Hospital incident command groups’ disaster medicine performance. A prospective study concerning decision-making and staff procedure skills during major incident simulations

Background Hospital incident command groups’ (HICG) performance may have a profound impact on hospital response to major incidents. Previous research has assessed hospital incident command group capacity as opposed to performance and factors associated to performance. The objective was to assess associations between decision-making and staff procedure skills of the hospital incident command group. Methods This was a prospective observational study using performance indicators to assess hospital incident command groups’ decision-making and performance. A total of six hospitals in Stockholm, Sweden, with their respective HICGs participated. Associations between decision-making skills and structural procedure skills during major incident simulations were assessed using measurable performance indicators as per the protocol of the Disaster Management Indicator tool. Results Decision-making skills are correlated to structural procedure skills and overall HICG performance. Proactive decision-making skills had significantly lower means than reactive decision-making skills and are significantly correlated to structural procedure skills. There is a significant correlation between decision-making skills and structural procedural skills. Hospital incident command groups’ proactive decision-making abilities tended to be less developed than reactive decision-making abilities and may be a predictive factor for overall hospital incident command performance. A lack of proactive decision-making ability may hamper efforts to mitigate the effects of a major incident.


Abstract Background
Hospital incident command groups' (HICG) performance may have a profound impact on hospital response to major incidents. Previous research has assessed hospital incident command group capacity as opposed to performance and factors associated to performance. The objective was to assess associations between decision-making and staff procedure skills of the hospital incident command group.

Methods
This was a prospective observational study using performance indicators to assess hospital incident command groups' decision-making and performance. A total of six hospitals in Stockholm, Sweden, with their respective HICGs participated. Associations between decision-making skills and structural procedure skills during major incident simulations were assessed using measurable performance indicators as per the protocol of the Disaster Management Indicator tool.

Results
Decision-making skills are correlated to structural procedure skills and overall HICG performance.
Proactive decision-making skills had significantly lower means than reactive decision-making skills and are significantly correlated to structural procedure skills.

Conclusion
There is a significant correlation between decision-making skills and structural procedural skills.
Hospital incident command groups' proactive decision-making abilities tended to be less developed than reactive decision-making abilities and may be a predictive factor for overall hospital incident command performance. A lack of proactive decision-making ability may hamper efforts to mitigate the effects of a major incident.

Background
Hospitals play vital roles during major incidents (MI) (1). Previous studies have demonstrated that well-prepared hospitals minimize the impact of the major incident as measured by morbidity and mortality. A consensus concerning a standardized method for assessing hospital disaster preparedness is lacking despite directives stipulating the need for hospital disaster preparedness (2, 3). Hospital response and performance is reliant on hospital management (4). While addressing aspects of hospital management, there are few studies focusing on hospital incident command group's' (HICG) performance (4)(5)(6)(7). However, there is mounting evidence suggesting that performance of the HICG as opposed to capacity can and should be assessed (8)(9)(10).

Measuring hospital incident command performance
Decisions and actions taken by the HICG during the initial phase of an incident are essential for managing resources during a major incident and may affect patient outcomes (11). Successful management of limited resources is contingent on planning, training and timely responses concerning the mobilization of limited resources (12). Of importance is the ability to mobilize resources to meet medical demands before all facts of an incident are known, relying on anticipatory or analytical abilities (13). It has been demonstrated that the HICG's ability to work in a structured fashion and its decision-making skills can be assessed by analyzing measurable indicators (3,8). The Disaster Management Indicator (DiMI) instrument which is based on process modeling and constructed through consensus by the Swedish National Board of Health and Welfare (3) is to the authors knowledge the only tool measuring HICG performance.
The DiMI allows for assessment of HICG performance by analyzing measurable indicators reflective of the operations of the HICS. The DiMI assesses whether actions relating to structures, process and decision-making were performed through two focal points; HICG's decision-making ability and staff procedure skills which is the staff's ability to work in a structured and organized way (3,14). A previous study providing a first analysis of associations between the two skill sets, identified a linear association between staff procedure and decision-making abilities and indicated that improved staff procedure skills would lead to improved decision-making skills (14). DiMI decision-making indicators can be divided into two sub-groups of indicators, reactive and proactive decision-making. Reactive decision-making can be defined as intuitive, reflexive decisions based on previous experiences and knowledge while utilizing minimal cognitive resources (15,16). Conversely, proactive decision-making may be defined as anticipatory, time consuming, deliberate requiring analytical process and is more demanding of cognitive efforts (15,16).
There are to our knowledge, few prospective, observational studies focusing on the association between decision-making skills and structural procedure skills and no studies analyzing the association between proactive decision-making and structural procedure skills during a simulated major incident.

Aim
The aim was to assess associations between decision-making skills and structural procedure skills of hospital incident command groups during major incident simulations using performance indicators as measured by DiMI.

Method
This was a prospective observational study using performance indicators to assess hospital incident command groups' decision-making and performance The designated hospital incident command groups, which are activated in accordance to the hospital disaster management plans, were the study subjects. Information concerning the nature of the respective incidents was withheld from participants prior to the exercise. The duration of each simulation ranged from 2 hours and 13 minutes to 6 hours and 52 minutes.

Data collection
Data collection was based on observation and included variables as required by the DiMI (

Data analysis
Data from all simulations was first imported to Microsoft Excel for Mac version 16.33 and analyzed using descriptive and inferential statistics.
Individual indicators were analyzed using ANOVA and DUNN post hoc analysis. Differences in means for decision-making and staff procedure skills were assessed using one-way ANOVA and Kruskal-Wallis Test. Pearson's correlation was used to assess the association between decision-making and staff procedure skills. Due to the data being rank-order data as well as a lack of assumption concerning the distribution of data, a Spearman's rho correlation coefficient was computed to measure the degree of association between the different groups of indicators, i.e. decision-making and staff procedure skills and subgroups of decision-making skills.
A ρ value <0.05 was considered significant.

Results
Medians and mean scores are presented. Mean scores are used with the aim of more accurately highlighting subtle, yet significant differences in performance. For instance, a mean score of 0.67 is closer to 1, than a median of 0.000, indicating that a task, on group-level was performed to a certain degree (0.67), as opposed to "not at all" that a median of 0 would indicate. The mean score for the decision-making indicators ranged from 0.67 to 2.0 while mean scores for staff procedure indicators ranged from 1.08 to 2.0. The sum of the mean scores for all six simulations concerning decisionmaking was 17.16 (table 1) while the sum of the mean scores for staff procedure skills was 19.66 (table 2). Indicator related to proactive decision-making indicated with (*). * consists of sub indicators as described (3).

Association of indicators
A one-way analysis of variance indicated a statistically significant differences between the decisionmaking skills and staff procedure (p= 0.036, d=0.386) ( Table 3). The correlation between decision-making skills and staff procedure skills was r=0.809, ρ = 0.51 ( figure 1, table 4).

Discussion
The current study identified a relationship between decision-making and staff procedure skills. In addition, this study identified a correlation between proactive decision-making and staff procedure skills. Proactive decision-making skills in particular may therefore have an impact on overall disaster performance of the HICG. Hospital incident command groups with lower scores for proactive decisionmaking skills, had statistically significantly lower performance scores. While a previous study suggested that improved staff procedure skills resulted in improved decision-making skills (14), to our knowledge, this is the first study to demonstrate an association between proactive decision-making and HICG disaster performance. Given the type of data and the nature of this study, it is not possible were delayed or not made, in line with a previous retrospective study assessing decision-making (9).
Of particular interest is the correlation between proactive decision-making indicators and staff procedure skills. The statistically lower means for proactive decision-making skills indicate that analytical skills may be an underdeveloped yet be a vital component as indicated by their correlation with structural procedure skills. The importance of analytical/anticipatory abilities is further illustrated by the lack of correlation between reactive decision-making and staff procedure skills.
While this study reports acceptable levels of HICG disaster preparedness, the frequency of training required to maintain or improve preparedness is an important factor to consider.
This study also further demonstrated that measurable indicators may be an effective method for facilitating a structured evaluation of the hospital incident command group. Furthermore, this study suggests that the DiMI may facilitate HICG performance if implemented as a guide for the HICG. While the DiMI is an efficient method for evaluating HICG preparedness, the DiMI may be compatible with other methods such as checklists, interviews or questionnaires.
In addition to facilitating HICG performance, these findings may guide pedagogical construction of training and educational programs targeting these skills. This in turn, may enhance disaster management while mitigating the somatic and psychological effects of a major incident.

Limitations
Previous research has demonstrated that experience is an important aspect for analytical ability (19,20). While not controlled for in this study, lower proactive abilities may be a result of a lack of experience or knowledge as reported in a 2007 study assessing proactive vs reactive decision-making in the clinical setting (20).
The data was treated as interval data. This choice was made in order to make the results comparative with earlier studies. All simulations in the current study were held within a short period of time and with similar scenarios, thereby facilitating analysis and comparison between participating hospitals.
While providing potentially vital information concerning HICG disaster medicine response, the generalizability of the results may be questionable due to the relatively low number of simulations.

Ethics approval and consent to participate
All representatives of the respective hospitals were informed of the study in written and oral form after which permission was granted. Participants were informed that participation was voluntary and could be withdrawn without consequences. Furthermore, confidentially was guaranteed.
Ethics approval applied for and received a waiver by the Swedish Regional Ethical Review Board.

Consent for publication
Not applicable

Availability of data
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.