Systematic reporting to improve the emergency medical response to major incidents: a pilot study

Quantitative data from each report was exported onto an Excel spreadsheet version 12.3.6 (©Microsoft Corporation, USA) and presented as frequencies with median and inter-quartile range (IQR). This was used to identify trends that, if consolidated with statistical data from a more significant number of reports, could change the way we respond to major incidents.

Perceived successes and failures were extracted as learning points in Fig. 3 to illustrate the potential of the database and data.

Ethics approval for registering data on the website was granted by the Norwegian Data Protection Authority. All reports used in this analysis have been guaranteed by the author to comply with local ethics regulations prior to publication on the website [22].

A summary of important time intervals is presented in Table 2. Mexico, England and Finland were the only three countries in this study to have a single dialling number for all emergency services. Also, the reports from these countries represented the shortest time interval between the major incident being declared and the arrival of first EMS vehicles (6 min, 11 min and 12 min respectively). They also have the shortest time interval from the major incident being declared to the reported time of initial communication between different rescue organisations (1 min, 25 min and 17 min, respectively).

A summary of time intervals for each incident report is given in Table 2. In five reports, a major incident was declared after arrival of the first EMS and the time ranged from 10 to 30 min (median 18 min, IQR 15–25 min). In one report, the time interval was missing, and for the remaining two reports, a major incident was declared prior to arrival of the first EMS. One was declared 5 min before and the other 95 min before the arrival of the first EMS.

The two fires, a tunnel fire in Norway and a prison fire in Chile, reported the longest time interval, spanning from occurrence of the major incident to EMS arrival of 49 and 77 min, respectively. Both reports represented the longest time interval from major incident occurred to major incident declared (66 and 72 min., respectively) and the shortest time interval from major incident occurred to time of initial communication between different rescue organisations (61 and 90 min. respectively).

Triage systems divide casualties into green (delayed), yellow (urgent), red (immediate) and black (dead) categories. Figure 4 depicts triage categories for each incident.

Three reports noted that the triage system used during major incidents was similar to the system they used on a daily basis. In relation to specific failures, three reports cited the lack of a common triage system between responders. In two reports it was highlighted that successful triage by skilled and experienced individuals prevented overcrowding of local hospitals.

Failure of communication both within the EMS response teams and between other emergency services (e.g. fire, police, military) was reported in five of the eight reports. Problems included inadequate radio systems with poor coverage, overloading and confusion over choice of communication group and difficulties in communication between two different incident sites resulting in a poor overview of the incident and separate response strategies.

In order to improve the emergency response, introduction of better communication systems with adequate coverage for more personnel and better systems for cooperating with other emergency services, was suggested.

In two reports, confusion over who held which role in the command structure was reported. In one report, delayed arrival of officers to their designated posts was reported to be due to long distances needed to travel. In two reports, they stated a need for more mandatory major incident training or exercises in order to improve MI command and control.

In one report, long distances from the incident site to the ambulance loading area was reported as a potential major incident EMS failure. A separate report praised their response for having a single port of access and egress to the incident for ambulances and other emergency vehicles. In two reports the use of volunteers for transporting of patients was suggested as one of their success criteria.

The Helicopter Emergency Medical Services (HEMS) was involved in five out of seven reports. In rural locations, HEMS was used both to transport and treat the patients on scene, while in the remaining reports, HEMS was involved only in triage or treatment on scene.

The only three countries to use a single dialling number for EMS, police and fire had the fastest times from occurrence of incident to arrival of first EMS and occurrence of incident to initial communication between different rescue organisations. If later studies show a significant association between these factors, the emergency services should adapt for this.

Compared to the other six reports analysed, the two incidents involving fires took longer to be attended by EMS, longer to be declared as major incidents and longer to establish communication between rescue organisations. If studies later show that there is a positive association between incidents involving fires and longer response times, further studies could be initiated to establish the reason for this and major incident plans could be adapted accordingly.

In most major incident plans, it is the role of the first EMS personnel who arrive on scene to declare or report a major incident [8]. In two out of seven reports, a major incident was declared before the arrival of the EMS. The appropriate declaration of a major incident should occur as early as possible. If later studies prove the hypothesis that declaration of a major incident by the Emergency Operations Centre before the arrival of the EMS is largely appropriate and effective, this information could be used to revise current major incident plans.

The findings in this study are supported by others. Failure in communication and confusion over command structure is a recurring theme in major incident case reports [12‐14, 23]. Similarly, making use of volunteers especially for transport of patients and resources, the camaraderie or “coming together” of people involved in the incident both from the rescue services and bystanders and their willingness to help beyond their means [24]. This reinforces the concept of “bystander-as-responder”. That bystanders and volunteers should be used more effectively during major incidents and their role should be factored in to major incident plans [25] Also commonly mentioned was the use of highly skilled personnel for triage. This is echoed in a number of publications [23, 26] including a paper by Aylwin et al. which found that overtriage rates were reduced when trained and experienced pre-hospital teams carried out initial scene triage during the London bombings [10].

This study illustrates how a database such as majorincidentreporting.net could facilitate an evidence base for emergency response planning. Studies of a larger number of more homogeneous incidents may provide more valid analysis. Such research initiatives are welcomed.

The number of reports analysed is small and heterogeneous. Additionally, potential subjective bias in the reports cannot be excluded. Most of the published reports have been written by pre-hospital anaesthetists instead of a multi-professional team consisting of paramedics, dispatchers, medical incident commanders and physicians. To overcome this problem, the website could be updated to incorporate a different method of data input so that multiple authors can report on one incident. Furthermore, the reports have been submitted from different countries with different kinds of emergency medical services. Therefore, the comparison of the reports has to be interpreted with caution.