13-Advancing the scientific study of prehospital mass casualty response through a Translational Science process- the T1 scoping literature review stage

European Journal of Trauma and Emergency Surgery (2023) 49:1647–1660 <a href="https://doi.org/10.1007/s00068-023-02266-0">https://doi.org/10.1007/s00068-023-02266-0</a><img src="/media/202408//1724838785.5262022.png" /><img src="/media/202408//1724838785.557735.png" />REVIEW ARTICLEAdvancing the scientifc study of prehospital mass casualty response through a Translational Science process: the T1 scoping literaturereview stageEric S. Weinstein<a href="http://orcid.org/0000-0002-1147-5656">1o</a>· Joseph L. Cuthbertson1 · Teri Lynn Herbert2 · George T. Voicescu1 · Michelangelo Bortolin1·Sabina Magalini3 · Daniele Gui3 · Mariana Helou4 · Kristina Lennquist Montan5 · Carl Montan5 · Chaim Rafalowsky6·Giuseppe Ratto7 · Stefano Damele7 · Simone Bazurro7 · Itamar Laist8 · Federica Marzi3 · Alessandro Borrello3·Pietro Fransvea3 · Andrea Fidanzio3 · Carlos Yanez Benitez8 · Roberto Faccincani8 · Luca Ragazzoni1,9 Marta Caviglia1,10·Received: 28 November 2022 / Accepted: 26 March 2023 / Published online: 15 April 2023 © The Author(s) 2023AbstractPurpose The European Union Horizon 2020 research and innovation funding program awarded the NIGHTINGALE grantto develop a toolkit to support frst responders engaged in prehospital (PH) mass casualty incident (MCI) response. To reach the projects’ objectives, the NIGHTINGALE consortium used a Translational Science (TS) process. The present work is the frst TS stage (T1) aimed to extract data relevant for the subsequent modifed Delphi study (T2) statements.Methods The authors were divided into three work groups (WGs) MCI Triage, PH Life Support and Damage Control(PHLSDC), and PH Processes (PHP). Each WG conducted simultaneous literature searches following the PRISMA exten- sion for scoping reviews. Relevant data were extracted from the included articles and indexed using pre-identifed PH MCI response themes and subthemes.Results The initial search yielded 925 total references to be considered for title and abstract review (MCI Triage 311,PHLSDC 329, PHP 285), then 483 articles for full reference review (MCI Triage 111, PHLSDC 216, PHP 156), and fnally 152 articles for the database extraction process (MCI Triage 27, PHLSDC 37, PHP 88). Most frequent subthemes and novel concepts have been identifed as a basis for the elaboration of draft statements for the T2 modifed Delphi study.Conclusion The three simultaneous scoping reviews allowed the extraction of relevant PH MCI subthemes and novel conceptsthat will enable the NIGHTINGALE consortium to create scientifcally anchored statements in the T2 modifed Delphi study.Keywords Scoping review · Translational science · Mass casualty incident · NIGHTINGALE project · Damage control interventions<img src="/media/202408//1724838785.611682.png" />12345Eric S. Weinsteineric.weinstein@uniupo.itCRIMEDIM—Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health, Università del Piemonte Orientale, Novara, ItalyResearch and Education Services, Medical University of South Carolina Library, Charleston, SC, USADepartment of Surgery, Policlinico Gemelli, Catholic University of the Sacred Heart, Rome, ItalySchool of Medicine, Department of Emergency Medicine, Lebanese American University, Beirut, LebanonMRMID—International Association for Medical Response to Major Incidents and Disasters, and Vascular Surgery,678910Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, SwedenMagen David Adom, National Emergency Medical, Disaster, Ambulance and Blood Bank Service, Ashkelon, IsraelEmergency Department, Azienda Sociosanitaria Ligure 2, Liguria, ItalyESTES—European Society for Trauma and EmergencySurgery, Disaster and Military Surgery Section, Milan, ItalyDepartment of Sustainable Development and EcologicalTransition, Università del Piemonte Orientale, Vercelli, ItalyDepartment of Translational Medicine, Università del Piemonte Orientale, Novara, Italya 灬IntroductionSudden onset disasters (SODs) and mass casualty inci- dents (MCIs) from the past have made it evident that col- laborative planning activities between public safety, public health, and clinical healthcare providers are essential for successful responses from the whole spectrum of prehos- pital (PH) response agencies, that must work together to forge and strengthen relationships to produce efcient and effective PH MCI responses [<a href="#bookmark1">1</a>–<a href="#bookmark2">3</a>] . As SODs and MCIs continue to increase, there is a real need to develop PH systems that are truly interoperable and integrated. Already in 2007, in response to the need for stronger con- nections and information exchange between response agencies, the United States Centers for Disease Control and Prevention (CDC) created the Terrorism Injuries: Information, Dissemination, and Exchange (TIIDE) pro- gram [<a href="#bookmark3">4</a>, <a href="#bookmark4">5</a>], ultimately aiming to decrease morbidity and mortality from MCIs, including those related to intentional acts of violence and terrorism. One of the projects awarded in the TIIDE was to work toward a national guideline for MCI response, gathering professionals that spanned over the continuum of care: emergency medical services, emergency medical specialists, and trauma surgeons . To achieve this objective, the TIIDE grant consortium partners used consensus methodology based on the best available science to propose the Sort, Assess, Life-Savinginterventions, Treatment and/or Transport (SALT) national triage guideline[<a href="#bookmark5">6</a>] and a model uniform core criteria for mass casualty triage (MUCC) [<a href="#bookmark6">7</a>]. (Fig. <a href="#bookmark7">1</a>).Despite the literature emerging from the TIIDE project, that spurred further research, discussion, policy, and proce- dure, current emergency medical services and non-medical civil practitioners involved in PH MCI response often have to rely on complicated or even outdated procedures, multiple protocols or lack of homogeneity in response methods and guidelines, and technology of the past. [<a href="#bookmark8">8</a>–<a href="#bookmark9">11</a>]To this end, the Directorate-General for European Civil Protection and Humanitarian Aid Operations has been emphasizing the need to promote frst responders’ prepar- edness through targeted actions that include the development and update of contingency plans, standard operating proce- dures, and multi-sector intervention, encouraging involve- ment of those afected by MCIs and disasters in the design and implementation of such preparedness actions. [<a href="#bookmark10">12</a>]In 2020, the European Research Executive Agency (REA), in conjunction with the European Union (EU) Horizon 2020 research and innovation funding program, awarded the Novel InteGrated toolkit for enhanced pre- Hospital life support and Triage IN challenGing And Large Emergencies (NIGHTINGALE) grant to a consortium com- prised of a similar wide distribution of PH MCI response agencies and research centers as TIIDE [<a href="#bookmark11">13</a>] (Fig. <a href="#bookmark7">1</a>.). The NIGHTINGALE project features 11 objectives ranging from developing and implementing advanced devices and<img src="/media/202408//1724838785.746219.jpeg" />Fig. 1 Evolution of the structure and methodology adopted between the TIIDE and NIGHTINGALE project. ACEP American College of Emergency Physicians, ACS-COT American College of Surgeons- Committee on Trauma, AMA American Medical Association, ASL2 Azienda Sociosanitaria Ligure 2 (Italy), EMS Emergency Medical Services, ESTES European Society for Trauma and Emergency Sur- gery, MCI Mass Casualty Incidents, MDA Magen David Adom— Israel National Emergency Pre-Hospital Medical and Blood Services, MININT Ministry of Interior Italy, MRMID Swedish International Association for Promotion of Education and Training in Major Inci-dents and Disasters, MUCC Model Uniform Core Criteria for Mass Casualty Triage, NAEMT National Association of Emergency Medi- cal Technicians (US), NAEMSE National Association of Emergency Medical System Educators (US), NAEMSP National Association of Emergency Medical System Physicians (US), NASEMSO National Association of State Emergency Medical System Ofcials (US), SAMU Service d'Aide Médicale Urgente, Paris (France), SALT Sort, Assess, Life-Saving interventions, Treatment and/or Transport, UPO Università del Piemonte Orientale (Italy), USCS Università Cattolica del Sacro Cuore (Italy)<a id="bookmark7"></a>a 灬Table 1 Scoping review search terms<table><tr><td colspan="2">FOUNDATION SPECIFIC SEARCH TERMS for all 3 Groups:Who are potential first responders?First responder, prehospital care, ambulance, EMT, paramedic, EMS, firefighter, lawenforcement, police, sheriff, constable, gendarme, military medic, public safety, emergencymanager, disaster manager, bystander, layperson, laypeople, responsible authorities, groupleader, EMS physician, Anaesthesiologist, Critical Care Physician, General Surgeon, Nurses,ambulance drivers, civil protection, community person, community member, citizenORWhat are possible first response systems?Incident management system, incident command system, incident control, crisis control, critical incident management,emergency management, disaster management, disaster planning, mass casualty response, disaster response, basic lifesupport, advanced life support, stop the bleed, advanced trauma life support, tactical care, tactical EMS, buddy-buddysupport, first response, triage, prehospital OR “out of hospital” OR field OR “forward deployed medical”ANDWhat are potential Sudden Onset Disasters?Disaster, Avalanche; land, mud, coal ash and slide, Earthquake, Sinkhole, Volcanic eruption, Dust storm, Sandstorm,Hydrological disaster, Flood, Tsunami, Tropical cyclone, Hurricane, Blizzard, Hailstorm, Ice storm, Super storm, Coldwave, Heat wave, Drought, Thunderstorm, Tornado, Firestorm, Wildfire, Space disasters, road accident, multi-vehiclepile-up, derailment; airplane, aircraft, helicopter, plane crash; bridge, building, levee OR dam AND breach ORcollapse; terrorism, explosion, bomb, artillery, shell and impact; mass shootingANDWhat is the incident called?Sudden onset disaster, mass casualty incident, mass casualty event ANDWORK GROUP SPECIFIC SEARCH TERMS:</td></tr><tr><td>PHLSDC</td><td>Lifesaving intervention, life support, damage control, damage control strategy,pre-hospital damage control, pre-hospital blood transfusion, needle decompression, sucking chest wound dressing, cricothyrotomy, airway control,intubation, airway management, laryngeal mask airway, nasal pharyngeal airway, chin-lift jaw thrust, open airway, hypotension, IV fluid, stop the bleeding, tourniquet, direct pressure, gauze packing, quick clot,haemostatic agent, thermal blanket, pelvic binders, splinting, spinal motion restriction, spinal immobilization, cervical collar, backboard, KED extraction device, scoopstretcher, cardiac monitor, electrocardiogram, telemetry, thermal blanket, pulse oximetry, thermography</td></tr><tr><td>MCI Triage</td><td>START,mSTART, Jump START, SALT, Sieve, Homebush triage, Standard, CareFlight, STM, Military, CESIRA Protocol, MASS, CBRNE triage, Burn Triage, META Triage, Mass Gathering Triage, SwiFT Triage, TEWS Triage,ASAV, SMART, Major trauma, minor trauma, airway,breathing, circulation, bleeding, mental status, walking, waving, Sort, assess, priority triage, primary triage, secondary triageANDAdvanced medical post, casualty collection point, definitive care, emergency department, hospital, health care facility, alternate care siteANDEMS, EMT, paramedic, transportation, ambulance, quick response vehicle, helicopter, fixed wing ANDEthics,Drones, Mobile applications, artificial intelligence</td></tr><tr><td>PHP</td><td>Incident command and control, crisis command, incident management system, patient identificationsystems, emergency medical tags, wearable electronic devices, Tracking of Emergency Patients, Tracking of Emergency Clients, surge, ration of resources OR scarce OR scarcity OR allocat*, communication from the scene to dispatch, transportation in transportation out, setting up field medical post, setting up casualty collection point, determining hospital capability, volunteermanagement, mass fatality management, forensic examination, surge capacity, medical rescue capacity, medical transport capacity, hospital treatment capacity, severity factor, familyreunification, people finder, child, adolescent, neonate, youth, paediatric, elderly, special needs, vulnerable populations, uninjured survivors</td></tr></table><a id="bookmark12"></a>artifcial intelligence, incorporating bystanders into the PH MCI response and addressing ethical challenges, enhancing the collaborative approach across diferent agencies (Sup- plementary Table 1). Having acknowledged the evidence produced by the TIIDE project [<a href="#bookmark13">14</a>], the NIGHTINGALEproject seeks to strengthen the existing research in the feld of PH MCI and to advance the depth and breadth of PH MCI response guidelines, as advocated by the REA. Therefore, the focus is to upgrade the evaluation of the injured, optimiz- ing life support and damage control procedures and allow aa 灬shared response across diferent MCI responding agencies, including emergency medical services, non-medical civil protection personnel, volunteers, and citizens. To guide the creation of such evidence-based guidelines, the NIGHTIN- GALE consortium adopted the Translational Science (TS) consensus process that features progressive stages aiming to translate research-informed data into new knowledge in the form of recommendations and guidelines [<a href="#bookmark14">15</a>] (Fig. <a href="#bookmark7">1</a>). As described by Caviglia et al., [<a href="#bookmark15">16</a>] starting from the TS ques- tion (T0), “how to develop, integrate, test, deploy, demon- strate and validate a Novel Integrated Toolkit for Emergency Medical Response which ensures an upgrade to PH MCI response?”, the application of TS in the NIGHTINGALE project entails the identifcation of current approaches and published data (T1, scoping literature review stage), the use of a consensus methodology as a basis for the development of evidence-based tools and guidelines (T2, modifed Del- phi), the translation into practice (T3, development of tools and guidelines), and a fnal evaluation stage (T4, evaluation and outcome assessment) (Fig. <a href="#bookmark7">1</a>). In the T1 stage, three simultaneous scoping literature reviews were designed to identify sources and references on MCI Triage, PH Life Support and Damage Control (PHLSDC) interventions, and PH processes (PHP) that could then be interrogated using a defned data extraction tool to determine concepts, theories, and knowledge gaps. [<a href="#bookmark14">15</a>, <a href="#bookmark15">16</a>] Hence, the aim of this work was to map, extract, and synthetize current evidence-based knowledge, gap, and challenges on MCI Triage, PHLSDC, and PHP through three diferent simultaneous scoping lit- erature reviews, to inform the creation of an initial set of statements for the T2 modifed Delphi study.MethodsThis study describes the structured T1 scoping literature reviews guided by the Preferred Reporting Items for System- atic Reviews and Meta-Analyses extension for scoping reviews (PRISMA-ScR) <a href="#bookmark16">[17</a>, <a href="#bookmark17">18</a>]. To specifcally address each compo- <a id="bookmark18"></a>nent of the PH MCI response, the authors were divided into theTable 2 PRISMA statement<table><tr><td></td><td>MCI Triage</td><td>PHLSDC</td><td>PHP</td></tr><tr><td>References retrieved via search</td><td>304</td><td>332</td><td>304</td></tr><tr><td>Additional via other means</td><td>11</td><td>2</td><td>61</td></tr><tr><td>Duplicates discarded</td><td>4</td><td>5</td><td>80</td></tr><tr><td>References screened</td><td>311</td><td>329</td><td>285</td></tr><tr><td>References discarded</td><td>200</td><td>113</td><td>129</td></tr><tr><td>References assessed</td><td>111</td><td>216</td><td>156</td></tr><tr><td>References discarded</td><td>84</td><td>179</td><td>68</td></tr><tr><td>References data extracted</td><td>27</td><td>37</td><td>88</td></tr></table>three work groups (WGs) of MCI Triage, PHLSDC, and PHP. Each WG included health professionals and researchers with specifc expertise in MCI response and patient management. Under the direction of a medical informaticist, the search strat- egy included only terms relating to or describing sudden onset disaster PH MCI response. The WGs conducted simultane- ous searches from November 2021 to January 2022 following the same search term methodology until the search became more specifc relating to each WG (MCI Triage, PHLSDC, and PHP), as shown in Table <a href="#bookmark12">1</a>.Eligibility criteriaThe search included English-language papers published from January 1983 to October 2021 on PubMed, SCOPUS, CINAHL (Cumulative Index to Nursing and Allied Health Literature, EBSCO, Elton B. Stephens Company, Ipswich, Massachusetts USA), DTIC (Defense Technical Information Center, U.S. Department of Defense), CRI (Emergency Care Research Institute, Plymouth Meeting, Pennsylvania, USA), and PsycInfo (American Psychological Association, Washing- ton D.C., USA). The search terms were adapted for use with other bibliographic databases in combination with database- specifcflters for controlled trials, where these were available. An ancestry search was also performed to identify additional references from the bibliography of references retrieved in the searches. The reference manager was EndNote™ X9 and 20 (Clarivate; Philadelphia, Pennsylvania, USA). References that did not meet the inclusion criteria, specifcally did not study or report an MCI or MCI exercise, were excluded.Search strategyAfter each WG conducted its initial search, duplicates were removed. Reviewers in each WG independently screened refer- ence titles and abstracts to determine if inclusion criteria were met. Any disagreement was resolved by discussion within the WG. Each WG removed any reference that did not meet inclusion criteria from further consideration. Subsequently, full texts of included articles were screened, disagreement was resolved by discussion, and references that did not meet inclusion criteria were removed. The remaining included articles for each WG underwent data extraction into an Excel database (Microsoft Corp.; Redmond, Washington, USA) that was developed using themes and subthemes from PH MCI response literature and in compliance with the NIGHTIN- GALE objectives. This raw data, together with other informa-tion gleaned from the full reference review process (such as relevant tables,fgures, or writings) constituted the base for the development of the initial set of statements in the T2 modifed Delphi stage. Specifcally, the data extraction process focused on extracting data that could lead to the creation of relevant statements for the T2 stage by identifying recurrent subjectsa 灬Table 3 Data retrieved from the three groups of MCI Triage, PHLSDC, and PHP, stratifed according to identifed themes and subthemes<table><tr><td>MCI Triage themes, subthemes, (number)</td><td>PHLSDC themes, subthemes, (number)</td><td>PHP Themes, Subthemes, (Number)</td></tr><tr><td>EducationJust in time (0)Initial curriculum (3)Maintenance curriculum (1)Simulation training Tabletop (1)Live full scale (5) Screen-based (0)Virtual reality (1) Artifcial reality (0) Audiovisual (0)Competency Initial (8)Maintenance (1)Regulatory requirement (2)Indications: history (collected over time from scene to defnitive care)Mechanism of injury (21) Time since injury (1)By-stander information/intervention/reaction (8)Warm ischemia time (entrapped) (0)Exposure to environment time (warm/cold/ wind/water/chemical/smoke) (3)Co-morbid conditions (1)Medications (1) Allergies (0)Indications: physical Initial cursory (14) Primary (22)Secondary (13)Equipment: standard BP cuf (16)Stethoscope (12)Equipment: resource scarcity (11) IV (start kits, tubing IVF) (5)Meds (2)Bandages (1) Splinting (0)Spinal motion restrictions (0) Other (3)Basic monitors used for MCI Triage Cardiac (12)Pulse oximetry (10)Advanced monitors for MCI Triage Ultrasound (1)Physiology monitor (cardiac output, blood vol) (1)Smart watch/bracelet) (2)</td><td>EducationJust in time (1)Initial curriculum (18)Maintenance curriculum (5)Simulation training Tabletop (5)Live full scale (3) Screen-based (0)Virtual reality (0) Artifcial reality (1) Audiovisual (0)Competency Initial (17)Maintenance (10)Regulatory requirement (3)Indications: history (collected over time from scene to defnitive care)Mechanism of injury (13) Time since injury (3)By-stander information/intervention/reaction (3)Warm ischemia time (entrapped) (1)Exposure to environment time (warm/cold/ wind/water/chemical/smoke) (12)Co-morbid conditions (0)Medications (3) Allergies (0)Indications: physical Initial cursory (11)Primary (26) Secondary (2)Equipment to perform PHLSDC Stopping the bleeding (11)Splinting (1)Placing spinal motion restriction (2) Needle decompression (2)Administering antidotes (6) Decontaminating (3)Starting IV's, IVF's (14); blood products (4)Basic monitors used to perform PHLSDC Cardiac (9)Pulse oximetry (6)Advanced monitors used to perform PHLSDC Ultrasound (2)Physiology monitor (cardiac output, blood vol) (7)Smart watch/bracelet (0)</td><td>EducationJust in Time (9)Initial Curriculum (3)Maintenance Curriculum (25) Terminology of MCI processes Mass Casualty Incident (25)Incident management system (3) Disaster response (23)Incident command system (4) Mass casualty response (21) Agreed terminology (4)Critical incident management (1) Incident control (1)Competency Initial (3)Maintenance (22)Regulatory requirement (5) Policy/Planning framework Government (18)Humanitarian/Non-government (3) Organizational (24)Vulnerable populations (3)Activation/incident notifcation (43) Government request (7)By-stander information/intervention/reac- tion (3)Organizational activation (23)Surge plans (9) Staf recall (1)Command system/authority Government (8)Non-government (2) Organizational (18)Resource augmentation/ allocation Human resources (15)Equipment (8)Air transport (9) Road transport (4)Mass fatality management (3) Family reunifcation (1)Field medical post (3)Telemedicine (3) Logistics (10)SafetyDeployment (5)Decontamination (10) PPE (1)Hazard assessment (15) Casualty DistributionLive time (1)Coordinated/planned (19) Patient tracking (1)Distribution model (19)</td></tr></table><a id="bookmark19"></a>a 灬Table 3 (continued)<table><tr><td>MCI Triage themes, subthemes, (number)</td><td>PHLSDC themes, subthemes, (number)</td><td>PHP Themes, Subthemes, (Number)</td></tr><tr><td>Record (patient chart)—electronic record (3)</td><td>Record (patient chart)</td><td>Reporting/Documentation</td></tr><tr><td>Paper: triage tag, patients' pocket (4)</td><td>Paper: triage tag, patients' pocket (5)</td><td>Electronic (6)</td></tr><tr><td>Radio (0)</td><td>Radio (4)</td><td>Paper (2)</td></tr><tr><td>Verbal (0)</td><td></td><td>Radio (2)</td></tr><tr><td>Reassessment</td><td>Reassessment</td><td>Communication/ Situational awareness</td></tr><tr><td>Warm ischemia (0)</td><td>Warm ischemia (4)</td><td>Social media (5)</td></tr><tr><td>Compartment syndrome (0)</td><td>Compartment syndrome (4)</td><td>Radio (10)</td></tr><tr><td>Time on backboard (0)</td><td>Time on backboard (2)</td><td>Telemetry (2)</td></tr><tr><td>Response to IV’s (3)</td><td>Response to IV’s (3)</td><td>Remote access/ live feed/drone (4)</td></tr><tr><td>Response to pain meds (0)</td><td>Response to pain meds (0)</td><td></td></tr><tr><td>Response to antiemetics (0)</td><td>Response to antiemetics (0)</td><td></td></tr><tr><td>New complaints (0)</td><td>New complaints (2)</td><td></td></tr><tr><td>Continuous vital signs monitoring (14)</td><td>Continuous vital signs monitoring (8)</td><td></td></tr><tr><td>Outcomes of decisions</td><td>Outcomes of decisions</td><td>First Responders</td></tr><tr><td>Treatment prioritization (15)</td><td>Treatment of prioritization (13)</td><td>All (Volunteer notifcation, Volunteer activa-</td></tr><tr><td>Evacuation prioritization (19)</td><td>Airway (8) Bleeding (6)Compartment syndrome (4)Pressure injuries due to prolonged spinal motion restriction (SMR) (0)Emesis with aspiration due to SMR (0)Malignant dysthymia due to hyperkalemia due to crush syndrome (2)Second spinal injury due to lack of SMR or not place SMR (1)Amputation (1)Pul edema due to over fuid resuscitate (1) Other (42)</td><td>tion/management, frst responder plans) (15)Volunteer activation/management (3) First Responder plans (3)</td></tr><tr><td>Patient tracking Triage tags (3)</td><td></td><td></td></tr><tr><td>RFID bracelets (1) Arm bands (1)</td><td></td><td></td></tr><tr><td>Smart watch/bracelets (1) Other (2)</td><td></td><td></td></tr><tr><td>Reporting (within the IMS transfer of care)</td><td>Report (within the IMS transfer of care) Elec-</td><td>Recovery/staf care</td></tr><tr><td>Electronic (1)</td><td>tronic (0)</td><td>Debrief (2)</td></tr><tr><td>Paper: triage tag, patients' pocket (0)</td><td>Paper: triage tag, patients' pocket (3)</td><td>Staf Welfare (1)</td></tr><tr><td>Radio (2)</td><td>Radio (4)</td><td></td></tr><tr><td>Phone (2)</td><td>Phone (1)</td><td></td></tr></table>The (N) identifes the number of times a reference discusses the subtheme (some references discuss more than one subtheme). BP blood pres- sure, IMS integrated management system, IV intravenous, IVF intravenous fuid, MCI mass casualty incident, PPE personal protective equip- ment, RFID radio frequency identifcation, SMR spine motor restrictionand innovative concepts that have the potential to improve cur- rent practices in PH MCI management but for which validation in clinical settings is still underway.ResultsThe initial search for all 3 WGs yielded 925 references. Fol- lowing title and abstract review, 483 articles were considered for full text review. Finally, 152 articles were included in the database extraction process: MCI Triage <a href="#bookmark20">[19–</a><a href="#bookmark21">45</a>], PHLSDC [<a href="#bookmark21">45</a>–<a href="#bookmark22">81</a>], PHP [<a href="#bookmark23">30</a>, <a href="#bookmark24">43</a>, <a href="#bookmark25">82</a>–<a href="#bookmark26">167</a>]. (Table <a href="#bookmark18">2</a>).Diferent thematic categories and related subthemes were created by each WG (Table <a href="#bookmark19">3</a>). The data extraction process drew attention to subthemes frequently mentioned in the included references. Specifcally, recurrent subthemes in the MCI Triage WG were the recording of mechanism of injury (n = 21), the involvement of bystanders (n = 8), the use of basic monitoring in support of PH triage procedures (including cardiac monitoring and pulse oximetry, respec- tively, mentioned n = 12 and n = 10 times), re-assessment of MCI casualties though continuous vital signs monitor- ing (n = 14), treatment prioritization (n = 15), and evacua- tion prioritization (n = 19) as the main outcomes of the MCI Triage process. Additionally, references included in the MCIa 灬Triage data extraction drew attention to the concepts of shock index, pulse pressure, and heart rate variability to be used in the PH assessment of casualties [<a href="#bookmark27">23</a>, <a href="#bookmark28">35</a>].Among the 37 references included in the PHLSDC data extraction, the subthemes more frequently identifed were the collection of the mechanism of injury (n = 13) and exposure to environment time (n = 12), the importance of stopping the bleeding maneuvers (n = 11) and PH fuid resuscitation (n = 14), basic and advanced monitoring to guide PHLSDC interventions, including cardiac monitoring (n = 9), pulse oximetry (n = 6), and physiological monitoring (n =7), re- assessment of MCI casualties through continuous vital signs monitoring (n = 8) and treatment of casualties according to triage prioritization (n = 13). Furthermore, the authors iden- tifed the following “hot” issues worthy of further attention: PH management of crush syndrome [<a href="#bookmark29">75</a>], resuscitation of avalanche victims [<a href="#bookmark30">53</a>, <a href="#bookmark31">54</a>], and shared CBRNE treatment protocols [<a href="#bookmark32">60</a>, <a href="#bookmark22">81</a>].Lastly, the subthemes commonly identifed in the PHP data extraction included aspects pertaining to MCI PHP terminology, policy and planning framework, and incident activation/notifcation. Aspects related to decontamination (n = 10) and hazard assessment (n = 15) were also frequently mentioned. Furthermore, subthemes related to casualty dis- tribution (either through coordinated/planned methodologies n = 19 or an ad hoc distribution model n = 19), communica- tion and situational awareness (including the use of social media, radio communication and drones), resource alloca- tion and the integration of technology to support PHP were identifed.DiscussionThe three simultaneous PRISMA scoping reviews were per- formed in the T1 stage of a TS process, ultimately seeking to advance MCI PH response guidelines in the framework of the EU-funded NIGHTINGALE project. This initial step of mapping current available evidence through the analysis of recurrent subthemes, common practices, and new concepts identifed in MCI Triage, PHLSDC, and PHP literature will serve as the basis for the development of three initial sets of statements during the T2 modifed Delphi stage. Indeed, results of the three scoping reviews emphasized several aspects that have been recurrently investigated in the MCI literature and for which expert consensus was deemed as needed by the authors.Despite MCI Triage being the mainstay of initial cas- ualty management, no global consensus or gold standard defnition exists across diferent countries, and most PH practitioners have received training in the initial MCI Tri- age system favored by their specifc agency and jurisdic- tion [<a href="#bookmark5">6</a>]. Since numerous attempts have been made towarddeveloping shared guidelines for MCI Triage <a href="#bookmark4">[5</a>] or in the attempt to create a universal triage tool [<a href="#bookmark33">168</a>], the NIGHTIN- GALE project recognizes the necessity to study these eforts as a progression of the previous above mentioned projects. Results of the MCI Triage scoping review determined that recording the mechanism of injury from the initial assess- ment and as more details emerge over the continuum of care is important for the defnitive treatment team [<a href="#bookmark20">19</a>, <a href="#bookmark34">21</a>, <a href="#bookmark27">23</a>–<a href="#bookmark35">26</a>, <a href="#bookmark36">29</a>–<a href="#bookmark37">37</a>, <a href="#bookmark38">39</a>, <a href="#bookmark39">41</a>–<a href="#bookmark21">45</a>]. This includes obtaining information not only from EMS staf but also non-medical bystanders who rendered frst aid or assisted EMS [<a href="#bookmark40">28</a>–<a href="#bookmark28">35</a>], reinforcing the concept that gathering relevant observations from bystand- ers could support the MCI response eforts, in compliance with the NIGHTINGALE objectives. Information support- ing the continuum of care involving the initial and subse- quent assessments of vital signs should determine treatment and evacuation prioritization, considering the use of cardiac monitors and pulse oximetry when available. While litera- ture suggests the use of advanced physiologic monitoring and the incorporation of point-of-care ultrasound in the con- tinuum of care [<a href="#bookmark34">21</a>, <a href="#bookmark41">31</a>], it is also evident that initial assess- ment of MCI casualties should remain quick, practical, easy to remember by all frst responders and applicable across diferent environments including austere settings, thus, to be performed without diagnostic equipment. Appropriate tag- ging and tracing of MCI casualties remains a pillar of any MCI Triage system adopted, opening the door for innovative solutions and tools possibly fulflling the triple function of tagging, tracing, and continuous monitoring [<a href="#bookmark42">27</a>, <a href="#bookmark43">42</a>, <a href="#bookmark44">44</a>].References from the PHLSDC scoping review high- lighted the need to focus on assessment and treatment guidelines for crush injuries during MCIs [<a href="#bookmark45">46</a>, <a href="#bookmark46">63</a>, <a href="#bookmark29">75</a>], as well as for the development of awareness on chemical, biological, radiological, nuclear, and explosive (CRBNE) events, advocating for education, training, and competen- cies to be developed across all agencies [<a href="#bookmark47">48</a>, <a href="#bookmark48">57</a>, <a href="#bookmark49">71</a>, <a href="#bookmark50">76</a>, <a href="#bookmark51">79</a>, <a href="#bookmark22">81</a>] . Similarly, control of major hemorrhages as an integral part of the triage process emerged as a recurrent topic in the included PHLSDC references, with a special emphasis on the role of non-medical bystanders, as specif- cally stressed by the Hartford Consensus after the Sandy Hook Elementary School mass shooting and by Lesafre and colleagues after the 2015 Paris attacks [<a href="#bookmark45">46</a>–<a href="#bookmark47">48</a>, <a href="#bookmark52">50</a>, <a href="#bookmark53">51</a>, <a href="#bookmark54">61</a>–<a href="#bookmark46">63</a>, <a href="#bookmark55">73</a>, <a href="#bookmark56">77</a>, <a href="#bookmark57">80</a>, <a href="#bookmark58">169</a>]. Overall, attention was given to the importance of continuous real-time monitoring and re-assessment of casualties to guide prioritization of life- saving interventions and transportation, suggesting the possibility to introduce deployable technology, provided it to be quick, reliable, and easy to use [<a href="#bookmark47">48</a>, <a href="#bookmark52">50</a>, <a href="#bookmark31">54</a>–<a href="#bookmark59">56</a>, <a href="#bookmark46">63</a>, <a href="#bookmark60">69</a>, <a href="#bookmark29">75</a>, <a href="#bookmark50">76</a>].Results of the PHP scoping review stressed the impor- tance of a common terminology to be adopted across all agencies working in the same jurisdiction, along with thea 灬urgent need to include practices that support gender diver- sity and are contextual to vulnerable groups and special needs populations [<a href="#bookmark23">30</a>, <a href="#bookmark61">111</a>, <a href="#bookmark62">140</a>, <a href="#bookmark63">147</a>, <a href="#bookmark64">159</a>, <a href="#bookmark65">160</a>]. Included references addressed the role of technology in support- ing the diferent PH MCI processes, from inter-agencies communication systems, to telemedicine and information management systems to coordinate the diferent resources deployed (including human resources, equipment, and vehicles) and to distribute MCI casualties in diferent health facilities [<a href="#bookmark66">90</a>, <a href="#bookmark67">92</a>, <a href="#bookmark68">99</a>, <a href="#bookmark69">146</a>, <a href="#bookmark65">160</a>] . Data supported that standard trauma transportation decisions and over- all MCI coordination may have to be adapted in context to the hazard impact and health system capacity, taking into account the possibility of CBRNE threats demanding from patient decontamination and personnel self-care [<a href="#bookmark70">86</a>, <a href="#bookmark71">88</a>, <a href="#bookmark72">89</a>, <a href="#bookmark73">100</a>, <a href="#bookmark74">102</a>, <a href="#bookmark75">103</a>, <a href="#bookmark76">108</a>, <a href="#bookmark77">136</a>]. Additionally, from the results emerged that frequently defnitive care may require alternative care sites to include feld hospitals, adapted structures such as conventions centers, schools, or reli- gious buildings like churches and mosques that have the capacity and capability to attend the injured [<a href="#bookmark78">105</a>, <a href="#bookmark79">131</a>, <a href="#bookmark80">151</a>] . The concept of enhancing situational awareness through available technology (such as drones) to better guide critical decision-making during MCIs emerged insome of the included references, especially in remote areaswith access constraints [<a href="#bookmark66">90</a>, <a href="#bookmark67">92</a>, <a href="#bookmark68">99</a>, <a href="#bookmark81">109</a>, <a href="#bookmark82">117</a>, <a href="#bookmark83">129</a>, <a href="#bookmark84">133</a>, <a href="#bookmark85">139</a>, <a href="#bookmark69">146</a>, <a href="#bookmark65">160</a>] . Moreover, the role of spontaneous vol- unteers and bystanders both in assisting relief eforts [<a href="#bookmark71">88</a>, <a href="#bookmark86">107</a>, <a href="#bookmark84">133</a>, <a href="#bookmark87">134</a>, <a href="#bookmark88">141</a>, <a href="#bookmark89">144</a>, <a href="#bookmark90">166</a>] and in providing information through social media that could be used for rapid situa- tion assessment [<a href="#bookmark83">129</a>] consistently emerges in the included references. Lastly, a recurrent notion highlighted in the included references was the need for a structured MCI plan able to regulate the use of technical advances, to fos- ter education and training competences across diferent agencies, to allow for structured debriefng in a collabora- tive manner, and to promote the use of key performance indicators to evaluate and improve the response [<a href="#bookmark91">83</a>–<a href="#bookmark70">86</a>, <a href="#bookmark92">91</a>, <a href="#bookmark93">98</a>, <a href="#bookmark73">100</a>–<a href="#bookmark94">104</a>, <a href="#bookmark86">107</a>, <a href="#bookmark81">109</a>–<a href="#bookmark95">112</a>, <a href="#bookmark96">116</a>, <a href="#bookmark97">119</a>, <a href="#bookmark98">120</a>, <a href="#bookmark99">122</a>, <a href="#bookmark100">124</a>,<a href="#bookmark79">131</a>, <a href="#bookmark101">135</a>, <a href="#bookmark102">137</a>, <a href="#bookmark103">142</a>, <a href="#bookmark104">145</a>, <a href="#bookmark105">148</a>, <a href="#bookmark106">153</a>, <a href="#bookmark107">158</a>, <a href="#bookmark65">160</a>, <a href="#bookmark108">164</a>, <a href="#bookmark90">166</a>].LimitationsA scoping review intends to capture all included peer- reviewed publications as well as the ancestry publicationsthat were cited in these publications. The Grey literature presents challenges to obtain relevant references and all attempts were made to include these references, but some may not have been obtained. There is no way to know if these potential missing references would have made a dif- ference in the available information to extract data. The raw data extracted by WG members and the work group lead are intended to undergo further analysis within each work groupto create the initial T2 modifed Delphi statements. This data extraction process, though intended to be encompassing and comprehensive, may not have captured relevant data due to the thematic approach of the database. There is no way to know if relevant data were not extracted but the secondary data retained by each work group member as they read each full reference article provide additional information for the statement creation process.ConclusionThe progression of the science to critically examine the PH MCI response peer-reviewed medical literature and other sources has enabled the NIGHTINGALE partners to methodically obtain raw data and secure relevant tables, fg- ures, or writings that will contribute to each WG’s creation of the initial T2 modifed Delphi study statements. Once submitted to experts, statements that achieve consensus will be used to defne guidelines and recommendation, in com- pliance with the objectives of the NIGHTINGALE project.Electronic supplementary material The online version of this article <a href="https://doi.org/10.1007/s00068-023-02266-0">(https://doi.org/10.1007/s00068-023-02266-0</a>) contains supplementary material, which is available to authorized users.Acknowledgements The authors thank the Partners of the NIGHT- INGALE Consortium and the User Advisory Board Members who provided their valuable inputs during the diferent steps of the TS methodology.Funding This paper is supported by the NIGHTINGALE project ‘Novel InteGrated toolkit for enhanced pre-Hospital life support and Triage IN challenging And Large Emergencies’. This project has received funding from the European Union’s Horizon 2020 research and innovation programme under grant agreement No 101021957.Data availability The authors confrm that the data supporting the fnd- ings of this study are available within the article and its supplementary materials.DeclarationsConflict of interest The authors declare that they have no known com- peting fnancial interests or personal relationships that could have ap- peared to infuence the work reported in this paper.Open Access This article is licensed under a Creative Commons Attri- bution 4.0 International License, which permits use, sharing, adapta- tion, 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 <a href="http://creativecommons.org/licenses/by/4.0/">http://creativecommons.org/licenses/by/4.0/</a>.a 灬<a id="bookmark15"></a><a id="bookmark1"></a>References1. Heide E. Disaster response: principles of preparation &amp; coordina- <a id="bookmark16"></a>tion. Publ Prod Manag Rev. 1989;1:15. <a href="https://doi.org/10.2307/3380618">https://doi.org/10.2307/</a> <a href="https://doi.org/10.2307/3380618">3380618</a>.2. Kapucu N. 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