Use of simulation models when developing and testing hospital evacuation plans: a tool for improving emergency preparedness

BACKGROUND

In recent decades, analyses of hospitals evacuations have generated valuable knowledge. Unfortunately, these evacuation case studies often lack crucial details and policies that would be helpful in evacuation preparedness. The aim of this study was to use a simulation model to illustrate how it can aid emergency planners in the development, testing, and revising of hospitals evacuation plans. This study includes evacuation exercises at two emergency hospitals in Region Stockholm, Sweden.

METHODS

A scientifically validated simulation system for "table top" exercises was used for interactive training of hospital medical staff, prehospital staff and collaborating agencies. All participants acted in their usual professionals' roles. The exercises were run in real-time and mirrored actual hospital resources with the aid of moveable magnetic symbols illustrating patients, staff and transport, presented on whiteboards. During the exercises, observers and independent instructors documented actions taken and post-exercise surveys were conducted to obtain reactions and compare results.

RESULTS

The simulation system allowed the emergency planner to test the whole evacuation process, making it possible to train and evaluate the important functions of management, coordination, and communication. Post-exercise surveys explored participants perception of the exercises. Analysis of open-ended questions included areas for improvement and resulted in five main categories: (1) management and liaison; (2) communication; (3) logistics; (4) medical care and patient prioritisation; and (5) resource utilisation.

CONCLUSIONS

This study has shown that "table top" exercises using a validated simulation system can serve to guide emergency planners when developing evacuation plans, procedures, and protocols as well in training of all medical staff. The system also served to train adaptive thinking, leadership, communication, and clarification of critical functions.

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).

Decision-making by medical officer in charge during major incidents: a qualitative study

BACKGROUND

An incident command structure is commonly used to manage responses to major incidents. In the hospital incident command structure, the medical officer in charge (MOC) is in a key position. The decision-making process is essential to effective management, but little is known about which factors influence the process. Therefore, the current study aimed to describe factors influencing decision-making of MOCs.

METHODS

A conventional content analysis was conducted based on 16 individual interviews with medical doctors who had been deployed as MOCs at Swedish hospitals during major incidents.

RESULTS

The results showed that the decision-making and re-evaluation process was a comprehensive analysis influenced by three categories of factors: event factors, including consequences from the type of event, levels of uncertainty and the circumstances; organizational factors, including the doctor's role, information management and the response to the event; and personal factors, such as competence, personality and mental preparedness.

CONCLUSIONS

Reliable and timely information management structure enabling the gathering and analysis of essential information, a clear command structure and appropriate personal qualities were essential and contributed to successful MOCs decision making in major incidents.

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.

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.

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.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.