Essential key indicators for disaster medical response suggested to be included in a national uniform protocol for documentation of major incidents: a Delphi study

There is a need for uniform data reporting of results from medical response management to major incidents (MIs) and disasters in order to make data available for evaluation, quality control, scientific analysis and development [1‐4]. Emergency medical service (EMS) documentation is often inadequate, hampering evaluation of disaster medical responses (DMR) and losing data for research [5]. The development of a standard template for registration of essential data from MIs and disasters can be achieved using various methods. Some published reports have used an international panel of researchers as informants, while others have been largely based on personal expert knowledge and experience [6‐8]. If we are to improve the impact of the DMR on patient outcome, however, there is a need to develop evidence-based improvements in medical response management [8]. So far, to our knowledge, no published studies on DMR have reported results in recommended format, which emphasizes the gap between research and practice. In spite of international initiatives the need to perform national or regional modifications, in order to develop a template that will be generally accepted and used, remains. The ideal would be for these modifications to be suitable in the national context as well as providing the possibility to contribute to international research. One reason for the delay in accepting an international standard is that there still is a lack of consensus on what DMR data is essential to serve the purposes mentioned above.

The Delphi study technique has been used in several contexts and has also demonstrated the possibility to reach consensus in the field of disaster medicine [8‐10]. A Delphi study can be described as mapping of expert opinion in the field of investigation, and it is especially suited for complex issues where difficulties in achieving group consensus exist [11, 12].

It is likely that a template based on national consensus is more easily implemented in the form of a quality register. The healthcare authorities of several countries have given priority to the development of national registers to be used as a basis for audit, quality improvement and research. Process indicators, often described as a tool for measuring steps of activities in medical care and often linked to patient outcome [13], have also been used in recent years for deriving criteria used for the assessment of the quality of DMR [5]. The most important outcome in disaster management is the reduction in morbidity and mortality. However, this is a fairly blunt instrument for evaluating the management of individual incidents, and therefore the assessment of processes and structure involved, is important in disaster medicine research. All DMR activities that influence patient outcome must therefore be identified. This approach has also been described in a recently published international consensus study [8].

The aim of this study was to identify key indicators essential for initial DMR registration. By this is meant nationally accepted processes involved, from the time of the emergency call to the emergency medical communication centre (EMCC) until medical care is provided at the emergency department (ED).

A modified Delphi technique, focusing on the initial DMR, was adopted for the present study. The Delphi technique is based on a systematic, iterative collection of expert opinions (not involving face-to-face meetings) to discuss a subject under investigation. The technique employs a series of rounds and begins with a questionnaire or an interview seeking the chosen experts’ opinion and comments on the subject under investigation [16]. After a pilot study involving three teachers in disaster medicine, minor modifications were made to the statements in the questionnaire. Level of agreement of statements or importance of issues between experts is scored and the data can be analysed statistically. Feedback on the results after each round is then given to the members of the expert panel. The Delphi process continues until the investigator no longer anticipates any further increase in statement consensus. During this process there is a risk that some experts lose interest and drop out. There must therefore be a balance between attempting to reach consensus and the risk of losing experts. As a consequence, the number of rounds is often predefined and the literature gives no strict guidelines on this matter [11, 16]. In the present study the distribution of questionnaires and collection of data were performed by e-mail and the number of rounds was set at three. Three reminder letters were sent to non-responders after each round.

Statements on which the experts reached or did not reach consensus are shown in Tables 3 and 4.

One strength of the Delphi method is that all experts have the same impact on the consensus process. The risk of influencing other participants is also reduced by avoiding face-to-face discussions [21]. The expert panel in the present study, although comprising participants with different fields of expertise, were treated as a homogenous group. In this respect, expert knowledge representing a variety of viewpoints can provide relevant inputs in the Delphi process, this can also help in minimising bias [11]. The majority of the participants have many years of experience in disaster medicine, and they are involved in these issues every day. From this perspective, their motivation to participate and their opinions and judgments can be seen as valid representation of the needs and requirements regarding standard data for reporting MI. The response rate was high, with 100 % in Round 1 and only one drop-out in Round 2. The high response rate could be due to the authors’ ongoing communication regarding the importance of each participant’s contribution, continual reminders and a limit set at three Rounds. It may also reflect the experts’ understanding of the importance of the study.

There seems to be a general consensus on the importance of data regarding the initial medical response, regarding processes, outcome as well as structure. This was no surprise since most experts in disaster medicine consider that it is during this initial phase that there is the greatest chance to influence the outcome of MIs [15]. It is reasonable to believe that adequate data from the first phase will provide clues on how to improve the DMR in the future. If important processes in this phase are documented and time logged this may well result in the finding of possible weak links in the early phase of the response chain, and also where communication and reporting need improvement. The fact that the expert panel commented the need for qualitative data such as content of reports, confirms the view that mere timelogs without procedure content have limited value. In accordance with the Delphi technique this was included in subsequent Rounds and consensus was also reached regarding several of these issues. It is interesting, however, that several experts commented on there being an abundance of timepoints, while others suggested the inclusion of even more. Furthermore, it was not until Round 2 that all data regarding patient characteristics reached expert consensus. Since it is a general belief that morbidity and mortality are the most importent outcomes when judging the effectiveness of the DMR, an explanation for these data not reaching consensus in the first Round could possibly lie in how the initial statement was formulated [8]. An interesting observation was the high number of statements suggested by the experts that reached general consensus 62% (23/37). One strength of the Delphi method is that it allows experts to influence the input of data, thereby adding important information that may previously have been overlooked. Round 3 resulted in just over half of the remaining statements reaching a consensus level of 51% (21/41). In this Round most statements regarding triage of patients reached expert consensus.

Triage is an important process in a DMR where, despite extensive research, more evidence-based facts are needed. Despite all efforts to include triage in textbooks, training programmes and exercises, there are few reports providing information on how triage is actually employed [22]. It is therefore surprising that consensus on inclusion of these data was only reached in Round 3. Perhaps future research based on qualitative methods may clarify issues on triage. There are similarities between internationally identified process indicators for collecting and reporting DMR. Most notably, less emphasis was placed on the use of triage system and protective equipment by the Swedish experts. The use of templates for collecting and reporting DMR can be used to determine where further teaching is required in medical response management, to enhance the planning and response to future events, and to see if processes contribute to the outcome. However, so far no studies on medical response management have reported results leading to a suggested template, which emphasizes the gap between DMR research and practice. Finally, the fact of the matter is that an international standard template for collecting and reporting DMR data is difficult since each country has its own DMR structure and an international data- reporting system may not be feasible. Even though, we have to start to identify accurate key indicators in the DMR performance. A majority of the study’s indicators are to a substantial extent identical to previous recommended by Debacker et al. [8]. This indicates that the DMR processes and general principles for response are based on the same fundamental activities despite differences in DMR structure and resources in different countries. The 77 statements will be presented to stakeholders on national level where the possibility for them to be included in training as well as in practice will be discussed and further developed.

The Delphi technique can be used to achieve consensus on data, comprising key indicators that are essential for registering the response to major incidents and disasters.

Study design (MR, MJ, AR, MC ). Data collection and analysis (MR, MJ, AR). Manuscript writing (MR, MJ, AR). Contribution to the writing of the manuscript (MC, LS, DG). All authors have read and approved the final manuscript (MR, MJ, AR, MC, LS, DG).