key: cord-0993568-8nxyhtd8
authors: Schorscher, Nora; Kippnich, Maximilian; Meybohm, Patrick; Wurmb, Thomas
title: Lessons learned from terror attacks: thematic priorities and development since 2001—results from a systematic review
date: 2022-01-13
journal: Eur J Trauma Emerg Surg
DOI: 10.1007/s00068-021-01858-y
sha: b88aa1838a2754fda516377166cf895399f6d948
doc_id: 993568
cord_uid: 8nxyhtd8

PURPOSE: The threat of national and international terrorism remains high. Preparation is the key requirement for the resilience of hospitals and out-of-hospital rescue forces. The scientific evidence for defining medical and tactical strategies often feeds on the analysis of real incidents and the lessons learned derived from them. This systematic review of the literature aims to identify and systematically report lessons learned from terrorist attacks since 2001. METHODS: PubMed was used as a database using predefined search strategies and eligibility criteria. All countries that are part of the Organization for Economic Cooperation and Development (OECD) were included. The time frame was set between 2001 and 2018. RESULTS: Finally 68 articles were included in the review. From these, 616 lessons learned were extracted and summarized into 15 categories. The data shows that despite the difference in attacks, countries, and casualties involved, many of the lessons learned are similar. We also found that the pattern of lessons learned is repeated continuously over the time period studied. CONCLUSIONS: The lessons from terrorist attacks since 2001 follow a certain pattern and remained constant over time. Therefore, it seems to be more accurate to talk about lessons identified rather than lessons learned. To save as many victims as possible, protect rescue forces from harm, and to prepare hospitals at the best possible level it is important to implement the lessons identified in training and preparation.

The emergency management of terrorist attacks has been one of the prominent topics in disaster and emergency medicine before the SARS-CoV-2 pandemic. The most recent attacks have shown that this particular threat is still present and highly relevant today [1] [2] [3] [4] . The idea of "stopping the dying as well as the killing", which has been coined by Park et al. after the London Bridge and Borough Market attacks in 2017, emphasizes the urgent need to focus on emergency management and early medical and surgical intervention [5] .

Rescue systems and hospitals must prepare themselves to manage terrorist attacks in order to save as many lives as possible and to return rescue forces from the missions unscathed. As it is impossible to conduct prospective, high-quality scientific studies, the definition of these medical and tactical strategies relies on the analysis of real incidents and the lessons learned derived from them. After the Paris terror attacks in 2015 for example, important publications, describing the events of the night of the 13th of November 2015, were published [6, 7] . Two publications, one by the French Health Ministry and one by Carli et al., about the "Parisian night of terror" have gone a step further and have clearly described the lessons learned from these attacks [8, 9] . Importantly, experts agree on the importance of the scientific and systematic evaluation of the most recent terror attacks [10] . Challen et al. proved the existence of a large body of literature on the topic in 2012 already, but questioned its validity and generalisability. The authors based their conclusion on a review, which focused on emergency planning for any kind of disaster [11] .

More than ever, the principle applies, that the preparation for extraordinary disastrous incidents is the decisive prerequisite for successful management. The lack of preparedness for the SARS-CoV-2 pandemic has taught modern society this lesson.

With the aim to identify and systematically report the lessons learned from terrorist attacks as an important basis for preparation, we conducted the presented systematic review of the literature.

This is a systematic review of the literature with the focus on lessons learned from terror attacks. A comprehensive literature search was performed to identify articles reporting medical and surgical management of terrorist attacks and lessons learned derived from them. PubMed was used as database. The first search term concentrated on terrorism, the second on medical/surgical management and the third on evaluation and lessons learned. Adapted PRISMA guidelines were used and all articles were checked and reported against its checklist [12] .

The search terms were formulated as an advanced search in PubMed in the following way: Search: ((Terror* OR Terror* Attack* OR Terrorism* OR Mass Casult* Incident* OR Mass Shooting* OR Suicide Attack* OR Suicide Bomb* OR Rampage* OR Amok*) AND (Prehospital* Care* OR Emergenc* Medical* Service* OR Emergenc* Service* OR Emergenc* Care* OR Rescue Mission* OR Triage* OR Disaster* Management* OR First* Respon*)) AND (Lesson* Learn* OR Quality Indicator* OR Evaluation* OR Analysis* OR Review* OR Report* OR Deficit* OR Problem*).

Time frame: The attack on the World Trade Centre in New York, the Pentagon in Arlington, and the crash of a hijacked airliner in 2001 is considered the event that brought international terrorism onto the world stage with the beginning of the new millennium. The attacks have been documented and analysed in great detail. For this reason, this analysis starts in 2001 and ends with the terrorist attacks in London and Manchester in 2017. The search history was extended to the year 2018.

Included countries: Terrorism is a worldwide phenomenon. Attempting to evaluate the data of all terrorist attacks that have occurred since 2001 seems impossible due to the extremely high number. The work therefore focuses mainly on Western-oriented democracies, for which a terrorist attack is still a relatively rare event and whose infrastructure and emergency services recently had to adapt to this challenge. The Organization for Economic Cooperation and Development (OECD)-countries therefore represent a reasonable selection of countries for this study.

Exclusion criteria:

1. Articles reporting mass casualty incidents without a terroristic background 2. Personal reports without any clear defined lessons learned 3. Articles dealing exclusively with chemical, biological, radiological and nuclear (CBRN) terrorism 4. Articles dealing with a narrow point of view and only dealing with specific types of injuries such as burns or psychiatry 5. Articles not written in English.

Articles dealing exclusively with chemical, biological, radiological and nuclear terrorism (CBRN-attacks) were excluded from the literature-search. The reason for this is the large number of special problems and issues associated with this type of incident. To address this adequately, a separate literature search would be necessary.

The lessons learned from each included article were extracted according to the inclusion and exclusion criteria. Duplicated data was excluded. As expected, there was a vast number of individual lessons learned. To summarize the results, it was imperative to divide them into categories. As a basis for developing the categories existing systems were used. The reporting system of Fattah et al. defines 6 categories, but these were not sufficient to represent all types of lessons learned [13] . Wurmb et al. had recently developed 13 clusters of quality indicators [14] , some of which we were able to adopt. However, both systems focused on categories that serve to describe the overall setting of a rescue mission and were therefore not fully suitable for clustering lessons learned. Finally these 15 categories were used for clustering the lessons learned: After defining the categories, the lessons learned were assigned to them. Where applicable, the lessons learned were divided into "pre-incident", "during incident" and "post-incident" within the different categories.

The extended PubMed Search yielded 1635 articles out of which 1434 articles were excluded on title selection only. The abstracts of the remaining 201 articles were evaluated and finally 68 articles were included in the analysis (Fig. 1) .

To evaluate the quality of the included studies, the PRISMA evaluation was used and all articles were checked and reported against its checklist and then rated as either high quality (HQ), acceptable quality (AQ) or low quality (LQ) paper (Table 1 ) [12] .

A total of 616 lessons learned were assigned to the 15 categories. If a lesson matched more than one category, it was assigned to all matching categories. Therefore, multiple entries occur in some cases. Table 2 shows the distribution of categories across all included articles, while Fig. 2 shows the number of articles in which each category appears. In this figure, the publications are assigned to the respective categories. This provides an overview of the number of articles dealing with each category. An overview of the distribution over time is later given in Fig. 3 . Lessons learned within the category "tactics/organisation/logistics" were mentioned most frequently, while the category "team spirit" was ranked last in this list.

To obtain a graphical overview over the entire study period, the frequency with which the categories were mentioned per year were colour-coded and presented in a matrix (Fig. 3) .

A summary of all lessons learned assigned to the 15 categories can be found in Table 3 .

This systematic review is the first of its kind to review the vast amount of literature dealing with lessons learned from terror attacks. It thus contributes to a better understanding of the consequences of terror attacks since 2001. It also brings order to the multitude of defined lessons learned and allows for an overview of all the important findings.

Our data has shown that, despite the difference in attacks, countries, social and political systems and casualties involved, many of the lessons learned and issues identified are similar. Important to note was the fact that time of article release did not relate to content. Many articles written after the London attacks in 2005 formulated similar if not the same lessons learned as articles written in 2017 about Utoya [36, 52] . This is a major point of concern as it indicates, that despite the knowledge about the issues and the existence of already developed, excellent concepts [56, 79, 80] , their [16] 2001 USA 9/11 Eye Witness AQ Cook et al. [17] 2001 USA 9/11 Eye Witness AQ Tamber et al. [18] 2001 USA 9/11 Expert Opinion AQ Simon et al. [19] 2001 USA 9/11 Review/Report AQ Mattox et al. [20] 2001 USA 9/11 Review/Report AQ Shapira et al. [21] 2002 Israel General Review HQ Frykberg et al. [22] 2002 Multiple Review/Report HQ Garcia-Castrillo et al. [23] 2003 Madrid, Spain Review/Report AQ Shamir et al. [24] 2004 Israel Review/Report HQ Einav et al. [25] 2004 Israel Guidelines HQ Almogy et al. [26] 2004 Israel Review/Report AQ Rodoplu et al. [27] 2004 Istanbul, Turkey Retrospective Study AQ Kluger et al. [28] 2004 Israel Review/Report AQ Gutierrez de Ceballos et al. [29] 2005 Madrid, Spain

Retrospective Study AQ Kirschbaum et al. [30] 2005 USA 9/11 Lessons Learned HQ Aschkenazy-Steuer et al. [31] 2005 Israel Retrospective Study HQ Lockey et al. [32] 2005 London, UK Retrospective Study HQ Hughes et al. [33] 2006 London, UK Review/Report AQ Shapira et al. [34] 2006 Israel Review/Report AQ Aylwin et al. [35] 2006 London, UK Review/Report HQ Mohammed et al. [36] 2006 London, UK Review/Report AQ Bland et al. [37] 2006 London, UK Personal Review AQ Leiba et al. [38] 2006 Israel Review/Report HQ Singer et al. [39] 2007 Israel Review/Report HQ Schwartz et al. [40] 2007 Israel Review/Report AQ Gomez et al. [41] 2007 Madrid, Spain Review/Report AQ Bloch et al. [42] 2007 Israel Review/Report AQ Bloch et al. [43] 2007 Israel Review/Report AQ Barnes et al. [44] 2007 London, UK Government Evaluation HQ Carresi et al. [45] 2008 Madrid, Spain Review/Report HQ Raiter et al. [46] 2008 Israel Review/Report HQ Shirley et al. [47] 2008 London, UK Review/Report HQ Almgody et al. [48] 2008 Multiple Review/Report AQ Turegano-Fuentes et al. [49] 2008 Madrid, Spain Review/Report AQ Pinkert et al. [50] 2008 Israel Review/Report HQ Pryor et al. [51] 2009 USA 9/11 Review/Report HQ Lockey et al. [52] 2012 Utoya, Norway Review/Report AQ Sollid et al. [53] 2012 Utoya, Norway Review/Report AQ Gaarder et al. [54] 2012 Utoya, Norway Review/Report AQ No authors listed [55] 2013 Boston USA Review/Report AQ Jacobs et al. [56] 2013 USA General Review AQ Gates et al. [57] 2014 Boston, USA Review/Report AQ Wang et al. [58] 2014 Multiple General Review HQ Ashkenazi et al. [59] 2014 Israel Overall Review AQ Thompson et al. [60] 2014 Multiple Retrospective AQ Rimstad et al. [61] 2015 Oslo, Norway Retrospective AQ Goralnick et al. [62] 2015 Boston, USA Retrospective AQ Hirsch et al. [6] 2015 Paris, France Personal Review HQ Lee et al. [63] 2016 San Bernadino, USA Personal Review HQ Pedersen et al. [64] 2016 Utoya, Norway Review/Report AQ successful implementation and continuous improvements seem to be lacking. One of these well-developed concepts, the Tactical Combat Casualty Care (TCCC), began as a special operations medical research programme in 1996 and is now an integral part of the US Army's trauma care [79] . The Committee on TCCC, which was established in 2001, ensures that the TCCC guidelines are regularly updated [79] . Many of the lessons learned listed in our review are an integral part of these guidelines and are addressed with concrete options for action. For Example, the principles of Tactical Evacuation Care provide detailed instructions on the management of casualties under the special conditions of evacuation from a danger zone [81] . Moreover, the lack of knowledge on how to deal with injuries caused by firearms or explosive devices, which was mentioned in many articles, could be remedied by a consistent integration of the TCCC guidelines into the training and drills of emergency service staff.

Another concept that deals with the management of terrorist attacks and mass shootings is the Medical Disaster Preparedness Concept "THREAT", which was published after the Hartford Consensus Conference in 2013 [56] . The authors defined seven deficits as lessons learned and recommended concrete measures to address them. These lessons were included in our review and were mentioned in one form or the other in many of the articles. The defined THREAT concept components were: T: Threat suppression H: Haemorrhage control RE: Rapid extraction to safety A: Assessment by medical providers T: Transport to definitive care.

Consistent implementation of these points in training and practice would be an important step towards improving preparation for terror attacks.

A good example of the successful implementation of an interprofessional concept is the 3 Echo concept (Enter, Evaluate, Evacuate) [80] . It was developed and introduced with the goal to optimize the management of mass shooting incidents. At the beginning of concept development stood the identification of deficits. Those deficits correspond to those that we found in the presented systematic review. The introduction of the concept in training and practice has led to successful management of a mass shooting event in Minneapolis, Minnesota, USA in 2012 [80] . This outlines once again the importance of translating lessons learned into concrete concepts, to integrate them into the training and to practice them regularly in interprofessional drills. Just as the 3 Echo concept is based on interprofessional cooperation, the Joint Emergency Services Interoperability Principles (JESIP) project is also based on this principle [82] . It is the standard in Great Britain for the interprofessional cooperation of emergency services in major emergencies or disasters. Through simple instructions and a clear concept, both the aspect of planning and preparation as well as the concrete management of operations are taken care of [82] .

In interpreting the lessons learned in this systematic review, the question arises whether they are specific to [8] 2016 Paris, France Government Review HQ Traumabase et al. [66] 2016 Paris, France Personal Review HQ Gregory et al. [67] 2016 Paris, France Review/Report AQ Ghanchi et al. [68] 2016 Paris, France Review/Report AQ Khorram-Manesh et al. [69] 2016 Multiple Review/Report HQ Goralnick et al. [10] 2017 Paris/Boston Expert Opinion AQ Lesaffre et al. [70] 2017 Paris, France Review/Report AQ Wurmb et al. [71] 2018 Würzburg, Germany Lessons Learned HQ Brandrud et al. [72] 2017 Utoya, Norway Review/Report HQ Carli et al. [9] 2017 Paris/Nice, France Review/Report HQ Borel et al. [73] 2017 Paris, France Review/Report AQ Bobko et al. [74] 2018 San Bernadino, USA Review/Report AQ Chauhan et al. [75] 2018 Multiple Review/Report HQ Hunt et al. [76] 2018 London/Manchester, UK Review/Report HQ Hunt et al. [77] 2018 London/Manchester, UK Review/Report HQ Hunt et al. [78] 2018 London/Manchester, UK Review/Report HQ HQ high quality, AQ acceptable quality, LQ low quality, USA United States of America, UK United Kingdom Study  Year 1  2  3  4  5  6  7  8  9  10  11  12  13  14  15 Roccaforte et al. [15] 2001 x x x x x x Martinez et al. [16] 2001 x x x x x x x x Cook et al. [17] 2001

x Tamber et al. [18] 2001 x x x x x x Simon et al. [19] 2001 [20] 2001 x x x x x x Shapira et al. [21] 2002 [23] 2003 x x x x x Shamir et al. [24] 2004

x Einav et al. [25] 2004 x x x x x x x Almogy et al. [26] 2004 x x x x x Rodoplu et al. [27] 2004 x x x x x x Kluger et al. [28] 2004 x x x x x Gutierrez de Ceballos et al. [29] 2005

x x x x x Kirschbaum et al. [30] 2005

x Hughes et al. [33] 2006 x x x x x x Shapira et al. [34] 2006 x x x x x Aylwin et al. [35] 2006 [40] 2007 x x x x x Gomez et al. [41] 2007 x x x x x x x Bloch et al. [42] 2007 x x x Bloch et al. [43] 2007 x x x x x x Barnes et al. [44] 2007 [45] 2008 x x x x x x x x x Raiter et al. [46] 2008 x x x x x Shirley et al. [47] 2008 x x x x x x x Almgody et al. [48] 2008 x x x x x x x Turegano-Fuentes et al. [49] 2008 x x x x x x x Pinkert et al. [50] 2008 x x x x x x Lockey et al. [52] 2012 x x x x x x Sollid et al. [53] 2012 x x x x x x Gaarder et al. [54] 2012 [55] 2013 x x x x x x x Jacobs et al. [56] 2013

x Gates et al. [57] 2014 x x x x x x Wang et al. [58] 2014 x x x x x Ashkenazi et al. [59] 2014 x x x Thompson et al. [60] 2014 x x x x x x Rimstad et al. [61] 2015 x x x x Goralnick et al. [62] 2015 x x x x x x x Hirsch et al. [6] 2015

x Lee et al. [63] 2016

x Pedersen et al. [64] 2016 x x x x x x terrorist attacks. Our review deals exclusively with lessons learned from terrorist attacks. Other publications, however, systematically addressed the management of terrorist and non-terrorist mass shootings and disasters. Turner et al.

reported the results of a systematic review of the literature on prehospital management of mass casualty civilian Raid et al. [65] 2016

x Traumabase et al. [66] 2016 x x x x Gregory et al. [67] 2016 x x x x x Ghanchi et al. [68] 2016

x Hunt et al. [78] 2018 shootings [83] . The authors identified the need for integration of tactical emergency medical services, improved crossservice education on effective haemorrhage control, the need for early and effective triage by senior clinicians and the need for regular mass casualty incident simulations [83] as key topics. Those correspond congruently with the lessons learned from terrorist attacks that were found and presented in this systematic review. Hugelius et al. performed a review study and identified five challenges when managing mass casualty incidents or disaster situations [84] . These were "to identify the situation and deal with uncertainty", "to balance the mismatch between contingency plan and reality", "to establish functional crisis organisation", "to adapt the medical response to actual and overall situation" and "to ensure a resilient response" [84] . The authors included 20 articles, of which 5 articles dealt with terror and mass shooting (including the terror attacks in Paris and Utoya). Although only 25% of the included articles dealt with terrorist attacks, the lessons learned are again very comparable to the results of this systematic review.

Challen et al. published the results from a scoping review in 2012 [11] . The authors stated that "although a large body of literature exists, its validity and generalisability is unclear" [11] . They concluded that the type and structure of evidence that would be of most value for emergency planners and policymakers has yet to be identified. If trying to summarise the development since that statement it can be assumed that on one hand sound concepts have been developed and implemented. On the other hand however, the lessons learned in recent terror attacks still emphasize similar issues as compared to those from the beginning of the analysis in 2001, showing that there is still work to be done. It should be mentioned at this point, that there was a federal conducted evaluation process in Germany after the European terror attacks in 2015/2016. The lessons learned Have a national standard for major incidents and a preparedness concept/disaster response plan 4

Adequate trauma centre concepts on national level 5

Use trauma guidelines 6

Conduct updated disaster plans/drills 7

Active pre-planned protocols-pre hospital protocol + hospital protocol 8

All hospitals should be included in contingency planning 9

Do not base disaster plan on average surge rates 10

Standardisation in hospital incident planning 11

Have an emergency plan for preparedness 12 Use standard Protocols but keep flexibility 13

Establishment of various anti-terror contingency plans (hijack/bombing/ shooting) 14 Mini disasters as basis for escalation (flu season) 15 Crisis management based on knowledge and data collection During the incident 16 Activate contingency/emergency plans soon 17

Organisation of trauma teams that stay with a patient 18

Cancellation of all elective surgery/discharge of all non-urgent patients 19 Establish a public information centre close to hospital 20

Alert all hospitals 21

Prehospital and hospital coordination + communication is necessary 22

Crowd control is important 23

Maximise surge capacity 24

Distance to hospital site is major distribution factor 25

Evacuation of the less critically ill to further away hospitals 26

Importance of controlled access to hospitals 27

Avoid main gate syndrome-overwhelmed resources at the closest hospital 28

Avoid overcrowding in the ER 29

Activation of white plan-all hospitals/all staff/empty beds → no shortage 30

Recruit help from outside early on 31

Do not forget flexibility 32

Combination of civil defence and emergency medical services 33

Designated treatment area 34

Rapid scene clearance-highly organised und efficient 35 Flexibility across incident sites/hospitals 36

Vehicle coordination and rapid accumulation 37

Set principles rather than fixed protocols to allow for flexibility 38 Importance of quick evacuation 39

Ambulance stacking area to allow access and reduce traffic jam 40

Important to declare major incident as soon as possible 41

Manage uncertainties and scene 42

Coordination of rescue-especially HEMS 43 Rapid logistical response 44 Divide emergency response into stages break into smaller parts Early decision by incidence commander needed 47 No headquarter at frontline 48

Peri-incident intensive care management-forward deployment 49 Critical mortality is reduced by rapid advanced major incident management 50

Use ICU staff for resuscitation and triage 51

Four step approach to terror attacks: analysis of scenario; description of capabilities, analysis of gaps, development of operational framework 52

Experienced personnel should treat patient and not take on organisation 53

Empty hospital immediately 54

Focus on increasing bed capacity especially ICU beds 55

Constant update on resources and surge limitation of all hospitals 56

Trauma leaders must be aware of bed capacities 57

Combined activation of major incident plans (all EMS services) 58

Early activation of surge capacity 59

Crucial interaction/communication between hospital/police/municipalities 60

Fullback structures but flexibility and improvisation important 61

Tactical management-get an overview and do not get stuck in details 62

Prehospital damage control-military concepts in civilian setting 63 Regional resource mobilisation vital 64 Have a plan but use continuous reassessment and modification of response strategy 65

Use METHANE to assess incident 66

Clear escalation plan 67

Coordination and collaboration should be planned and practised at intra/ inter-regional, multiagency and multiprofessional levels 68

Improved forensic management 69

Logistic is important for operational strategic roles 70

Maintaining access to other emergencies MI/stroke, etc. 71

Gradual De-escalation -part of contingency plan 72

Issue: recognition of situational aspect and severity + complexityevolving risk 73

Cockpit view due to HEMS-helpful in big sweep of casualties 74

Limited mobilisation at remote hospitals 75

Incident commander appoints: liaison officer; public information officer; personnel officer; logistics officer; data officer; medical command officer; patient/family information officer 76 "ABCD response": assess incident size and severity, alert backup personnel, perform initial casualty care, and provide definitive treatment 77

Authority and command structure-two command posts-administrational vs medical management 78

Med Students used as runners 79

Tape fixed with name/specialty 80

Delays should be expected 81

Disruption in transport-lengthens rescue effort 82

Guidelines on biochemical warfare 83

Structural organisation important 84

Clear and well-structured coordination 85 Management of uninjured survivors and relatives-good communication Importance of public communication centre 16 Communication between disaster scene/EMS and hospital is often big problem 17

Use of protected phone lines and walkie-talkies 18

Early information/communication from site to assess severity 19

Early on radio/bleep system-later use of mobile phones possible 20

Clear, well-structured communication and coordination 21

Increase supplies through early communication with vendors 22

Bleeps and cable phones as cell service is often unreliable 23

Multiple scenes create difficult command and communication problems Do not solely rely on mobile phones-danger of collapse 26

Establish a public information centre close to hospital 27

Use robust communication methods 28 Communication lines often fail-be prepared 29

Management of uninjured survivors and relatives-good communication 30

Concentrate initially on relaying as much information as possible 31

Important information: (1) the nature of the event (2) Turn off all non-critical mobile cell phones during terror event (government implementation) 34

Communication centre for relatives 35 No media inside hospital-media centre set up 36

Importance of communication mechanisms during terror 37

Communication with public-use of media 38

Good telecommunication system-with backup options 39

Create database of victims/casualties 40 Importance of communication/coordination between incident site and hospitals 41

Importance of even distribution between hospitals-communication 42

Early press briefings to stop hysteria 43

Communication failure will always happen 44

Good care despite communication failure-hence senior well-trained personnel 45 Communication-use of standardised operational terms 46

Good in-hospital communication between specialties 47

Decision making without all information-lack of communication unavoidable 48 Public Reassurance through good communication 49

Restricted internet access to avoid breakage 50

Communication with relatives 51

Better communication of patient information between prehospital and hospital setting 52

Communication channel between police, EMS and hospitals 53

Public relations and communication 54

Readiness of hospitals-good communication and preparation 55

Mutual communication systems 56 Better Integration of operators of different rescue chains + communication 57

Provide patient lists to police to ease communication/information gathering for relatives 58 Importance of patient hand over communication 59

Effective communication-improve information sharing 60

Sharing of corporate knowledge-communication of information 61

Good communication and situational awareness-use liaison officers 62

Media policy and communication-robust and well informed 63

Consider radio control mechanisms 64

Confidentiality when it comes to communication with media Terror awareness-train the public 3

Trained prehospital personnel is a crucial factor 4

Update disaster plans-train them 5

Different sort of drills to prepare (manager drills/full scale drills) 6 Training is most important 7

Have and follow a pre-existing plan-based on experience 8

Thorough good quality preparation 9

Good prehospital care systems improve survival 10

Training of triage to reduce over and under triage 11

Debrief early and in a structured way 12

Preparation for incidents and injury types 13

Be prepared: have 1-3 months supply of surgical disposables 14

All hospitals should be included in contingency planning 15 All hospitals should be prepared to act as evacuation hospital-drills and training 16 Importance of damage control concepts-training 17

Cancellation of all elective surgical procedure 18

Emptying of ICU and wards 19

Importance of planning, coordination, training, financial support and well equipped medical services 20

Clear out hospital during latent phase 21 Have a major incident plan-have it rehearsed 22

Analysis based on past incidences 23

Analysis of gaps between scenario and response needed 24

Pre-event preparedness crucial-extensive planning improve outcome 25 Train core of nurses in emergency medicine skills 26 Have an emergency plan even if not a level one trauma centre 27

Rehearsal of emergency plan 28

Every hospital should be prepared for a major incident with terrorist background -solid emergency plans in situ 29

Importance of thorough analysis and short fallings 30

Good mix between planning and improvisation 31

A major incident plan is necessary-on a local as well as regional level 32

Meticulous planning 33

Extensive education 34

Regular review of the contingency plans 35

Emergency and disaster preparation and planning is crucial 36

All hospitals should be ATLS trained and have major incident drills 37

Regional major incident plan to help allocate resources 38 Have and activate contingency plans soon 39

Be prepared for uncertainty and unsafe environment 40

Having experience best preparation for next incident 41

Training saves lives 42

Drills based on past experiences Teaching of trauma management to med students 59

Therapy of paediatric cases-training is essential 60

Anticipation and planning-Plan Blanc obligatory 61

Awareness of tactical threat-idea of hazardous area response team 62

Training in trauma management 63 Planning and training-the value of organised learning 64

National process for debriefing and lessons learned 65

Regional standards for training

During the incident 1 Strict command and control structures with designated hierarchy 2 Establish incident command system/centre-this is important 3

Early command and control structure-be prepared to rebuild 4

Avoid improvisation in command structure 5

Identification vests help communication and command structures-clear roles 6 Most senior medical officer = commander 7

Prompt and vigorous leadership 8

Civil defence coordinates and has overall command-clear structure 9

Importance of chain of command 10

Command structures-medical director vs administrative director 11

Incident commander appoints: liaison officer; public information officer; personnel officer; logistics officer; data officer; medical command officer; patient/family information officer 12

Chain of command: most senior official from all important specialties plus hospital admin 13

Multiple scenes create difficult command and communication problems 14 Have experienced decision maker 15

Command and control-regular trauma meetings 16 Importance of EMS command centre 17

Accept chaos phase-command structures will follow 18

Importance of local command structures-most senior official = commander in chief 19 Communication/cooperation between managers of different EMS 20

Work within established command and control structures Command and control vs collaboration-both important 28 Flexible leadership 29

Leadership through ER physicians 30

Central Command-Health emergencies crisis management centre 31

Central command in hospital-director of medical operations 32

Good crisis management/command important 33

Multidisciplinary management 34

Clear communication, organization and decision making skills vital 35

Robust and simple organisation and command 36

Crisis management based on knowledge and data collection 37

Solid command structures and leadership based on experience and knowledge 38

Tactical management-get an overview and do not get stuck in details 39

Leadership/coordination through experienced healthcare professionals 40

Tactical command post in safe zone

Pre-incident 1 Establish national triage guidelines 2 Improve triage skills 3

Reproducible triage standards 4

Triage according to three ECHO-coloured cards 5

Casualty disposition framework with an effective enhanced triage process During the incident 6 Priority is quick triage, evacuation and transport to hospital 7

Establish casualty collection points/triage simple and early 8

Multiple triage areas-staff with freelancers 9

Coloured tags for triage 10

Use START system-simple triage rapid treatment 11

Doctors not deployed in red zone -triage in safe zone 12

Triage by most senior personnel 13

In-hospital triage according to ATLS 14 Systematic planning for triage, stabilisation and evacuation to hospital through chain of treatment stations 15

Triage at a distant site to disaster 16 Importance of triage-good triager-absolute authority 17

Deploy small medical teams for 2nd triage 18

Senior general surgeon triages at hospital entrance 19

Triage on arrival at hospital entrance as prehospital triage not necessarily reliable 20

Rapid primary triage-evacuation of the critical ill to nearest hospital (evacuation hospital) for stabilisation 21 Beware of undertriage Staff imprints lessons from mini-disasters and use this experience 3

Establishment of human resource pools-especially with volunteers 4

Too few nurses-improve incentives 5

Description of relevant capabilities of the medical system 6

Staff training in combat medicine-cooperation with the military 7

Up-to-date list of available staffing important During the incident 8 Descale as soon as possible → rest time for staff 9

Staff Safety is a major concern 10

Freelancers are important but difficult to manage 11

Multiple triage areas-possible staffing with freelancers 12

Quick response-increase staffing as soon as possible 13

Maximal increase of staffing needed-most important factor 14

Forward deployment of anaesthetist-allows for continuity of care 15 Relieve staff after 8-12 h for breaks 16 Optimise utilisation of manpower and supplies Gather information and personnel during latent phase 20

Helicopters to transport staff and equipment 21

Triple: anaesthetist trauma surgeon abdominal surgery lead assessment and allocation to definite care 22

Efficient staff allocation 23

Pre hospital physicians useful 24

Using tags for triage-no resuscitation efforts until enough staffing 25 Train core of nurses in emergency medicine skills 26

Different specialties (ENT/psych) needed 27

Spread out teams to attend more patients 28

Too much staff available in ER-overcrowding 29

Good care despite communication failure-hence senior well trained personnel 30

Triage by senior medical officers 31

Keep track of staff showing up 32

Keep personnel in reserve/on standby 33

Experienced staff is vitally important 34

Surge in equipment and staff vital 35

Safety of personnel-idea of SWAT paramedics-therapy under fire 36

Increase blood bank staff 37

Photography staff/service to document injury Post-incident 38 Follow up on personnel-psychological and physiological [86] . Finally it is important to mention, that hospitals and rescue systems must prepare not only for terrorist attacks, but also for a wide spectrum of disasters. Ultimately, this is the key to increased resilience and successful mission management. 

This systematic review has several limitations. Due to the vast amount of information only PubMed was used as a source. From the authors' point of view, this is a formal disadvantage, but it does not change the significance of the study as in contrast to the question of therapy effectiveness or the comparison of two forms of therapy, the aim here is to systematically present lessons learned. To get even more information, the data search could have been extended to other databases (e.g. Cochrane Library, Web of science) and the grey literature. Given the number of included articles, it is questionable whether this would have significantly changed the central message of the study. It is even possible that this would have made a systematic presentation and discussion even more difficult. CBRN attacks have been excluded from the research. The reason for that was that many special aspects have to be taken into account in these attacks. Nevertheless CBRN attacks are an important topic, which would need further exploration in the future. The restriction to OECD countries certainly causes a special view on the lessons learned and is thus also a source of bias. However, the aim was to look specifically at countries where terror attacks are a rather rare event and rescue forces and hospitals are often unfamiliar with managing these challenges. Special injury patterns associated with terror attacks were not considered. This reduces the overall spectrum of included articles, but from the authors' point of view, a consideration of these would have exceeded the scope of this review.

The first thing that stands out is that most lessons learned followed a certain pattern which repeated itself over the entire time frame considered in the systematic review. It can be assumed that in many cases it is therefore less a matter of lessons learned than of lessons identified. Although sound concepts exist, they do not seem to be sufficiently implemented in training and practice. This clearly shows that the improvement process has not yet been completed and a great deal of work still needs to be done. The important practical consequence is to implement the lessons identified in training and preparation. This is mandatory to save as many victims of terrorist attacks as possible, to protect rescue forces from harm and to prepare hospitals and public health at the best possible level.

Author contributions All authors contributed substantially to the study conception and design. Material preparation, data collection and analysis were performed by NS and TW. The first draft of the manuscript was written by NS and TW and all authors commented on previous and following versions of the manuscript. All authors read and approved the final manuscript.

Funding Open Access funding enabled and organized by Projekt DEAL. The authors did not receive support from any organization for the submitted work. No funding was received to assist with the preparation of this manuscript. No funding was received for conducting this study. No funds, grants, or other support was received.

The authors have no conflicts of interest to declare that are relevant to the content of this article.

Availability of data and materials Not applicable.

Code availability Not applicable.

Ethics approval Not applicable.

Consent to participate Not applicable.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.

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The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration

Wisborg T. A consensus based template for reporting of pre-hospital major incident medical management

Qualitätsindikatoren für rettungsdienstliche Einsätze bei Terroranschlägen oder anderen Bedrohungslagen : Eine Pilotstudie nach dem Würzburger Terroranschlag vom Juli 2016 [Quality indicators for rescue operations in terrorist attacks or other threats : a pilot study after the Würzburg terrorist attack of

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