09-Lean approach in the application of new technologies- integration of risk, situational awareness, and resilience by a prehospital emergency medical service

<a href="http://crossmark.crossref.org/dialog/?doi=10.1007/s10669-023-09930-1&amp;domain=pdf"><img src="/media/202408//1724856297.156415.png" /></a>Lean approach in the application of new technologies: integration of risk, situational awareness, and resilience by a prehospitalemergency medical serviceAna MaríaCintora‑Sanz1,2 · Carmen Colmenar‑García1 · Cristina Gómez‑Usabiaga1 · Ricardo García‑Martinez1·Raquel Lafuente‑Saenz1 · Teresa Sierra‑García1 · Carmen Montero‑Pernía1 · Alberto Blanco‑Lara1·Tatiana Vázquez‑Rodríguez1 · Cristina Horrillo‑García1Accepted: 29 July 2023 / Published online: 14 August 2023 © The Author(s) 2023AbstractAfter an earthquake or an industrial chemical release, a timely andefective response is crucial and can prevent or signifcantly reduce the risk of casualties. To this end, frst responders and rescue teams have been equipped with state-of-the-art tools and specialised instruments to improve their capabilities in terms of accuracy, rapid location, and reduction of false alarms. The European Union-funded Search and Rescue project (Emerging technologies for the Early location of Entrapped victims under Collapsed Structures and Advanced Wearables for risk assessment and First Responders Safety in SAR operations) has designed, implemented and tested a highly compatible open architecture platform for frst responders in a pilot case study of a chemical incident. An analysis of major chemical accidents classifed by the eMars database (Major Accident Reporting System, established by the European Seveso Directive) was carried out; it has determined the types of companies that have sufered chemical accidents with the highest number of injuries and fatalities. Based on this previous analysis, a chemical spill pilot study was devised to test advanced user equipment systems and backup applications, improving frst responders’ decision-making and providing a common, dynamic operational perspective of the disaster. The Lean Method was used to evaluate processes, identify waste, test new solutions and, fnally, increase the value of the product and service produced.Keywords Lean method · Prehospital emergency care · Mass casualty incident · New technologies · Coordination and communication1 IntroductionMultiple casualty incident (MCI) management by prehospi- tal emergency medical systems is a complex issue of increas- ing concern. The existence of multiple cascading efects,<img src="/media/202408//1724856297.174405.png" /> Ana María Cintora-Sanzanamaria.cintora@salud.madrid.org Carmen Colmenar-Garcíamariadelcarmen.colmenar@salud.madrid.orgCristina Gómez-Usabiagacgomezu@salud.madrid.orgRicardo García-Martinezrgarciamartinez2@salud.madrid.orgRaquel Lafuente-Saenzraquel.lafuente@salud.madrid.org Teresa Sierra-Garcíateresa.sierra@salud.madrid.orglimited knowledge of the situation and need for coordination amongst several responders are time-dependent factors that need to be dealt with one by one and solved to avoid poten- tially serious consequences (Kadri et al. <a href="#bookmark1">2013</a>; Acinas and Patricia <a href="#bookmark2">2007</a>).Carmen Montero-Perníamariadelcarmen.montero@salud.madrid.org Alberto Blanco-Laraalberto.blanco@salud.madrid.orgTatiana Vázquez-Rodrígueztatiana.vazquez@salud.madrid.org Cristina Horrillo-Garcíacristina.horrillo@salud.madrid.org1 Prehospital Medical Service Madrid Region, SUMMA112, Antracita No. 2, CP 28045 Madrid, Spain2 Universidad Autónoma de Madrid, Madrid, Spain<img src="/media/202408//1724856297.1905751.png" />a 灬Emergency incident management, using the coordina- tion systems of all responding teams involved, is one of the most important factors of complexity and a serious chal- lenge for emergency medical teams and other emergency professionals (Piraina and Trucco <a href="#bookmark3">2022</a>). To this end, pre- hospital emergency teams have been equipped with state- of-the-art tools and specialised instruments to improve decision-making, precision, rapid location of victims and safety and to reduce false alarm rates (S&amp;R—Search and Rescue Project <a href="#bookmark4">2023</a>).This study aims to develop an approach based on improv- ing emergency management capacity and adaptability to prevailing and/or unpredictable circumstances by applying it at the scene of the incident. This framework is suitable for modelling the capabilities of out-of-hospital emergency services (OES) in diferent operational contexts and critical scenarios. It is also particularly useful for the assessment of industries with chemical risk by insurance companies, tak-ing into account the infographic prioritisation of industries with a higher risk of sufering accidents with injuries and fatalities based on the 30 years of record of serious chemical incidents in the EMars database.Part of the problem afecting emergency management is undoubtedly the physical and operational relationships amongst diferent emergency response units, including med- ical teams, State Security Forces, fre fghters and Civil Pro- tection; this vital coordination is one of the most important factors of complexity and becomes a real challenge for efec- tive synchronisation of frst responders. Since it is impos- sible for a single organisation to provide all necessary skills and resources to respond to a disaster, cooperation amongst stakeholders is essential for the execution of an efective emergency response (Cedergren et al. <a href="#bookmark5">2018</a>).<img src="/media/202408//1724856297.203873.png" />The integration of technological, human and organisa- tional components is fundamental for emergency manage- ment capacity and it is crucial to understand the behaviour of organisations, the roles and responsibilities within them <a id="bookmark6"></a>and resources that can be deployed, as well as internal andexternal information fows and other means of coordination (Piraina and Trucco <a href="#bookmark3">2022</a>).This study aims to address these problems by promoting an approach to emergency management based on improving coordination, communication and safety capacity by imple- menting the Lean methodology framework (Dickson et al. <a href="#bookmark7">2009</a>; de Barros et al. <a href="#bookmark8">2021</a>).1.1 MethodologyThe methodological sequence of this case study is shown in Fig. <a href="#bookmark6">1</a>.In order to give an adequate response to the question, “How to minimise or alleviate the consequences of a chemi- cal incident, to optimise risk analysis and address emergency scenarios following disasters”, the European H2020 Search and Rescue (S&amp;R) project came into being. This 3-year project saw the development of technological tools, which were evaluated using the Lean methodology and suggested improvements in the following diferent areas when respond- ing to this kind of emergency: (1) in communication chan- nels during chemical incidents, (2) in the safety of respond- ers and (3) in victim rescue times.Currently, at community level, the protocol for action in the event of chemical incidents follows the following com- munication and emergency response or intervention fow- chart (Figs. <a href="#bookmark9">2</a>, <a href="#bookmark10">3</a>).In this protocol, the areas for improvement that were detected are (1) at the pre-response stage—drafting of a risk map of chemical incidents for the region and (2) at the response stage during the course of the incident—communi- cation, safety of responders and faster rescue times.To work on these improvements, diferent Information and Communication technologies (ICTs) are being devel- oped as part of the S&amp;R project, funded by the European Commission, with the participation of diferent emergency professionals, universities and technological and communi- cation companies from diferent countries in Europe. TheirFig. 1 Methodology diagram used in the case studya 灬<a id="bookmark9"></a>Fig. 2 Communicationfowchart in a CBRN incident assisted by the PrehospitalEmergency Service<table><tr><td><img src="/media/202408//1724856297.257165.png" /><img src="/media/202408//1724856297.281522.png" /><img src="/media/202408//1724856297.283849.png" />Activation ofresources bysector and usualworking channel.<img src="/media/202408//1724856297.287405.png" /></td><td><img src="/media/202408//1724856297.290196.png" /><img src="/media/202408//1724856297.2960262.png" /> Notification to all <img src="/media/202408//1724856297.300108.png" />Multiple CasualtyIncident resourcesand change ofcommunicationschannel to specificchannel 1 radio<img src="/media/202408//1724856297.303933.png" /> frequency.</td><td>First resourcecommunications by 2ndAdvanced SupportCommand takensecond or subsequentunitsAdvanced MedicalPost Officersradio channel.</td><td><img src="/media/202408//1724856297.3074958.png" /><img src="/media/202408//1724856297.310195.png" />Request forhospital transferbetween Officeron Call andIncidentManagement</td><td><img src="/media/202408//1724856297.313219.png" /><img src="/media/202408//1724856297.316417.png" /><img src="/media/202408//1724856297.323788.png" /><img src="/media/202408//1724856297.3565729.png" /><img src="/media/202408//1724856297.3606038.png" />End ofincident after indication from Officer on Call 	via all radiochannels<img src="/media/202408//1724856297.365452.png" /><img src="/media/202408//1724856297.368184.png" /></td></tr></table><a id="bookmark10"></a>Fig. 3 Incident coordination tetra radio communicationfowchart<img src="/media/202408//1724856297.3711429.png" />Triage OﬃcerCoordinatingTeam at theEmergencyOperationsCentreSupervisor of victimswith green Medicalcard Post OfficerChief Medical Officeron Channel 2radiofrequencyResourcesaim is to develop technologies that can be used in chemi- cal incidents: (1) a communication platform called CON- CORDE (Angelidis et al. <a href="#bookmark11">2022</a>), which includes a decision- making system, monitoring of rescuers via GPS, alarm systems with chemical gas sensor and environmental risk notifcation, (2) smart uniform for rescuers with vital signs sensor and GPS (Girald et al. <a href="#bookmark12">2021</a>), (3) chemical gas sen- sor, (4) drones, (5) smartwatch, (6) paediatric immobilisersystem and (7) virtual reality glasses for training in this type of incident.Assessment was carried out using performance, ef- ciency and usability indicators, frst in laboratories and then under real conditions involving seven simulations, or Use Cases, carried out in diferent European cities. In Spain, the Use Case was carried out in December 2022 in the former Oncology Hospital in Villaviciosa de Odón (Madrid) and consisted of an earthquake causing aa 灬chemical spill of ammonia and chlorine, in which a Urban Search &amp; Rescue (USAR) team, Emergency Medical Ser- vice, canine rescue team and the National Police took part.To assess the potential risk of chemical incidents in the region per industry, a risk map was developed using the eMARS database (EUROPA—EMARS Dashboard— European Commission <a href="#bookmark13">2023</a>). This analysis consisted of assessing chemical incidents involving the highest number of fatalities and direct injuries. A descriptive cross-sectional study was conducted for the period January 1980 to Decem- ber 2020. The impact of chemical accidents at EU facilities and others registered in the eMARS database was analysed, taking into account the highest number of injuries and fatali- ties caused by severe registered accidents.In the following infographics, we have listed the compa- nies with highest risk to lowest risk of having fatalities and injuries in chemical incidents, based on the above analysis. These data would be of value for being considered by insur- ance in order to assess the risks of the chemical activity of the companies, based on the experience of previous serious chemical incidents (Chapter 30. Development of a Chemical Risk Map of the Madrid Community Using the Descriptive Analysis of the Seveso Directive’s EMars Database—Nova Science Publishers <a href="#bookmark14">2023</a>) (Figs. <a href="#bookmark15">4</a>, <a href="#bookmark16">5</a>).A risk map was drawn up for the Community of Madrid, based on diferent industries in the area and their possible release of toxic substances causing the worst-case scenario taken from the eMARS database and list of industries reg- istered in the Civil Protection Regulations for the Commu- nity of Madrid (Chapter 30. Development of a Chemical Risk Map of the Madrid Community Using the Descriptive Analysis of the Seveso Directive’s EMars Database—Nova Science Publishers <a href="#bookmark14">2023</a>).On the other hand, during the pilot study, diferent observ- ers/evaluators from diferent technologies were deployed to report on improvements obtained over standard protocols, mainly in the three areas described above: (1) communica- tion, (2) safety of responders and (3) rescue (Chalaris et al. <a href="#bookmark17">2021</a>).1.2 Communications during Multiple Casualty IncidentsFirstly, for standard operations, the Community of Madrid’s SUMMA 112 emergency service is divided into three response areas, each with its own communications chan- nel, in this case referred to as SECTOR 1, SECTOR 2 and SECTOR 3.When a response to an emergency that is classifed as a Multiple Casualty Incident (MCI), the fow of communica- tions, emergency needs and information to be transmitted are obviously much higher than usual and the communicationssystem often collapses, so separate channels are used to avoid collapsing the channels normally used for each sector.Once the emergency situation and Multiple Casualty Incident have been declared, a role solely assigned to the Ofcer on Call, an independent team is organised by the Emergency Operations Centre (EOC) to handle the inci- dent, made up of a doctor, nurse and Emergency Medi- cal Technicians (EMTs), also referred to as the Incident Management Team (IMT), each with their own respective roles.As for communications, frstly one member from the IMT informs all resources in route or during the operation that an emergency response procedure has been activated, involving switching communications to its own channel, Channel 1 (assigned for all resources in route), and all those involved have to acknowledge notifcation to the EOC.The only Ofcer who may communicate and liaise with the other Ofcers and the EOC is the Chief Medical Ofcer (CMO) to ensure that a single decision-maker has all the necessary information at their fngertips.First, the CMO, after receiving information from the Ofcers belonging to the other emergency services (Police and Fire Brigade) at the Advanced Command Post (ACP) must transmit the following information to the rest of the Ofcers via the handheld radio transmitter:– To the EOC: the information available on the type, char- acteristics and possible number of casualties.– To the Triage Ofcer: when triage can begin and whether or not the triage area is safe for its carrying out. The per- son in charge of minor casualties initially goes along on this mission.– To the Resources Ofcer: to fnd suitable access and evacuation routes and to locate possible resources to be used in the emergency.For their part, the frst Ofcers must exchange information with the CMO via the handheld radio transmitters and con- vey the following: a summary of all communications/infor- mation transmitted during the Multiple Casualty Incident.In a Multiple Casualty Incident (MCI), specifc commu- nication channels are used to handle the situation in order to avoid collapsing the usual working channels, namely:– SUMMA Channel 01: channel for all resources in route to the incident, and for all resources on site, other than those performing Ofcer duties. This is referred to as the ‘Listening Channel’.– SUMMA Channel 02: channel for Ofcers involved in the emergency, i.e. all those wearing identifcation waist- coats: Advanced Medical Post Ofcer, Triage Ofcer, Green Victim Supervisor and Resource Ofcer. These ofcers may only convey information to the Chief Medi-a 灬Fig. 4 List of companies andtheir fatalities chemical incidentrates<img src="/media/202408//1724856297.40799.png" /><a id="bookmark15"></a>Ranking of industries generating proportionally the highest number of fatalitiesProduction and storage of pesticides, biocides, fungicides0.28 0.33Production and manufacturing of pulp and paperRateFatalities / Nº EventsGeneral chemicals manufacture 	Wood treatment and furniture Production and storage of fertilizers0.651.00 1.00 1.00 1.06 1.13 1.18Production of pharmaceuticalsWholesale and retail storage and distributionManufacture of food products and beveragesPlastic and rubber manufacture 	Petrochemical / Oil Refineries Agriculture products warehouses1.39 1.43 1.551.67Processing of metalsFuel storage (including heating, retailsale, etc.)Industrie typeMining activities (tailings &amp; physicochemical processes)2.00Handling and transportation2.33 2.50centres(ports,airports, lorry parks..)Power generation, supply and distributionProduction of basic organic chemicals3.00Production and storage of fireworks3.43 3.54Production, destruction and storage of explosivesLPG production, bottling and bulk distribution4.00 4.30Chemical installations Waste storage, treatment and disposal6.30Rate 0.00 10.00(number of fatalities between number of events)cal Ofcer (CMO), who is the only valid interlocutor with the EOC.– SUMMA Channel 03: channel for managing hospital assignment, for the EOC nurse to communicate with the Chief Medical Ofcer (CMO) for allocating beds.All clinical data are transmitted and a suitable hospital is assigned.These communication channels are used until all casualties have been stabilised and/or taken to theira 灬<a id="bookmark16"></a>Fig. 5 List of industries andtheir rate of injured people in the curse of chemical incidents<img src="/media/202408//1724856297.422679.png" />Ranking of industries generating proportionally the highest number of injuriesProduction and storage of fireworks 434.14Waste storage, treatment and disposalProduction, destruction and storage of explosivesProduction of pharmaceuticalsAgriculture products warehousesPower generation, supply and distributionGeneral chemicals manufactureManufacture of food products and beveragesType of InterpriseProduction and storage of pesticides, biocides, fungicidesLeisure and sport activities (e.g. icerink)Production and manufacturing of pulp and paperProcessing of metals 	Petrochemical / Oil Refineries Textiles manufacturing and treatment Production of basic organic chemicalsWood treatment and furnitureWholesale and retail storage anddistribution...Building &amp; works of engineeringconstructionProduction and storage of fertilizersHandling and transportation centres(ports, airports, lorry parks,...Plastic and rubber manufactureChemical installationsFuel storage (including heating, retailsale, etc.)Liquefied petroleum gas (LPG) production, bottling and bulk...132.50112.4229.3326.1422.8314.2811.5610.5010.4010.008.338.057.005.005.004.854.004.003.003.002.801.671.00Rate(injuries/nº events)0.00 200.00 400.00 600.00corresponding hospitals. Once fnished, all units return to their normal working channels. The problem with this method of communication via TETRA channels is that each channel is independent and not simultaneous. TheChief Medical Ofcer (CMO) and staf must use one chan- nel after the other, without being able to communicate between or intercept them, plus the fact that the qual- ity of communication, on being oral, is usually bad, and far less precise than when written and/or accompanieda 灬Table 1 CBRN incident response key points<table><tr><td></td><td>First response</td><td>Second response</td></tr><tr><td>Command and coordination</td><td>First 0–5 min∙ Chief Medical Ofcer (CMO) declares CBRN incident∙ Awareness and risk assessment ∙ Gather information reported∙ Incident Management Team (IMT)∙ Nurse coordinators alert to referral hospitals</td><td>Until CMO declares fnalisation of incident∙ Continuous risk assessment to sources in the feld∙ Booking specifc Hospital beds∙ Ensures patient traceability regarding patient safety</td></tr><tr><td>Zoning</td><td>5 to frst 15 min after the incident has begun∙ Hot zone (intervention)∙ Warm zone (relief): casualty concentration área, emergency treatment and sanitarydecontamination stations∙ Cold zone: advanced medical post</td><td>∙ Value the weather conditions, if changes, the CMO in the Advance Command Post (ACP) consider re-evaluating the zones</td></tr><tr><td>Communications</td><td>From minute 0 till the incident is declared fnalised∙ Essential process∙ More fow of communications and informa- tion∙ Specifc radio channels (little information)</td><td>Essential during all the phases∙ Technical support specialised in communica- tions∙ Field communications vehicle</td></tr><tr><td>Risk analysis. Detection of toxic agent</td><td>Risk analysis: minute 0 ∙ Early suspicion∙ Asses the 5 signs of a CBRN incident ∙ Report to the CMO</td><td>Detection of the toxic agent: When personnel with PPE entry into the area∙ Toxic agent detectors</td></tr><tr><td>Self-Protection</td><td>Minute 0 until the threat has been neutralised ∙ Remove∙ Personal Protective Equipment (PPE)</td><td>∙ SUMMA112 CBRN unit staf access with a category III, type 3 PPE</td></tr><tr><td>TriageEmergency Treatment Station (ETS)</td><td>Sources at scene: minute 5 until several hours ∙ First triage (dual). ‘Walk or cannot walk’∙ Second triage. Priority of assistance: STARTtriage∙ Second triage in warm zone in casualty concentration área</td><td>Triage can last from minute 5 till the end of incident∙ ETS: specifc treatment and antidotes</td></tr><tr><td>Contamination control point CBRNDS</td><td></td><td>From the frst 20 min to several hours∙ Measure the contamination ∙ Warm zone∙ SUMMA112 decontaminates the victims ∙ PPE is needed</td></tr><tr><td>StabilisationEvacuation priority</td><td></td><td>From the minute 20 to several hours ∙ Third triage: priority of evacuation ∙ Cold zone∙ Usual PPE</td></tr><tr><td>Reducing efects on population and environ- ment</td><td>From the minute that the sources approach and incident and apply waste management protocols</td><td>From the minute 20, when set up the SanitaryDecontamination Station∙ Foot baths are required∙ Waste collection Company</td></tr></table>by visual information, which consequently leads to an important bottleneck and delay when it comes to efcient communication.<a id="bookmark18"></a>2 Chemical, biological, radiological and nuclear (CBRN) incident value fowchart• The experience gathered over time from the long history of chemical incidents has forced us all to develop strate- gies based on the lessons learned, including a regulatory framework and training protocols. The Community of Madrid’s Emergency Medical Service, SUMMA112, responds to incidents of a CBRN nature with two linesa 灬<img src="/media/202408//1724856297.447697.jpeg" />Fig. 6 CBRN incident communication fowchart<a id="bookmark19"></a>of action: a frst response involving organisational tasks and medical assistance and a second response, CBRN specifc, involving specifc decontamination, agent neu- tralisation and treatment, as detailed in Table <a href="#bookmark18">1</a>.• Following the Lean Healthcare method, we have created a step map to display what happens at each step and stage that a contaminated patient afected by a CBRN incident goes through, from the time they are afected until they arrive at the hospital for fnal treatment. Once an inci- dent occurs, all initial processes are primarily aimed at reducing harm to casualties and improving their survival rate. Reducing response times, improving the safety of responders and patients, guaranteeing the quality of care and prioritising evacuation to appropriate centres are fun- damental objectives in this process.Amongst some of the potential improvements to SUM- MA112’s response value stream would be to implement tools for use at the Emergency Operations Centre (EOC) to enable early CBRN incident detection; initial accept- ance to do so would improve triggering of the specific protocol, help optimise response times and increase the safety of responders; such tools would allow for trans- versal communication flows and offer adequate informa- tion at different response phases, so essential for ensuring smooth procedural continuity; coordinating early inter- vention by simultaneously communicating with other response teams, equipping SUMMA112 with CBRNrisk detection systems, providing early information on detected risks and improving systems for detecting excep- tional risks are actions to be seriously considered in the future for a perfect response using high-quality criteria (Fig. <a href="#bookmark19">6</a>).3 Pilot study descriptionIn Spain, a case study (Use Case 7) was carried out at the end of 2022 in the Old Oncology Hospital in Villaviciosa de Odón (Madrid). SUMMA 112 and a Rescue and Detection Team with dogs carried out an earthquake drill for two dif- ferent scenarios. The frst consisted of a search-and-rescue operation for victims in collapsed structures following an earthquake. Subsequently, a second scenario showed a hypo- thetical ammonia and chlorine release. All the professionalsinvolved participated in a voluntary way. They received and signed an inform consent following the requirements of Law 14/2007, of July 3, 2007, on biomedical research, of Organic Law 3/2018, of December 5, 2018, on Personal Data Protec- tion and guarantee of digital rights, and the regulations that develop them.Thirty minutes after the start of the incident, the gas detection monitor warned of the presence of fammable gas. As a result of the earthquake, a gas leak occurred in a ware- house, causing defagration followed by an explosion. The ammonia leak was caused by a burst refrigeration pipe. This ammonia leak was simulated using liquefed gas, causing aa 灬<img src="/media/202408//1724856297.464336.jpeg" />Fig. 7 Concorde inter-stage platform<a id="bookmark20"></a>toxic cloud in the area. SUMMA 112 and GIRECAN (Inter- national Rescue Group for Natural Disasters) responded to this situation by implementing the CBRN protocol.Both scenarios required the coordination plan of dif- ferent emergency teams, including fre fghters, a canine rescue group, Civil Protection and the Emergency Medi- cal Service with its SUMMA 112 call coordination centre belonging to the Community of Madrid. The technical partners and coordination of SnR project supported the pilot there, in a complete form.The new technological tools tested in this pro - ject included the CONCORDE communication plat- form (Angelidis et al. <a href="#bookmark11">2022</a>), which provided the EOC and medical staf with real-time information on everything that was happening at the scene of the incident. This commu- nication system collected information on both the victims and on what happened at the scene. On this platform, dif- ferent roles were assigned, allowing for a better response to the emergency situation. The “High Commander” was based at the EOC using the programme with a laptop com- puter, being the frst person responsible and the one who registered the incident in the system; they also allowed access to the rest of the participants and teams involved in the emergency. At the scene of the incident, the “Field Commander”, using a tablet computer, coordinated the entire operation from the working area. Both roles, from their diferent positions, received real-time information from the “Triage Runner”, the person in charge of making a rapid assessment of the vital signs of the casualties and prioritising them for evacuation (Fig. <a href="#bookmark20">7</a>).Similarly, both the High Commander and the Field Com- mander were able to communicate with the other responders, one of whom was wearing a smartwatch with an emergencycommunication app to provide messaging and hazard alert functions, as well as an emergency notifcation service to alert civilians of hazards and send directions to the popula- tion on appropriate exit routes from the disaster area and safe points of assistance. The responders also tested and validated a smart textile uniform (Girald et al. <a href="#bookmark12">2021</a>), which sent real-time information to the High Commander and Field Commander, as well as a smart paediatric immobilisation device (Giraldi et al. <a href="#bookmark21">2023</a>). The latter was used to carry a baby located under debris, guaranteeing its safety, avoiding further risks and preventing future sequelae.On the other hand, the use and integration within the Con- corde system of scanning performed by a rescue professional carrying a six-gas monitor connected to the Concorde hand- held application was tested, the monitor consisting of several chemical sensors, the appropriate ones being used to detect ammonia and carbon monoxide from human activities. This type of monitor increased personal protection levels, includ- ing safer entry into semi-enclosed or enclosed spaces and detection of gas leaks at the scene of the incident. The simu- lated gases detected were ammonia and carbon monoxide (Search and Rescue H2020 Project <a href="#bookmark22">2023</a>).4 ResultsWhen applying new technologies to a CBRN incident, the areas for improvement detected during a CBRN disaster by the emergency services of the Community of Madrid were taken into account. The identifcation of shortcomings was carried out by analysing both the initial phases, prior to the response protocol, as well as during the incident response phase.a 灬This improvement of capabilities in the face of CBRN disasters increases the resilience of the emergency health service that serves the population and thus the entire afected community.Disaster risk reduction is a common concern for all states and the extent to which emergency services and countries can improve and efectively implement disaster policies and measures, in the context of their respective circumstances and capabilities, aligns with the ultimate goal of increasing global disaster resilience (What is the Sendai Framework for Disaster Risk Reduction? <a href="#bookmark23">2023</a>).Improvements to a CBRN incident under this Search and Rescue initiative were achieved by implementing the Con- corde platform, a state-of-the-art software tool that facili- tated coordination and decision-making processes during the crisis and improved small- and medium-scale medical emergency responses, both local and regional, from respond- ers, ofcers and managers alike. This coordination amongst those involved in the emergency involved immediate feed- back from the monitored results of the rescuers’ smart uni- forms, both during the frst response phase of the earthquake and afterwards (the smart uniform includes the vital signs sensor, under the personal protective equipment against CBRN risks). The platform synchronises with the chemical gas detector, smartwatch and GPS. Warning alerts can be immediately issued and transversally shared for zones where toxic concentrations of carbon monoxide are dangerous.Using the “Assess” screen of the Concorde communica- tion platform, information was collected on the health condi- tion of the casualties attended, providing triage-correlated results with standardised severity colours (in accordance with the score after algorithmic analysis of injuries), includ- ing the identifcation of casualties (when conscious, assign- ing an identifcation number in all cases).The results of this pilot study show the improvements when using technological tools in the processes involved in coordination, search and rescue and medical assistance during CBRN incidents. Coordination improved, reducing response times compared to using TETRA communication, zoning and warning times also decreased, and the safety of responders, communication between diferent teams, inter- disciplinary collaboration and inter-organisational informa- tion exchange on the ground, as well as with the EOC, all saw a defnite improvement. As a result, response times in rescuing victims are reduced, signifcantly improving casu- alty assistance and medical care.The on-the-ground application of the Concorde software platform improved coordination, communication and deci- sion-making during emergencies at both small-scale (intra- organisational) and large-scale levels, encompassing local and community zoning. This is made possible thanks to the real-time collection of incident data via sensors incorporated into the rescuers’ smart uniform, also by Global PositioningSystem (GPS) geolocation of rescuers, as well as casual- ties and potential hazards, such as CBRN risks, allowing immediate risk assessment for responders to be evaluated from the EOC.The Concorde communication platform helped us to immediately convey information to the EOC and all main players in real time as to what was happening during the emergency, thereby improving communication, response safety and decision-making by frst responders, optimis- ing victim rescue times and providing a shared, dynamic operational approach to the earthquake and its subsequent chemical release.In terms of user-friendliness, all participants who tested this device rated the platform positively, saying it provided a lot of information in real time and has an intuitive, easy to use interface.The smartwatch, worn by the frst responder wearing the smart uniform, has a built-in emergency communication application by Bluetooth that ofers messaging, vital signs monitoring and warning functions, all interfacing with the Concorde platform, providing added safety for frst respond- ers that was previously unavailable during a CBRN emer- gency. In terms of usability, the responders who tested this device agreed that it is the perfect size and weight.The gas detector present in the frst responder’s smart uni- form is the optimal solution for detecting ammonia, propane, carbon monoxide, oxygen, chlorine and carbon dioxide, allowing the zoning of hazardous areas and informing all responders of their location; geolocation of a CBRN atmos- phere and communication to all teams simultaneously, was previously very difcult without this device. In terms of user-friendliness, those who tested this device suggested that it should be lighter in weight to improve usability.The inbuilt mobile GPS tracker included in the respond- er’s smart phone, remotely tracks and synchronises in real time to the Concorde platform, correctly transmitting data and increasing safety for responders that was previously unavailable during a CBRN emergency. In terms of ease of use during the pilot study, the device was found to provide real-time location of both victims and responders.The smart uniform equipped with body sensors also improved results compared to what we had before: previ- ously, during a CBRN incident, there was no possibility to geolocate personnel involved in the emergency in a risk area, nor did we have access to vital signs (heart rate, respiratory rate, blood pressure, oxygen saturation, electrocardiogram and temperature) and were therefore unable to transmit in real time the electrophysiological, biomechanical and envi- ronmental data that we can now send directly to the Con- corde application using the sensors in the smart uniform, which is why it ofers far more protection for personnel in terms of chemical injuries. In terms of usability, respondersa 灬Fig. 8 Rescuer in smart uniform sensing at height whilst provid- ing assistance<img src="/media/202408//1724856297.510667.jpeg" />Fig. 9 Female rescuer insmart uniform using paediatric immobiliser for victim transfer (simulation of natural disaster second response)<a id="bookmark24"></a>who tested this device found it comfortable and easy to use, giving a sense of real protection (Fig. <a href="#bookmark24">8</a>).The child rescue system is a device designed to meet the needs of frst responders, based on an aluminium profle structure which is lightweight and very robust, adjusting to the height and weight of the casualty, so the child can be conveniently transported. Compared to devices designed for transporting adults, this is a defnite improvement when transporting minors. In terms of ease of use, responders who tested this device considered the child rescue system to be safe, although they recommended a smaller size forhard-to-reach areas. They considered the weight of the device suitable for carrying and easy to handle and use (Fig. <a href="#bookmark24">9</a>).In the short term, better coordination and response of intervening teams at a natural and complicated disaster zone, with a chemical risk domino efect (Piraina and Trucco <a href="#bookmark3">2022</a>), was assessed, compared to the usual previous work- ing procedures and communication systems. The integrated version of CONCORDE EMS, within the SnR platform, has contained all the functionalities that end users identifed andrated as very important during the CONCORDE piloting and<img src="/media/202408//1724856297.521705.jpeg" />a 灬enhanced with the latest advances in technologies related to the development of a chemical incident.– The applications, services and back-end portals pro- vided decision support capabilities to the out-of-hospital emergency service. Ad hoc web portals and additions to stakeholder systems and back-ofces provided a com- mon, uniform and ubiquitous platform to collect, analyse and share real-time data from sensors, head triage and smart uniform to support management decisions. Certi- fed security access allowed the various stakeholders to access the services provided by the stakeholders. The results of the pilot and testing can be assessed in depth in this link (Aumayr et al. <a href="#bookmark25">2021</a>). It has implemented com- mon, accepted and validated standard operating proce- dures, which have promoted more efcient multi-national and multi-organisational disaster response actions and are fully compatible with existing standard operating procedures (SOPs) in health emergency organisations, EU Member States and international organisations, tech- nological framework and interoperability concepts.5 ArgumentsModelling of emergency management capacity as a method of planning emergency management operations and related information fows is crucial when dealing with a multi-cas- ualty incident from an inter-organisational perspective.This pilot S&amp;R case study used the simulation model to consider the benefts of integrating new technologies. It involved the development of a person-centric, technology- driven solution to support and simplify collaborative plan- ning for optimal frst responder performance and disaster recovery. The simulation model was widely used in this case, given the difculty of fnding results from an experimen- tal analytical point of view due to the limited number of multiple-casualty incidents of this type (Piraina and Trucco <a href="#bookmark3">2022</a>); both advantages and disadvantages were found.The chemical sensors, gas detectors, uniform, smartwatch and integrated mobile GPS tracker used in the project study and implemented during the pilot study showed a defnite increase in safety levels of responders and improved com- munication with the EOC and rest of those involved.These devices allowed monitoring of vital signs, remote geolocation of casualties, responders and chemical hazards, a defnite advantage that was previously unavailable at such short notice during responses to this type of emergency Real-time cross-communication of data using the Concorde platform also enabled recommendation of adequate triage per casualty and the possibility of giving the diferent Ofc- ers involved in the incident vital information regarding risks,survivability and other data concerning the allocation of resources on the ground.Proof of concept and superiority demonstrates that use of the new technologies implemented in this pilot project com- pares meaningfully and has defnite advantages over cur- rent methods and solutions being used; this rationale stems from the positive feedback from responders and excellent results regarding multi-casualty incident coordination, accu- rate triage application and efectiveness of interdisciplinary communication on the ground. However, it should be noted that the use of Concorde in other types of disasters involv- ing diferent emergency services requires the assignment of clear roles and responsibilities, good coordination of opera- tional synchronisation and the smooth fow of information received by those involved in the incident; these are just some of the difculties to face when deploying emergency services as critical infrastructure and collaboration therewith (Piraina and Trucco <a href="#bookmark3">2022</a>). It should also be pointed out that Concorde has been designed to meet the specifc needs of diferent emergency services (Final Report Summary— CONCORDE (Development of Coordination Mechanisms During Diferent Kinds of Emergencies) | FP7 | CORDIS | European Commission <a href="#bookmark26">2023</a>). A method for implementing new technologies in disasters has been developed in line with value-based healthcare standards and integration of technical solutions into current emergency procedures in Europe.As previously mentioned, a key aspect in managing a CBRN incident is early risk detection and reporting thereof to the EOC, where a series of decisions are taken, including the ofcial declaration of a Multiple Casualty Incident and mobilisation of specifc second response units (CBRNUnit), implementing the aforesaid technologies helps improve safety of responders and reduce response times by enabling the detection of a CBRN threat in under 5 min. By geolo- cating victims, responders and the CBRN threat itself via GPS; such technology improves the quality of assistance given, improving communication with the ICP and facilitat- ing decision-making via the Concorde platform.Our results are consistent with those found in the study by (Zambrano Cancañón et al. <a href="#bookmark27">2019</a>), demonstrating that the application of the Lean method in medical assistance increases the quality of services provided, reduces time, ofers a complete solution for users, optimises the efcient use of resources and reduces risk situations for emergency professionals and volunteers.Our fndings are also consistent with the conclusions reached by Dickson in his work published in Annals of Emergency Medicine (Dickson et al. <a href="#bookmark7">2009</a>), which show that the principles of Lean methodology can lead to changes in behaviour and substantial improvements in the quality of emergency assistance. However, the latter paper states that improvements are not universal and are afected bya 灬leadership and the involvement of frontline workers, sug- gesting the importance of team leaders and workers them- selves in improving and changing the process to obtain better results, as well as suitable follow-up with positive reinforce- ment of the measures implemented in line with the afore-said methodology to guarantee that process improvement issustained over time.5.1 LimitationsIn order to prospectively confrm Dickson’s previous state- ments, results would need to be reviewed in later pilot stud- ies and with a diferent type of scenario belonging to the so-called CBRN category. This has been partially mitigated by recruiting local emergency personnel from the diferent fre, medical, and police services involved in the project in the seven case studies, although results have been obtained that imply improvement at all levels contemplated in said study. These results, however, would beneft from long-term tracking and evaluation, following the dynamics of continu- ous quality improvement.<a id="bookmark11"></a>6 Conclusion<a id="bookmark25"></a>This case study may serve as a reference for emergency services in diferent contexts involving diferent groups, both for operational response in disasters and to support <a id="bookmark5"></a>emergency planning and risk analysis. The results of this study support new ways of delivering value-based medi- <a id="bookmark17"></a>cal assistance that focuses on each individual and profes- sional by implementing ICT healthcare solutions in disasters <a id="bookmark14"></a>and fnally contributing to societal resilience to disasters. Through the lean method, we have found critical points for improvement. Efective performance and communication between the actors involved in disasters, supported by new technologies, allows for improvement in the resolution and safety of this type of incident.These technologies help emergency services to improve the results of their interventions, reducing the impact of dis- asters on the environment, structures, and people.<a id="bookmark7"></a>It is vital the special surveillance and assurance of build- ings and surroundings that present a higher risk in case of a Chemical incident, considering that these types of structures can be very close to population centres.Author contributions AMC-S, CC-G, CH-G, CG-U, and RG-M wrote the abstract, keywords, introduction, and methodology and prepared the fgures. RL-S and TS-G wrote the pilot description; CM-P and AMC-S wrote the results, AB-L, TV-R and AMC-S wrote the argu- ments, AMC-S and CC-G wrote the conclusions. All authors reviewed the manuscript.Funding This article has received funding from the European Union’s Horizon 2020 research and innovation programme under the projectSearch and Rescue “Emerging technologies for the Early location of Entrapped victims under Collapsed Structures and Advanced Weara- bles for risk assessment and First Responders Safety in Search and Rescue operations” with the Grant Agreement No 882897.DeclarationsConflict of interest The authors declare that they have no confict of interest.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. 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