Patient needs in evacuation of a tertiary oncology center.

To inform ongoing contingency planning, hospital staff conducted a cross-sectional survey of patients' needs in the event of a full-facility evacuation of a tertiary oncology center. Both outpatients and inpatients were included. Of the total of 269 patients, 76.6 percent were able to evacuate by walking out of the hospital and be transported sitting. Only 30 patients needed evacuation by an ambulance. Assessment of the lowest acceptable level of care after evacuation revealed that 66.5 percent of the patients could be discharged to their own home, including 40.8 percent of all inpatients. Due to the need to continue specialized cancer treatment, fewer patients could be transferred to other hospitals than found in previous studies of general acute care hospitals.

A Qualitative Study on Researchers' Experiences after Publishing Scientific Reports on Major Incidents, Mass-Casualty Incidents, and Disasters.

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.

Quality of care, resource use and patient outcome by use of emergency response team compared with standard care for critically ill medical patients in the emergency department: a retrospective single-centre cohort study from Norway.

OBJECTIVE: The study aimed to investigate quality of care, resource use and patient outcome in management by an emergency response team versus standard care for critically ill medical patients in the emergency department (ED). The emergency response team was multidisciplinary and had eight members, with a registrar in internal medicine as team leader. DESIGN: Register-based retrospective cohort study. SETTING: Tertiary hospital in Norway. PARTICIPANTS: The study included 1120 patients with National Early Warning Score 2 (NEWS2) 5-10 points from 2015 and 2016. Patients missing ≥3 NEWS2 part scores, <18 years and with orders 'Not for ICU' or 'Not for resuscitation' were excluded. OUTCOME MEASURES: Quality of care: pain assessment documented, analgesics given within 20 min, complete set of vital signs documented and antibiotics within 60 min if sepsis. Resource use: >3 diagnostic interventions, critical care in the ED and ED length of stay (LOS) <180 min. Patient outcome: intensive care unit (ICU) admission, ICU LOS <66 hours, hospital LOS <194 hours and mortality. RESULTS: The median age was 66 years, 53.5% were male, 44.3% were admitted to the ICU and the mortality rate was 10.6%. Altogether 691 patients received team management and 429 standard care. Team management had a positive association with 'complete set of vital signs documented' (OR 1.720, CI 1.254 to 2.360), 'analgesics given within 20 minutes' (OR 3.268, CI 1.375 to 7.767) and 'antibiotics within 60 minutes if sepsis' (OR 7.880, CI 3.322 to 18.691), but a negative association with ' pain assessment documented' (OR 0.068, CI 0.037 to 0.128). Team management was also associated with 'critical care in the ED' (OR 9.900, CI 7.127 to 13.751), 'ED LOS <180 min' (OR 2.944, CI 2.070 to 4.187), 'ICU admission' (OR 2.763, CI 1.962 to 3.891) and 'mortality' (OR 1.882, CI 1.142 to 3.102). CONCLUSIONS: Team management showed positive results for quality of care and resource use. The results for later outcomes such as mortality, ICU LOS and hospital LOS were more ambiguous.

Characteristics, management and outcome of critically ill general medical patients in the Emergency Department: An observational study.

BACKGROUND: Critically ill general medical patients are an increasing group in the Emergency Department (ED). This register-based cohort study aimed to examine these patients' characteristics, ED management and outcome, and investigate factors associated with ICU admission. METHODS: The study comprised all adult medical triage 1 patients treated by a specialized multidisciplinary team in 2015 and 2016. Univariate and multivariate analysis were used. RESULTS: 1294 patients were included. Mean age was 59 years, 56% (n = 725) were male, mean National Early Warning Score 2 (NEWS2) was 7, intensive care unit (ICU) admission was 56.8% (n = 735) and mortality rate was 16.8% (n = 217). Median ED length of stay (LOS) was 1.6 h, 1.2 h if admitted to ICU. The most frequent discharge diagnosis was acute poisoning (24.0%, n = 308). Younger age, male gender, arriving at nighttime weekdays, higher NEWS2 at arrival, critical care interventions or medications in the ED was associated with ICU admission. CONCLUSION: More than half of the patients were admitted to ICU, and the mortality rate was 16.8%. A large proportion was diagnosed with acute poisoning. Younger age, higher NEWS and critical care in ED were associated with ICU admission. The short ED LOS suggests that management by a multidisciplinary team is beneficial.

NEWS2 versus a single-parameter system to identify critically ill medical patients in the emergency department.

AIM: To test National Early Warning Score 2 (NEWS2) versus a single-parameter system to identify critically ill general medical patients in the emergency department (ED), by 1) testing NEWS2s prediction of and association with primary outcome 'mortality' (hospital or 30 day) and secondary outcomes 'intensive care unit (ICU) admission' and 'critical care in ED' and 2) comparing this for different NEWS2 cut-offs and the single-parameter system in use. METHODS: Register-data on adult triage 1 and 2 patients with complete NEWS2 from 2015 and 2016 were retrieved. Prediction was assessed using area under the receiver-operating characteristic curve. Associations were analyzed using multiple logistic regression. RESULTS: 1586 patients were included. NEWS2 showed poor prediction of 'mortality' (AUC 0.686, CI 0.633-0.739) and adequate prediction of 'ICU admission' (AUC 0.716, CI 0.690-0.742) and 'critical care in ED' (AUC 0.756, CI 0.732-0.780). It was strongly associated with all outcomes (all p<0.001). All NEWS2 cut-offs and the single-parameter system showed poor prediction of all outcomes (all AUCs <0.7). The single-parameter system had the strongest association with 'mortality' (OR 1.688, CI 1.052-2.708, p<0.05) and 'critical care in ED' (OR 3.267, CI 2.490-4.286, p<0.001). NEWS2 > 4 had the strongest association with 'ICU admission' (OR 2.339, CI 1.742-3.141, p<0.001). CONCLUSION: For identification in order to trigger a response in the ED, outcomes closest in time seem most clinically relevant. As such, the single-parameter system had acceptable performance. NEWS2 > 4 should be considered as an additional trigger due to its association with ICU admission.

A cross-sectional survey of patient needs in hospital evacuation.

To aid development of contingency plans, a cross-sectional survey of inpatient needs in the event of a total hospital evacuation within a few hours was undertaken. The hospital is a part of a tertiary care facility with a mixed surgical and medical population and a relatively large load of emergency medicine. A doctor or nurse on each ward registered patients' physical mobility, special needs complicating transportation (intensive care, labor, isolation, etc), and the lowest acceptable level of care after evacuation. Of the 760 included patients, 57.8 percent could walk, 20.0 percent needed wheelchair, and 22.2 percent needed transport on stretcher. Special needs were registered for 18.2 percent of patients. Only 49.7 percent of patients needed to be evacuated to another hospital to continue care on an acceptable level, while 37.6 percent could be discharged to their own home, and 12.6 percent could be evacuated to a nursing home. Patients in psychiatric wards and high dependency units had distinctly different needs than patients in ordinary somatic wards. The differences between patients in surgical and nonsurgical wards were minor. Patient discharge seems to be a considerable capacity buffer in a hospital crisis situation.

A retrospective observational study of medical incident command and decision-making in the 2011 Oslo bombing.

BACKGROUND: A core task for commanders in charge of an emergency response operation is to make decisions. The purposes of the study were to describe what critical decisions the ambulance commander and the medical commander make in a mass casualty incident response and to explore what the underlying conditions affecting decision-making are. The study was conducted in the context of the 2011 government district terrorist bombing in Norway. METHODS: The study was a retrospective, descriptive observational study collecting data through participating observation, semi-structured interviews, and recordings of emergency medical services' radio communications. Analysis was conducted using systematic text condensation. The ambulance commander was interviewed using the critical decision method. RESULTS: The medical emergency response lasted 6.5 h, with little clinical activity after 2 h. Most critical decisions were made within the first 30 min, with the ambulance commander making the bulk of decisions. Situation assessment and underlying uncertainties strongly affected decision-making, but there was a mutual interaction between these three factors that developed throughout the different stages of the operation. Knowledge and experience were major determinants of how easily commanders picked up sensory cues and translated them into situation assessments. The number and magnitude of uncertainties were largest in the development stage, after most of the critical decisions had been made. CONCLUSIONS: In the studied mass casualty incident, the commanders made most critical decisions in the early stages of the emergency response when resources did not meet demand. Decisions were made under significant uncertainty and time pressure. Ambulance and medical commanders should be prepared to make situation assessments and decisions early and be ready to adjust as uncertainties are reduced.

Literature review on medical incident command.

INTRODUCTION: It is not known what constitutes the optimal emergency management system, nor is there a consensus on how effectiveness and efficiency in emergency response should be measured or evaluated. Literature on the role and tasks of commanders in the prehospital emergency services in the setting of mass-casualty incidents has not been summarized and published. PROBLEM: This comprehensive literature review addresses some of the needs for future research in emergency management through three research questions: (1) What are the basic assumptions underlying incident command systems (ICSs)? (2) What are the tasks of ambulance and medical commanders in the field? And (3) How can field commanders' performances be measured and assessed? METHODS: A systematic literature search in MEDLINE, PubMed, PsycINFO, Embase, Cochrane Central Register of Controlled Trials, Cochrane Library, ISI Web of Science, Scopus, International Security & Counter Terrorism Reference Center, Current Controlled Trials, and PROSPERO covering January 1, 1990 through March 1, 2014 was conducted. Reference lists of included literature were hand searched. Included papers were analyzed using Framework synthesis. RESULTS: The literature search identified 6,049 unique records, of which, 76 articles and books where included in qualitative synthesis. Most ICSs are described commonly as hierarchical, bureaucratic, and based on military principles. These assumptions are contested strongly, as is the applicability of such systems. Linking of the chains of command in cooperating agencies is a basic difficulty. Incident command systems are flexible in the sense that the organization may be expanded as needed. Commanders may command by direction, by planning, or by influence. Commanders' tasks may be summarized as: conducting scene assessment, developing an action plan, distributing resources, monitoring operations, and making decisions. There is considerable variation between authors in nomenclature and what tasks are included or highlighted. There are no widely acknowledged measurement tools of commanders' performances, though several performance indicators have been suggested. CONCLUSION: The competence and experience of the commanders, upon which an efficient ICS has to rely, cannot be compensated significantly by plans and procedures, or even by guidance from superior organizational elements such as coordination centers. This study finds that neither a certain system or structure, or a specific set of plans, are better than others, nor can it conclude what system prerequisites are necessary or sufficient for efficient incident management. Commanders need to be sure about their authority, responsibility, and the functional demands posed upon them.

A cross-sectional survey of patient needs in hospital evacuation.

To aid development of contingency plans, a cross-sectional survey of inpatient needs in the event of a total hospital evacuation within a few hours was undertaken. The hospital is a part of a tertiary care facility with a mixed surgical and medical population and a relatively large load of emergency medicine. A doctor or nurse on each ward registered patients' physical mobility, special needs complicating transportation (intensive care, labor, isolation, etc), and the lowest acceptable level of care after evacuation. Of the 760 included patients, 57.8 percent could walk, 20.0 percent needed wheelchair, and 22.2 percent needed transport on stretcher. Special needs were registered for 18.2 percent of patients. Only 49.7 percent of patients needed to be evacuated to another hospital to continue care on an acceptable level, while 37.6 percent could be discharged to their own home, and 12.6 percent could be evacuated to a nursing home. Patients in psychiatric wards and high dependency units had distinctly different needs than patients in ordinary somatic wards. The differences between patients in surgical and nonsurgical wards were minor. Patient discharge seems to be a considerable capacity buffer in a hospital crisis situation.

The twin terrorist attacks in Norway on July 22, 2011: the trauma center response.

BACKGROUND: The terrorist attacks in Norway on July 22, 2011, consisted of a bomb explosion in central Oslo, followed by a shooting spree in a youth camp. We describe the trauma center response, identifying possible success factors and suggesting improvements for institutional major incident plans. METHODS: The in-hospital response is analyzed. Data on triage, patient flow, injuries, treatment, resources, and outcome were collected. RESULTS: The explosion caused a total of 98 casualties and 8 died at scene. Ten patients were triaged to the trauma center, with the first patient arriving 18 minutes after the explosion and 7 patients within the next 19 minutes. The shooting caused 68 deaths at the scene and 61 injured. The trauma center received a total of 21 patients from the shooting incident.Surgical leadership was divided between emergency department triage with control of personnel and communication as well as control and supervision of treatment with retriage and optimal use of trauma surgical resources (dual command). Surge capacity was never exceeded in the emergency department, operating rooms, or intensive care units.Of the 31 patients treated at the trauma center, 20 had an Injury Severity Score of more than 15 and 25 required repeated operation, for a total of 125 operations during the first 4 weeks. One patient died, for a critical mortality of 5%. CONCLUSION: A trauma center can handle many patients with severe injury, with low critical mortality when protected from a large number of walking wounded. Limited specific trauma surgical competence was managed by the adoption of a dual surgical command model. LEVEL OF EVIDENCE: Therapeutic/care management study, level V.

Oslo government district bombing and Utøya island shooting July 22, 2011: the immediate prehospital emergency medical service response.

BACKGROUND: On July 22, 2011, a single perpetrator killed 77 people in a car bomb attack and a shooting spree incident in Norway. This article describes the emergency medical service (EMS) response elicited by the two incidents. METHODS: A retrospective and observational study was conducted based on data from the EMS systems involved and the public domain. The study was approved by the Data Protection Official and was defined as a quality improvement project. RESULTS: We describe the timeline and logistics of the EMS response, focusing on alarm, dispatch, initial response, triage and evacuation. The scenes in the Oslo government district and at Utøya island are described separately. CONCLUSIONS: Many EMS units were activated and effectively used despite the occurrence of two geographically separate incidents within a short time frame. Important lessons were learned regarding triage and evacuation, patient flow and communication, the use of and need for emergency equipment and the coordination of helicopter EMS.