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

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Fig. 1: The OPEN concept in use during the evacuation of the 22nd of July 2011 Utøya terrorist incident (Photograph: All Over Press)

Major incident patient evacuation: full-scale field exercise feasibility study

Major incident management relies on efficient patient transportation. Prompt initiation improves pati- Authors: ent outcome and optimizes resource expenditure (1). The evacuation of patients is the third initiative Marius Rehn in the hierarchy of medical support at major incidents: triage, treatment, and transport (2). Casualty Norwegian Air Ambulance evacuation should be dynamic, because mode of transport, evacuation priority and final destination Foundation, Drøbak & will be influenced by triage and treatment decisions. To ensure optimal outcomes, patients should Akershus University Hospital, Lørenskog, Norway, be transported as efficiently as possible from the scene to the hospital providing definitive care. In marius.rehn@ order to avoid unnecessary delay, treatment and packaging should be limited to that necessary for norskluftambulanse.no transport (2). Optimal care therefore relies on a well-organized transportation chain using field-friendly Trond Vigerust evacuation equipment to ensure transport of the “Right Patient to the Right Place at the Right time.” Norwegian Air Ambulance Foundation, Drøbak Major incidents are infrequent, overwhelming events with a heterogeneous nature that favours the “all- Jan E. Andersen hazards” approach. Because rescue capacity varies between systems, an incident may be considered Norwegian Air Ambulance major by one emergency medical service (EMS) but not by another service (2). Foundation, Drøbak, Norway EMS systems are primarily designed to respond to the In the absence of a coherent and interoperable nation- Andreas J. Krüger daily burden of injuries and can have delayed access to al civil system for major incident management, the Norwe- Norwegian Air Ambulance evacuation material for multiple casualties. Even when gian Air Ambulance Foundation developed and funded the Foundation, Drøbak, Norway & St. Olav University Hospital, major incidents are flooded with resources, rescue work- Interdisciplinary Emergency Service Cooperation Course Department of Anesthesia ers struggle to coordinate and optimize patient evacuation (TAS), a no-cost training course for all emergency services and Emergency Medicine, (3, 4). Additionally, major incident management usually in Norway. The TAS program was established in 1998. Trondheim, Norway involves emergency workers from multiple rescue serv- By 2009, approximately 15,500 professionals had par- Hans M. Lossius ices. Standardizing the equipment for patient evacua- ticipated in one of more than 500 available courses. The Norwegian Air Ambulance tion seems essential given the multitude of responders. TAS curriculum has gradually evolved, and the principles Foundation, Drøbak, Norway & University of Bergen, Providing rescue workers with rapid access to a large for disaster health education as proposed by World As- Department of Surgical quantity of standardized stretchers may improve patient sociation for Disaster and Emergency Medicine have been Sciences, Bergen transportation efficacy. adapted progressively (5). Norway is a sparsely populated,

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subarctic country with time-consuming, weather-depend- ent patient transport (6). Although large-scale incidents are infrequent in our region, such incidents demand advanced interdisciplinary cooperation of local EMS, fire fighters, police, rescue technicians, and air medical resources. In remote areas, single EMS units may handle multiple casualties for pro- longed periods until inter disciplinary assistance arrives. In the absence of a standardized field-friendly approach to multiple casualty management, the Norwegian Air Ambu- lance Foundation developed “Optimal Patient Evacuation Norway” (OPEN). The OPEN concept has been incorpo- rated as a module in the TAS courses. OPEN aims to save time, improve patient handling, prevent hypothermia, and simplify scene management. In this study, we assessed access to patient evacuation supplies among Norwegian EMS personnel participating in TAS courses. Furthermore, we assessed the feasibility of the OPEN concept for major incident patient evacuation in the extrication and triage phase of full-scale major incident field exercises. Fig. 2: Car- and helicopter- friendly bags containing five Methods multiple casualty stretchers, stretcher carry harnesses, and TAS course triage equipment (Photographs: From March to May 2010, we conducted four 2-day TAS Norwegian Air Ambulance courses in mixed urban/rural and coastal/inland munici- Foundation) palities. The courses were free of charge for the participants. The didactic program was piloted and refined Study Design through 43 TAS courses before the study. The TAS course The full-scale major incident field exercise started with combines theoretical and practical didactical techniques students receiving a dispatch call informing them of a to teach local emergency service personnel (healthcare, bus accident and ended when all patients were trans- police, and fire and rescue technicians) major incident ported to the evacuation clearing station. For practical cooperation, triage, and patient evacuation (OPEN). The purposes, no patients were transported to definitive care. students participated in major incident field exercises, The students answered a before-and-after questionnaire, using a standardized bus collision scenario with approxi- and the instructors measured time expenditure. We linked mately 20 patients (range, 17 to 21) and a full-size, post- the two questionnaires without compromising anonym- collision bus. The patients were located inside the bus and ity and calculated self-efficacy and reaction to patient Fig. 3: Stretcher bag inside were provided with standardized descriptions of injury evacuation. The Regional Committee for Medical and a helicopter: Stretchers fit all type and physiologic parameters for triage purposes. The vehicles and helicopters major incident field exercise was performed once before the OPEN lectures were given, when participants lacked formal OPEN competence and access to OPEN equipment, and once at the end of the course, when participants had formal OPEN competence and access to OPEN equipment.

The OPEN Concept We designed car- and helicopter-friendly bags (Figs. 2 and 3) containing five heavy-duty multiple-casualty stretchers (Fig. 6), stretcher carry harnesses, and triage equipment to provide EMS units with rapid access to large quantities of standardized equipment.7,8 Ideally, all units responding to the incident should carry a minimum of one stretcher bag. To save time, prevent hypothermia, and avoid patient manipulation, one standardized light- weight, insulating stretcher was allocated to each patient throughout the evacuation chain. These stretchers fit all ground and air EMS units and are radiolucent to optimize logistics during radiological evaluation at the hospital. Furthermore, we designed a fieldfriendly action card (Fig. 5) depicting the principles for scene-management organization.

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Fig. 4: Field-friendly stretcher Health Research Ethics deemed that approval was un- design: Insulating and radiolucent necessary (2009/1390a). The Norwegian Social Science stretchers (Norwegian Air Data Services approved the study (22991/2/MAB). The Ambulance Foundation) SQUIRE (Standards for QUality Improvement Reporting) guidelines and the STROBE (STrengthening the Reporting of OBservational studies in Epidemiology) guidelines for reporting observational studies were used in the drafting of this article (9, 10).

Data analysis Data were collected in Excel spreadsheets (2007; Mi- crosoft Corporation, Redmond, WA) and analyzed in STATA/SE 10.1 (Statacorp, College Station, TX). Continuous variables measured before and after the TAS course were compared using the paired- sample t-test.

Results Student background and access to major incident material Among the 110 emergency service professionals who to “How did patient evacuation work?” with mean 5.4 attended the course, 93 (84.5%) enrolled in the study. (95% CI, 5.2–5.6) before the course versus a mean of 5.8 Among the study participants, 26 (28.0%) worked in (95% CI, 5.7–6.0), after the course (P ! .001). Students’ health care (nurse, ambulance, other), 47 (50.5%) were estimations of the success of interdisciplinary cooperation firefighters, 13 (14.0%) were police officers, and 7 (7.5%) improved, with a mean of 5.4 (95% CI, 5.2–5.6) before had “other” backgrounds. The mean participant age was the course and a mean of 5.8 (95% CI, 5.7–6.0) after the 38.6 years (range, 20-62), with a median working experi- course (P ! .001). The students also described improved ence of 8 years (range, 0–34), and 83.7% were men. use of patient evacuation materials between their initial Approximately half of the students (51.2%) were not (mean, 5.3 [95% CI, 5.0–5.5]) and postcourse (mean, aware of any stretcher storage in their coverage area. 6.0 [95% CI, 5.8–6.15]) evaluations (P ! .001). The mean A minority (18.6%) of the learners confirmed that fewer time from “scene secured” to complete patient evacuation than 16 stretchers were available, and 30.2% had access to the casualty clearing station was 22 minutes (range, to over 15 stretchers. Thirty-one percent of the students 19–26) without and 21 minutes (range, 17–28) with TAS– confirmed that multiple stretchers could be available at OPEN training and supplies. Both the stretcher bag and the scene within 30 minutes in their catchment area, the scene-management action card were reported to work 26.4% would need longer than 30 minutes, and 42.5% adequately (median, 6 [interquartile range (IQR), 6–7] and were unable to describe stretcher delivery times. median, 6 (IQR, 5–6), respectively).

Self-efficacy and reaction to training Discussion Each question on the questionnaire was scored on a We found the OPEN concept for multiple casualty evacua- Fig. 5: Principles for scene- management organization: Field- 7-point Likert scale, with points labeled “Did not work” tion to be feasible for interdisciplinary emergency service friendly action card (Norwegian Air (1) through “Worked excellently” (7). The students replied personnel participating in full-scale major incident field Ambulance Foundation) exercises. The students found the stretcher equipment useful in evacuating patients in a structured and field- friendly manner. Unnecessary patient mobilization is a time-consuming threat to patient safety, and several papers describe movement-associated adverse events (11-13). Although these studies are conducted inside the hospital, eliminating unnecessary physical movement of the patient will result in safer and more effective major incident management. Currently, the absence of standardized patient evacuation equipment increases the risk for patient manipulation both during the immediate scene management phase and during later organization of the patient evacuation clearing station. The OPEN concept stresses rapid EMS access to large number of stretchers, allowing provision of a per- sonal stretcher to every patient in the extrication phase. Our study confirmed that Norwegian rescue workers struggle to provide all patients with rapid access to a

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stretcher. By avoiding improvised transportation methods that occur when stretchers are unavailable, OPEN reduced unnecessary physical manipulation of the injured. The OPEN stretcher fits all patient transportation units in our area, and it reduces the inherent risks of patient mobilization associated with variable stretcher types across EMS units. Efficient patient evacuation relies on interdisciplinary cooperation from all emergency services managing the scene. We found high interdisciplinary satisfaction with both the equipment and the principles. The OPEN concept introduced standardized handling of patient evacuation from scene extrication through patient evacuation clearing station without increasing on- scene time expenditure. We believe the time required for complete evacuation and transport to definitive care will most likely be reduced. However, we acknowledge that this study did not evaluate the entire evacuation chain, Fig. 6: Providing rescue and we plan to address this question in a future study. ties. The low incidence of large accidents favours systems workers with rapid access to a We intended to ensure the appropriateness of the that allow providers to follow their daily routine. We found large quantity of standardized stretchers may improve patient OPEN concept for safe implementation in our vehicle and that Norwegian EMS providers have reduced access to transportation efficacy helicopter EMS units. Optimally, the stretcher material and field-friendly patient evacuation equipment. Delayed ac- scene-management principles would have been evaluated cess to stretchers combined with absence of interdisci- in real multiple-casualty incidents to avoid the unrealistic plinary routines for patient evacuation remains a gap in aspects of exercises. However, research on major incident Norwegian preparedness for major incidents. management is mostly observational, because disasters are difficult to study via interventional study designs. Fur- Conclusions thermore, this study relied on self-reported variables as Efficient and structured patient evacuation can be taught measures of effect, although they may vary in accuracy effectively to multidisciplinary emergency service pro- (14). To address this limitation, the instructors measured fessionals attending a 2-day major incident course. The An earlier version of this article appeared in the Air Medical time consumption objectively. OPEN concept provides rapid access to standardized, Journal, May-June 2011: Major incidents are infrequent in our area, and EMS field-friendly patient evacuation equipment in a feasible 153-157. Reprinted with providers have little experience handling multiple casual- and time-efficient manner. ~ permission of the publisher.

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