Title: Improving patient outcomes in the ‘hot zone’ during major incidents: a mixed-methods medical research approach.
Funder: Department of Health and Social Care

Abstract: 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.

Lay abstract: The majority of deaths in terrorist events occur at the scene of the attacks. This is especially true in modern times where there may be an unknown number of roving attackers in multiple areas. In this case a hot zone is designated by the police and no medical personnel may enter. It may take hours to clear this hot zone, and some victims may die during this time. The overall aim of our study is to determine whether some lives could be saved by trained personnel entering the hot zone to deliver specific medical treatments to the casualties. To do this we want to find out what causes people injured in terrorist attacks to die prior to reaching hospital, and in what timeframe. If we know why they die, we will know if any of the medical interventions that are currently available could have stopped them dying, and what type of police officer, paramedic or doctor would be able to deliver it. If we know how long they were alive for, we can work out when the medical intervention would need to happen in order to save their life. We will conduct four linked projects to address these questions. We will collect data on the mode and time of deaths and also on some life-threatening injuries in terrorist events by (1) reviewing published information on previous terror events; and (2) by analysing available datasets of contemporary terrorist events in the UK, France and the USA. We will use this data to determine which of these deaths might be preventable, and what treatments (and therefore which personnel) would be required in a hot zone. In our next project (3) we will interview emergency providers to ascertain their thoughts on being deployed in a hot zone and their willingness to take on such risks and perform these interventions, and survivors to understand their expectations. (4) Finally we will use this information to develop a computer model of casualties in terrorist events so we can determine how many lives might be saved in different types of events, while exposing the fewest staff to potential attacks. Our clinical and research services have strong patient and public involvement groups which will provide strong representation at all stages of project design and delivery. We believe the patient and public view on putting emergency responders at risk will be extremely important in considering various service delivery options and to assess the outputs of the model. The main outcome will be to determine whether we can improve survival from the very real threat of future terrorist attacks, and to develop practice recommendations for hot zone working to be developed into emergency response policies across the UK.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: DISPUTED AETIOLOGY AND OTHER