A Delphi-based consensus study into planning for biological incidents

Abstract

Objective Biological incidents present a significant threat to health services in the UK. The objective of this study was to achieve consensus in all phases of biological incident planning and response.

Methods A three-round Delphi study was conducted using a panel of 23 experts from specialities involved in the management of biological incidents. The consensus and non-consensus outcomes from the Delphi study were subsequently presented for discussion in four syndicate groups at a one-day consensus conference funded by the Health Protection Agency.

Results The results of each syndicate group discussion were presented at a subsequent plenary session at the end of the conference. Further iteration of both the consensus and the non-consensus outcomes of the Delphi study resulted in the endorsement, modification, integration or rejection of individual statements. 125 consensus statements were produced.

Conclusions The 125 synopsis consensus statements that all phases of biological incident planning and response. These can be used to inform policy decisions and translated into practical guidance for emergency planners and first responders at local, regional and national levels.

Introduction

A biological incident can be described as the overt or covert natural, accidental or deliberate release of a biological agent.

The possibility of an influenza pandemic^1–3 and the threat of the terrorist use of biological weapons against civilian populations^4,5 have recently raised concern among emergency planners and first responders that the level of preparedness in the UK is inadequate to respond to a significant biological incident. For many years, the level of preparedness in the UK for major incidents has been of concern.^6–9 However, because of the potentially high consequences of such events, low probability of occurrence is no longer an acceptable defence for inadequate planning.¹⁰

Biological incidents require a different approach to most health services’ major incidents. The onset may be insidious and geographically widespread. Time may be required to isolate and identify the biological agent before effective containment and treatment strategies can be implemented. Although such a delay is probably inevitable, the health services will have to respond to an incident as it evolves. Health services must therefore ensure that appropriate health care measures are provided to both guard the health, safety and welfare of their own employees and also assist and treat potentially large numbers of patients. Most recently, part 1 of the Civil Contingencies Act 2004,¹¹ supporting regulations¹² and statutory guidance¹³ have established a clear set of roles and responsibilities for all those involved in emergency preparedness and response.

The purpose of this study was to achieve consensus in all phases of biological incident planning and response, which can be used to inform policy decisions and translated into practical guidance for emergency planners and first responders at local, regional and national levels.

Methods

A three-round Delphi study was conducted between June 2002 and May 2003 using a panel of 23 experts identified by the authors from specialities involved in the management of biological incidents.

Expertise was ascribed using two criteria: (i) evidence of experience in biological incidents; (ii) whether individuals have held positions of authority and influence within the sphere of emergency planning. Table 1 summarizes the list of the members of the Delphi panel.

A total of 28 individuals were approached, of whom 23 agreed to participate. Sixteen participants (69.6%) completed round one, 22 participants (95.6%) completed round two and 18 participants (78.3%) completed round three. Time pressures due to other work commitments were consistently cited as reasons for the inability to participate in/complete the rounds.

Round one of the Delphi study asked participants to consider biological incidents broadly in the areas of preparation, primary response, hospital response, specialist unit response and post-incident care and follow-up. Their replies were collated into a series of statements.

Round two comprised 324 statements. Panel members were required to express their level of agreement with each statement using a nine-point Likert scale.

The third and final round of the Delphi study presented those statements that had not reached consensus at the end of round two, together with a summary of the rest of the panel’s findings. In this round, panel members could change their opinions in the light of those of the rest of the group.

Consensus was defined a priori to be >94% and >89% (at the end of rounds two and three, respectively) of members scoring agreement with an individual statement scoring it as 6 or above. Statements that reached consensus at the end of round two were not reiterated in round three.

Data were collated and analysed using SPSS version 10.0 to calculate frequencies, median and interquartile range.

The consensus and non-consensus outcomes from the Delphi study were subsequently presented for discussion in four syndicate groups at a one-day consensus conference funded by the Health Protection Agency on 22 March 2004. All those originally approached to participate in the Delphi study were invited to attend, along with other stakeholders as identified by the Health Protection Agency. The results of each syndicate group discussion were presented at a subsequent plenary session at the end of the conference. Further iteration of both the consensus and the non-consensus outcomes of the Delphi study resulted in the endorsement, modification, integration or rejection of individual statements.

Results

A total of 139 of 324 statements had reached consensus upon completion of rounds two and three. This represents 42.9% of the total number of statements. Of these, 54 reached consensus at >94% and 85 reached consensus at >89%. The Delphi study also produced a series of statements on which the panel of experts did not produce consensus at the designated level. These were 185 statements (57.1%). Following further iteration of both the consensus and the non-consensus outcomes at the one-day consensus conference, a series of 125 synopsis consensus statements were agreed that cover all phases of biological incident planning and response. These are included in Appendix 1 (supplementary data are available at Pubmed online).

Discussion

Main findings of this study

This article provides a series of 125 synopsis consensus statements from a multidisciplinary expert group, which can be used to inform policy decisions and translated into practical guidance for emergency planners and first responders at local, regional and national levels. Although some of the synopsis consensus statements may appear unsurprising to those with subject knowledge, many offer considerable insight to those without. Although of direct relevance to those in the UK, many of the themes identified are also relevant to emergency planners and first responders planning for biological incidents in other countries.

What is already known on this topic

We believe that our approach is unique in planning for biological incidents. The Delphi method has previously been used successfully to improve other aspects of emergency planning.^14–19 Current national guidance on the management of biological incidents, while clearly important, is relatively non-specific and lacks the details required by emergency planners and first responders.^13,20–22

What this study adds

Throughout this study, there has been an underlying concern among the expert group that the level of preparedness in the UK is inadequate to respond to a significant biological incident. The synopsis consensus statements can be used to inform policy decisions and translated into practical guidance for emergency planners and first responders at local, regional and national levels. As examples, in our opinion, the following identified areas/themes are of particular concern.

Planning

• Failure to follow an integrated (local, regional and national components) approach is the first obstacle to effective management of a biological incident.

• A dedicated budget (covering as a minimum the provision of equipment and training) should be provided.

Equipment

• Each hospital should have a designated area for the appropriate isolation of potential infectious disease patients.

Training

• Training for biological incidents should form part of the hospital induction programme for all health care workers, with the level of training dependent upon their perceived roles and responsibilities in a biological incident.

• Basic training for biological incidents should include

  • identifying risk;

  • universal precautions/personal protective equipment (PPE);

  • containment/contamination;

  • infectivity/transmissibility and

  • accessing advice

• Rapid delivery training should be developed so that all hospitals can be brought on-line to improve the capability to manage large numbers of potential infectious disease patients and

• Training programmes should be simplified, linked in with a universal system of response and delivered nationally.

Limitations of this study

The Delphi method was chosen as a structured process to allow a panel of experts to reach consensus on an imprecise issue.²³ One of the strengths of the Delphi method is its anonymity, which reduces the bias inherent in face-to-face discussions through confounding by interpersonal relationships.^24,25 It is not usual to conclude a Delphi study with a consensus conference consisting of syndicate group discussions and a plenary session. While we recognize the limitations of this approach, it was important for practical reasons that further iteration of all outcomes of the Delphi study resulted in the endorsement, modification, integration or rejection of individual statements, thereby allowing us to produce a comprehensive series of synopsis consensus statements.

Concerns among the expert group that the level of preparedness in the UK is inadequate to respond to a significant biological incident have not been formally assessed by this study. We believe that an urgent review should now be undertaken to compare the current level of preparedness in the UK with that suggested by the synopsis consensus statements identified by the expert group.

Summary

A Delphi-based consensus study has used an expert group to produce a series of 125 synopsis consensus statements that cover all phases of biological incident planning and response. These can be used to inform policy decisions and translated into practical guidance for emergency planners and first responders at local, regional and national levels.

Competing interests

All authors have made substantial contribution to study conception and design, execution or analysis and interpretation of data. All authors have been involved in drafting the article or revising it critically for important intellectual content and have read and approved the final version of the manuscript.

Ethical approval

Ethical approval was not required for this study.

Funding
 No funding was provided for this study.

References