Summary of Findings

The pattern of communication in major incidents is frequent breakdowns for mainly unspecified reasons. The challenges are predominantly inter-authority communication, system overload and incompatibility, and insufficient introduction and training in the use of communication devices. The majority of papers were case reports (78.1%), ranking low in the hierarchy of research. However, the ability to answer the review question was generally good and provides a foundation to identify knowledge and research gaps for future research efforts. The lack of high-quality observational studies hinders conclusions that can be used by policy-makers to develop guidelines for MI management.

Major Incident Characteristics from Included Literature

In general, the included papers described MI and disasters with a high degree of detail. Most papers addressed relevant incident data, access to the incident site, and the characteristics of injured patients and deceased patients. The heterogeneous nature of MI and disasters is mirrored in the descriptions that range from compensated MI with ample resources to sheer chaos, endangering the survival and outcome of the victims. Therefore, the included literature ranges from relatively simple MI related to road traffic incidents to uncompensated natural disasters and complex terrorist attacks killing thousands of people. The included incidents are reported from all over the world, excluding Africa, which is incidental.

The EM-DAT database ^{Reference Yamamura, Kaneda and Mizobata55,56} provides full insight into the demographic and geographical distribution of MIs and disasters. The database provides information that natural disasters kill approximately 45 000 people each year. ^{Reference Yamamura, Kaneda and Mizobata55} This number has decreased significantly in the last decade ⁵⁶ as the result of better standards of living, infrastructure, and enhanced response systems in World Bank defined ^{Reference Fattah, Rehn, Reierth and Wisborg58} low-income countries.

Communication Breakdown

The scoping review found that communication failure was predominant in the included literature, with breakdown reported in 25 of 29 papers disclosing operational data. Failure may rank from intermittent to permanent, and the consequences depend on the mitigating efforts to rectify or compensate for the breakdown. The definitions by majorincidentreporting.net ²¹ and Major Incident Medical Management and Support Courses (MIMMS) ⁵⁹ focus on the availability of extraordinary resources. Therefore, the geo-political and socio-economic setting is paramount, that is, an EMS response to a road traffic incident in Finland may be standard due to ample resources, whereas the similar injury mechanism may represent an MI in Sudan. Accordingly, consequences of communication breakdown will depend on the setting of the MI.

When communication is compromised, command and control may be lost. Measures to mitigate episodes of lost command and control are simple in everyday operations; however, in an MI, the complexity of the situation and the breakdown of essential systems may hamper such attempts. From the definition, ^{Reference Sammut, Cato and Homer60,Reference Vassiliou, Alberts and Agre61} it follows that the “organizational and technical attributes and processes that employs human, physical, and information resources to solve problems and accomplish missions” are complex entities that involve a solid framework, substantial basic and ongoing training, and the support from leadership and management.

The consequences of a breakdown in command and control may be immense, with unnecessary fatalities ^{Reference Kapucu45,46} and prolonged interventions ^{Reference Sollid54} before a society’s return to a normal state. Therefore, mitigating actions to re-establish command and control should be part of any MI preparedness framework, ^{Reference Pigeau and McCann62–64} describing alternative communication pathways and redundancy.

Inter-Authority Communication Challenges

Communication is one of the key foundations of inter-authority cooperation. ⁶⁵ However, several obstacles may compromise communication between authorities, including different terminology and perception of nomenclature; the widespread use of abbreviations; different nomenclature between authorities; and, finally, different priorities in respective sectors.

Especially the use of abbreviations may be a challenge in inter-authority communication and lead to mistakes, described by Holper. ^{Reference Mondal, Van Belle and Maioni66} In the study, the authors found that more than 30% of all abbreviations used in a general medical unit were ambiguous. Coghlan et al. ^{Reference Holper, Barmanray and Colman67} found the same pattern in the use of abbreviations in hospital discharge summaries, leading to potentially compromised patient care.

MI managers from different sectors have the same objective, but different approaches and priorities may hinder common tactical progression in the management. However, in complex arenas such as MIs, organizations tend to develop both formal and informal relationships for joint efforts, described by Kapucu. ^{Reference Coghlan, Turner and Coverdale68} Grounded in network and complexity theories, a concept of interdependency between authorities in extreme situations is described. Interdependency may positively influence organizations in their adaptation to complicated or dynamic arenas such as MIs, enabling a better outcome.

Communication Systems Overload and Incompatibility

System overload and/or incompatibility are represented in 18 of the included papers, echoing the fact that communication systems are vulnerable, complex, and subjected to financial priorities, for example. Communication systems that operate close to maximum capacity ^{Reference Kapucu69} under normal day-to-day conditions will invariably overload and may consequently suffer breakdown during surge situations such as an MI. Similarly, the compatibility of communication systems between different authorities and sectors ^{Reference Barrett, Ford and Zhu70,Reference Manoj and Alexandra71} may present a barrier to MI communication, for example, between military and civilian authorities related to secrecy and encryption.

Insufficient Pre-Incident Major Incident Plans and Guidelines

In 12 papers, insufficient pre-incident MI plans and non-intuitive MI guidelines are reported. EMS personnel may be challenged by MI guidelines ^{Reference Pigeau and McCann62–64} that are significantly different from daily operations, although they clearly describe MI communication. Guidelines should serve to establish, maintain, and execute command and control. ^{Reference Sammut, Cato and Homer60,Reference Vassiliou, Alberts and Agre61}

Consequences of Lacking Initial Training in the Use of Communication Devices

Holm ^{Reference Rogers and Lea72} has described the effects of lacking initial training in the use of communication devices among Danish prehospital physicians, reported in 2 papers. This study found that 38% had not received any initial training at all, whereas 29% rated their skills as advanced or expert level. Thirty-one percent of the responders did not feel capable of being able to handle communication sufficiently in an MI.

Simulation training in the use of radio communication has not been utilized extensively, ^{Reference Holm73} whereas simulations in prehospital trauma care ^{Reference Abelsson, Rystedt, Suserud and Lindwall74} and ultrasound, ^{Reference Bredmose, Habig and Davies75,Reference Krogh, Steinmetz and Rudolph76} for example, are widely implemented with significantly improved performance after completing training. In the study by Holm, ^{Reference Rogers and Lea72} implementation of a simulation is recommended for improvement of communication skills.

Major Incident Case Reports

Most of the included literature in the scoping review are case reports, which are limited by their retrospective, non-blinded, and nonrandomized trial design. As such, this constitutes a source of bias that may affect the study outcome. ^{Reference Bøtker, Jacobsen, Rudolph and Knudsen77} Any findings provided by case reports might not be generalizable and therefore may not be useful in establishing a cause-effect relationship, with a consequentially high risk of over-interpretation.

A study by Krusenvik ^{Reference Sampayo-Cordero, Miguel-Huguet and Malfettone78} found that case reports may provide in-depth relevant data since they originate from reality and may promote an understanding of complex, real-life situations. Findings are context-sensitive and may enhance new theories and add strength to previous research findings. The disadvantages are their limited generalizability and rigor.

Crowe et al. ^{Reference Krusenvik79} found that case studies are suitable for the detailed, real-life context description of critical events and interventions, for example. Therefore, case studies should be considered when no available experimental design is appropriate to answer the research question or it is impossible regarding setting, legislation, ethics, and so on.

Future Research Perspectives

An agreement on a uniformly accepted nomenclature and a common definition of MI and disasters is essential. The use of common entities in the description of an MI will enhance the evaluation and dissemination of lessons learned in MI management locally and internationally.

This scoping review found that the predominant research design consisted of case reports, suggesting that until hypotheses have been generated for future research, systematic reporting should be endorsed or mandated by EMS management. Reporting resources such as the website, majorincidentreporting.net, ²¹ and similar portals should enjoy the support and endorsement from management and authorities, perhaps using public outreach in forums such as EUPHOREA. ^{Reference Crowe, Bower and Cash80}

The future might call for an international multicenter, prospective observational study on MI communication with a focus on command and control and intra- and inter-disciplinary communication. Similarly, feasibility or simulation studies of new communication methods and implementation of guidelines could provide knowledge on future MI communication progression. This scoping review has demonstrated research and knowledge gaps that would benefit from a deeper understanding of experience, for example, from studies performed during large-scale exercises or tabletop scenarios.

Systematic scientific research in the field is called for, since most of the included papers describe communication breakdowns, with both potential and actual consequences for patient survival and outcome and for society’s expedited return to a normal state.

Implications of the Findings

The included material discloses that communication challenges and breakdowns are predominant in MIs and represent potential and actual threats to (1) command and control, and (2) patient survival and outcome. There is a need for high fidelity and reliable communication devices and easy-to-follow guidelines for communication with a clearly defined grid. Pre-incident training in the use of communication devices should be highly prioritized at the same level as medical skills, and efforts to enhance resilience are paramount. The implications may be applied worldwide, as MI mechanisms and mitigating actions are uniform, however, context-sensitive, which should be taken into account in MI preparedness planning.