After several consecutive steps in this research, the components of EMS preparedness in MCIs which were the main objectives of the study were finally determined. One of the reasons why the research team decided to do a mixed-method work was the importance of the area. Maybe, if we had a single study approach to achieve the main goal, we could not confidently trust the obtained result. Therefore, the mixed method was adopted. Systematic review studies contain rich results, and we have made comprehensive findings in this phase. The findings of the systematic review included the experiences of EMS systems around the world in response to MCIs. Most of the results of this phase, according to the selected articles, were taken from the real experiences of EMS systems, and this was a turning point in the findings obtained in this research. Considering that this study was in a special context (the field of emergencies and disasters), it would be better to consider complementary methods to achieve the goals. Therefore, we decided to look for unwritten experiences in disaster context, in addition to the published documents. For this reason, we chose a qualitative approach to obtain the experiences of people who spend their lives in EMS systems. The purpose of conducting a qualitative study was to enrich the results in this mixed method. A qualitative study was conducted with in-depth semi-structured interviews in Iran, and the results obtained were mostly consistent with those of the systematic review phase. After passing through these two steps, we integrated the findings in a systematic way to obtain more comprehensive results. After several consecutive stages, 22 main components were finalized, which were drawn in a conceptual model in 5 main levels including command, operation, resources, communication and information, and group and individual empowerment for better understanding and implementation. Although the known components in this research have many similarities with the studies done, the differences mostly originate from regional and national structures and policies. One of the highlights of this study was the removal of the component of “EMS decontamination teams in CBRNE” in the first round of Delphi. Although this component was extracted from the systematic review [16], it was not accepted in the remaining stages, including the qualitative study [20], Delphi stage, and panel of experts. One of the reasons this issue arose in the qualitative study and expert panel was that EMS has complex tasks in triage, treatment, transfer, and other incident management processes [25], and decontamination is a sensitive operation that requires specialized logistics and equipment that is beyond the scope of most EMS systems. In most emergency systems, the duty of decontamination (according to the type of the risk) is the responsibility of the fire department, army, safety units of refineries and factories, and so on. However, this component must be accepted in some EMS systems due to the existence of resources, equipment, integration of rescue teams, and regional policies [26]. Due to the complexity of CBRNE incidents, regional policies are essential, and this component may not be accepted globally in an EMS setting. However, this issue depends on national and regional policies.
In addition, components such as a common emergency contact number, common triage and treatment system, and tactical teams that are used in many emergency systems still have pros and cons in some countries. However, the rest of the components, including the unified command, strengthening of communication, education and training, physical and psychological factors, and so on, are present in most EMS systems as the main indicators of readiness although there may be differences in how they are implemented. Nonetheless, in this research, the components of EMS preparedness in MCIs were explored in several stages so that a model with reliable indicators for planning and policymaking can be developed.
Various methods have been used in developing EMS preparedness and response models in MCIs. Among these, dynamic modeling methods, computer modeling, conceptual modeling, and modeling with cause-effect relationships can be mentioned.
A study by Lee aimed to simulate the distribution of emergency relief equipment for disaster response operations. In this study, the concern was that in the event of disasters such as storms, earthquakes, and terrorism, there is a need to distribute emergency relief equipment to the victims to protect their health and lives. The research team developed a modeling framework for disaster response in which the supply chain of relief supplies and distribution operations were simulated and analyzed to test the optimal transportation of relief supplies to various distribution points. The disaster response simulation model included the modeling of the relief resource supply chain and operations at the distribution point. The results showed that the model could evaluate a wide range of disaster scenarios, evaluate disaster response plans and policies, and identify better approaches for government agencies and first responders [27].
In another study, a simulated model of EMS services in MCIs was designed by Su in Taiwan. In this study, object-oriented simulation software was used to improve EMS care. In this research, a computer virtual simulated model was designed. The results showed that the most efficient part of this model in caring for the injured is when the integrated deployment of EMS is launched along with the increase of emergency networks and specialized life-saving protocols [28].
Another research was conducted by Pasupathy in Belgium to design a simulated model of casualty management in disasters and emergencies. In this study, a profile of the real injured was drawn by the elites of the pre-hospital field. These profiles were drawn in a medical emergency model where a single response was given by the system to real casualties. The medical emergency response model focused on emergency services operations including triage, evacuation, and medical procedures. Medical decisions such as whether to evacuate or treat at the scene were based on the victim’s breathing, heart rate, and motor response. Finally, a simulated model was designed that was related to road accidents and showed how much resources could affect the prognosis in these incidents [29].
In China, a model entitled EMS response dynamic model was designed in response to MCIs. This study was conducted to find out the EMS-MCI modeling in Shanghai, improving rescue efficiency in MCIs and providing a possible method for quick decision making in these incidents. This model was designed using the Vensim DSS program and intervention scenarios by adjusting the scales of accidents, ambulance allocation, emergency medical staff allocation and the efficiency of organization and command. The results showed that by increasing the number of ambulances and improving the efficiency of the organization and command, the mortality rate decreased significantly [30].
Tseng in China designed a theoretical model of EMS response in tunnel-related traffic incidents as a scenario-based computer simulation model. In this study, based on a theory, data related to the general characteristics and components of MCIs were collected in order to create a simulation model based on the method of emergency response plans. In this method, a disaster response simulation model was presented using realistic accidents taken from previous experiences. In this study, the main variables included EMS response components in MCIs, pre-hospital time indicators, the ability to save and preserve hospital life, and the level of organizational and command efficiency. This model is called causal curve diagram and included 5 main parameters with 102 variables, which were connected in the form of curvilinear flows and based on one-way or two-way relation. In addition, the subsystems of this model include 5 items: MCIs, hospital rescue and life preservation operations, organization and control, emergency center, and finally prognosis of the injured which were connected through input and output variables [31].
The results of this mixed method indicate that EMS systems need to strengthen specific components to increase their readiness in response to MCIs. The components extracted from this study were identified in depth with several approaches which were finally drawn in the form of a simple model. Due to the deep and scientific view in the methodology of this research and the extraction of validated findings, these results can be theoretically used in EMS planning and policies in the field of disasters. In addition, EMS systems and Partner organizations can use the results of this research in practice and personnel training. Due to the importance of the mixed method in achieving rich results in the field of disasters, the method of this study can be used more than single approaches. Also, the methodology and techniques of this research can be used as a pattern in the design of future studies in important areas such as disasters where it is necessary to achieve valid and vital results.
Due to the complexity of management and operational planning in most MCIs, it would be better to draw the preparedness plans in a simple and comprehensible way so that a quick and effective response can be delivered. In this research, the goal was to create a simple conceptual model that represents the main components of EMS preparedness in MCIs. The most important distinguishing feature of the model designed in this study was that simulation, computer and special software methods were not used as in the above-mentioned studies and the main attempt was to design a model to cover the important readiness indicators of EMS systems in response to MCIs so that they can be used easily. Although most of the components were identified and validated in this study, there may be other components that can be unique to states and regional policies. For example, some specific indicators were related to the regions with specific climatic and geographical conditions that overshadow the EMS response. However, in this research the components of EMS preparedness in MCIs were only introduced and presented in the form of a model, and the effectiveness of this model was not measured practically. Therefore, it is recommended that the effectiveness of this model in the management of MCIs in practical exercises, simulations and real incidents should be measured.
Limitations
In the systematic review phase, one of the limitations was the lack of access to some electronic databases such as Web of science (WOS), for searching articles. Unfortunately, due to economic and political sanctions in Iran, some databases were not available at the time of the search and we had to ignore them. This issue worried us because we might have missed some studies. However, we tried to use other reliable electronic databases such as PubMed, Scopus, Science direct, ProQuest, and Cochrane.
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