Improving patient outcomes in the ‘hot zone’ during major incidents: a mixed-methods medical research approach.

Background During the initial phase of terrorist events, a hot zone is created where there may be on-going terrorist activities with active threats to life. The vast majority of deaths occur at scene before emergency services are allowed in the hot zone. Recent evidence suggests some patients die in the hot zone from potentially survivable injuries.

If consistent across other events, providing trauma care in the hot zone could dramatically reduce deaths.

To send emergency personnel into an area where there is an active terrorist threat to their own life is a major decision. Key information on which to make this decision does not currently exist.

We propose a multimodal study to fill this evidence gap, to establish critical information on prehospital deaths in terrorist events, their preventability, time course of deterioration, and which therapeutic interventions would be required, in order to assess the potential impact of hot zone working and thus potential to reduce overall mortality.

Aims and objectives The aim of this project is to determine whether prehospital deaths in terrorist events could be prevented by the delivery of specific interventions in hot zones, and to determine the impact of such changes on mortality in varying scales of future events.

The objectives of this project are to: 1) determine the incidence, causes and timings of potentially preventable pre-hospital deaths and life-changing injuries from terrorist incidents reported in the literature; 2) identify the incidence, causes, timings and potential survivability of pre-hospital deaths from past terrorist events; 3) understanding of the relative willingness of, and barriers to, emergency responders deploying in hot zones; 4) assess the impact of such hot zone interventions on reducing mortality.

Methods Our plan includes four interlinked studies.

Work Packages (WP) 1 and 2 we will collect data on the nature and timing of prehospital deaths and life-changing injuries (WP1) from the available literature of terrorist events and (WP2) from available datasets of international terrorist events and from a civilian database of prehospital deaths from violent penetrating injuries (WP2).

From these we will determine which deaths may be been prevented, and which interventions would be required to improve survival.

In WP3 we will conduct a qualitative study to interview prehospital providers regarding their willingness and capability to provide these interventions in hot zones, and the public regarding their expected response.

In WP4 we will develop a mathematical model of the prehospital phase of mass casualty events based to ascertain the impact of hot zone inerventions.

Anticipated impact and dissemination The proposed research project will provide evidence to inform policy and practice for the planning, preparation and organisation of response to mass casualty incidents, secondary to terrorism attacks.

The key outputs from this work will be an evidence package and model-derived impact assessments that can be developed into policy and practice guidance to guide responses to future events. The applicants will develop a set of recommendations for future training, practice and delivery.

Dissemination pathways will include academic research publications, conference presentations, newsletters, media releases, and on websites.