Regular drills are crucial if a mass casualty plan is to work in a wartime situation. Focusing on staff safety in the plan itself and taking information flows into account are also important factors for success. These are the findings of a study from Linköping University published in the scientific journal Disaster Medicine and Public Health Preparedness.

Across a Europe that had long been spared war, many countries are now planning and building up their preparedness following Russia’s invasion of Ukraine. In war, hospitals and transports carrying injured people are increasingly being deliberately attacked, creating a major need to adapt emergency healthcare preparedness to this new reality.

“We need to prepare our hospitals for the asymmetric warfare we see around the world, where the aggressor doesn’t care about the Geneva Conventions,” says Maximilian Nerlander a PhD student at the Centre for Disaster Medicine at Linköping University and a specialist physician in emergency medicine. Maximilian Nerlander is also a visiting scholar at the Hebrew University of Jerusalem Braun School of Public Health and Community Medicine, Jerusalem, Israel.

Preparedness includes having what are known as mass casualty incident plans in place and training the staff who will work in them during war and other crises.

Israel’s healthcare system is similar to those in Western Europe, but unlike these, it has real wartime experience. Together with two other colleagues, Maximilian Nerlander has led a study on how the mass casualty plan at an Israeli hospital, Assuta Ashdod Public University Hospital, was affected during the Hamas-led attacks on Israel on 7 October 2023.

The study, based on interviews with 19 members of staff from the hospital’s emergency department who were on duty on 7 October, shows how the hospital’s regular mass casualty training exercises – held four times a year – enabled staff to work almost automatically when the crisis struck.

“Drills mean that you function better under the extreme stress that arises during war and can carry out the work automatically. In a sudden war, there’s no time to familiarise yourself with protocols and procedures; they have to be second nature,” says Maximilian Nerlander, who works clinically as a lead physician at the emergency department at Växjö Hospital, Sweden.

The study shows that staff safety is another important factor in wartime mass casualty incidents. Staff were at risk of being attacked on their way to the hospital, which is something that needs to be taken into account in mass casualty plans. If staff are physically unable to get to the hospital, the entire system fails. At the hospital in the study, the emergency department is housed in a building which is reinforced to withstand rocket attacks, providing a safe working environment.

“It was remarkable, but really a no-brainer, how important it was for staff to feel safe in order to be able to do their jobs, and this also benefited clinical patient safety. Isn’t this something we should take into account when we build new hospitals here in Europe?” asks Maximilian Nerlander.

The researchers also note that communication is challenged in several ways during a surprise attack. One conclusion of the study is therefore that a function that sorts and coordinates incoming unstructured information from, for example, patients, ambulance crews, and social media, and passes it on to incident command in a structured way, can be an important component in maintaining situational awareness. Another conclusion is that it is important to develop a shared reporting system for civilian and military healthcare, as the researchers found that a great deal of information was lost when patients were transferred between military and civilian ambulances.

The fact that the attacks took place during a major Jewish holiday, when many people were off work, was a vulnerability. According to the researchers, preparedness planning must therefore take account of periods of increased vulnerability, such as holidays when many people are off work.

The study was conducted together with Adam J. Rose at the Hebrew University of Jerusalem Braun School of Public Health and Community Medicine, in Jerusalem, Israel, and Debra Gershov West at the Emergency Department, Samson Assuta Ashdod Medical Center in Ashdod, Israel. The study was approved by the Swedish Ethical Review Authority and funded by Region Kronoberg.