Content analysis exercise - Topic Read Adini, B., Goldberg, A., Loar, D., Cohen, R., and Yoen Bar-Dayan, Y. (2006).

Content analysis exercise – TopicRead Adini, B., Goldberg, A., Loar, D., Cohen, R., and Yoen Bar-Dayan, Y. (2006). Factors That May Influence the Preparation of Standards of Procedures for Dealing with Mass-Casualty Incidents. Prehospital and Disaster Medicine. May–June 2007 located in the Web Resources are of the e-classroom under Week 5. Writing assignmentConduct a two-page content analysis on this report to determine its major priority and message. In your response, explain how you determined the priority and message and upload to your Student Folder. The goal of this assignment is to articulate what this report is trying to convey.May–June 2007 http://pdm.medicine.wisc.edu Prehospital and Disaster MedicineORIGINAL RESEARCH1. Emergency and Disaster ManagementDivision, Ministry of Health, Israel2. Faculty of Health Sciences, Ben GurionUniversity of the Negev, Beer-Sheva,Israel3. Center for Medical Education, HebrewUniversity, Jerusalem, Israel4. Israel Defense Forces Home FrontCommandCorrespondence:Col. Dr. Y. Bar-Dayan MD MHA16 Dolev St. Neve Savion, Or-YehudaIsraelE-mail: .ilKeywords: evaluation; hospitals; management;mass-casualty incident; preparedness;standards of procedureAbbreviations:MCI = mass-casualty incidentSOP = standards of procedureReceived: 15 June 2006Accepted: 19 September 2006Web publication: 19 June 2007Factors That May Influence the Preparationof Standards of Procedures for Dealing withMass-Casualty IncidentsBruria Adini, MA;1,2 Avishay Goldberg, MA,MPH, PhD;2 Danny Laor,MD, MHA;1Robert Cohen, PhD;3 Col. Yaron Bar-Dayan MD,MHA2,4IntroductionGeneral hospitals in Israel are required to develop and maintain standards ofprocedures (SOPs) to facilitate the management of a mass-casualty incident(MCI).1 These SOPs provide guidelines for the hospital to plan its responseto MCIs, prepare the infrastructure required, and train medical teams to dealwith MCIs.2 The guidelines and checklists that comprise the SOP are necessarycomponents of the process required for maintaining a high level of preparedness;however, they are only the beginning of this process.3,4For an SOP to be effective in guiding hospital personnel in the managementof MCIs, a number of basic steps must be adopted by the hospital: (1) theSOP must be distributed widely among the departments that are likely to beinvolved in the management of a MCI; (2) drills must be conducted to pro-AbstractIntroduction: General hospitals in Israel are required to develop standards ofprocedures (SOPs) to facilitate the management of mass-casualty incidents(MCIs). These SOPs represent the initial step in a continuous process, providingguidelines for hospitals to manage MCIs in an organized and efficientmanner. Evaluation of the preparedness levels of hospitals in dealing withMCIs is required in order to promote an effective response, and to identifyfactors that might impact the quality of SOPs. The aim of this study was toidentify the characteristics of hospitals that have an impact on the preparationof SOPs.Methods:An evaluation tool was developed to assess the SOPs from 22 hospitalsduring the management of a MCI. The results of the evaluations wereanalyzed, in relation to the size, trauma capabilities, ownership, geographiclocation, urban versus rural status of the hospitals, the proximity to other hospitals,participation in drills during the year prior to the evaluation, and numberof actual MCIs the hospital managed in the past three years.Results: The evaluation scores of the SOPs of 11 of the 22 hospitals (50%)were very high, so their SOPs did not require modifications.The SOPs of fourhospitals (18%) were rated highly, requiring only minor modifications. TheSOPs of four hospitals (18%) received poor ratings, requiring major modifications,and three hospitals (14%) were found to have incomplete SOPs andreceived very poor ratings.No significant differences were found between theratings of SOPs in relation to the different characteristics of the hospitalsanalyzed. A low correlation between the level of SOPs and the number ofMCIs that the hospital managed was found (r = 0.266, NS).Conclusions: The tool developed to evaluate the quality of the SOPs of hospitalsto manage MCIs was logistically feasible and capable of differentiatingbetween hospital SOPs. The comprehensiveness and completeness of theSOPs appears to be unrelated to the characteristics of the hospitals includedin this study. Of particular note was the lack of a significant correlation betweenthe SOP rating and the number of actual MCIs managed by a hospital.Adini B, Goldberg A, Laor D, Cohen R, Bar-Dayan Y: Factors that mayinfluence the preparation of standards of procedures for dealing with masscasualtyincidents. Prehosp Disast Med 2007;22(3):175–180.Prehospital and Disaster Medicine http://pdm.medicine.wisc.edu Vol. 22,No. 3176 Factors that May Influence Preparation of Standardsvide the opportunity to practice teamwork, analyze shortcomings,and identify areas that require improvement;5,6 and(3) hospital personnel, on a regular basis, should evaluate theapplicability of the SOP, preferably from the lessons learnedfrom conducting MCI drills.7 Mass-casualty incident drills,such as actual simulations and tabletop exercises, are importantin the process of maintaining readiness to manageMCIs, as they provide some indication of the ability of thehospital to manage MCIs. A number of studies have shownthat drills can positively impact the performance of hospitalsin dealing with MCIs.8The fact that a hospital has prepared a SOP does notautomatically result in the effective management of MCIs.9Evaluation of preparedness levels for a MCI are required inorder to promote an effective response.10The impact of various characteristics of hospitals on thecompleteness and comprehensiveness of SOPs for managingMCIs, such as the size of the hospital, trauma capabilities,geographic location, urban versus rural facilities, proximity toother hospitals, participation in drills, and experience in copingwith MCIs, has not been well-documented. The aim ofthis study was to investigate the impact of selected hospitalcharacteristics on the completeness and comprehensivenessof hospital SOPs for the management of MCIs.Organization of the Israeli Healthcare System for theManagement of MCIsThe National Health Insurance Act in Israel mandates that thehealthcare system must provide comprehensive medical servicesto all citizens.11 Twenty-four general hospitals operateemergency rooms capable of managing MCIs.The Ministry ofHealth provides directives to all general hospitals requiringthem to prepare SOPs based on a national doctrine for themanagement of MCIs. These plans define the operationalresponse model deemed appropriate for each type of MCI.MethodsEvaluation of SOPs for MCIsIn order to assess the quality of hospital SOPs, parametersdeemed as being required for the effective management of aMCI were identified.The parameters were identified by meansof a comprehensive literature review and the recommendationsof health professionals who were identified as experts in themanagement of MCIs, from the Ministry of Health, HomeFront Command, and general hospitals. There were a total of95 parameters identified that were classified into 11 categoriesaccording to their operational function (Table 1).In order to evaluate the SOPs for MCIs, an evaluationtool was developed based on the 95 parameters that wereidentified as having an impact on emergency preparedness.The parameters were classified into categories by a team ofemergency preparedness experts according to their importancefor managing MCIs in an efficient and competentmanner. The relative importance of each category wasdefined. The parameters in each category were classifiedinto one of three levels of importance: Level A consisted ofthe parameters that were rated as being very important(and contributed 60% of the total grade); Level B consistedof parameters that were rated as having a moderateimpact (30% of total grade); and Level C consisted of parametershaving the lowest impact (10% of total grade). Therelative importance of the categories and the extent ofparameters in each category, are presented in Table 1. Thescaling and classifications were made utilizing a modifiedDelphi process with the content experts.12Utilizing an Evaluation Tool to Measure Quality of SOP for MCIsThe evaluation tool was tested in a pilot study conductedin two hospitals, and subsequently, modifications weremade to the evaluation tool as required. The final evaluationtool was distributed to all the general hospitals inIsrael to enable them to familiarize themselves with theelements to be included in the SOP evaluation process.Three months after the distribution of the evaluation tool,the SOPs of 22 general hospitals were evaluated by theMinistry of Health and the Home Front Command. Thetwo hospitals that participated in the pilot study were notincluded in the study.In each of the 22 hospitals, the evaluation was conductedby two evaluators who were required to make their ratings ofthe SOP independently.When the rating process was complete,the two evaluators compared their ratings—differenceswere identified and discussed until they mutually agreedupon a rating. A single rating representing the consensusbetween the two evaluators for each of the 95 parameterswere entered into a computer program written specificallyfor calculating the level of preparedness of the hospital.Based on the final score, the SOPs were classified into fourgroups: (1) Very High (91–100%) indicating that the SOPrequired no modifications; (2) High (81–90%), SOP requiredonly minor modifications; (3) Poor (65–80%), SOP requiredmajor modifications; and (4) Very Poor (<65%), SOP inadequateand a new SOP must be prepared.Relationship between the Quality of SOPs and SelectedHospital CharacteristicsThe quality of SOPs for dealing with MCIs was evaluated utilizinga pre-formulated evaluation tool.The derived evaluationscores were analyzed to determine if there was a relationshipbetween the quality (comprehensiveness and completeness) ofthe SOP and the following hospitals characteristics:1. Size of hospitals—Six small hospitals with <400 beds,nine medium size hospitals with 400–700 beds, andseven large hospitals with >700 beds.2. Trauma capabilities—Six Level-1 trauma centers, 12hospitals with Level-2 trauma rooms, and four hospitalswith limited trauma capabilities.3. Ownership of hospitals—Eight government-ownedhospitals (operated by the Ministry of Health), twomunicipal hospitals (operated by the municipalities of TelAviv and Haifa), five semi-private hospitals (operated bynon-profit foundations), and seven hospitals owned bythe Health Maintenance Organization (HMO).4. Geographic location—Seven northern region hospitals,eight central region hospitals, four Jerusalemarea hospitals, and three southern region hospitals.5. Urban versus peripheral hospitals—16 hospitals werelocated in urban areas, and six in the peripheral areas.May–June 2007 http://pdm.medicine.wisc.edu Prehospital and Disaster MedicineAdini, Goldberg, Laor, et al 177Table 1—Importance and impact of categories and parameters of emergency preparedness1Parameters with high impact on emergency preparedness (signify 60% of quality of category)2Parameters with moderate impact on emergency preparedness (signify 30% of quality of category)3Parameters with low impact on emergency preparedness (signify 10% of quality of category)Adini © 2007 Prehospital and Disaster MedicineNumber Category RelativeImportance (%) Levels of parametersA1 B2 C3 Total1 General 6 1 1 7 92 Policies of mass-casualty incident operation 11 1 8 -- 93 Nursing director in emergency room 19 6 1 -- 74 Command and control (operation center) 10 1 5 3 95 Admitting sites 10 2 -- 11 136 Operating rooms 14 4 2 -- 67 Support systems (imaging, blood bank, etc.) 6 1 1 7 98 Security and patient transport 6 1 1 7 99 Logistics (equipment, infrastructure, etc.) 6 1 2 6 910 Information center 9 1 6 2 911 Spokesperson 3 -- 3 3 6Total 100 19 30 46 956. Proximity to other hospitals—15 hospitals were situatedin the vicinity of other hospitals (<15 minutedrive to next closest hospital), and seven hospitalswere located in towns in which they were the solehospital (³30 minutes drive to the closest hospital).7. Participation in a drill—Seven hospitals had participatedin a conventional MCI drill in the last year and 15hospitals did not participate in such a drill in the last year.8. Actual MCIs managed in the last three years—A MCIwas defined as an event in which there were >20casualties (Table 2).Statistical AnalysisData were processed using SPSS 13.1 (SPSS Inc., Chicago,Illinois), using the following tests: Pearson correlation, t-test,and one-way analysis of variance (Post-Hoc Test,Duncan).ResultsThe SOPs from 22 out of 24 general hospitals (92%) wereevaluated. The following conclusions were made: (1) theSOPs of 11 hospitals received very high ratings andrequired no modifications; (2) the SOPs of four of the hospitalsreceived high ratings and required minor modificationsin order to bring them up to an acceptable standard;(3) the SOPs from four hospitals received poor ratings andrequired major modifications to bring them up to anacceptable standard; and (4) the remaining three hospitalswere very poor signifying an unacceptable level of SOPs.The ratings of the SOPs are presented in Figure 1.Impact of the Size of the HospitalThe SOP scores of the smaller hospitals were found to beslightly higher (average = 94%) than those of the largerhospitals (average = 92%). The SOP scores of the mediumsizedhospitals were lower (average = 82.2%) (Figure 2). Aone-way analysis of variance test showed that the differencesbetween the hospitals were not statistically significant (p >0.05).Trauma CapabilitiesThe quality of SOPs was higher in Level-1 trauma centers(average of 92%) and in hospitals with limited traumacapabilities (average = 93.2%). A lower level was identifiedin hospitals with Level-2 trauma rooms (average = 83.9%)(Figure 3). A one-way analysis of variance test indicated thatthere was no significant difference between hospitals (p >0.05).Ownership of HospitalsThe evaluation scores of publicly-owned hospitals andmunicipal hospitals were the highest (93%), followed byNumber of hospitals Number of MCIs5 01 22 31 42 54 63 73 81 12Table 2—Actual mass-casualty incidents (MCIs) managedin the last three yearsAdini © 2007 Prehospital and Disaster Medicine178 Factors that May Influence Preparation of StandardsPrehospital and Disaster Medicine http://pdm.medicine.wisc.edu Vol. 22,No. 3those owned by a major Health Maintenance Organization(89.2%) (Figure 4). Government-owned hospitals receivedthe lowest evaluation score (85.8%). A one-way analysis ofvariance indicated that the differences between the hospitalswere not statistically significant (p >0.05).Geographic DistrictsThe SOPs of hospitals located in the southern part of thecountry had higher evaluation scores (average = 92.3%), followedby the hospitals in the Jerusalem area and in the centralarea (average = 90%). The SOPs of hospitals located inthe northern part of the country were the lowest (average =86%; Figure 5). A one-way analysis of variance showed thatthe differences were not statistically significant (p >0.05).Urban versus Peripheral Medical CentersThe evaluation scores of SOPs in hospitals situated inurban areas were higher compared to those located inperipheral areas (average = 89.9% and 85.6%, respectively;Figure 6). The differences between the hospitals were notstatistically significant (p >0.05).Proximity to Other HospitalsNo statistically significant (p >0.05) differences were identifiedin the evaluation scores of SOPs of hospitals in relationto their proximity to other hospitals (Figure 7).Participation in DrillsA comparison of the evaluation scores of SOPs for hospitalsthat had or had not participated in a conventional MCIFigure 1—Level of standards of procedureAdini © 2007 Prehospital and Disaster MedicineFigure 3—Levels of standards of procedure according totrauma capabilitiesAdini © 2007 Prehospital and Disaster MedicineFigure 6—Levels of standards of procedure according totype of hospitalAdini © 2007 Prehospital and Disaster MedicineFigure 2—Levels of standards of procedure according tohospital sizeAdini © 2007 Prehospital and Disaster MedicineFigure 5—Levels of standards of procedure according togeographic locationAdini © 2007 Prehospital and Disaster MedicineFigure 4—Levels of standards of procedure according tohospital ownershipAdini © 2007 Prehospital and Disaster MedicineMay–June 2007 http://pdm.medicine.wisc.edu Prehospital and Disaster MedicineAdini, Goldberg, Laor, et al 179drill during the past year showed an average of 85% and88%, respectively (Figure 8). The differences were not statisticallysignificant (p >0.05).Experience in Coping with Actual MCIsThe correlation between the number of actual MCIs that ahospital had managed and the evaluation scores of theSOPs was low (r = 0.266, NS). Hospitals involved in managingMCIs during the past three years scored an averageof 88%, while hospitals that had not managed an actualMCI scored an average of 84%. A hospital that had managedthree MCIs during the past three years scored a levelof 88%, while hospitals that managed six and 12 MCIs,scored averages of 95% and 96% respectively. The data aregraphed in Figure 9.DiscussionMass-casualty incidents, due to either natural occurrences,accidents, and/or terrorism are events that all societies copewith regularly. For healthcare systems, specifically hospitals,to be able to deal with MCIs in an organized and efficientmanner, they must prepare for these events and maintain ahigh level of readiness. Given that it is impossible to predictwhich hospitals will be required to manage MCIs, andsince the disposition of casualties is determined during theevent itself, all general hospitals must be prepared to dealwith an MCI.13 The impact of various characteristics ofhospitals, such as size, trauma capabilities, or participationin MCIs, on the quality of SOPs is not well-documentedin the literature.This evaluation of SOPs indicates that the majority ofgeneral hospitals in Israel have prepared high standards ofSOPs for managing MCIs. There was no correlationbetween the various characteristics of the hospitals analyzedand the evaluation scores of the SOPs. The size, traumacapability, geographic area, urban versus rural hospital,proximity to other hospitals, or whether or not a hospitalparticipated in conventional MCI drills had no impact onthe quality of the SOPs. It might be expected that theexperience of a hospital in dealing with actual MCIs wouldhave an impact on the quality of MCIs, and that the hospitalwould incorporate these lessons learned from themanagement of the actual MCIs into the SOP. This analysisindicated that this was not the case. A weak correlationwas noted between management of actual MCIs and the evaluationscore for the SOP.The quality of a SOP appears to be unrelated to the variouscharacteristics of the hospital or to the experience ofmanaging actual MCIs. This may be explained by the factthat the medical system in Israel has accumulated a greatdeal of experience coping with MCIs. In addition, theMinistry of Health provides national doctrines and guidelinesto all hospitals, instructing them on how to prepareSOPs for the different types of MCIs that the healthcaresystem is expected to cope with. Each hospital is onlyrequired to modify the doctrine according to the organizationalinfrastructure and resources. The continuous threatof terrorism and the realization that the medical systemmust be continually prepared to deal with conventional andthe threat of non-conventional MCIs, requires that generalhospitals prepare and maintain well-developed SOPs.ConclusionsThe quality of SOPs developed by general hospitals in Israelto deal with MCIs is comprehensive and well-documented.The quality of the SOPs appears to be unrelated to thecharacteristics of the hospitals analyzed. Similarly, the numberof actual MCIs managed by hospitals is unrelated to thequality of the SOPs.Figure 7—Levels of standards of procedure according tovicinity of other hospitalsAdini © 2007 Prehospital and Disaster MedicineFigure 9—Levels of standards of procedure according toexperience in managing mass-casualty incidentsAdini © 2007 Prehospital and Disaster MedicineFigure 8—Levels of standards of procedure according toparticipation in drillsAdini © 2007 Prehospital and Disaster MedicinePrehospital and Disaster Medicine http://pdm.medicine.wisc.edu Vol. 22,No. 3180 Factors that May Influence Preparation of StandardsReferences1. Joint Commission on the Accreditation of Healthcare Organization: JointCommission Perspectives. 2001 Special issue; 21(12):1–21. Available at:http://www.jcrinc.com/subscribers/perspectives.asp?durki=1122. Accessed15 October 2005.2. Simon R,Teperman S: The World Trade Center attack: Lessons for disastermanagement. Crit Care 2001;5(6):318–320.3. 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