We performed a national survey assessing awareness and knowledge of MCI plans and adherence to relevant trauma system criteria. Although more than 95% of the interviewed trauma team members were aware of their hospital’s MCI plan, limited compliance with trauma system requirements concerning competency and training was identified both in TCs and NTCs.
Recent studies, including the experience gained in Norway on July 22, 2011,(7) have demonstrated that the closest hospital in the event of an MCI will receive the highest number of patients indicating the need for MCI preparedness at all hospitals receiving trauma victims.(13–15)
Most Norwegian hospitals have limited exposure to trauma, i.e. receive very few severely injured on an annual basis, and have limited surgical trauma competency.(12) However, due to the settlement pattern in Norway including a lot of small communities with long transportation distances to the regional TC, the NTCs have to be prepared to take care of severely injured patients under normal circumstances as well as under an MCI.(12, 16, 17)
Obviously, regular training, both theoretical and practical, becomes even more important in the NTCs if adequate trauma care in daily practice and in an MCI situation is to be delivered.(18) Only 27% of the surgical residents in NTCs reported at least 4 years of surgical training which is a minimum to fulfill the role as team leader during a regular trauma team activation according to the criteria in the national trauma plan. On that background, the consultant surgeon on call will have to take on the role as trauma team leader in almost every Norwegian NTC and almost 90% of the interviewed consultant surgeons working in NTCs reported to be ATLS trained which is another prerequisite to fulfill that role. Moreover, as severely injured patients might need damage control surgery as part of initial care, surgeons need to be specifically trained for this. Advanced surgical course participation (like DSTC) is another criterion to be met and 90% of consultant surgeons at NTCs were DSTC trained and represents a major improvement compared to the situation before July 22, 2011.(19)
As only 32% of resident surgeons at NTCs were DSTC trained, the need for early consultant surgeon presence is evident. Even though most consultant surgeons were DSTC providers, their real MCI and trauma surgery experience is limited.(6–9, 20) Frequent, goal directed training is therefore a prerequisite to achieve acceptable preparedness in all Norwegian hospitals. Training for MCIs results in improved skills, knowledge and attitudes,(21) and the outcome of an MCI is largely dependent on preparedness.(3)
Trauma team training is especially important in low volume centers and in our study almost 90% of the interviewed health care workers at NTCs had participated within the last 3 months. Fewer (68%) had participated in trauma team training at TCs probably reflecting that the frequency of trauma team training is not proportional to the number of staff. That the physician-based roles in the team training in TCs were mainly covered by residents might be attributed to the fact that they are more experienced compared to the interviewed residents at NTCs. However, senior staff should be present to supervise and interfere both during training and real situations to improve performance and outcomes.(22, 23) The interviewed nursing staff reported high levels of experience and competence both in NTCs and TCs. Their important role in the trauma team cannot be overestimated including their roles as continuity carriers.
Our study revealed that in the NTCs no consultant surgeons and less than 40% of the consultant anesthetists on call are in-house after normal working hours. Hence, simple and written guidelines to secure immediate notification and early presence of the consultants under ordinary trauma team activations as in a possible MCI situation should be mandatory.
An MCI plan is the core of a hospital’s MCI preparedness.(4, 5, 24) Trauma care in the event of an MCI should be based on a trauma system’s everyday practice.(1, 5, 20) MCI plans should be readily available and healthcare workers need to be familiar with their role and confident with their function during an MCI. In our study over 95% were aware of the MCI plan but only 50% had read the plan within the last 6 months. One can argue that knowledge of the plan is enough. In our study, on the other hand, more than 25% were not sure whether they could fulfill their designated role during an MCI, possibly reflecting the lack of regular training. Moreover, only 54% of the interviewed personnel had ever participated in a hospital MCI exercise, possibly reflecting an ever-increasing demand for hospital effectiveness. However, Norwegian law mandates all hospitals to have an MCI plan, conduct exercises and train all relevant personnel.(25, 26) As full-scale MCI exercises and evacuating hospital units has an economic cost and might affect outcome in ordinary patients negatively, cheaper alternatives have to be sought. Although small scale exercises, such as tabletop triage training, are valuable options,(5, 27) in our study less than 25% reported such an experience. The need to evacuate the ED is a challenging task but described recently by Hojman and coworkers after the Boston marathon bombing.(28) Although only 14% had ever participated in an ED evacuation exercise in our study, preparation and training at OUH-U lead to a successful evacuation of the ED in 45 minutes during the twin terrorist attack in 2011.(6)