the online version of this article ( doi:10.1007/s00068 - 010 - 0067 - 0 ) contains supplementary material , which is available to authorized users .
a disaster or major incident causes a sudden , unexpected surge of casualties . in general , disasters produce physical injury .
medical management does not simply involve treating these like in regular trauma care in upscaled proportions , but requires a paradigm change in concepts , approaches and mindset .
preparation and training is essential to cope with the challenge of providing optimal care and to minimize excess morbidity and mortality [ 1 , 2 ] .
since 1991 , the netherlands has had a major incident hospital ( mih ) to provide immediate medical emergency care for multiple casualties under exceptional circumstances .
this unique facility is strictly reserved , with expertise and complete infrastructure waiting to provide large scale emergency care with disasters and major incidents .
its missions are divided into five scenarios indicating deployment : war ( threat ) , crisis or conflict management in which large numbers of casualties need careaccidents abroad involving dutch citizens , civilian or military , in need of repatriation and medical carespecific incidents , attacks or large - scale accidents in the netherlands that exceed the regular care capacityinternational medical assistance from the dutch government concerning the treatment of foreign victimsquarantine care for patients with special infectious and highly contagious diseases , such as sars ( severe acute respiratory syndrome ) .
war ( threat ) , crisis or conflict management in which large numbers of casualties need care accidents abroad involving dutch citizens , civilian or military , in need of repatriation and medical care specific incidents , attacks or large - scale accidents in the netherlands that exceed the regular care capacity international medical assistance from the dutch government concerning the treatment of foreign victims quarantine care for patients with special infectious and highly contagious diseases , such as sars ( severe acute respiratory syndrome ) .
the opening of the mih is an essential part of the disaster plan of the university medical centre utrecht ( umcu ) and the central military hospital ( cmh ) .
the mih is located in a nuclear bunker under the umcu , which is in turn connected to the cmh by a corridor .
an emergency response protocol enables admittance to the normally dormant hospital of up to 100 patients after a start - up time of only 15  min . with an additional 45  min
the organization , infrastructure and training are all directed around triage to guide patient flow through successive echelons of care in order to deliver the greatest care to the greatest number of people ( figs .  1 , 2 ) .
the patient barcode registration system ( pbrs ) with european article numbering ( ean ) codes guarantees quick and adequate registration to facilitate good medical coordination and follow - up during a major incident .fig . 
2entrance of the ambulance hall of the mih entrance of the ambulance hall of the mih as analysis of the implemented organization and clinical management could identify helpful decisions and errors , we evaluated the use of the mih and its admissions during the past 19  years .
research and evaluation of past incidents provide knowledge for preparedness and response to unknown future incidents and are essential for further improvements . systematically evaluating
the quality of medical response to major incidents is difficult , though , especially because of obvious differences in the types of disasters and a wide variety in modes of evaluation .
performance indicators for the quality of the medical response are scarce but have been evolving in the past decade .
critical mortality rate ( the percentage of severely wounded victims who die ) , for example , gives an indication of the magnitude of the disaster and of the effectiveness of the medical management [ 5 , 6 ] . to evaluate the performance of the mih
, however , this tool would be too general and more reflective of the performance of the total of disaster response than of hospital care alone .
suggest a set of 20 performance indicators that they applied to 13 earlier reports on major incidents issued by the kamedo organization in sweden .
these consist mainly of timeframes for decisions and actions at the scene and at the level of command and control , predominantly prehospital .
they also developed some performance indicators for testing the skills of hospital management groups in simulation exercises .
some indicators of preparedness , not performance , have been used to evaluate us trauma centre preparedness .
lennquist suggested a template to report major incidents , the protocol for reports from major accidents and disasters ( prmd ) .
it offers a standardized methodology for reporting results and experiences from major accidents and disasters to improve comparability .
the protocol is divided in 18 headings concerning components of the incident as well as of the response , complemented with standardized tables .
although originally developed to evaluate and report about individual major incidents , it offers us a concise and practical template to direct the evaluation of the mih deployment , as well as a standardized method for reporting .
in this study , we evaluate the use of the mih since its founding in 1991 , according to the prmd   and along with our five scenarios for activation .
what are the strong points in group treatment ? which changes led to identifiable and sustainable improvements ?
inclusion of the prehospital evaluation for 34 incidents is beyond the scope of this analysis .
we retrieved all data from the evaluation reports of every mih deployment since its founding in 1991 .
reports had been made directly after the event as part of the debriefing in almost every admission , and had been discussed among involved disciplines for learning points and accuracy .
one of the authors ( jvde ) participated in all admissions and evaluations until 2008 except the repatriation of fugitives from kosovo ( 1999 ) .
demographic and quantitative data were registered ( such as number of patients , types of injuries , hospital resources ) .
all applicable data were registered according to the pmrd protocol , which is divided into 18 headings that we used to direct our evaluation ( see table  1 ) .
the standardized tables from the protocol were used , sometimes extended with additional columns . for qualitative , descriptive values we abstracted the results of all admissions and further discussed admissions which revealed the most interesting learning points.table  1headings from protocol for reports from major accidents and disasters headings1short summary of the scenario*2description of hazard(s ) causing the accident*3description of the accident*4prehospital resources available and alerted5hospital resources available and alerted*6utilization of transport resources7hospital alert plan and response*8coordination and command*9hospital damage*10communication system*11computer technology and back - up systems*12total number and type of injuries*13severity of injuries*14hospital load*15psychological reactions*16outcome17estimated number of people affected but not injured18post - accident evaluation * * data available for analysis headings from protocol for reports from major accidents and disasters   * data available for analysis
the subheadings in this paragraph are analogous to the 18 subheadings of the prmd.summary of the scenario / hazard , description of accidentall 34 consecutive deployments of the mih are depicted in table  2 , summarized with short descriptions of each event and the type of activation scenario .
military victims ( 29 ) accounted for 5% of the admitted patients and 18% of the deployments .
two hundred and twenty - six ( 38% ) dutch victims of major incidents abroad were repatriated in 12 group admissions , whereas national incidents accounted for 260 patients ( 47% ) and 35% of the deployments of the mih .
the rest consist of 4 openings to offer care for foreign incident disaster victims ( 44 patients , 10% ) .
special infectious disease admissions did not take place . for national incidents the distances from the scene to the mih ( 0.360  km )
, the country of repatriation is depicted , at distances varying from several hundred to thousands of kilometers.table  2overview of use of the mih : year , number of admitted patients , short description of the incident , distance ( km ) from the scene , cohort quarantine and main type of scenario for deployment of the mih ( see below)yearnumber of patientsincident characteristics ( location of incident)distance , or country if abroadquarantinemain scenario*19919methyl bromide intoxication ( used by gardeners decontaminating greenhouses)45  kmno319919carbon monoxide intoxication ; insufficient boiler in non ventilated space ( utrecht)510  kmno3199210carbon monoxide intoxication of fireman on duty510  kmno319925exposure to nitrous damps (  ) 510  kmno3199228evacuation of a hospital in a war setting ( bosnia herzegovina)bosniayes4199213plane crash ( faro ) with a fireportugalyes2199343bus accident ( lyon)franceyes219935evacuation of a hospital in a war setting ( bosnia herzegovina)bosniayes419944bus accident ( regensburg , germany)germanyyes21995143evacuation of a flooded hospital52  kmno319957benzyl bromide exposure ( utrecht)510  kmno3199629bus accident of dutch singing choir ( winterberg)germanyyes2199612cannabis intoxication ( zeist)8  kmno319966aluminium pollution of fluids in dialysis centrecuracaono4199611bus accident ( antalya)turkeyyes2199615carbon monoxide intoxication by inadequate boiler in insufficiently ventilated building510  kmno3199610bus accident of tourist bus from netherlands ( thionville)franceyes219977military accident ( novi travnik , bosnia herzegovina)bosniayes1199713bus accidentsyriayes2199820bus accident of tourist bus from the netherlands ( metz)franceyes219995repatriation of fugitiveskososvoyes4199912earthquake , turkish , dutch residents on holidayturkeyyes220009military accidentgermanyno1200225bus accident of tourist bus from netherlands ( metz , france)franceyes2200221bus accident of tourist bus from netherlands ( manching , germany)germanyyes2200313lab accident , analysis of glue - damp with eye and airway irritation ( methyl metacrylate)0.3  kmno3200525repatriation of wounded dutch tsunami victimsasiayes220076collapse of crane on a campus building0.4  kmno320074repatriation of soldiers from afghanistan ( victims of a suicide bombing while on patrol)afghanistanyes1200825evacuation ( 350 emloyees ) from a contaminated building in amersfoort ( unknown substance)23  kmno320096airplane crash near schiphol airport (  polder crash  ) with 135 passengers60  kmno320094repatriation of military victims afghanistanafghanistanyes120092repatriation of military victims afghanistanafghanistanyes120093repatriation of military victims afghanistanafghanistanyes1total559 * scenario s for activation of the mih : ( 1 ) military victims , ( 2 ) repatriation of dutch victims of accidents or incidents abroad , cohort - isolation for methicilline resistant staphylococcus aureus ( mrsa ) according to guidelines of the netherlands health care inspectorate , ( 3 ) activation of the mih for a national major incident or disaster , ( 4 ) international medical assistance from the dutch government concerning the treatment of foreign victims , ( 5 ) quarantine care for patients with special infectious and highly contagious diseases , e.g. sarsevaluation of  prehospital resources available and alerted  lies beyond the scope of this reporthospital resources available or alertedas the mih is a reserved facility for major incidents , availability of triage rooms ( 35 beds ) , low and medium care beds ( 200 ) , icu beds ( 12 ) , ventilators , radiology unit , operating theaters and trauma unit is guaranteed .
, staffing has never proved to be a problem ; the capacity could always be operational for the first 100 beds within 15  min to half an hour .
training issues of deployed staff are discussed below ( figs . 3 , 4 , 5 , 6).fig . 
6triage and treatment area - red bay , stabilisation of a patient ( photo b de meijer)in the evaluation of optimal use of resources , situations in which the mih was available but not deployed are particularly interesting.an example is the volendam caf fire on new year s eve , 2001 , where 98 victims were transported to 20 hospitals and 100 victims went to different ers of hospitals on their own .
the mih was alerted 7  h after the incident with the request to receive two burn patients that could be regularly admitted to the umcu . in total 11 patients
numerous patients were transferred to a widespread variety of hospitals and it took a full day afterwards to get an overview . a bus with 20  t3 victims ( in the four scale triage system ) was sent to a hospital that turned out to have no capacity left and had to divert to another hospital .
the mih could have better contributed to care and simplifying patient logistics had it been deployed in an earlier stage.the collapse of stairs during a musical parade in 2008   is an example where 19 patients were seen in one trauma centre and the mih was not deployed .
in this case , using the trauma centre or mih were both good options and the choice was a matter of preference of the staff on call . using the mih for first relief would have eased logistics and communication with supporting facilities that were now problematic due to provisional patient numbering .after the plane crash near schiphol (  polder crash 
2009 ) , 42 of the 135 victims patients were transported from the triage site by bus to a sports complex after being triaged as t3 .
the two triage doctors at the sports complex concluded that they needed hospital transfer due to high energy characteristics of the crash and triage levels higher than t3 .
they were spread to several hospitals and it took 4  days to reconstruct the victim list and whereabouts of the patients .
only six patients were transported to the mih.one of the other specialties of the mih is relief of groups of patients in quarantine , which otherwise often generates logistic problems and delay of repatriation to regular hospitals.in 1994 , a group of dutch victims from a bus accident in poland were repatriated to a city hospital instead of to the mih due to political choices of the hometown government , despite prior alert and readiness of the mih .
this resulted in a forced temporary closure of the regular surgery and orthopedic departments due to mrsa contamination.in the faro plane crash in 1992 , 95 patients were repatriated to 6 hospitals including the mih .
this corresponds with 14% of the mrsa category ii patients ( patients with minimum 24  h stay or invasive procedures in a foreign hospital ) .
this led to secondary spread to other patients and staff in one of the burn centers.repatriation in quarantine from thailand to the mih after the 2004 tsunami showed several carriers of mrsa and other multi - resistant microorganisms .
repatriations of military victims from kosovo and afghanistan to our facility also showed multiple victims with mrsa and acinetobacter colonization.of all the quarantine admissions , 61% or more of the patients could be discharged home within the 5  days that are set as a directive to close the mih , or quarantine could be ended due to negative swabs .
transfers under quarantine conditions were reduced to 32% of the patients who were initially treated in quarantine.during the sars threat we adapted our facilities and training to prepare for patients with special highly infectious diseases . since 2003 ,
the mih has changed the air treatment and can provide 4 isolation boxes and 30 medium care beds for this type of scenario.utilization of transport resources was not applicable / evaluated.hospital alert plan and responseopening of the mih is always based on activation of the local disaster plan . when the emergency response program is started , the medical manager of the emergency room activates the personnel alert system through the national civilian telephone network .
this system has specially reserved capacity for use by the disaster management chain . during all deployments ,
communication through this system was never hindered by the inundation of the regular mobile network , as often occurs in disaster situations .
in contrast to a normal , time consuming  calling tree  , results are monitored and adjustable once running , as personnel respond to the system if and when they are available . this system enabled us to tailor the alert . at first
, we worked with different lists adapted to several scenarios but these incurred too much overlap . in the current system
, we can compose the alerted staff by choosing and combining groups , e.g. , 
the system is tested every 6  months for effectivity and to keep numbers updated .
alerts resulted in an average direct availability of 50% , with slightly lower rates at night .
under - alert has not occurred , except for two cases were the radiology department was not included in the initial call .
over - alert was the case in the polder crash ( 2009 ) . within 45  min after the crash we contacted the regional command center dealing with the crash to inform them that we were available to receive patients within half an hour .
this was after seeing the information on the internet and after the umcu had been alarmed by the regional ambulance service .
in fact , the mih was never formally approached or informed by the central coordination centre nor by the national crisis team .
the mih was opened based on controversial information from the scene and a second alert from the regional ambulance service that the first four patients were already on their way to our centre .
one hundred forty - three staff members were alerted , of which 39 were deployed and the rest were sent home . finally , only six patients ( four t2 and two t3 ) were transferred to our hospital .organization of coordination and commandevaluation of preparedness and function scores of all prehospital units of the response chain lies beyond the scope of this report.for the mih , the trauma surgeon on call is fully licensed to open the mih , which benefitted opening speed .
this means that the command team focuses on organization of the relief and treatment of the victims in the major incident hospital itself , and a separate management team is responsible for external logistics , continuity of the care in the cmh and umc , internal and external communication and the organization of first relief of family / relatives .
this proved to keep the command team alert and in control and prevented distraction by external business beyond patient relief.hospital damage due to a disaster was never the case .
admission of 13 patients with an inhalation problem from the umcu laboratory and the collapse of the crane on the same university campus were the nearest scenarios.communication systemin the beginning , team leaders carried portable phones .
this proved distracting as it generated a lot of ( unnecessary ) use and people did not always know how to use them effectively , not being accustomed to them in the daily setting .
after 1992 the pbrs provided continuous and updated group and patient data in every area and at every working station in the mih .
this resulted in clear improvement in medical , nursing and logistic handling and covered many of the communication needs .
it enabled staff to better anticipate and manage care requirements and effectively use resources and personnel up to discharge .
the operational unit supervisors discuss all crucial steps with the command team and make logistic decisions and other arrangements between all participating units , ranging from security to operation rooms .
this proved very effective in sharing information and plans quickly and greatly simplified procedures to get things done and manage the entire organisation.computer technology and back - up systemswe did not encounter major computer system failures during admissions .
the pbrs that we developed showed 25% fewer inaccuracies when compared with the handwritten medical charts , despite the greater number of items entered .
the follow up chart of patient care in the mih is not computerized , yet ; that is a goal for the future.total number and type of injuriestotal number and type of injuries are depicted in table  3 .
almost half of the patients ( 254 , 45% ) were admitted with injuries due to mechanical violence .
inhalation accounts for 16% ( 93 ) of the admitted patients.table  3total number and type of injuriestypenumber of injuredmechanical violence254  military ( 29 )  non - military ( 225)fire13inhalation93  methyl bromide ( 9 )  carbon monoxide ( 34 )  nitrous damps ( 5 )  other ( 45)corrosive agents0irradiation0cold0drowning0biological contamination0other199  mixed hospital population , external evacuation causes ( war , flooding ) ( 181 )  cannabis intoxication ( 12 )  aluminium intoxication ( 6)total559severity of injuriesall patients were triaged on admission . except for triage on admission
, we did not use a standard scoring system as for example , the injury severity score ( iss ) .
severity of injuries according to treatment is depicted in table  4 and was relatively low ( as well as retrospectively estimated iss above 15 ) .
intensive care use ( 4/559  =  0.7% ) and ventilator dependency were scarce ( 4/559  =  0.7% ) , as was need of immediate surgery ( defined as within 1  h ) ( 0%).table  4severity of injuries according to treatmenttypenumberrepatriationnational incidenttotalless severe injuries not examined or treated by medical professionalsn.a.less to moderately severe injuries examined and/or treated by medical professionals  outside hospitaln.a .  in hospital21315injuries requiring in - hospital care / observation in297247544  regular ward289175464  medium care47276  intensive care404  requiring ventilator404injuries requiring surgery ( general anaesthesia)31 * 0 * 31 *  immediately000  within 6  h707  delayed24 * 0 * 24*n.a .
not applicable * in four admissions several additional delayed surgery procedures in referral clinicmedical professionals defined as ambulance staff , paramedics , nurses and doctorshospital loadcongestion , lack of material , resources or personnel influencing optimal patient care did not occur in any of the deployments .
volunteers from the red cross to assist in patient care and transport within the mih proved to be a valuable addition to the professional pool ( fig . 7 ) .
discharge and transfer procedures were delayed and sometimes congested because often many patients were discharged at the same time and definite discharge papers had to be prepared , which requires staff time .
therefore , in 1999 , we developed an automated patient discharge letter system and appointed one person in medical staff to supervise this .
7patient transport by volunteers of the red cross ( photo b de meijer)psychological reactions and managementin every admission , staff members from the psychology and psychiatric department are available to provide psychological support for victims , relatives and staff .
they are supported by volunteers from the red cross who assist patients in personal care and offer a listening ear .
long term evaluation among the repatriated tsunami victims showed that need for professional support often arises at a later stage than directly after the disaster , sometimes even after months or years .
we are currently exploring how we can address this by offering a gateway to professional help through a site that can be accessed at any time after the disaster . in analogy with the site launched after the tsunami ( http://www.tisei.org )   this site combines self help through mutual victim contact and self - assessment with econsult possibilities.post-deployment evaluations with personnel showed that they experienced substantially more emotional burden when caring for incident victims than in regular hospital care .
this was not determined by severity of wounds or physical trauma but mostly by the impressive stories , emotional reunion of victims with families and ( media ) attention that comes with major incidents . during victim relief and during shift changes , a consultative psychiatric nurse is present for personnel . an aftercare team contacts them afterwards .
informal gatherings after the admission proved to give more room for sharing emotions and feelings than meetings labeled to address emotional impact.outcome with regard to mortality and persistent disabilityin - hospital mortality was low ( 1/559  =  0.2% ) .
this concerns a patient that was repatriated from a military mission to confirm brain death and to stop treatment amidst his family .
persistent disability was not scored and was difficult to quantify , as the mih is a short - term facility that closes after a few days .
clinical patients were then transferred to other hospitals and follow - up of outpatients was done mainly in the home city hospitals . from the 559 patients , 256 patients ( 46% )
were transferred to other hospitals , while 303 ( 54% ) could be discharged home within closing time of the mih.estimated number of people affected , not injured was not scored.post-accident evaluationpost accident evaluation of preparednessthe disaster plan is the basis for the mih and was always activated in the case of admissions .
another important finding in the evaluations concerns preparedness for situations that require decontamination . during the evacuation from a building contaminated with an initially unknown gas in 2008 , patients entered the mih without decontamination .
afterwards , decontamination proved unnecessary as it turned out to be smoke from an aircon fire , but this reinforced reevaluation of the disaster plans regarding when and how to start decontamination procedures . in a training session for decontamination within the mih , we also concluded that our ability to decontaminate large groups of patients was insufficient .
we further extended training and are currently improving the infrastructure and decontamination facilities ( fig . 8).fig . 
8training with decontamination in a multidisciplinary excercise with 100 victims , mih 2010post accident evaluation of training in the first years , optimal relief was sometimes hindered by the fact that the majority of the alarmed personnel was still relatively unfamiliar with procedures and logistics in the mih .
this mandated the expansion of training activities and starting up a pool of personnel who spend part of their time performing tasks in regular care when the mih is dormant , but spend the rest of their time outside deployment times on training and preparedness .
they now form the basis for training the rest of the pool of dedicated doctors , nurses and support team from all umcu / cmh departments that can be alerted .
regular theoretical classes , case exercises and disaster simulations within the mih or together with the whole chain resulted in smoother cooperation and better preparedness ( fig .
where teams are always assembled from a big pool , and of which a considerable portion is made up of residents that change every 2  years , the intensity of training with a strong base proved crucial.fig . 
9cooperation between military and civil services ( ambulance hall mih ) summary of the scenario / hazard , description of accident all 34 consecutive deployments of the mih are depicted in table  2 , summarized with short descriptions of each event and the type of activation scenario .
military victims ( 29 ) accounted for 5% of the admitted patients and 18% of the deployments .
two hundred and twenty - six ( 38% ) dutch victims of major incidents abroad were repatriated in 12 group admissions , whereas national incidents accounted for 260 patients ( 47% ) and 35% of the deployments of the mih .
the rest consist of 4 openings to offer care for foreign incident disaster victims ( 44 patients , 10% ) .
the distances from the scene to the mih ( 0.360  km ) are also depicted in table  2 . for international deployment
, the country of repatriation is depicted , at distances varying from several hundred to thousands of kilometers.table  2overview of use of the mih : year , number of admitted patients , short description of the incident , distance ( km ) from the scene , cohort quarantine and main type of scenario for deployment of the mih ( see below)yearnumber of patientsincident characteristics ( location of incident)distance , or country if abroadquarantinemain scenario*19919methyl bromide intoxication ( used by gardeners decontaminating greenhouses)45  kmno319919carbon monoxide intoxication ; insufficient boiler in non ventilated space ( utrecht)510  kmno3199210carbon monoxide intoxication of fireman on duty510  kmno319925exposure to nitrous damps (  ) 510  kmno3199228evacuation of a hospital in a war setting ( bosnia herzegovina)bosniayes4199213plane crash ( faro ) with a fireportugalyes2199343bus accident ( lyon)franceyes219935evacuation of a hospital in a war setting ( bosnia herzegovina)bosniayes419944bus accident ( regensburg , germany)germanyyes21995143evacuation of a flooded hospital52  kmno319957benzyl bromide exposure ( utrecht)510  kmno3199629bus accident of dutch singing choir ( winterberg)germanyyes2199612cannabis intoxication ( zeist)8  kmno319966aluminium pollution of fluids in dialysis centrecuracaono4199611bus accident ( antalya)turkeyyes2199615carbon monoxide intoxication by inadequate boiler in insufficiently ventilated building510  kmno3199610bus accident of tourist bus from netherlands ( thionville)franceyes219977military accident ( novi travnik , bosnia herzegovina)bosniayes1199713bus accidentsyriayes2199820bus accident of tourist bus from the netherlands ( metz)franceyes219995repatriation of fugitiveskososvoyes4199912earthquake , turkish , dutch residents on holidayturkeyyes220009military accidentgermanyno1200225bus accident of tourist bus from netherlands ( metz , france)franceyes2200221bus accident of tourist bus from netherlands ( manching , germany)germanyyes2200313lab accident , analysis of glue - damp with eye and airway irritation ( methyl metacrylate)0.3  kmno3200525repatriation of wounded dutch tsunami victimsasiayes220076collapse of crane on a campus building0.4  kmno320074repatriation of soldiers from afghanistan ( victims of a suicide bombing while on patrol)afghanistanyes1200825evacuation ( 350 emloyees ) from a contaminated building in amersfoort ( unknown substance)23  kmno320096airplane crash near schiphol airport (  polder crash  ) with 135 passengers60  kmno320094repatriation of military victims afghanistanafghanistanyes120092repatriation of military victims afghanistanafghanistanyes120093repatriation of military victims afghanistanafghanistanyes1total559 * scenario s for activation of the mih : ( 1 ) military victims , ( 2 ) repatriation of dutch victims of accidents or incidents abroad , cohort - isolation for methicilline resistant staphylococcus aureus ( mrsa ) according to guidelines of the netherlands health care inspectorate , ( 3 ) activation of the mih for a national major incident or disaster , ( 4 ) international medical assistance from the dutch government concerning the treatment of foreign victims , ( 5 ) quarantine care for patients with special infectious and highly contagious diseases , e.g. sars overview of use of the mih : year , number of admitted patients , short description of the incident , distance ( km ) from the scene , cohort quarantine and main type of scenario for deployment of the mih ( see below ) * scenario s for activation of the mih : ( 1 ) military victims , ( 2 ) repatriation of dutch victims of accidents or incidents abroad , cohort - isolation for methicilline resistant staphylococcus aureus ( mrsa ) according to guidelines of the netherlands health care inspectorate , ( 3 ) activation of the mih for a national major incident or disaster , ( 4 ) international medical assistance from the dutch government concerning the treatment of foreign victims , ( 5 ) quarantine care for patients with special infectious and highly contagious diseases , e.g. sars evaluation of  prehospital resources available and alerted  lies beyond the scope of this report hospital resources available or alerted as the mih is a reserved facility for major incidents , availability of triage rooms ( 35 beds ) , low and medium care beds ( 200 ) , icu beds ( 12 ) , ventilators , radiology unit , operating theaters and trauma unit is guaranteed .
, staffing has never proved to be a problem ; the capacity could always be operational for the first 100 beds within 15  min to half an hour .
training issues of deployed staff are discussed below ( figs . 3 , 4 , 5 , 6).fig . 
6triage and treatment area - red bay , stabilisation of a patient ( photo b de meijer ) low care unit in dormant times triage and treatment area , red bay ( photo b de meijer ) triage and treatment area - red bay , stabilisation of a patient ( photo b de meijer ) in the evaluation of optimal use of resources , situations in which the mih was available but not deployed are particularly interesting .
an example is the volendam caf fire on new year s eve , 2001 , where 98 victims were transported to 20 hospitals and 100 victims went to different ers of hospitals on their own .
the mih was alerted 7  h after the incident with the request to receive two burn patients that could be regularly admitted to the umcu . in total 11 patients
numerous patients were transferred to a widespread variety of hospitals and it took a full day afterwards to get an overview . a bus with 20  t3 victims ( in the four scale triage system ) was sent to a hospital that turned out to have no capacity left and had to divert to another hospital .
the mih could have better contributed to care and simplifying patient logistics had it been deployed in an earlier stage .
the collapse of stairs during a musical parade in 2008   is an example where 19 patients were seen in one trauma centre and the mih was not deployed .
medical management went well and was within surge capacity of the hospital . in this case , using the trauma centre or mih were both good options and the choice was a matter of preference of the staff on call . using the mih for first relief would have eased logistics and communication with supporting facilities that were now problematic due to provisional patient numbering .
after the plane crash near schiphol (  polder crash  2009 ) , 42 of the 135 victims patients were transported from the triage site by bus to a sports complex after being triaged as t3 .
the two triage doctors at the sports complex concluded that they needed hospital transfer due to high energy characteristics of the crash and triage levels higher than t3 .
they were spread to several hospitals and it took 4  days to reconstruct the victim list and whereabouts of the patients .
one of the other specialties of the mih is relief of groups of patients in quarantine , which otherwise often generates logistic problems and delay of repatriation to regular hospitals . in 1994 ,
a group of dutch victims from a bus accident in poland were repatriated to a city hospital instead of to the mih due to political choices of the hometown government , despite prior alert and readiness of the mih .
this resulted in a forced temporary closure of the regular surgery and orthopedic departments due to mrsa contamination . in the faro plane crash in 1992
this corresponds with 14% of the mrsa category ii patients ( patients with minimum 24  h stay or invasive procedures in a foreign hospital ) .
this led to secondary spread to other patients and staff in one of the burn centers .
repatriation in quarantine from thailand to the mih after the 2004 tsunami showed several carriers of mrsa and other multi - resistant microorganisms .
repatriations of military victims from kosovo and afghanistan to our facility also showed multiple victims with mrsa and acinetobacter colonization .
of all the quarantine admissions , 61% or more of the patients could be discharged home within the 5  days that are set as a directive to close the mih , or quarantine could be ended due to negative swabs .
transfers under quarantine conditions were reduced to 32% of the patients who were initially treated in quarantine . during the sars threat we adapted our facilities and training to prepare for patients with special highly infectious diseases . since 2003 ,
the mih has changed the air treatment and can provide 4 isolation boxes and 30 medium care beds for this type of scenario .
hospital alert plan and response opening of the mih is always based on activation of the local disaster plan .
when the emergency response program is started , the medical manager of the emergency room activates the personnel alert system through the national civilian telephone network .
this system has specially reserved capacity for use by the disaster management chain . during all deployments ,
communication through this system was never hindered by the inundation of the regular mobile network , as often occurs in disaster situations .
in contrast to a normal , time consuming  calling tree  , results are monitored and adjustable once running , as personnel respond to the system if and when they are available . this system enabled us to tailor the alert . at first , we worked with different lists adapted to several scenarios but these incurred too much overlap . in the current system , we can compose the alerted staff by choosing and combining groups , e.g. , 
the system is tested every 6  months for effectivity and to keep numbers updated .
alerts resulted in an average direct availability of 50% , with slightly lower rates at night . under - alert has not occurred , except for two cases were the radiology department was not included in the initial call . over - alert was the case in the polder crash ( 2009 ) . within 45  min after the crash we contacted the regional command center dealing with the crash to inform them that we were available to receive patients within half an hour .
this was after seeing the information on the internet and after the umcu had been alarmed by the regional ambulance service .
in fact , the mih was never formally approached or informed by the central coordination centre nor by the national crisis team .
the mih was opened based on controversial information from the scene and a second alert from the regional ambulance service that the first four patients were already on their way to our centre .
one hundred forty - three staff members were alerted , of which 39 were deployed and the rest were sent home . finally , only six patients ( four t2 and two t3 ) were transferred to our hospital .
organization of coordination and command evaluation of preparedness and function scores of all prehospital units of the response chain lies beyond the scope of this report . for the mih , the trauma surgeon on call
this means that the command team focuses on organization of the relief and treatment of the victims in the major incident hospital itself , and a separate management team is responsible for external logistics , continuity of the care in the cmh and umc , internal and external communication and the organization of first relief of family / relatives .
this proved to keep the command team alert and in control and prevented distraction by external business beyond patient relief .
admission of 13 patients with an inhalation problem from the umcu laboratory and the collapse of the crane on the same university campus were the nearest scenarios . in the beginning
this proved distracting as it generated a lot of ( unnecessary ) use and people did not always know how to use them effectively , not being accustomed to them in the daily setting .
after 1992 the pbrs provided continuous and updated group and patient data in every area and at every working station in the mih .
this resulted in clear improvement in medical , nursing and logistic handling and covered many of the communication needs .
it enabled staff to better anticipate and manage care requirements and effectively use resources and personnel up to discharge .
the operational unit supervisors discuss all crucial steps with the command team and make logistic decisions and other arrangements between all participating units , ranging from security to operation rooms .
this proved very effective in sharing information and plans quickly and greatly simplified procedures to get things done and manage the entire organisation .
computer technology and back - up systems we did not encounter major computer system failures during admissions .
the pbrs that we developed showed 25% fewer inaccuracies when compared with the handwritten medical charts , despite the greater number of items entered .
the follow up chart of patient care in the mih is not computerized , yet ; that is a goal for the future .
total number and type of injuries total number and type of injuries are depicted in table  3 .
almost half of the patients ( 254 , 45% ) were admitted with injuries due to mechanical violence .
inhalation accounts for 16% ( 93 ) of the admitted patients.table  3total number and type of injuriestypenumber of injuredmechanical violence254  military ( 29 )  non - military ( 225)fire13inhalation93  methyl bromide ( 9 )  carbon monoxide ( 34 )  nitrous damps ( 5 )  other ( 45)corrosive agents0irradiation0cold0drowning0biological contamination0other199  mixed hospital population , external evacuation causes ( war , flooding ) ( 181 )  cannabis intoxication ( 12 )  aluminium intoxication ( 6)total559 total number and type of injuries all patients were triaged on admission . except for triage on admission
, we did not use a standard scoring system as for example , the injury severity score ( iss ) .
severity of injuries according to treatment is depicted in table  4 and was relatively low ( as well as retrospectively estimated iss above 15 ) .
intensive care use ( 4/559  =  0.7% ) and ventilator dependency were scarce ( 4/559  =  0.7% ) , as was need of immediate surgery ( defined as within 1  h ) ( 0%).table  4severity of injuries according to treatmenttypenumberrepatriationnational incidenttotalless severe injuries not examined or treated by medical professionalsn.a.less to moderately severe injuries examined and/or treated by medical professionals  outside hospitaln.a .  in hospital21315injuries requiring in - hospital care / observation in297247544  regular ward289175464  medium care47276  intensive care404  requiring ventilator404injuries requiring surgery ( general anaesthesia)31 * 0 * 31 *  immediately000  within 6  h707  delayed24 * 0 * 24*n.a .
not applicable * in four admissions several additional delayed surgery procedures in referral clinicmedical professionals defined as ambulance staff , paramedics , nurses and doctors severity of injuries according to treatment * in four admissions several additional delayed surgery procedures in referral clinic medical professionals defined as ambulance staff , paramedics , nurses and doctors congestion , lack of material , resources or personnel influencing optimal patient care did not occur in any of the deployments .
volunteers from the red cross to assist in patient care and transport within the mih proved to be a valuable addition to the professional pool ( fig . 7 ) .
discharge and transfer procedures were delayed and sometimes congested because often many patients were discharged at the same time and definite discharge papers had to be prepared , which requires staff time .
therefore , in 1999 , we developed an automated patient discharge letter system and appointed one person in medical staff to supervise this .
7patient transport by volunteers of the red cross ( photo b de meijer ) patient transport by volunteers of the red cross ( photo b de meijer ) psychological reactions and management in every admission , staff members from the psychology and psychiatric department are available to provide psychological support for victims , relatives and staff . they are supported by volunteers from the red cross who assist patients in personal care and offer a listening ear .
long term evaluation among the repatriated tsunami victims showed that need for professional support often arises at a later stage than directly after the disaster , sometimes even after months or years .
we are currently exploring how we can address this by offering a gateway to professional help through a site that can be accessed at any time after the disaster .
in analogy with the site launched after the tsunami ( http://www.tisei.org )   this site combines self help through mutual victim contact and self - assessment with econsult possibilities .
post - deployment evaluations with personnel showed that they experienced substantially more emotional burden when caring for incident victims than in regular hospital care .
this was not determined by severity of wounds or physical trauma but mostly by the impressive stories , emotional reunion of victims with families and ( media ) attention that comes with major incidents . during victim relief and during shift changes , a consultative psychiatric nurse is present for personnel . an aftercare team contacts them afterwards .
informal gatherings after the admission proved to give more room for sharing emotions and feelings than meetings labeled to address emotional impact .
outcome with regard to mortality and persistent disability in - hospital mortality was low ( 1/559  =  0.2% ) .
this concerns a patient that was repatriated from a military mission to confirm brain death and to stop treatment amidst his family .
persistent disability was not scored and was difficult to quantify , as the mih is a short - term facility that closes after a few days .
clinical patients were then transferred to other hospitals and follow - up of outpatients was done mainly in the home city hospitals . from the 559 patients , 256 patients ( 46% )
were transferred to other hospitals , while 303 ( 54% ) could be discharged home within closing time of the mih .
post - accident evaluation post accident evaluation of preparedness the disaster plan is the basis for the mih and was always activated in the case of admissions .
some of the adaptations are described in the above paragraphs . another important finding in the evaluations concerns preparedness for situations that require decontamination . during the evacuation from a building contaminated with an initially unknown gas in 2008
afterwards , decontamination proved unnecessary as it turned out to be smoke from an aircon fire , but this reinforced reevaluation of the disaster plans regarding when and how to start decontamination procedures . in a training session for decontamination within the mih , we also concluded that our ability to decontaminate large groups of patients was insufficient .
we further extended training and are currently improving the infrastructure and decontamination facilities ( fig . 8).fig . 
8training with decontamination in a multidisciplinary excercise with 100 victims , mih 2010 training with decontamination in a multidisciplinary excercise with 100 victims , mih 2010 post accident evaluation of training in the first years , optimal relief was sometimes hindered by the fact that the majority of the alarmed personnel was still relatively unfamiliar with procedures and logistics in the mih .
this mandated the expansion of training activities and starting up a pool of personnel who spend part of their time performing tasks in regular care when the mih is dormant , but spend the rest of their time outside deployment times on training and preparedness .
they now form the basis for training the rest of the pool of dedicated doctors , nurses and support team from all umcu / cmh departments that can be alerted .
regular theoretical classes , case exercises and disaster simulations within the mih or together with the whole chain resulted in smoother cooperation and better preparedness ( fig .
where teams are always assembled from a big pool , and of which a considerable portion is made up of residents that change every 2  years , the intensity of training with a strong base proved crucial.fig . 
9cooperation between military and civil services ( ambulance hall mih ) cooperation between military and civil services ( ambulance hall mih )
the goal of availability , preparedness and quick performance was met in four of the five deployment criteria of the mih . a major incident with contagious diseases or material ( fifth criterion , added since 2003 ) has not yet occurred . in the relief and repatriation of military victims ( first scenario ) the mih has proved its surplus value in availability of the total range of care ( low care till icu and or as well as radiology facilities ) without quarantine restrictions and disturbance of regular care .
this facilitates quick repatriation and initiation of treatment , which is often not possible in war / mission setting .
mih staff is partly military and is familiar with repatriation procedures and concurrent emotional impact for patients and family .
the same advantages account for civil repatriations ( second scenario ) in quarantine after incidents and disasters abroad .
the netherlands follows a strict quarantine policy for all foreign patients in order to rule out potential infection with mrsa and other multi - resistant bacteria to prevent transmission to other patients or healthcare workers .
this policy is reinforced by recent literature that shows that mrsa types have a predominantly regional distribution in europe .
this finding is indicative of the selection and spread of a limited number of clones within health care networks , suggesting that control efforts aimed at interrupting the spread within and between health care institutions may not only be feasible but ultimately successful and , therefore , desirable . in this evaluation , ( mrsa )
group - wise relief in quarantine has the advantage of availability , risk reduction for regular care and reduction of further quarantine efforts . in the quarantine admissions ,
the majority of the patients could be discharged home before closure of mih , or quarantine could be ended due to negative swabs .
transfers under quarantine conditions could be greatly reduced and have the advantage of preparation time for the receiving hospital .
preparation time is not only favorable for quarantine issues but time also permitted selection of the most suitable follow - up hospital for each individual patient with regard to expertise and geography . since the repatriation from the bus accident in poland ( 1994 ) , the dutch policy is to perform all group wise repatriations in quarantine in the mih . for the third opening scenario , national major incidents ,
the deployment of the mih was relatively low and its availability and capacity were certainly not used to maximum advantage .
distance to the scene might be a reason for using other facilities , but in many cases this was not an issue .
for example , in the polder crash the mih was well within 60  km of the accident , comparable to distances to some of the other deployed hospitals .
we believe the most important factor is suboptimal embedding of the mih in the dutch system of incident relief .
the organization of disaster relief in the netherlands is strongly developing and new liaisons with the mih are still in progress .
the fact that the mih is not used in regular trauma care might also contribute to suboptimal use of its capacity .
the regional medical officer in charge of an incident , as well as the regional command center , might not always be familiar with the advantages the mih has to offer .
the national coordination centre was not always deployed , although it is appointed for interregional activities and major incidents .
furthermore , hospitals in the affected region , and especially trauma centers , are eager to care for  their own  patients and do what they trained for in trauma care and in their hospital disaster plans .
performance of the regular dutch trauma centers and hospitals proved to be good for multiple trauma / incident patients in terms of direct care within surge capacity [ 14 , 15 , 21 ] .
leap - frogging could guard these capacities in not - too - extensive incidents , but it also complicates communication , patient overview , logistics , impact on regular care ( over- and under - alert of several hospitals ) , family support , media and security [ 13 , 15 , 21 ] . the mih could make a valuable contribution in effective use of all available capacity and delivering the best care to the greatest number of patients .
a good distribution could be to transport t1 victims to trauma centers and group t2 and t3 victims to the mih .
this allows trauma centers and local hospitals to focus on t1 victims and unavoidable self - referrals .
meanwhile the mih can sort out the bulk , eventually with some of the t1 victims , in a situation that is designed for further triage through successive echelons of care , and where other conditions for good group wise treatment are prearranged , such as reserved availability of resources ( 100300 beds ; 12 icu , 38 medium care and 50 low care , or , radiology , etc . ) , registration , psychological support , media , family issues and security .
in contrast to the situation after the polder crash , for example , where completing the victim list took 4  days , institutions have only to contact one hospital with regard to numbers of patients , severity of injury and personal data . the pbrs directly provides a real time overview .
relief for t1 victims is also possible in the mih , but this patient group benefits most from fast treatment , justifying transportation to the nearest adequate facility .
furthermore , they generally have a longer and more intense treatment path that merits significant and highly qualified personnel and resources .
spreading of these patients among trauma centers can probably guarantee better continuity of care after first relief . for these patients
irrespective of the type of scenario , group - wise treatment had several advantages , including mutual support among patients and ( pre)arrangements for logistics , registration , family and media .
looking at the other points we evaluated , communication and computer technologies deserve further development .
although the pbrs functions well and brings unique advantages for real time overview and management , extension of patient registration and tracking to the prehospital setting would be desirable .
for this goal we developed a victim tracking and tracing system ( vitts ) , that will be discussed in another paper .
digitalization of the entire medical chart within the mih would maximize yield of the pbrs , the discharge letter system and would facilitate research .
this is an internationally used scoring system , useful for categorizing severity as well as for reporting .
this would allow easier comparisons , also with regular trauma care and with outcome related to iss . among our admitted patients
were relatively few t1 patients or patients with retrospectively estimated injury severity scores above 15 .
this observation has three explanations : in some incidents severely injured patients went to other hospitals ( e.g. , polder crash 2009 ) , in some cases ( e.g. , crane collapse , bus accident and evacuation of flooded hospital ) the incident itself produced mainly t2 or t3 victims , as in most mechanical disasters   and finally because some admissions were repatriations with a selected group that was stable enough to travel ( e.g. , tsunami repatriation ) .
the mih has demonstrated its ability to provide group - wise emergency care to military as well as civil victims of major incidents and disasters , national or from abroad , in all scenarios for activation except care for special highly infectious diseases ( as this did not occur ) .
group - wise treatment proved to be advantageous for quarantine , logistics , registration , emotional support and ( pre)arrangements for family , media and security . preparedness and availability , irrespective of mrsa status , including icu , x - ray and or facilities and prearranged cooperation , e.g. , with the umcu , nvic and the military , are strong points . evaluation and training resulted in developments such as the pbrs and continuous adaptations to improve preparedness .
key recommendations for further development are : better imbedding in regional and national procedures to optimize use of availability in case of national disasters ; expand involvement of other trauma centers.continued training , research and development , preservation of a pool of dedicated staff to keep the organization alive and moving.improvement of nuclear / biological / chemical decontamination facilities , adaptation to external developments.expansion of the pbrs within the mih and in the prehospital phase : create fully electronic patient charts and prehospital patient tracking and tracing.implementation of standardized scoring systems to record injury type and severity to facilitate research and comparability .
better imbedding in regional and national procedures to optimize use of availability in case of national disasters ; expand involvement of other trauma centers
. continued training , research and development , preservation of a pool of dedicated staff to keep the organization alive and moving .
expansion of the pbrs within the mih and in the prehospital phase : create fully electronic patient charts and prehospital patient tracking and tracing .
implementation of standardized scoring systems to record injury type and severity to facilitate research and comparability .
supplementary material 1 ( jpg 1.10 mb ) supplementary material 2 ( jpg 1.38  mb ) supplementary material 3 ( jpg 1.38  mb ) supplementary material 4 ( jpg 1.17  mb ) supplementary material 5 ( jpg 94.9  kb ) supplementary material 6 ( jpg 128  kb )
 introductionthe major incident hospital ( mih ) is a unique facility strictly reserved to provide immediate large - scale emergency care for victims of disasters and major incidents . 
 we evaluated the implemented organization to identify strengths and weaknesses , and provide knowledge essential for further improvement of preparedness.methodaccording to the protocol for reports from major accidents and disasters ( prmd ) and along with our five scenarios for activation , we analyzed all the data from evaluation reports of all our deployments since the mih was founded in 1991.resultsthe mih was able to provide group - wise emergency care to military ( 29 admissions ) as well as civilian victims of major incidents and disasters , both national ( 260 ) and international ( 226 ) . 
 group - wise treatment was advantageous for quarantine , logistics , registration , emotional support and ( pre)arrangements for family , media and security . 
 strong points are preparedness and availability of a dedicated facility , including icu , x - ray and or facilities , irrespective of mrsa status and prearranged cooperation , e.g. , with a trauma centre , poison centre and the military . 
 evaluation , research and training resulted in a barcode registration system and continuous adaptations to improve preparedness . 
 shortage of resources did not occur ; use of the mih s available resources for national incidents though , could be further optimized.conclusionsrecommendations for the future are : improvement of imbedding in regional and national procedures , continued dedicated time and staff for training , research and development , improvement of nuclear / biological / chemical decontamination facilities and preparedness , implementation of standardized scoring systems and expansion of registration systems to the prehospital setting.electronic supplementary materialthe online version of this article ( doi:10.1007/s00068 - 010 - 0067 - 0 ) contains supplementary material , which is available to authorized users . 
Electronic supplementary material
Introduction
Objective
Materials and methods
Results
Discussion
Conclusions
Electronic supplementary material