Major Incident Exercise Research Articles

“Together We Are Strong”: Emergency Associations for the Protection of Germany's Cultural Heritage

ABSTRACT This article presents an overview of the creation and development of emergency associations for the protection of archives, libraries, and museums in Germany. This is a response to several wake-up calls, notably the Elbe floods of 2002, the destruction by fire of a significant portion of the Duchess Anna Amalia Library in Weimar in 2004, and the collapse of the Cologne City Archive building in 2009. The emergency associations have come together on a voluntary basis to offer mutual support in the event of natural and human-made disasters. Drawing on the experience of the Augsburg association founded in 2015, the author explains the role and success of the new networks. Annual meetings have consolidated regional and nationwide collaboration, and deepened experience and preparedness. Training courses and major incident exercises with fire services as well as the German Federal Agency for Technical Relief form the bedrock of the cooperation.

The timeline of information exchange: a service evaluation of London Ambulance Service NHS Trust's front line communication and emergency response to Exercise Unified Response.

Introduction:Exercise Unified Response, Europe’s largest major incident training exercise to date, provided a rich environment for the emergency services to test their multi-agency crisis response capabilities. Supported by the London Ambulance Service NHS Trust, this service evaluation examined London Ambulance Service NHS Trust front line communication and decision-making via body-worn camera footage.Methods:Twenty London Ambulance Service NHS Trust front line responders and evaluators were each equipped with a body-worn camera during Exercise Unified Response. The service evaluation aimed to: (a) produce timelines of the London Ambulance Service NHS Trust’s response in order to identify key events and actions during the ‘golden hour’ (the crucial first hour in the care of trauma patients), the proceedings of command meetings and the multi-agency response; and (b) develop recommendations for future training and evaluations.Results:The service evaluation identified that, within the golden hour, London Ambulance Service NHS Trust first responders rightly and rapidly declared the event a major incident, requested resources and assigned roles. Triage crews were tasked quickly, though it was identified that their efficiency may be further enhanced through more detailed triage briefings prior to entering the scene. The command meetings (led by the Metropolitan Police) lacked efficiency, and all agencies could make more effective use of the multi-agency shared radio network to address ongoing matters. Finally, London Fire Brigade and London Ambulance Service NHS Trust teams demonstrated clear communication and co-ordination towards casualty extraction.Conclusion:Successful multi-agency working requires clear communication, information sharing and timely command meetings. It is recommended that Joint Emergency Services Interoperability Principles multi-agency talk groups should be utilised more frequently and used to complete a joint METHANE report. In addition, training in areas such as communication skills and detailed briefings will enhance the front line response. Finally, body-worn cameras are shown to be an effective service evaluation tool, as a basis for promoting best practice as well as highlighting areas for future training and evaluations.

Developing Collaboration Quality Indicators for Major Incidents in an Underground Mine

Introduction:The underground mining industry has one of the most hazardous industrial occupations, and requires an increased level of preparedness for injury incidents. The most important outcome for seriously injured victims is the reduction in morbidity and mortality. Receiving effective and timely care may mean the difference between life and death. However, mines are usually located in a rural area and the incident site may be deep underground which makes it an extraordinary challenge for the rescue services. A successful rescue response in an extraordinary milieu demands a high level of inter-organizational cooperation skills at the incident site.Aim:To analyze statements of collaborate activities during a major incident exercise in the underground mine industry, essentially for patient outcome.Methods:A Delphi technique was performed, asking opinions from experts in iterative rounds to generate, understand, and form consensus on group opinion around this complex issue. The experts were personnel from disaster medicine (n=3), emergency and prehospital medicine (n=10), rescue service (n=16), and mine industry (n=9), all with operative command positions.Results:Three iterative rounds were performed. The first round was conducted as a workshop to collect opinions about the most important inter-organization cooperation activities to optimize patient outcome from an injury incident in an underground mine. This resulted in 63 statements. The statements included information about: early alarm routines, collaborative support and efforts of early life-saving interventions, relevant resources and equipment, command and control room, and functions. In round two participants shared and communicated decisions about safety, situation awareness, and guidelines for response. All statements reached consensus among the experts in round three.Discussion:These inter-organizational statements are considered important by experts, and could be used to evaluate collaboration in major incident exercises. Hence, the statements can also be quality indicators for reporting results from major incident management.

Evaluating Full-Scale Exercises to Optimize Patient Outcome in an Underground Mine

Introduction:Major incident exercises are expensive to plan and execute, and often difficult to evaluate objectively. There is a need for a generic methodology for reporting results and experiences from major incidents so that data can be used for analysis, to compare results, exchange experiences, and for international collaboration in methodological development. Most protocols use data describing the incident hazards, prehospital and hospital resources available and alerted transport resources, and communication systems. However, the successful management of a rescue response during a major incident also demands a high level of command skills.Aim:The aim of this study was to analyze the command and collaboration skills among the emergency service on-scene commanders and the mine director for safety and security during a full-scale major incident exercise in an underground mine.Methods:The commander functions were observed during a full-scale major incident exercise. Audio and video observations and notes were analyzed using a study-specific scheme developed through a Delphi study, including inter-agency collaborative support and efforts of early life-saving interventions; relevant resources and equipment; and shared and communicated decisions about safety, situation awareness and medical guidelines for response. After the exercise additional interviews were made with those responsible for the command functions.Results:Preliminary results indicate that most decisions were not taken in collaboration. Elaborated results will be presented at the conference.Discussion:Command and collaboration skills can benefit from objective evaluations of full-scale major incident exercises to identify areas that must be improved to optimize patient outcome.

Resilience Training of Regional Medical Command and Control

Introduction:Resilience is often described as a desirable holistic approach to disaster preparedness. However, the term has a wide variety of meanings and is hard to operationalize and implement in disaster management. A goal for the EU H2020 project DARWIN was to operationalize resilience for incident management teams.Aim:To test the resilience operationalization by analyzing command team behaviors in a major incident exercise and trace observations to resilience theory.Methods:A regional medical command and control team (n=11) was observed when performing in a functional simulation exercise of a mass casualty incident (300 injured, 1800 uninjured) following the collision of a cruise ship and an oil tanker close to the Swedish coast. Audio and video recordings of behaviors and communications were reviewed for resilient behaviors based on the DARWIN guidelines using the “resilience markers for small teams” framework (Furniss et al., 2011).Results:A total of 121 observed instances of resilient behaviors were found in the material. In 95 cases (79%) the observed behaviors followed a priori hypothesized connections between resilient strategies and general markers. Certain marker-strategy combinations occurred frequently, such as 18 observations where the strategy “understand crucial assumptions” occurred together with the marker “adapting to expected and unexpected events.”Discussion:Resilience has the potential to contribute to a more holistic disaster management approach. The findings that the observations, in general, correspond to the expected relationship between theoretical concretization and contextualization supports the DARWIN effort to operationalize resilience theory. This is a prerequisite for developing observational protocols for training and further studies of resilient behaviors in disaster management teams.

Developing the Fourth Evaluation Dimension: A Protocol for Evaluation of Video From the Patient's Perspective During Major Incident Exercises.

Presently used evaluation techniques rely on 3 traditional dimensions: reports from observers, registration system data, and observational cameras. Some of these techniques are observer-dependent and are not reproducible for a second review. This proof-of-concept study aimed to test the feasibility of extending evaluation to a fourth dimension, the patient's perspective. Footage was obtained during a large, full-scale hospital trauma drill. Two mock victims were equipped with point-of-view cameras filming from the patient's head. Based on the Major Incident Hospital's first experience during the drill, a protocol was developed for a prospective, standardized method to evaluate a hospital's major incident response from the patient's perspective. The protocol was then tested in a second drill for its feasibility. New insights were gained after review of the footage. The traditional observer missed some of the evaluation points, which were seen on the point-of-view cameras. The information gained from the patient's perspective proved to be implementable into the designed protocol. Use of point-of-view camera recordings from a mock patient's perspective is a valuable addition to traditional evaluation of trauma drills and trauma care. Protocols should be designed to optimize and objectify judgement of such footage. (Disaster Med Public Health Preparedness. 2017;11:594-599).

Hospital evacuation: Exercise versus reality

IntroductionThe Dutch Major Incident Hospital (MIH) is a standby, highly prepared, 200-bed hospital strictly reserved to provide immediate, large-scale, and emergency care for victims of disasters and major incidents. It has long-standing experience training for various major incident scenarios, including functioning as a back-up facility for the Netherlands. In 1995, the MIH had experience with overtaking an evacuated hospital when that hospital was threatened by flooding. In November 2014, an exercise was performed to transfer an evacuating hospital to the MIH. The scenario again became reality when a neighbouring hospital had to evacuate in September 2015. This article evaluates the events and compares the exercise to the real events in order to further optimise future training. MethodsAll three events were analysed using the Protocol for Reports from Major Accidents and Disasters, a standardised protocol to evaluate medical responses to a major incident. ResultsDuring the 2014 exercise, 72 patients were received, compared with 143 and 70, respectively, in the real events in 1995 and 2015. Personnel from the evacuating hospitals accompanied the patients and continued working in the MIH. The patient surge differed on all three occasions. The information technology (IT) systems proved to be more prone to fail during the real event, and legal implications to have staff from another hospital work in the MIH had to be put in protocol during the deployment. The acute phase was comparable in all three events, and performance was good. However, the exercise did not last long enough to analyse the implications on multiday care, as experienced during a multiday deployment. ConclusionLarge-scale major incident exercises are a great benchmark for the medical response in the acute phase of relief. The MIH was shown to be highly prepared to admit an entire evacuating hospital or large groups of patients in such a scenario. Experiences from the past, combined with regular training that closely resembles reality, guarantee the level of preparedness. Key differences between a true deployment and an exercise are the inability to train multiple days, and in our experience, a successful operation of IT systems in test environments does not guarantee their successful use during live events.

Major Incident Preparation for Acute Hospitals: Current State-of-the-Art, Training Needs Analysis, and the Role of Novel Virtual Worlds Simulation Technologies

BackgroundThere is growing evidence that health systems in developed countries are poorly prepared to deal with major incidents. Study ObjectivesThis study aimed to determine the skills required for successful major incident response, the factors that contribute to a successful major incident exercise, and whether there is a role for using novel simulation training (virtual worlds) in preparing for major incidents. MethodsThis was a qualitative semi-structured interview study. Fourteen health care staff with experience of major incident planning and training in the United Kingdom were recruited. Interviews were content-analyzed to identify emergent themes. ResultsThe aims and benefits of current exercises were categorized into three major themes: Organizational, Interpersonal, and Cognitive. Participants felt that the main objective of current exercises is to see how a major incident plan is implemented, rather than training individual staff. Communications was the most frequently commented-on area requiring improvement. Participants felt that lack of constructive feedback reduced the effectiveness of the exercises. All participants commented that virtual worlds technology could be successfully utilized for training. The creation of an immersive environment, increased training opportunity, and improved participant feedback were thought to be amongst the greatest benefits. ConclusionThere are clear deficiencies with current major incident preparation. Utilizing virtual worlds technology as an adjunct to existing exercises could improve training and response in the future.

Major Incident Patient Evacuation: Full-Scale Field Exercise Feasibility Study

Introduction Major incident management relies on efficient patient transportation. In the absence of a standardized, field-friendly approach to multiple casualty management, the Norwegian Air Ambulance Foundation developed Optimal Patient Evacuation Norway (OPEN). OPEN aims to save time, improve patient handling, prevent hypothermia, and simplify scene management. We evaluated the feasibility of the OPEN concept in full-scale major incident field exercises. Methods Emergency service personnel participated in two standardized bus crash field exercises, without and with access to OPEN. The instructors timed completion of patient evacuation, and the students participated in a self-report before and after study. Each question was scored on a 7-point Likert scale, with points labeled “Did not work” (1) through “Worked excellently” (7). Results Among the 93 study participants, 31% confirmed that stretchers could be available at the scene within 30 minutes in their catchment area. The students reported improved interdisciplinary cooperation for patient evacuation after the course (mean, 5.8, with 95% CI 5.7–6.0 after vs. 5.4 with 95% CI 5.2–5.6 before, P < .001). Conclusion OPEN is a feasible and time-efficient way to standardize patient transport and may serve as a candidate for a future national standard for major incident patient evacuation.

Major incident tabletop exercises: a high tech, low cost evolution

Traditional tabletop exercises, that facilitate major incident (MI) planning and education, use paper plans and models. We describe a low-cost, electronic whiteboard that explores how interactive software can advance this educational scenario. The authors intend to demonstrate this technology. The infra-red tracking device within the Nintendo Wii handset is the key to this setup's functionality. When connected to a computer and projector it provides an ad hoc interactive whiteboard, operated with infra-red pens, comparable to proprietary wall-mounted solutions yet easily transportable. Capturing a team's work, by enabling print-outs at principal stages of exercises, is additionally advantageous. Utilising this technology we ran an exercise to determine our new Paediatric Emergency Department Unit's MI Plan. The software was purpose-built so the incident played out on the departmental floor plan, allowing scrutiny of patient flow within our own physical environment. Questionnaires employing 1–5 Likert scales (where 1 and 5 indicated strong disagreement and agreement, respectively), were retrospectively completed by participants. Median values and interquartile ranges (IQR) were calculated. Although from a small sample size (n = 10), the results from this ‘mini-trial’ were very encouraging. The response rate was 100%. A high level of positive concordance was maintained across the feedback received. The main outcome was whether the setup facilitated MI Plan development. The median response found unilateral strong agreement for this and none of the users found the setup distracting. Additionally, novice contributors found the equipment easy to use (median = 4; IQR = 4.0–4.75). By combining new, affordable technology and bespoke software, this novel set up demonstrates a new approach to updating the current tabletop exercises used in MI training and practise. We were able to positively apply the feedback generated to develop the new Paediatric Unit's MI Plan. Future work with this innovation will include adapting our MI Plan for a new Emergency Department currently under-construction.

Evaluation of Medical Command and Control Using Performance Indicators in a Full-Scale, Major Aircraft Accident Exercise

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. 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. 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 greater than 11 were considered as acceptable. 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. 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.

Learning from a major incident exercise.

It was a beautiful October morning as the train sped along the track. The passengers, mostly children, were in a jovial mood unaware of the fate which was about to befall them.

Improved trauma management with advanced trauma life support (ATLS) training.

OBJECTIVE: To determine the value of advanced trauma life support (ATLS) training for medical staff in a major incident situation, based upon performance in a simulated exercise. METHODS: A major...

Assessment of a triage label system during a major incident exercise.

The Metag triage label system was assessed during a major incident exercise at an international airport. The exercise simulated a crash of a plane carrying 40 passengers within the airport boundaries. A secondary incident also was staged involving an explosion resulting in a fire with three victims injured. The exercise involved the airport, fire, police, ambulance, and medical services of three counties--Leicestershire, Derbyshire, and Nottinghamshire. Use of the labels enabled evaluation of the triage process, early medical intervention for victims, and completion of the cards.