Alert was defined as a warning signal and threat, which might result in a) an incident defined as a single distinct event or a public disturbance or to b) an alarm, defined as a fear or dismay. All data concerning an alert is registered in a log. This registry (PKMC-registry) started in 1999, and was initially paper-based, but since 2006-01-01, a web-based log (Saltwater™) has been used [10]. The information is available from any computer with an Internet connection, allowing multiple users to be on-line simultaneously. Based on the nature of alerts, RTiB undertook(made an action as POC such as initiation of a disaster plan, redistributing of regional resources) or mediated(informed other authorities to take actions) an action. Activities are time-stamped as they are entered and data are mirrored on two separate servers.

Data were organized in pre-defined variables to cover a wide field of incidents. However, there are open fields to complete or add data if necessary. The data from this registry between 2006-01-01 and 2008-12-31 has been transferred to Excel (Microsoft Corp, USA) for review and analysis, presented as below. When needed the results were presented in mean ± SD.

1. Number of alerts (weekdays, months, and number of people involved)

2. Demography (regional, national, within Europe, outside Europe)

5. Workload (0–4 h, 4–12 h, 12–24 h, and > 24 h)

6. Training, exercises and Education

There is a need for adaptation and expansion of basic healthcare infrastructure to cope with all implications of a disaster. Such transformation may be possible through research, education and exercises. In the current study, we report how Region Västra Götaland in Sweden has created a center with the formal position to act as POC for potential disasters, to act as a crisis management center for the healthcare services and also to provide training in disaster management.

An effective disaster response depends on structured and organized cooperation and communication between different agencies/services, institutions and individuals [3]. The lack of, or deficiencies in understanding, coordination, communication and a jointly trained organization have been recognized as important factors in failure to respond properly to disasters and major incidents [3, 12]. A very clear governing body is desirable to further improve the delivery of aid and to maximize resources [3, 5, 12]. Studies within the field of trauma care have shown that experience, training and strict protocols are important factors to improve the outcome. Therefore, regional medical operation centers have been established in many countries to tune up disaster response and reduce mortality [3, 13–16].

Data from this registry showed an increase in the number of alerts, which might be due to earlier activation of RTiB by SOS Alarm on a relatively low suspicion of an emerging major incident (Appendix 1). It might also reflect the global awareness of disasters and terror-related incidents in the aftermath of disasters such as the 9/11 and the South-East Asian Tsunami when a psychological fearfulness for replication in a new time and zone exists [4–6]. Thus, often the anticipation of some major incidents necessitated performance of risk management by the centre's staff. Although the number of alerts was rather stable, the duration and intensity of consequent activities varied. The data concerning the increase in mass-gatherings and sport events in the region are vital for planning and distributing the regional resources. The high number of measures and contacts taken during these activities demonstrate the absolute need for communication and coordination (Table 2). To assert perfect and desirable ground for communication and coordination with other agencies e.g. Police, Fire and Rescue departments and EMS, the centre organizes continuous dialog meetings. These authorities are also invited to send staff as participants in the centre's various courses in disaster and disaster-related subjects. Personal knowledge about other agencies and their staff, gained during these activities, seems to be one of the most valuable factors in enhancing collaboration, when real major incident strikes.

During the study period, the number of local incidents decreased in favor of national and international incidents, which is a simple indicator of the globalization of the world [8, 15]. It also emphasizes the permanent need for international cooperation based on common language and education; one of the main reasons for PKMC's cooperation with ALSG, UK [11]. Similar centers with redundant power to coordinate and communicate during a disaster have been reported in the literature [3, 17]. However, to the best of our knowledge few, if any, have the regional responsibility for staff training by conducting disaster and disaster-related courses and training. The involvement of the same people in both planning for emergencies and disasters, training the staff for such events as well as executing the emergency and disaster plans in real life, adds strength to the organization. No shorter feed-back loop between planning and executing can exist!

The increased number of hospital-related alerts during the study period raises concern, since it has a negative impact on preparedness ("surge capacity") for medical emergencies as well as major incidents within the affected area. This has been reported by other investigators [17–19], but seems to be a new and emerging problem for Sweden. The reduction of hospital beds as a consequence of economic constraint, increased sub-specialization of hospitals as well as increased dependency on high-tech equipments can be factors contributing to this problem, making the whole healthcare system more vulnerable in case of major incidents [20].

There are some limitations imposed to our study by its retrospective design and lack of primary relevant research questions. In addition the database was not primarily designed for research, thus, there is lack of clear definitions and operating rules for the data set. However, this registry is the tool, which for the first time has recorded these events. Although this is a retrospective study, the use of a web-based system reduces some of the limitation a retrospective study may have, e.g. standardization of data input, and open up for new studies such as evaluation of ambulance transport (diversion and secondary transports) or evaluation of hospital bed resources; information needed for politicians to make important healthcare and socio-economical decisions. These data may also emphasize the importance of research and education within the field of disaster medicine.

In conclusion, disasters are inevitable, but can be mitigated through data accumulation, planning, educating, research and practice. To coordinate these tasks regional centers with redundant authorizations are needed. The combination of risk assessment, disaster planning and training of staff together with executive responsibility at the time of disaster may not only reveal various short-comings within our organizations and the healthcare system, but may also prevent the disastrous outcome and consequences of such short-comings.