Evaluation of medical response in disaster preparedness : with special reference to full-scale exercises

Background: Disaster exercises and simulations serves as teaching and training tool for improving medical response in disaster preparedness. Rapid and effective medical response in major incidents is known as a “key phase” to optimise resources, and this requires that management systems have an “all hazards” approach. Decision-making at all levels of management is based on available information and involves allocation of medical resources and triage decisions. Aim: The overall aim of this thesis was to increase our knowledge of the impact of quantitative evaluation of medical response on disaster preparedness. The specific aims were: to increase the ability to learn from full-scale exercises by applying quality indicators at two levels of command and control (I, II); to identify key indicators essential for initial disaster medical response registration (III); to explore ambulance staff attitudes towards practising triage tagging (IV); and to increase our knowledge of the applicability of a technical support system and its potential to provide real-time, overall situation awareness available to those overseeing the medical management of the operation. Methods: Study I, II and V were observational studies based on data collections from full-scale exercises. Templates with measurable performance indicators for evaluation of command and control were used in Study I and II and the same performance indicators combined with outcome indicators was also included in Study II. A consensus method, the Delphi technique, with 30 experts was used in Study III. Study IV used mixed methods, a pre-and post web survey answered by ambulance nurses and physicians (n=57 respectively 57) before and after a time limited strategy with triage tags and three focus groups interviews comprising 21 ambulance nurses and emergency medical technicians. Study V used major two incidents simulations to test the applicability of Radio Frequency Identification (RFID tags) technology and compare it with traditionally paper-based triage tags (n= 20 respectively 20). The quantitative data were analysed using descriptive statistics, and content analysis was used for the qualitative data. Results: The evaluation model exposed several problems occurring in the initial decision-making process that were repeatedly observed (I, II). These results in study II also demonstrated to have a major impact on patient outcome.Out of 17 severely injured patients five respectively seven were at risk for preventable death. A total of 97 statements were generated, of these 77 statements reached experts consensus, and 20 did not (III). Ambulance staffs believe in the usefulness of standardised triage methods, but the sparse application of triage tags at the scene indicates that the tags are not used frequently. Infrequent use in daily practice prevents participants from feeling confident with the triage tool (IV).The Radio Frequency Identification system improved situational awareness in disaster management. Triage information was available at least one hour earlier compared to a paper-based triage system (V). Conclusions: The presented evaluation model can be used in an objective, systematic and reproducible way to evaluate complex medical responses, which is a prerequisite for quality assurance, identification of problems, and the development of disaster preparedness

Open Access

Essential key indicators for disaster medical response suggested to be included in a national uniform protocol for documentation of major incidents: a Delphi stud

Hospital incident command groups' performance during major incident simulations : A prospective observational study

BACKGROUND: Hospital incident command groups' (HICG) performance may have a profound impact on hospital response to major incidents. Previous research has assessed hospital incident command group capacity as opposed to performance and factors associated to performance. The objective was to assess associations between decision-making and staff procedure skills of the hospital incident command group. METHODS: This was a prospective observational study using performance indicators to assess hospital incident command groups' decision-making and performance. A total of six hospitals in Stockholm, Sweden, with their respective HICGs participated. Associations between decision-making skills and staff procedure skills during major incident simulations were assessed using measurable performance indicators. RESULTS: Decision-making skills are correlated to staff procedure skills and overall HICG performance. Proactive decision-making skills had significantly lower means than reactive decision-making skills and are significantly correlated to staff procedure skills. CONCLUSION: There is a significant correlation between decision-making skills and staff procedural skills. Hospital incident command groups' proactive decision-making abilities tended to be less developed than reactive decision-making abilities. These proactive decision-making skills may be a predictive factor for overall hospital incident command group performance. A lack of proactive decision-making ability may hamper efforts to mitigate the effects of a major incident

Charge nurses’ perceived experience in managing daily work and major incidents in emergency departments : A qualitative study

Background Emergency department charge nurses are expected to oversee the quality of patient care, direct work, and the allocation of resources. The charge nurse is the unit’s frontline leader, and he/she must have proper leadership training and support to carry out duties effectively. This study explores how charge nurses perceive their role in managing daily work and major incidents at the emergency department. Methods A qualitative study based on focus group discussions using a semi-structured interview. Participants were 12 charge nurses from four Swedish emergency departments. Results For data analysis, a systematic text condensation method was used. The analysis of data generated four categories: (1) Coping with chaos; (2) Need for further training; (3) Feeling of inadequacy; and (4) Lack of strategies. Conclusions The study concluded that the emergency department charge nurse has frontline duties that are diverse, multifaceted, require good leadership qualities, and lack detailed job description. Charge nurses confront many challenges in their daily work, often with little training or the opportunity to develop in their professional. This study provides understanding of the concerns charge nurses hold about working as frontline leaders and that departmental heads must support the education and training of their charge nurses

Evaluation of Disaster Preparedness Based on Simulation Exercises : A Comparison of Two Models

OBJECTIVE: The objective of this study was to highlight 2 models, the Hospital Incident Command System (HICS) and the Disaster Management Indicator model (DiMI), for evaluating the in-hospital management of a disaster situation through simulation exercises. METHODS: Two disaster exercises, A and B, with similar scenarios were performed. Both exercises were evaluated with regard to actions, processes, and structures. After the exercises, the results were calculated and compared. RESULTS: In exercise A the HICS model indicated that 32% of the required positions for the immediate phase were taken under consideration with an average performance of 70%. For exercise B, the corresponding scores were 42% and 68%, respectively. According to the DiMI model, the results for exercise A were a score of 68% for management processes and 63% for management structure (staff skills). In B the results were 77% and 86%, respectively. CONCLUSIONS: Both models demonstrated acceptable results in relation to previous studies. More research in this area is needed to validate which of these methods best evaluates disaster preparedness based on simulation exercises or whether the methods are complementary and should therefore be used together

Essential key indicators for disaster medical response suggested to be included in a national uniform protocol for documentation of major incidents : a Delphi study

BACKGROUND: Registration of data from a major incident or disaster serves several purposes such as to record data for evaluation of response as well as for research. Data needed can often be retrieved after an incident while other must be recorded during the incident. There is a need for a consensus on what is essential to record from a disaster response. The aim of this study was to identify key indicators essential for initial disaster medical response registration. By this is meant nationally accepted processes involved, from the time of the emergency call to the emergency medical communication centre until medical care is provided at the emergency department. METHODS: A three round Delphi study was conducted. Thirty experts with a broad knowledge in disaster and emergency response and medical management were invited. In this study we estimated 30 experts to be approximately one third of the number in Sweden eligible for recruitment. Process, structure and outcome indicators for the initial disaster medical response were identified. These were based on previous research and expressed as statements and were grouped into eight categories, and presented to the panel of experts. The experts were instructed to score each statement, using a five point Likert scale, and were also invited to include additional statements. Statements reaching a predefined consensus level of 80% were considered as essential to register. RESULTS: In total 97 statements were generated, 77 statements reached consensus. The 77 statements covered parts of all relevant aspects involved in the initial disaster medical response. The 20 indicators that did not reach consensus mostly concerned patient related times in hospital, types of support systems and security for health care staff. CONCLUSIONS: The Delphi technique can be used for reaching consensus of data, comprising process, structure and outcome indicators, identified as essential for recording from major incidents and disasters

Registered nurses' experience as disaster preparedness coordinators during a major incident : A qualitative study

AIMS: To explore registered nurses' experiences as disaster preparedness coordinators of hospital incident command groups' during a major incident. DESIGN: A qualitative descriptive design using semi-structured interview. METHODS: This was a qualitative study based on one focus group discussion and six individual follow-up interviews. Participants were registered nurses in their capacity as disaster preparedness coordinators with experience from Major Incident simulations and a real-life Major Incident. The interviews were transcribed verbatim and analysed using content analysis. The COREQ checklist was used for reporting the findings. RESULTS: The analysis of data generated the main category: Expectations, previous experience and uncertainty affect hospital incident command group response during a Major Incident and three categories, (I) Gaining situational awareness (containing two subcategories), (II) Transitioning to management (containing three subcategories) and (III) Actions taken during uncertainty (containing two subcategories)

Emergency department registered nurses overestimate their disaster competency : A cross-sectional study

BACKGROUND: Major incidents continue to pose a threat to health care systems by overwhelming them with a sudden surge of patients. A major factor impacting a hospital's surge capacity is the skills, abilities, and knowledge of emergency department (ED) registered nurses (RN). The level of disaster nursing competency they possess affects patient safety and outcome. ED RNs' ability to accurately assess their competency and knowledge is imperative for mitigating the effect of major incidents. ED RN's perception of overall disaster preparedness has not been thoroughly addressed. The aim of this study was to assess emergency department registered nurses' self-perceived disaster preparedness. METHOD: The study was a cross-sectional study per the STROBE checklist. A self-assessment questionnaire based on the results of a study identifying specific disaster nursing competencies for ED RNs was distributed to all ED RNs at six participating hospitals between January 10th to February 19th of 2019. A five-point Likert-type scale was used to assess competency. RESULTS: ED RNs' disaster preparedness according to the Total Disaster Competency mean was low. Furthermore, the results indicate that ED RNs' significantly overestimate their disaster nursing competency when compared to the Total Disaster Competency mean. Additionally, this study identified factors such as experience and education were positively associated with disaster preparedness and self-assessment ability. CONCLUSION: ED RNs' overestimate their disaster preparedness. However, ED RNs with experience and education may be better prepared. ED RNs with formal disaster education appeared to have better insight concerning their preparedness. Clinical experience, advanced levels of education, and training were positively associated with preparedness. Overestimating disaster competencies may negatively impact patient outcomes during a major incident

Combining performance and outcome indicators can be used in a standardized way: a pilot study of two multidisciplinary, full-scale major aircraft exercises

<p>Abstract</p> <p>Background</p> <p>Disaster medicine is a fairly young scientific discipline and there is a need for the development of new methods for evaluation and research. This includes full-scale disaster exercisers. A standardized concept on how to evaluate these exercises, could lead to easier identification of pitfalls caused by system-errors in the organization. The aim of this study was to demonstrate the feasibility of using a combination of performance and outcome indicators so that results can be compared in standardized full-scale exercises.</p> <p>Methods</p> <p>Two multidisciplinary, full-scale exercises were studied in 2008 and 2010. The panorama had the same setup. Sets of performance indicators combined with indicators for unfavorable patient outcome were recorded in predesigned templates. Evaluators, all trained in a standardized way at a national disaster medicine centre, scored the results on predetermined locations; at the scene, at hospital and at the regional command and control.</p> <p>Results</p> <p>All data regarding the performance indicators of the participants during the exercises were obtained as well as all data regarding indicators for patient outcome. Both exercises could therefore be compared regarding performance (processes) as well as outcome indicators. The data from the performance indicators during the exercises showed higher scores for the prehospital command in the second exercise 15 points and 3 points respectively. Results from the outcome indicators, patient survival and patient complications, demonstrated a higher number of preventable deaths and a lower number of preventable complications in the exercise 2010. In the exercise 2008 the number of preventable deaths was lower and the number of preventable complications was higher.</p> <p>Conclusions</p> <p>Standardized multidisciplinary, full-scale exercises in different settings can be conducted and evaluated with performance indicators combined with outcome indicators enabling results from exercises to be compared. If exercises are performed in a standardized way, results may serve as a basis for lessons learned. Future use of the same concept using the combination of performance indicators and patient outcome indicators may demonstrate new and important evidence that could lead to new and better knowledge that also may be applied during real incidents.</p