Incident commander decision making: Quantitative evaluation of instantaneous and considered decisions.

The Incident Commander (IC) decision-making process has previously been modeled primarily by qualitative evaluation methods, which has made it difficult to generalize an objective model. In this study, we took a quantitative approach to elucidate a decision-making model based on the "dual-process" model that consists of instantaneous decisions ("System 1") and considered decisions ("System 2") to gain new insights regarding the IC decision-making process. High-fidelity simulation data from eight mass-casualty incidents (MCIs) were analyzed in two categories. The first category represents cues of new information and the IC's actions, divided into three main subcategories: actions following the MCI protocol, responses following cues, and actions without a cue. The second category divides the simulation into three MCI management phases: (1) evaluation and triage, (2) treatment and preparedness for evacuation, and (3) evacuation. Actions that followed the MCI protocol were significantly higher in the first phase compared to the other two phases (p<0.01 for both phases). Responses following cues were significantly higher in the second phase compared to the first (p<0.01). Actions without a cue were significantly higher in both the second and third phases compared to the first (p<0.01 for both phases). The results reveal that the IC followed MCI protocol guidance in the simulation initiation and immediately responded to cues, which fits "System 1". As the simulation evolved, the IC made more planned tasks and initiated actions without leading cues, which fits "System 2". The study found that ICs can change their decision-making mode, and this understanding can serve to improve their decision-making process and increase casualty survival rates.

Reviewing stakeholders during the Itaewon Halloween crowd crush, Korea 2022: Qualitative content analysis.

Background: The issue of crowd crushes has been not only very complicated but also uncertain. This article aimed to evaluate how situations such as the Itaewon Halloween crowd crush in South Korea in 2022 can be better managed to reduce human loss. Methods: Qualitative analysis was the key methodology used to compare emergency planning for ordinary events with contingency planning for special events, focusing on four stakeholders, namely governments, businesses, voluntary organizations, and other local communities. Results: The key finding was that all stakeholders would need to supplement emergency planning for ordinary events with contingency planning for special events for the nation. They must embody cooperation, cutting-edge technologies, routinized updates, situation awareness, political rationality, training and exercise, and others, based on inclusion. Conclusions: This is a pioneer study that examined the Itaewon crowd crush more comprehensively than others in particular by including many disaster management principles.

Project APRED: A web-based data analytics platform for supporting community disaster resilience.

In this paper, we introduce the Analysis Platform for Risk, Resilience, and Expenditure in Disasters (APRED)-a disaster-analytic platform developed for crisis practitioners and economic developers across the United States (US). APRED provides practitioners with a centralized platform for exploring disaster resilience and vulnerability profiles of all counties across the US. The platform comprises five sections including: (1) Disaster Resilience Index, (2) Business Vulnerability Index, (3) Disaster Declaration History, (4) County Profile, and (5) Storm History sections. We further describe our end-to-end human-centered design and engineering process that involved contextual inquiry, community-based participatory design, and rapid prototyping with the support of US Economic Development Administration representatives and regional economic developers across the US. Findings from our study revealed that distributed cognition, content heuristic, shareability, and human-centered systems are crucial considerations for developing data-intensive visualization platforms for resilience planning. We discuss the implications of these findings and inform future research on developing sociotechnical visualization platforms to support resilience planning.

Public Health Emergency Preparedness: Qualitative Analysis of After-Action Reports.

After-Action Reports (AARs) are retrospective summaries that capture key information and lessons learned from emergency response exercises and real incidents. The AAR is a commonly used evaluation tool used by the Centers for Disease Control and Prevention as part of the Public Health Emergency Preparedness (PHEP) program. It is used as a metric of accountability and awardee performance. The objectives of this study were to qualitatively analyze AARs of public health preparedness programs and develop a coding scheme for standardizing future review and analysis of AARs. We evaluated 14 AARs (4 exercises and 10 real incidents) generated between 2012 and 2018. We applied inductive qualitative analyses using ATLAS.Ti software. While, previous exercises focused on medical countermeasure responses, real-world incidents focused on natural disasters and infectious disease outbreaks. Six overarching themes emerged: Communications, Coordination, Resource Distribution, Unified Planning, Surveillance, and Knowledge Sharing. A standardized analysis format is proposed for future use.

Factors Associated With Delayed Pre-Hospital Times During Trauma-Related Mass Casualty Incidents: A Systematic Review.

OBJECTIVE: Critically injured patients have experienced delays in being transported to hospitals during Mass Casualty Incidents (MCIs). Extended pre-hospital times (PHTs) are associated with increased mortality. It is not clear which factors affect overall PHT during an MCI. This systematic review aimed to investigate PHTs in trauma-related MCIs and identify factors associated with delays for triaged patients at incident scenes. METHODS: This systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Web of Science, CINAHL, MEDLINE, and EMBASE were searched between January and February 2022 for evidence. Research studies of any methodology, and grey literature in English, were eligible for inclusion. Studies were narratively synthesized according to Cochrane guidance. RESULTS: Of the 2025 publications identified from the initial search, 12 papers met the inclusion criteria. 6 observational cohort studies and 6 case reports described a diverse range of MCIs. PHTs were reported variably across incidents, from a median of 35 minutes to 8 hours, 8 minutes. Factors associated with prolonged PHT included: challenging incident locations, concerns about scene safety, and adverse decision-making in MCI triage responses. Casualty numbers did not consistently influence PHTs. Study quality was rated moderate to high. CONCLUSION: PHT delays of more than 2 hours were common. Future MCI planning should consider responses within challenging environments and enhanced timely triage decision-making.

Are the healthcare providers willing and able to respond to disasters: An assessment of tertiary health care system of Khyber Pakhtunkhwa.

For the tertiary health care system to provide adequate care during disasters, willing and able healthcare providers must be available to respond to the abnormal surge of the patients. Health care professionals (HCPs) constantly face a dilemma because of their profession to either respond to disasters or protect themselves. This study was conducted to assess the willingness and ability of HCPs working in the tertiary healthcare system of Khyber Pakhtunkhwa to respond to disasters. This cross-sectional survey was conducted in all the 8 tertiary care hospitals of the Khyber Pakhtunkhwa province of Pakistan. For different disaster scenarios, between 6% and 47% of HCP indicated their unwillingness, and between 3% & 41% of HCPs indicated that they were unable to respond to the given disaster scenarios. HCPs with childcare obligation indicated significantly lower willingness (p<0.05) to respond to earthquakes, MCIs, and an outbreak of Influenza, and SARS. Male HCPs showed a significantly (p<0.05) higher willingness to respond to earthquakes, MCIs, and an outbreak of Influenza as compared to their female counterparts. The overall ability indicated by HCPs for various disaster scenarios ranged between 54.1% [95% CI 0.503,0.578] for responding to victims of nuclear war and 96.4% [95% CI 0.947,0.976] for responding to conventional war. The HCPs who indicated childcare obligation showed a significantly lower ability (p<0.05) to respond to environmental disaster, influenza outbreak, and responding to victims of nuclear war. Female HCPs indicated significantly higher ability (p<0.05) as compared to their male counterparts. This survey provides an opportunity for the tertiary healthcare system to build on the findings and develop disaster mitigation plans to address the barriers to improving the HCPs' availability during disasters.

Determining surgical surge capacity with a hybrid simulation exercise.

Background: To help test and improve surgical surge capacity, mass casualty incident (MCI) exercises generate valuable information. Both large scale table-top exercises (TTX) and full-scale exercises (FSX) have limitations if you want to test an organisation's capability and structure. A hybrid exercise incorporating the advantages of TTX and FSX is a possible way forward, but is no standardised exercise method, yet. This study aims at evaluating the exercise results to determine the feasibility of a hybrid TTX/FSX exercise for an organization's capability and structure. Methods: A hybrid MCI simulation using moulaged figurants and simulation cards was designed, where the emergency department of a level 1 trauma centre receives 103 casualties over 4 h. After registration and triage, all casualties are expected to be resuscitated in real time and are transferred for further treatment inside the hospital (radiology, operating theatres, intensive care unit (ICU)/postop and wards). When reaching operation theatre, ICU or ward, figurants are replaced by simulation cards. Observers ensured that those procedures performed were adequate and adhered to realistic times. Use of resources (materials, drugs etc.) were registered. Primary endpoint was average time spent in the emergency department, from time of arrival, to transfer out. Secondary endpoints were related to patient flow and avoidable fatalities. Results: The hospital managed to deal with the flow of patients without collapse of existing systems. Operating theatres as well as ICU and ward beds were available at the end of the exercise. Several details in the hospital response were observed that had not been noticed during previous TTX. Conclusion: FSX have a valuable role in training, equipping, exercising, and evaluating MCI management. Hybrid simulations combining both FSX and TTX may optimise resource utilisation and allow more frequent exercises with similar organisational benefit.

The Field's mass shooting: emergency medical services response.

BACKGROUND: Major incidents (MI) happen infrequently in Scandinavia and mass shootings are even less frequently occurring. Case reports and research are called for, as literature is scarce. On 3rd July 2022, a mass shooting took place at the shopping mall Field's in Copenhagen, Denmark. Three people were killed and seven injured by a gunman, firing a rifle inside the mall. A further 21 people suffered minor injuries during the evacuation of the mall. In this case report, we describe the emergency medical services (EMS) incident response and evaluate the EMS´ adherence to the MI management guidelines to identify possible areas of improvement. CASE PRESENTATION: Forty-eight EMS units including five Tactical Emergency Medical Service teams were dispatched to the incident. Four critically injured patients were taken to two trauma hospitals. The deceased patients were declared dead at the scene and remained there for the sake of the investigation. A total of 24 patients with less severe and minor injuries were treated at four different hospitals in connection with the attack. The ambulance resources were inherently limited in the initial phase of the MI, mandating improvisation in medical incident command. Though challenged, Command and Control, Safety, Communication, Assessment, Triage, Treatment, Transport (CSCATTT) principles were followed. CONCLUSIONS: The EMS response generally adhered to national guidelines for MI. The activation of EMS and the hospital preparedness program was relevant. Important findings were communication shortcomings; inherent lack of readily available ambulance resources in the initial critical phase; uncertainty regarding the number of perpetrators; uncertainty regarding number of casualties and social media rumors that unnecessarily hampered and prolonged the response. The incident command had to use non-standard measures to mitigate potential challenges.

Catalysts for change: How partnerships and transparency created the Maryland Department of Emergency Management.

The Maryland Department of Emergency Management was established in October 2021 after decades of reorganisation and relocation within state government. The elevation of the agency from under the Maryland Military Department to a cabinet-level department was a result of years of partnership building with stakeholders as well as two significant external pressures: the COVID-19 response and the interest in improving 911 delivery through the implementation of next-generation 911 technology. This case study examines the history of emergency management organisation in Maryland and highlights lessons learned and best practices for emergency managers seeking to elevate emergency management from a subagency level to a cabinet level or direct report to the highest elected official.

Legal considerations when advising on business continuity.

With the rise of climatic concerns and cybersecurity incidents comes the expectation that investments are made in business continuity measures. This expectation has legal teeth from the perspective of shareholders as well as regulatory bodies, contracting attorneys, vendors and supply chain entities. This paper explores the use of US legal system as a tool for enforcing liability and action from decision makers like the board of directors and C-suite officers, as well as between the parties of contracts. Shareholder derivative lawsuits, which occur predominately in the USA but have, as recently as 2020, started to include foreign-owned businesses, and breach of contract claims are two of the more prominent issues with business continuity tie-ins. This paper intends to arm the business continuity professional with a knowledge base about legal liability for failure to have a business continuity plan, an understanding of how disasters and disruptions will excuse the full performance of a contract and an ability to determine proper courses of action with respect to supply allocation after an incident.

Assessing and complying with regulatory oversight on utility performance.

This paper emphasises the importance of - and the complexity inherent in - the navigation of regulatory oversight and legal requirements in the area of electric utility performance. With a particular focus on utility companies in New York State, it discusses recent measures taken to adapt to the changing demands of regulatory compliance.

The use of shared digital platform solutions to address challenges to multi-agency preparedness, response and recovery work within the UK.

This paper discusses ResilienceDirect - the UK's strategic resilience platform for response and information sharing, designed to support the multi-agency aspects of emergency response. The paper will focus on the functionality of the system as well as the related challenges. The paper identifies a set of recommendations for addressing the challenges to improve usability and uptake. The recommendations will consider best practices from other multi-agency response platforms and feedback from ResilienceDirect users.

Assessment of active shooter preparedness in US hospital systems.

BACKGROUND: Active shooter events are horrific, unfortunate realities in American hospitals. Protecting patients and staff in an active shooter event is made more difficult in the cases of critically ill and otherwise immobile patients. Previous work has proposed theoretical mitigation strategies for active shooter events. This study assesses American hospitals' current, active preparedness plans. METHODS: This is a survey-based study with questionnaires distributed to leaders in American healthcare. The survey assessed current active shooter protocols with a particular emphasis on managing critically ill patients. Data were summarized with frequency and percentage. RESULTS: The survey was distributed to 294 hospital systems across the United States, and representatives from 60 hospital systems responded. Ninety-eight percent of these hospital systems have an active shooter protocol; 24 percent report a plan to provide care for critically ill patients. Among those hospital systems with a plan for caring for immobile patients, substantial heterogeneity exists in the philosophy and implementation of these protocols. Additionally, 52 percent of hospital systems routinely practice response drills to active shooter events. Notably, hospital systems that had experienced an active shooter event in the past were more likely to practice implementing active shooter protocols. CONCLUSIONS: While most hospital systems have an active shooter protocol in place, these plans are infrequently practiced and generally do not include contingency arrangements for the sickest, immobile patients. The results from this study highlight a significant opportunity for improvement in American hospital safety procedures.

Historical narratives about the COVID-19 pandemic are motivationally biased.

How people recall the SARS-CoV-2 pandemic is likely to prove crucial in future societal debates on pandemic preparedness and appropriate political action. Beyond simple forgetting, previous research suggests that recall may be distorted by strong motivations and anchoring perceptions on the current situation1-6. Here, using 4 studies across 11 countries (total n = 10,776), we show that recall of perceived risk, trust in institutions and protective behaviours depended strongly on current evaluations. Although both vaccinated and unvaccinated individuals were affected by this bias, people who identified strongly with their vaccination status-whether vaccinated or unvaccinated-tended to exhibit greater and, notably, opposite distortions of recall. Biased recall was not reduced by providing information about common recall errors or small monetary incentives for accurate recall, but was partially reduced by high incentives. Thus, it seems that motivation and identity influence the direction in which the recall of the past is distorted. Biased recall was further related to the evaluation of past political action and future behavioural intent, including adhering to regulations during a future pandemic or punishing politicians and scientists. Together, the findings indicate that historical narratives about the COVID-19 pandemic are motivationally biased, sustain societal polarization and affect preparation for future pandemics. Consequently, future measures must look beyond immediate public-health implications to the longer-term consequences for societal cohesion and trust.

The perceived self-efficacy of senior, middle, and operations managers of the incident command system dealing with emergencies and disasters during the COVID-19 pandemic.

BACKGROUND: Natural disasters, health, terrorism, infectious diseases, and social unrest affect more than 200 million people worldwide each year. The present study is an attempt to evaluate the self-efficacy of senior, middle, and operational managers of the Incident Command System (ICS) of Zahedan University of Medical Sciences in Iran. METHODS: The study examined the perceived self-efficacy of 103 senior, middle, and operational managers of the Incidence Command System (ICS) of Zahedan University of Medical Sciences in 2021. Sampling was done by census using a designed questionnaire based on Bandura's self-efficacy concepts. Based on Factor Analysis, 4 factors were extracted. The factors were labeled and analyzed. RESULTS: The number of people who had passed the crisis management course was 57. Seventy-one participants reported their participation in crisis management. The score obtained by men in Factor 3 (F3) was significantly higher than women, but not in other factors. People with stable employment scored far higher in Factor 1 (F1) than those with unsustainable employment conditions. Those who had passed the Crisis Management courses had a higher average score, but only in the three factors 1, 2, and 4, this difference was significant. CONCLUSION: Even training the temporary staff is an organizational investment that can return benefits to the system. This enhances their perceived self-efficacy and promotes their commitment to the organization. Therefore, empowering these managers should be a priority.

Disaster Preparedness of Nursing Students in Northern Cyprus: Descriptive Cross-Sectional Study.

OBJECTIVE: This study aims to evaluate disaster preparedness of undergraduate nursing students. METHODS: This descriptive cross-sectional study included 302 voluntary nursing students from a university in Northern Cyprus. Data were collected through an online survey using Google Forms, which included a descriptive information form and the General Disaster Preparedness Belief Scale (GDPBS). RESULTS: The mean age of the participants was 20.64 ± 2.02 years. Among the participants, 41.7% had prior experience with disasters, and 77.2% expressed a need for disaster education. The average GDPBS total score was high, and the mean score of the sub-dimensions was moderate. Nursing students who expressed a need for disaster education had higher scores on the severity and self-efficacy subscales of the GDPBS (p<0.05). CONCLUSION: The level of disease preparedness was moderate in nursing students in Northern Cyprus. Therefore, education based on the health belief model, which assumes that positive health behaviors are affected by knowledge and attitudes, may be useful to improve disaster preparedness in nursing students.