International Journal of Advance Research, Ideas and Innovations in Technology

ISSN: 2454-132X
Impact Factor: 4.295
(Volume7, Issue2 - V7I2-1156)
Available online at: https://www.ijariit.com
Improving paramedic preparedness to mass casualty incidents:
an implementation study using PARIHS framework
Ahmed Alharbi
[email protected]
Emergency Medical Services, Ministry of Health. Kuwait

ABSTRACT
It has been observed that healthcare workers, prehospital care providers, as well as other frontline responders, are often made
responsible to be both willing and able to provide a timely response in the events of disaster. Even though Kuwait is situated in
a politically conflicting zone where the country has witnessed several major incidents, prehospital care providers are still not
given standardized preparation training to respond to these incidents of disaster. There is also a lack of evidence related to the
ambulance staff’s preparedness status in Kuwait to manage disasters. Moreover, to evaluate the socio-contextual factors related
to the implementation procedures of mass casualty training, limited studies have been conducted in the existing body of literature.
Problem: This study has tried to address the problems or barriers that are undermining the preparedness of prehospital care
providers under the events of disaster or mass causality by utilizing the PARIHS model.

Keywords: Paramedic, Disaster Medicine, Mass Casualty, Professionalism, PARIHS Framework, Leadership
1. INTRODUCTION
It has been observed that emergency medical services (EMS) often play a crucial role under planning, recovery, and providing
timely responses while dealing with the events of disaster. 1 In this regard, agencies related to prehospital care are typically made
responsible to deal with such incidents or major disasters. This is because in these situations their role typically exceeds in
comparison to normal or every day cases of emergencies in which they are required to attend to a single patient. Moreover, they are
also considered as first responders who deal with disturbing or stressful situations which also sometimes compels them to work
under risky or hazardous weather conditions. 2

In such disastrous incidents, it is also considered highly important for prehospital care providers to act swiftly to provide the utmost
benefits to their patients by also maintaining their own safety, as well as the safety of others who are found on the scene. To do this,
they are required to set control and command, triage, provide treatment to victims, and transfer these victims/patients at the nearby
healthcare facilities.3

Thus, one can infer that without modern and effective healthcare system under prehospital settings, people can suffer from additional
or preventable mortality and morbidity under the occurrence of major incidents.4 In this regard, the interest in creating and providing
robust service related to medical emergencies and empowering prehospital care staff can be considered as a highly significant issue
related to public policy. In such issues, key stakeholders that are impacted after the occurrence of a casualty/disastrous incident
include the healthcare officials, government institutions, health professionals, national security agencies, as well as other
businesses.5

There is also a consensus that appropriate training should be given to the prehospital care providers so that they can provide adequate
responses by utilizing a formal major incident management command system. 6 This approach is usually described as an organized
process for managing resources and personnel during the occurrence of a mass casualty event. 7 Thus, the main objective of this
study is based on implementing a training intervention to enhance the awareness and knowledge of paramedics and EMTs under
the Kuwait Emergency Medical Service (KEMS).

It has also tried to enhance the preparedness of prehospital care providers related to managing such mass casualty events. By using
the PARiHS framework, the study has also assessed the socio-contextual factors that are hindering the appropriate implementation

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 International Journal of Advance Research, Ideas and Innovations in Technology

of mass casualty training under a prehospital setting. Finally, by introducing a training program associated with the mass casualty,
the study has tried to increase both the confidence and knowledge of prehospital providers in providing adequate responses under
the crisis situation.

2. METHODS
This research has utilized a mixed methodology8 for which a case study was used to carry out qualitative analysis, while the
quantitative analyses were conducted by making post-test and pre-test evaluations of the effectiveness of MCIs training that was
implemented in KEMS. The case study method was used to obtain information and study the political, economic, and social factors
that are currently prevailing in Kuwait and impacting the effectiveness of prehospital care providers. Whereas, for quantitative
analysis, post-test and pre-test evaluations were made by using PARiHS framework.9

This framework can be described as a setting or an environment under which healthcare services are offered to the patient. It can
also be defined as an environment where change practices are used and evidence is implemented. However, in this study, a
modified/updated PARiHS framework was used to offer clear operational and conceptual definitions, practical information, and
data about the realities of application and measurement approaches. Moreover, the framework involved the use of four modified
steps related to gathering data, creating and testing educational programs, conducting analyses of the collected data, and
refining/reviewing the program based on the results of the analyses.10

The framework was utilized as an intervention to enhance the preparedness of prehospital caregivers. Furthermore, under this design,
questionnaires were used to collect data and while conducting the pre-test analysis, performance, and situations in which prehospital
caregivers work were examined, including thessir competence and quality of services. From different ambulance districts of Kuwait,
thirty-one participants were also chosen (by using convenience sampling method) who were asked to fill the questionnaires and they
were also given disaster management training under the Kuwait EMS department.

In addition to this, after the implementation of this training program which was created by considering the framework of PARiHS,
post-analysis was made to again assess the potential improvements under the competence and quality of services that are provided
by prehospital caregivers. The utilization of mixed research also helped in gaining more information related to creating effective
intervention strategies.

To analyze the quantitative data under this study, SPSS software edition 22 was used (which is provided by IBM).11 This also includes
the implementation of a dependent t-test to assess the mean difference under the knowledge scale between immediate post-tests/pre-
test results and delayed post-test scores. Standard deviations and means were utilized to comprehend the responses of the patients
towards post-training and pre-training surveys where the p-value of <0.001 was considered statistically significant. Similarly, t-test,
repeated measures analysis of variance, as well as one-way ANOVA test were also utilized to study and analyze the collected data in
this research.

3. RESULTS
The results of the first intervention indicated that changes under the knowledge at the mean score were substantially higher,
immediately after the implementation of this intervention at t(30) = -15.3, p < 0.01. The mean score of the participants for twenty
multiple-choice questions was higher (i.e., 12.35) under the pre-test results in comparison to post-test results (i.e., 18.19). Whereas,
the lowest mark that was recorded in the pre-intervention was 6 but it was increased to 14 as per the post-test results. Many
respondents were also able to score 20 marks within the post-tests, indicating that the training was effective to enhance the
knowledge of participants about MCIs management (see appendix 1).

After the first intervention, the results of the second follow-up intervention also revealed that the changes under the knowledge of
the respondents at the mean score were substantially higher immediately after the implementation of this intervention at p-value
(0.000 < 0.01). The mean score in the 20 multiple choice questions under the post-test was observed to be around 18.19. Whereas,
after this post-test training, the lowest score of 2 was increased to 14 marks in comparison to the lowest score of 6 under the initial
pre-intervention of the first training program. Moreover, many respondents were also found to score as high as 20 marks, indicating
the effectiveness of the training in enhancing their knowledge about MCIs management.

At the end of the training under the second intervention, participants were also given another test after 3 months and the combined
results of all these tests indicated a noteworthy difference within the knowledge assessment scores of all three occasions (i.e., 3
months post- intervention, pre-test, and post-test). After the implementation of the second training course, an increase can be
observed under the mean score by 19.80. Moreover, the results are also highlighting significant differences under the attempts that
were made in all the three tests at p- value < 0.01. Furthermore, the scores indicating improvements under the results of both post-
test 1 and 2 were also recorded at t(30) = -5.1, p < 0.001 (see appendix 2).

4. DISCUSSION
The test results related to the first intervention showed that the training course (having a duration of five hours) was more beneficial
in meeting the training requirements of prehospital care providers at KEMS. These benefits were also evident under the training
sessions, including the results that were obtained from the course evaluation report. Score comparison before and after the
intervention also indicated that the training sessions were able to improve both the awareness and knowledge of the prehospital care
providers. The overall evaluation of the facilitation factors and context of these training sessions was conducted by using the
PARIHS assessment tool and the ratings for each of these facilitation factors and context has been provided in table 3 (see appendix
3).

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 International Journal of Advance Research, Ideas and Innovations in Technology

Similarly, the results of the second training course were also able to confirm the value and worthiness of the MCIs preparedness
training for enhancing the awareness and knowledge of prehospital care providers. The first intervention was found to positively
impact both the participants, as well as other paramedics’ understanding and knowledge about MCI. This positive impact was also
verified from the applications that were sent to the planning department that was part of the training courses. This, as a result, helped
in raising the awareness of the significance of these training sessions and convinced both the first-line managers and directors of
KEMS to provide support in carrying out the second training course.

The cultural and contextual enhancement further facilitated the implementation procedures for the second training session/course.
The results of this experimental intervention also helped in formulating a novel constructive and receptive culture in KEMS that has
the potential to foster collaboration and coordination for future training projects. However, the findings of these experiments also
revealed that the submission of the training course as a standardized training procedure under the authority of the KEMS department
could have further helped in strengthening the intervention. This, in turn, would have helped in achieving continuous quality
improvements. The results of the assessments that were conducted by using the PARiHS framework to measure the effectiveness
of the second intervention have been provided in appendix 4.

However, this study is not without its limitations. For instance, one such limitation is related to the small size of the sample that can
compromise the external validity of the above findings and their generalization in the larger population. 12 Moreover, the inferences
that have been made in this study are also limited to the prehospital care settings, thus the results obtained from the analyses cannot
be generalized on other types of respondents. Future studies on this topic should try to narrow down the analysis to conducting more
specific evaluations like determining the significance of management and technology in enhancing the skills of healthcare workers
and improving the performance of the prehospital care sector.

5. CONCLUSION
Due to the growing number of emergency incidents in Kuwait, the need for well-trained prehospital care providers cannot be
overlooked. Emergency incidents from explosions, terrorist attacks, and major accidents all require a well-educated and experienced
workforce at the scene to properly handle MCIs. 13 The Ministry of Health in its efforts to ensure preparedness in managing mass
causality events should ensure that proper and well-trained prehospital providers are employed in ambulance centers. Training of
staff also stands to be the best method of preparing for emergencies.

For help care providers, it is essential for the Ministry of Health to enhance their professionalism and competence through
approaches such as continuous education. Moreover, this study has demonstrated that the EMS provider’s interests of enhanced
knowledge should be encouraged by health authorities such as the Ministry of Health and other healthcare organizations that are
committed to implementing training programs. Furthermore, improper coordination and collaboration between different
departments in health facilities is captured as one of the barriers to effective training of EMS providers despite the EMS providers’
interest in being trained. EMS should, therefore, ensure sufficient training manpower to deal with manmade and natural disasters.
Similarly, as reflected in the PARiHS framework evaluation, it is evident that consistent training of the prehospital caregivers should
be the foundation of improving the skills and professionalism of these individuals. However, for this to take effect, it is important
for organizations to adopt effective leadership and management strategies. In summary, this research has established that there is a
need for consistent training among prehospital care providers which is related to improving their abilities to deal with disasters and
mass casualty catastrophes. Important aspects of enhancing these individuals’ skills include effective management and performance
appraisal which improves their motivation. Thus, it can be concluded that it is important for emergency medical services departments
that they always ensure lifelong learning among the prehospital caregivers and improve on leadership and management approaches
that can aid in enhancing the welfare of the patients and reduce the mortality rates.

6. REFERENCES
[1] Lennquist, Sten, ed. Medical response to major incidents and disasters: a practical guide for all medical staff. Springer Science
& Business Media, 2012.
[2] Davis, Dave, and Robert Galbraith. "Continuing medical education effect on practice performance: effectiveness of continuing
medical education: American College of Chest Physicians Evidence-Based Educational Guidelines." Chest 135, no. 3 (2009):
42S-48S.
[3] Terrill, W. Andrew. Kuwaiti national security and the US-Kuwaiti strategic relationship after Saddam. Strategic Studies
Institute, US Army War College, 2007.
[4] Al-Kandary, Nadia, and Salah Al-Waheeb. "Patterns of accidental deaths in Kuwait: a retrospective descriptive study from
2003–2009." BMC public health 15, no. 1 (2015): 1-5.
[5] Angantyr, Lars-Göran, Eskil Häggeström, and Per Kulling. "KAMEDO Report No. 93—The Power Failure at Karolinska
University Hospital, Huddinge, 07 April 2007." Prehospital and disaster medicine 24, no. 5 (2009): 468.
[6] Beaton, Randal D., and L. Clark Johnson. "Instrument development and evaluation of domestic preparedness training for first
responders." Prehospital and disaster medicine 17, no. 3 (2002): 119-125.
[7] Chaffee, Mary. "Willingness of health care personnel to work in a disaster: an integrative review of the literature." Disaster
medicine and public health preparedness 3, no. 1 (2009): 42- 56.
[8] Kettles, A. M., John W. Creswell, and Wanqing Zhang. "Mixed methods research in mental health nursing." Journal of
psychiatric and mental health nursing 18, no. 6 (2011): 535-542.
[9] Stetler, Cheryl B., Laura J. Damschroder, Christian D. Helfrich, and Hildi J. Hagedorn. "A guide for applying a revised version
of the PARIHS framework for
[10] implementation." Implementation Science 6, no. 1 (2011): 99.
[11] Harvey, Gill, and Alison Kitson. "PARIHS revisited: from heuristic to integrated framework for the successful implementation

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 International Journal of Advance Research, Ideas and Innovations in Technology

of knowledge into practice." Implementation science 11, no. 1 (2015): 1-13.

[12] Santoso, Singgih. "SPSS 22 from essential to expert skills." Jakarta: PT Elex Media Komputindo (2014).
[13] Etikan, Ilker, and Kabiru Bala. "Sampling and sampling methods." Biometrics & Biostatistics International Journal 5, no. 6
(2017): 00149.
[14] Alharbi, Ahmad Abdullah. "Effect of Mass Casualty Training Program on Prehospital Care Staff in Kuwait." The Egyptian
Journal of Hospital Medicine 71, no. 6 (2018): 3393-3397.

APPENDICES

Appendix: 1
Table 1: Comparison between pre and posttests results
N Minimum Maximum Mean SD
Pretest results 31 6 18 12.4 2.8
Posttest results 31 14 20 18.2 1.9

Appendix: 2
Table 2: The posttest knowledge score after the second training
N Minimum Maximum Mean SD
Posttest results 31 18 20 19.8 0.5

Appendix: 3

Table 3: Results of PARiHS culture and facilitation Assessment for the first intervention
PARiHS construct and sub-elements First Intervention
Context
Leadership Low – Leadership support the MCIs training.
Culture Low – Low awareness, local environment is
unsupportive, limited opportunity for
innovation.
Evaluation Mixed – Some auditing of and/or feedback on
group and/or individual performance.
Context assessment Low context (C)
Facilitation
Characteristics of facilitator and style High – Exhibition of commendation of
respect, credibility, and empathy.

Role of facilitator High- Participants reported that facilitator a

flexible. Well defined and clearly role to support
implementation.
Facilitation assessment High facilitation ( F )

Overall ratings of PARiHS constructs LC, HF

Appendix: 4
Table 4: Results of PARiHS Assessment for the Second Intervention
PARiHS construct and sub-elements First Intervention
Context
Leadership Mixed – Majority of leadership support the MCIs training. Still conflict
present and incoordination.
Culture Mixed- Awareness improved, local
environment became more supportive, the intervention perceived positively.
Evaluation Mixed – Some auditing of and/or feedback on
group and/or individual performance.
Context assessment Mixed context (C)
Facilitation
Characteristics of facilitator and style High – Exhibition of commendation of
respect, credibility, and empathy.
Role of facilitator High- Participants reported that facilitator a
flexible. Well defined and clearly role to support implementation.
Facilitation assessment Mixed facilitation ( F )
Overall ratings of PARiHS constructs MC, HF

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