsThe lowest scored performance indicators were “first report to dispatch”, “second report from scene” and “first patient evacuated”. Due to insufficient response and evacuation times of victims to the receiving hospitals the unfavourable patient outcome, regarding preventable deaths and preventable complications were 28% (n = 18) and 41% (n = 17), respectively.ConclusionsStandardized full-scale exercises where the same type of results is recorded can be conducted. This combination of performance indicators and Emergo Train System® leads to probabilities of development and better command and control response. Future use of the same concept may demonstrate important results that will lead to new and better knowledge that can be applied during real incidents.

IntroductionCommunication and information are cornerstones of management during major incidents and disasters. To support medical command and control, the Web-based support system called Paratus Major Incident can be used. The Paratus Major Incident system can provide management staff with online information from the incident area, and support management and patient handling at both single and mass-casualty incidents. The purpose of the Web-based information technology (IT) system is to ensure communication and information between the medical management at the scene, hospital management, and regional medical command and control (gold level).ExperiencesIn the region of Östergötland, Sweden, Paratus Major Incident system is used in operating topics such as: (1) information dissemination from the incident area; (2) communication between prehospital, regional, and hospital management; (3) continuous updates between the dispatch centre and medical commanders at all levels; (4) digital log-files for medical management and patient records; (4) database used for follow-up studies and quality control.ResultsDuring 2,161 incidents, 746 “first incident reports” from ambulance on scene were sent to regional medical command and control within 2 minutes. Four hundred and fifty-six “verification reports” were sent within 10 minutes. During 15 incidents, the designated duty officer on regional level confirmed “major incident” directly via the digital system, thereby notifying all arriving ambulance resources and involved medical managements.ConclusionThis Web-based IT system successfully has been used daily within prehospital management since 2005. The system includes medical command and control at the regional level and all involved hospitals in a major incident.

Background: A previous study has shown no measurable improvement in triage accuracy among physicians attending the Advanced Trauma Life Support (ATLS) course and suggests a curriculum revision regarding triage. Other studies have indicated that cooperative learning helps students acquire knowledge. Objective: The present study was designed to evaluate the effectiveness of trauma cards in triage training for firemen. Methods: Eighty-six firemen were randomly assigned into two groups: the trauma card group and the direct instruction group. Both groups received the same 30-min PowerPoint lecture on how to perform triage according to the Sort Assess Lifesaving interventions Treatment and transport (SALT) Mass Casualty Triage Algorithm. In the trauma card group, the participants were divided into groups of 3-5 and instructed to triage 10 trauma victims according to the descriptions on the trauma cards. In the direct instruction group, written forms about the same 10 victims were used and discussed as a continuation of the PowerPoint lecture. Total training time was 60 min for both groups. A test was distributed before and after the educational intervention to measure the individual triage skills. The same test was applied again 6 months later. Results: There was a significant improvement in triage skills directly after the intervention and this was sustained 6 months later. No significant difference in triage skills was seen between the trauma card group and the direct instruction group. Previous experience of multi-casualty incidents, years in service, level of education or age did not have any measurable effects on triage accuracy. Conclusions: One hour of triage training with the SALT Mass Casualty Triage Algorithm was enough to significantly improve triage accuracy in both groups of firemen with sustained skills 6 months later. Further studies on the first assessment on scene versus patient outcome are necessary to provide evidence that this training can improve casualty outcome. The efficacy and validity of trauma cards for disaster management training need to be tested in future studies. Funding Agencies|Swedish Civil Contingencies Agency