Understanding the psychological impacts of responding to a terrorist incident.

Background: Responding to a mass casualty event can cause significant distress, even for highly trained medical and emergency services personnel. Objective: The purpose of the study was to understand more about first responders' perspectives about their participation in major incident responses, specifically how and which individual and system factors contributed to their preparedness or may have enabled or hindered their response. The aim of the work was to improve preparedness and response for future incidents. Methods: This study reports a detailed analysis of qualitative interview data from frontline staff who responded to a large mass casualty terrorist incident in the UK in 2017. Data highlighted the psychological distress caused by responding to terrorist events and thus became the focus of further, detailed analysis. Results: Participants (n = 21) articulated in their own words the psychological distress experienced by many of the first responders to the event. Participants reported that they were not prepared to deal with psychological impact associated with this mass casualty terrorist incident and their role in the response, and that follow-up support was inconsistent. Multiple factors were identified as potentially increasing psychological distress. Social support provided by peers and organizational debriefs were identified as two most common support mechanisms. Organizational support was identified as inconsistent. Conclusions: This research contributes to the literature the voices of first responders to UK terrorist incidents, building on existing findings while further contributing unique contextual perspectives. This research reinforces the importance of psychosocial support for those who respond to these tragic incidents, and offers a number of recommendations for organizational preparedness for future events. Abbreviations: A&E: Accident and Emergency; EPRR: Emergency Preparedness, Resilience and Response; ERD: Emergency Response Department; HEPE: Health Emergency Preparedness Exercise; PHE: Public Health England; PHE REGG: Public Health England Research Ethics and Governance Group; MCI: Mass Casualty Incident; NHS: National Health Service.

Antecedentes: Responder a un evento con presencia masiva de víctimas puede causar una angustia psicológica significativa, aún para el personal médico y de emergencias altamente entrenados.Objetivo: El propósito del estudio fue tener una mayor comprensión acerca de la perspectiva de los primeros respondedores sobre su participación en la respuesta a incidentes mayores, específicamente cómo y qué factores individuales y del sistema contribuyeron a su preparación o que pudieron haber habilitado u obstaculizado su respuesta. El objetivo del trabajo fue de mejorar la preparación y respuesta para futuros incidentes.Métodos: Este estudio reporta un análisis detallado de los datos de entrevistas cualitativas realizadas al personal de primera línea que respondieron a un gran incidente terrorista con víctimas masivas en el Reino Unido durante el 2017. Los datos destacaron la angustia psicológica causada por responder a eventos terroristas y, por lo tanto, se convirtieron en el foco de un análisis más detallado.Resultados: Los participantes (n = 21) articularon en sus propias palabras la angustia psicológica experimentada por muchos de los primeros en responder al evento. Los participantes reportaron que no se encontraban preparados para lidiar con el impacto psicológico asociado con este incidente terrorista con víctimas masivas y su rol en la respuesta, y que el soporte durante el seguimiento fue inconsistente. Se identificaron múltiples factores con pueden incrementar la angustia psicológica. El apoyo social proporcionado por los pares y el 'debriefing' organizacional fueron identificados como los dos mecanismos de apoyo más comunes. El apoyo organizacional se identificó como inconsistente.Conclusiones: Esta investigación contribuye a la literatura las voces de los primeros respondedores a los incidentes terroristas del Reino Unido, basándose en los hallazgos existentes y, al mismo tiempo, aporta perspectivas contextuales únicas. Esta investigación refuerza la importancia del apoyo psicosocial para quienes responden a estos trágicos incidentes, y ofrece una serie de recomendaciones para la preparación organizacional para eventos futuros.

UK healthcare staff experiences and perceptions of a mass casualty terrorist incident response: a mixed-methods study.

INTRODUCTION: System learning from major incidents is a crucial element of improving preparedness for response to any future incidents. Sharing good practice and limitations stimulates further actions to improve preparedness and prevents duplicating mistakes. METHODS: This convergent parallel mixed methods study comprises data from responses to an online survey and individual interviews with healthcare staff who took part in the responses to three terrorist incidents in the UK in 2017 (Westminster Bridge attack, Manchester Arena Bombing and London Bridge attack) to understand limitations in the response and share good practices. RESULTS: The dedication of NHS staff, staff availability and effective team work were the most frequently mentioned enabling factors in the response. Effective coordination between teams and a functional major incident plan facilitated an effective response. Rapid access to blood products, by positioning the blood bank in the ED, treating children and parents together and sharing resources between trauma centres were recognised as very effective innovative practices. Recent health emergency preparedness exercises (HEPEs) were valued for preparing both Trusts and individual staff for the response. Challenges included communication between ambulance services and hospitals, difficulties with patient identification and tracking and managing the return to 'normal' work patterns post event. Lack of immediately available clinical protocols to deal with blast injuries was the most commonly mentioned clinical issue. The need for psychosocial support for responding and supporting staff was identified. DISCUSSION: Between-agencies communication and information sharing appear as the most common recurring problems in mass casualty incidents (MCIs). Recent HEPEs, which allowed teams, interdisciplinary groups, and different agencies to practice responding to similar simulated incidents, were important and informed actions during the real response. Immediate and delayed psychosocial support should be in place for healthcare staff responding to MCIs.

The role of emergency preparedness exercises in the response to a mass casualty terrorist incident: A mixed methods study.

Simulation exercises are an important part of emergency preparedness activities for the healthcare community but evidence of their impact on the response to real major incidents is limited. This project studied the impact of health emergency preparedness exercises (HEPEs) on the response to a mass casualty terrorist incident. The mixed methods study design was adopted comprising an on-line survey and follow up individual interviews. Participants were healthcare staff who took part in responses to three major terrorist incidents in the UK in 2017. Descriptive statistics and analysis of variance were undertaken with quantitative data. Content and thematic analysis methods were used for qualitative data analysis. The online survey generated 86 responses; 79 (92%) were from the responders to the Manchester Arena bombing. Twenty-one survey respondents shared their experiences in in-depth interviews. Healthcare staff who took part in HEPEs felt better prepared to respond than those who did not attend an exercise. The most commonly reported benefits from HEPEs were awareness of major incident plans and having the opportunity to practice responding to a similar scenario in the recent exercise. Specific benefits included: improved coordination of the response through adherence to recently practiced incident plans; confidence with response roles; real-time modifications of the response and support provided to staff who did not take part in exercises. Exercise recency was highlighted as an important facilitating factor. The study provides strong objective evidence that the response to a mass casualty terrorist incident was enhanced by training and service development achieved through HEPEs.

A scoping review of evaluation methods for health emergency preparedness exercises.

OBJECTIVE: To review and analyze evaluation methods currently utilized in health emergency preparedness exercises (HEPE). DESIGN: This study, part of a larger scoping review that systematically collected and reviewed published evidence related to the benefits of HEPE, provides a further analysis of the evaluation methods utilized in such exercises. We separately analyzed discussion-based and operation-based exercises according to their purpose. This addresses a methodological limitation related to the poorly understood relationship between the purpose and context in which a specific evaluation method is selected to be used. RESULTS: In the reviewed 64 studies, a variety of evaluation methods were utilized for HEPE including observations, participants' survey, and post-exercise debriefs. At present, the selection and use of these methods is not guided by any methodology, but seems rather arbitrary. No specific evaluation methods were isolated for any exercise type. CONCLUSIONS: The purpose of evaluation should guide the selection of evaluation methods for HEPE, and these are not context specific. If evaluation is for accountability purposes, such as to test organizational capability to respond, participant feedback should be collected in addition to objective data on performance in an exercise. Advantages of routinely collecting data from exercise participants to study their reactions (exercise feedback, perceptions, satisfaction with the exercise) and routinely conducting post-exercise debriefs (both hot debrief and cold debrief), are discussed to support evaluation for development or learning purposes in any context.

Child, Teacher and Parent Perceptions of the FRIENDS Classroom-Based Universal Anxiety Prevention Programme: A Qualitative Study.

School-based mental health prevention programmes can be effective but their adoption within schools will depend on their social acceptability. We report a qualitative evaluation summarising the views of children (115), parents (20) and school staff (47) about a universal school-based anxiety prevention programme FRIENDS. This study was conducted as part of a large scale randomised controlled trial (n = 1362) involving 40 schools in the UK providing primary education to children aged 7-11. Reported overall experience of the programme was very positive, with all three major components of the cognitive behaviour therapy programme (emotional, cognitive, and behavioural) being accepted well and understood by children. The programme was considered to be enjoyable and valuable in teaching children important skills, particularly emotional regulation and coping. Children provided examples of using the skills learned during FRIENDS to manage their emotions and solve problems. However, teachers were concerned that the programme overlapped with the current school curriculum, required additional time and almost half were unable to identify any tangible changes in the children's behaviour. Whilst this paper provides evidence to support the social validity of the FRIENDS anxiety prevention programme, the concerns raised by teachers question the longer-term sustainability of the programme.

Effect of a universal anxiety prevention programme (FRIENDS) on children's academic performance: results from a randomised controlled trial.

BACKGROUND: Evaluations of school-based anxiety prevention programmes have reported improvements in psychological functioning although little is known about their effect upon educational outcomes. METHODS: One thousand three hundred and sixty-two children from 40 primary schools in England took part in the randomised controlled trial, Preventing Anxiety in Children through Education in Schools. The trial investigated the effectiveness of a universal school-based cognitive behaviour therapy prevention programme, FRIENDS, delivered by health care staff or school staff compared with usual personal, social, health and education (PSHE) lessons. Self-report psychological outcomes and educational attainment on national standardised attainment tests in reading, writing and maths were collected 12 months postintervention. Analysis was performed at individual level using multivariable mixed effect models controlling for gender, type of intervention and school effect. Registered trial: ISRCTN: 23563048. RESULTS: At 12 months, anxiety reduced in the health-led FRIENDS group compared to school-led FRIENDS and PSHE. There were no between-group differences in academic performance regardless of gender, deprivation, ethnicity and additional educational needs. CONCLUSIONS: School-based mental health interventions should assess psychological and educational outcomes. Further research should directly compare the effects of interventions led by health and school staff.

The prevention of anxiety in children through school-based interventions: study protocol for a 24-month follow-up of the PACES project.

BACKGROUND: Anxiety in children is common and incapacitating and increases the risk of mental health disorders in adulthood. Although effective interventions are available, few children are identified and referred for specialist treatment. Alternative approaches in which prevention programmes are delivered in school appear promising. However, comparatively little is known about the best intervention leader (health care-led vs. school-led), long-term effects or the primary preventive value of such programmes. METHODS/DESIGN: Preventing Anxiety in Children through Education in Schools, or PACES, is a pragmatic cluster randomised controlled trial evaluating the effectiveness of a cognitive-behavioural therapy prevention programme (FRIENDS) on symptoms of anxiety and low mood in 9- to 10-year-old children. Forty-one schools were randomly assigned to one of three conditions: school-led FRIENDS, health care-led FRIENDS or treatment as usual. Assessments were undertaken at baseline, 6 months and 12 months, with the primary outcome measure being the Revised Child Anxiety and Depression Scale score at 12 months. Secondary outcome measures are changes in self-esteem, worries, bullying and life satisfaction. DISCUSSION: This protocol summarises the procedure for the 24-month follow-up of this cohort. The study will determine the medium-term effectiveness of an anxiety prevention programme delivered in schools. TRIAL REGISTRATION: ISRCTN23563048.

Classroom-based cognitive behaviour therapy (FRIENDS): a cluster randomised controlled trial to Prevent Anxiety in Children through Education in Schools (PACES).

BACKGROUND: Anxiety in children is common, impairs everyday functioning, and increases the risk of severe mental health disorders in adulthood. We investigated the effect of a classroom-based cognitive behaviour therapy prevention programme (FRIENDS) on anxiety symptoms in children. METHODS: Preventing Anxiety in Children though Education in Schools (PACES) is a three-group parallel cluster randomised controlled trial. Interventions were given between September, 2011, and July, 2012, with schools as the unit of allocation and individual participants as the unit of analysis. We enrolled state-funded junior schools in southwest England. We sent information to all eligible schools (state-funded junior schools in southwest England) inviting them to enrol in the study. School year groups were assigned by computer-generated randomisation (1:1:1) to receive either school-led FRIENDS (led by teacher or school staff member), health-led FRIENDS (led by two trained health facilitators), or usual school provision. Children were not masked to treatment allocation. The allocated programme was given to all students (aged 9-10 years) in the school year (ie, universal delivery) as part of the school curriculum as nine, 60 min weekly sessions. Outcomes were collected by self-completed questionnaire administered by researchers masked to allocation. Primary outcome was symptoms of anxiety and low mood at 12 months assessed by the Revised Child Anxiety and Depression Scale (RCADS 30). Analyses were intention to treat and accounted for the clustered nature of the design. The study is registered, number ISRCTN23563048. FINDINGS: 45 schools were enrolled: 14 (n=497 children) were randomly assigned to school-led FRIENDS, 14 (n=509) to health-led FRIENDS, and 12 (n=442) to usual school provision. 1257 (92%) children completed 12 month assessments (449 in health-led FRIENDS, 436 in school-led FRIENDS, and 372 in usual school provision). We recorded a difference at 12 months in adjusted mean child-reported RCADS scores for health-led versus school-led FRIENDS (19·49 [SD 14·81] vs 22·86 [15·24]; adjusted difference -3·91, 95% CI -6·48 to -1·35; p=0·0004) and health-led FRIENDS versus usual school provision (19·49 [14·81] vs 22·48 [15·74]; -2·66, -5·22 to -0·09; p=0·043). We noted no differences in parent or teacher ratings. Training teachers to deliver mental health programmes was not as effective as delivery by health professionals. INTERPRETATION: Universally delivered anxiety prevention programmes can be effective when used in schools. However, programme effectiveness varies depending on who delivers them. FUNDING: National Institute for Health Research Public Health Research Programme.

School-based intervention to reduce anxiety in children: study protocol for a randomized controlled trial (PACES).

BACKGROUND: Emotional problems such as anxiety and low mood in children are common, impair everyday functioning and increase the risk of severe mental health disorders in adulthood. Relatively few children with emotional health problems are identified and referred for treatment indicating the need to investigate preventive approaches. METHODS/DESIGN: The study is designed to be a pragmatic cluster randomized controlled trial evaluating the effectiveness of an efficacious school-based cognitive behavior therapy (CBT) prevention program (FRIENDS) on symptoms of anxiety and low mood in children 9 to 10 years of age. The unit of allocation is schools which are assigned to one of three conditions: school-led FRIENDS, health-led FRIENDS or treatment as usual. Assessments will be undertaken at baseline, 6 months and 12 months. The primary outcome measure is change on the Revised Child Anxiety and Depression Scale. Secondary outcome measures assess changes in self-esteem, worries, bullying and life satisfaction. An economic evaluation will be undertaken. DISCUSSION: As of September 2011, 41 schools have been recruited and randomized. Final 12-month assessments are scheduled to be completed by May 2013. TRIAL REGISTRATION: ISRCTN23563048.

Disposable infusion pumps.

PURPOSE: The properties, performance, and applications of nonelectric disposable infusion pumps are reviewed. SUMMARY: All nonelectric disposable infusion pumps exploit the same physical principle: mechanical restriction within the flow path determines the speed of pressurized fluid. The pressure generated by disposable pumps on fluid is 250-600 mm Hg, compared with 5-1200 mm Hg of pressure for electric pumps. There are several types of disposable infusion pumps, including elastomeric, positive-pressure (spring-powered and gas-pressure-powered), negative-pressure (vacuum), and patient-controlled analgesia (PCA) pumps. The accuracy of each pump's flow rate is dependent on several factors, including temperature, fluid viscosity, atmospheric pressure, back pressure, partial filling, and storage. Disposable infusion pumps can be used in many areas, including home care, PCA, patient-controlled epidural analgesia, continuous peripheral analgesia, continuous epidural analgesia, continuous i.v. analgesia, and pediatrics applications. The advantages of disposable infusion pumps include their light weight, small size, simplicity of use, independence from an external power supply, elimination of programming errors, and disposability. Disadvantages include the possibility of inaccurate flow rates, fixed reservoir volume, lack of a facility to change the flow rate and bolus-dose volume to provide adequate analgesia, inability to trace the history of the analgesia demand by patients, inability to combine PCA with background continuous infusions, and long-term cost. CONCLUSION: Despite some disadvantages and limited areas of applicability, disposable infusion pumps provide patients with advantages, such as portability, simplicity, and disposability, especially for the administration of analgesia. Understanding their physical and mechanical characteristics and their appropriate application may optimize patient care.