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Original research
Local emergency medical response after a terrorist attack in Norway: a qualitative study
  1. Aleidis S Brandrud1,2,
  2. Michael Bretthauer3,4,
  3. Guttorm Brattebø5,6,
  4. May JB Pedersen, Head of Department7,
  5. Kent Håpnes, Head of Department8,
  6. Karin Møller9,
  7. Trond Bjorge10,
  8. Bjørnar Nyen11,
  9. Lars Strauman12,
  10. Ada Schreiner13,
  11. Gro S Haldorsen14,
  12. Maria Bergli1,
  13. Eugene Nelson, Co-supervisor and coauthor15,
  14. Tamara S Morgan15,
  15. Per Hjortdahl16
  1. 1 Quality Department, Vestre Viken HF, Drammen, Buskerud, Norway
  2. 2 Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
  3. 3 Clinical Effectiveness Research Group, Institute of Health and Society, University of Oslo, Oslo, Norway
  4. 4 Department of Transplantation Medicine and K G Jebsen Center for Colorectal Cancer Research, Oslo University Hospital, Oslo, Norway
  5. 5 Norwegian National Advisory Unit on Trauma, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
  6. 6 Department of Anaesthesia & Intensive Care, Haukeland University Hospital, Bergen, Norway
  7. 7 Department of General and Orthopedic Surgery, Obstetrics, Anaesthesia and Intensive Care, Ringerike Hospital, Vestre Viken HF, Drammen, Buskerud, Norway
  8. 8 Division of Mental Health and Addiction, Ringerike DPS, Vestre Viken HF, Drammen, Buskerud, Norway
  9. 9 Department of Medicine, Municipality of Ringerike, Honefoss, Buskerud, Norway
  10. 10 Department of Pulmonary Diseases, Ostfold Hospital, Kalnes, Ostfold, Norway
  11. 11 Department of Medicine, Municipality of Porsgrunn, Porsgrunn, Norway
  12. 12 Department of Medicine, Nordland Hospital, Lofoten, Nordland, Norway
  13. 13 Norwegian Federation of Organizations of Disabled People, Oslo, Norway
  14. 14 Department of Quality, Medicine and Patient Safety, South-Eastern Norway Regional Health Authority, Hamar, Norway
  15. 15 The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
  16. 16 Department of Family Medicine, Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
  1. Correspondence to Aleidis S Brandrud; aleidis{at}online.no

Abstract

Introduction On 22 July 2011, Norway suffered a devastating terrorist attack targeting a political youth camp on a remote island. Within a few hours, 35 injured terrorist victims were admitted to the local Ringerike community hospital. All victims survived. The local emergency medical service (EMS), despite limited resources, was evaluated by three external bodies as successful in handling this crisis. This study investigates the determinants for the success of that EMS as a model for quality improvement in healthcare.

Methods We performed focus group interviews using the critical incident technique with 30 healthcare professionals involved in the care of the attack victims to establish determinants of the EMS’ success. Two independent teams of professional experts classified and validated the identified determinants.

Results Our findings suggest a combination of four elements essential for the success of the EMS: (1) major emergency preparedness and competence based on continuous planning, training and learning; (2) crisis management based on knowledge, trust and data collection; (3) empowerment through multiprofessional networks; and (4) the ability to improvise based on acquired structure and competence. The informants reported the successful response was specifically based on multiprofessional trauma education, team training, and prehospital and in-hospital networking including mental healthcare. The powerful combination of preparedness, competence and crisis management built on empowerment enabled the healthcare workers to trust themselves and each other to make professional decisions and creative improvisations in an unpredictable situation.

Conclusion The determinants for success derived from this qualitative study (preparedness, management, networking, ability to improvise) may be universally applicable to understanding the conditions for resilient and safe healthcare services, and of general interest for quality improvement in healthcare.

  • quality improvement
  • medical emergency team
  • communication
  • team-training
  • crisis management

https://doi.org/10.1136/bmjqs-2017-006517

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    Footnotes

    • Contributors ASB (RN, MSc): As the main researcher, I am responsible for every part of the study and the manuscript, and have a deep knowledge of the database and its content. I designed the study, collected data in focus groups and interviews and in dialogue with the experts in the two research teams. I managed the interaction in dynamic cycles of exchange among questions, discussions, data refinement, analysis and writing. I am accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. MiB (MD, PhD): MiB has supervised the design and conduction of the work described in the article, know the database and its content, has revised the paper critically for important intellectual content, and participated in writing the manuscript and in the final approval of the version published. GB (MD): As a member of the internal research team, GB has contributed substantial to the data collection part of the study, know the database and its content, has participated in the analysis and in writing the manuscript, revised it critically for important intellectual content and participated in the final approval of the version published. MJBP (RN): As a member of the internal research team, MJBP has contributed to the data collection part of the study, know the database and its content, has participated in the analysis, participated in writing the manuscript, revised it critically for important intellectual content and participated in the final approval of the version published. KH (RN MSc): As a member of the internal research team, KH has contributed to the data collection part of the study, know the database and its content, has participated in the analysis, contributed to the writing of the manuscript and participated in the final approval of the version published. KM (MD): As a member of the internal research team, KM has contributed to the data collection part of the study, know the database and its content, has participated in the analysis, contributed to the writing of the manuscript and participated in the final approval of the version published. TB (MD): As a member of the internal research team, TB has contributed substantially to the data collection part of the study, know the database and its content, and has participated in the analysis and in the final approval of the version published. BN (MD): As a member of the external research team, BN has contributed substantially to the analysis part of the study, know the database and its content, and has participated in editing the manuscript and in the final approval of the version published. LS (MD): As a member of the external research team, LS has contributed substantial to the analysis part of the study, know the database and its content, and has participated in editing the manuscript and in the final approval of the version published. AS (BS): As a member of the external research team, AS has contributed substantially to the analysis part of the study, know the database and its content, and has participated in editing the manuscript and in the final approval of the version published. GSH (RN, MSc): As a member of the external research team, GSH has contributed to the analysis part of the study, know the database and its content, and has participated in editing the manuscript and in the final approval of the version published. MaB (MSc): As a member of the external research team, MaB has contributed to the analysis part of the study, know the database and its content, and has participated in editing the manuscript and in the final approval of the version published. EN (MPH, DSc): As a cosupervisor, EN assisted in planning the study and the data collection method, and participated in outlining the contents of the article and in the final approval of the version published. TSM (MA): TSM has participated in editing the paper, revised it critically for important content and English language and participated in the final approval of the version published. PH (MD, PhD): PH assisted in planning and designing the project, know the database and its content, supervised the initial data analysis by the external research team, has revised the paper critically for important intellectual content and participated in the final approval of the version published.

    • Competing interests None declared.

    • Patient consent We are studying the clinicians' assessments of healthcare as a system. No patient, guardian or next of kin were involved in this study. Because the terrorism is a traumatic event, we considered the risk of causing emotional or psychological harm to the study participants, and decided to exclude three groups from the research: (a) survivors and bereaved families; (b) providers who were personally affected by losing a sibling, family friend or neighbour at Utøya; and (c) providers with health problems who had been absent from work because of the terrorist event. Permissions were obtained from the relevant managers before individuals (rescue workers, 22–24 July 2011) were approached. Study participation was voluntary, confidential and based on informed verbal consent, as well as a written consent with freedom to terminate participation at any time without consequences. Participants were also informed (in writing) that a support team by District Psychiatric Services was available in case they should need help after recalling the traumatic events in the process of data collection. The lead researcher is unaware if informants sought psychological help after their participation in the study because this is viewed as a confidential and private matter. The data were stored on the research server of Vestre Viken Health Trust, and the informants’ names were separately encrypted as required by the Data Protection Office of Human Subjects.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement The 400 statements of this study are available by contacting the main researcher at aleidis@online.no. 150 of the most relevant statements are translated from Norwegian to English.

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