Rationale for and development of HOSPEX in Australia

Following the formation of 2 GHB, the first two commanding officers (CO), both former British Army Medical Support Officers, considered how it would be possible to confirm that the unit was capable of deploying in support of Australian forces on operations. The first was concerned that the previous certification exercise the unit was subject to was cursory, did not focus on clinical supervision and leadership and seemed more appropriate to a traditional Field Ambulance than a Field Hospital-like unit. It also seemed to have no relevance to what he had seen as the Coalition Deputy Commander Medical (J07) in Iraq in 2003 or the lessons learnt coming from our coalition partners who had deployed hospital-like units. He had some involvement in developing the requirement for HOSPEX when he was in the British Army working in the Army Medical Directorate. He facilitated the attendance of several ADF officers as observers at the UK HOSPEX and refocussed 2 GHB on clinical training, clinical governance and clinical leadership.

The second CO built on this initiative. His unit was newly formed, there was no recent history of deployment in support of modern high-intensity military operations at a unit or subunit level within the ADF, many of his full-time personnel were not experienced or familiar within their roles, and the key personnel he would be relying on to provide surgical capacity were reservists whom he had never met. He felt that a simulation exercise similar to the UK HOSPEX might meet some of his identified needs to demonstrate his ability to deliver health capacity. He discussed his needs with the CO of his reserve support unit 3 HSB and his Brigade Commander. In 2012, the two COs, accompanied by their Brigade director of clinical services, a reservist anaesthetist, travelled to the UK to witness HOSPEX. They came back with intellectual property such as the marking matrix and scoring systems10 and received an introduction to the key performance indicators for military trauma care laid out in the UK JSP 999.11

3 HSB then assumed as one of its roles, the responsibility for preparing personnel to conduct a HOSPEX-type evaluation, to develop a number of simulated scenarios across the surgical services of 2 GHB and to conduct this modified HOSPEX evaluation. Since this activity commenced in early 2013, there have been three HOSPEX-type exercises conducted in Australia. The current concept of operations is that early in each calendar year a HOSPEX exercise will be conducted with the aim to identify knowledge and skill gaps within the personnel of 2 GHB. This will happen as part of the annual first field deployment exercise in 2 GHB. Later in the year, a formal accreditation type HOSPEX is conducted, generally run on a major deployment training exercise. This activity serves the purpose of confirming that 2 GHB is capable of providing contemporary healthcare in a deployed environment in ‘a War’ to the highest standard.

There are close links between 2 GHB and its supporting and training unit 3 HSB, the reserve holding unit. Many 3 HSB personnel contribute to the exercises of 2 GHB. Given the large distances, the small number of reservists in each company location where 3 HSB is located and the cost of replicating the deployable medical equipment used by the ADF in each location, attending these exercises is the best opportunity for reservists to gain an intimate knowledge of the capabilities and equipment of 2 GHB and to develop close links with their full-time counterparts. The training needs identified for 2 GHB will carry across into the training programme of 3 HSB personnel in their reserve training depots.

The Australian HOSPEX attempts to test 2 GHB under a variety of conditions and is conducted in the field. This is the major difference between the UK and Australian versions of HOSPEX. The ADF has had no fixed facility or currently known mission that would direct the training of health personnel preparing for deployment. Possible scenarios in Australian planning for 2 GHB include being fully deployed with its entire inventory (a logistical task requiring a transport regiment; Figure 1), operating out of fixed building facilities with a reduced logistical footprint and deploying as a light scale surgical facility by either air or sea. While there is a strong emphasis on the ability of 2 GHB to deal with major severe military trauma, there is a need to test the unit's capability to provide care to civilian populations in disaster situations both within and outside Australia as the Australian government has tasked the ADF to be prepared to conduct such operations. HOSPEX also provides the opportunity to examine the non-surgical capabilities of the unit such as primary medical care, environmental health, psychological support and dental services. Examining these roles of 2 GHB was arrived independently without any reference to the UK experience in this area.

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Figure 1

The main spine of 2nd General Health Battalion tentage.

Due to the current restricted capability of 2 GHB, a small observer/trainer (OT) team, currently seven personnel, conducts the Australian HOSPEX. Prior to each HOSPEX the OT team meet to develop scenarios which will involve care across the continuum of casualty care: reception, triage, initial resuscitation, first surgery, admission to ward or to intensive care unit and preparation for rearward evacuation. The personnel involved have included the Director Health Services-Army Reserve, a very experienced trauma surgeon, a trauma surgeon with extensive operational experience in Iraq and Afghanistan, the ADF Professor of Military Medicine and Surgery—an intensivist from an anaesthetic background, a general practitioner whose civilian occupation is a professor of general practice with broad experience in prehospital care, two nursing officers with extensive deployment experience who currently work as ambulance paramedics, a nursing officer who works as a perioperative nurse and the General Service Officer Project Officer, with experience as a medical casualty regulator on secondment to UK forces in Iraq, who collates the data. 3 HSB aims to develop and broaden the cadre or collegiate of OTs over the coming years to encompass allied health, general medicine and environmental health.

Some scenarios will have involvement of the primary care, psychological support, dental elements and environmental health team in providing care. Clinical findings, patient observations, diagnostic imaging and pathology results are prepared for each simulated casualty. Where use is made of live actors, who are in the main out of exercise personnel from 2 GHB, they are provided with a laminated story card and suggested actions (Figure 2). For some scenarios such as cardiopulmonary resuscitation or when paediatric patients are used, the use is made of both programmable and static mannequins. The project officer assisted by the assessing team has modified, for Australian conditions, a number of performance indicators for each element of the hospital from the UK publication JSP 99911 and from civilian Australian health standards.12

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Figure 2

Simulated local child casualty accompanied by father in Emergency Bay.

Building on the British experience there is a strong emphasis in the scenarios on examining non-technical aspects of care, team situational awareness, clinical leadership, transmission of information during handover of care to a follow-up team and a general testing of 2 GHB administrative processes around casualty movement, casualty notification, overall situational awareness and special logistical requirements.13 ,14 A specific Higher Control team is not used for the actual HOSPEX exercise as 2 GHB uses other aspects of its field training to develop responses to hostile action or significant loss of essential equipment. Scenarios include tests of the principles for managing civilian casualties including eligibility for care from 2 GHB and the level of care that it is reasonable to provide in other countries. Such casualties are particularly intended to test the so-called front gate administration. Other casualty scenarios, which have been used, include that of enemy combatants, intended to examine the application of international humanitarian law and unit internal security procedures particularly decontamination of arriving casualties.

The scenarios are difficult and intended to extend the knowledge and coping mechanisms of the whole hospital including treating teams, command and supporting elements. Considerable effort is made to make the scenarios macrosimulation activities, so the focus of the OT team is on the assessment of the whole system rather than individual skills.13 ,14 There is a strong emphasis on non-technical aspects of care.15 Any notionality in terms of the time required to process a casualty is minimised. If it will take 2 h to solve a surgical problem, the emergency resuscitation team will not be able to access the surgeon for that time (Figure 3). Only by doing this it is possible to test how the hospital copes with patients who really need operating theatre treatment when this will be delayed. Patient flow within and out of the hospital must be realistic and controlled by command elements as it would be in a deployment situation. At the direction of the OT team, casualties may suddenly deteriorate and require emergency treatment. Following the end of the scenario, the treating teams will debrief themselves and there will be some input where it is required from the OT team. The OT team's tasks are to:

• observe and report on the individual and collective proficiency of an individual and team undertaking an operational task

• determine the senior clinician in their allocated area and ‘shadow’ them

• observe and report proficiency using the assessment tool

• umpire the scenario

• provide mentorship when necessary and appropriate

• provide constructive feedback to the individual and team at the appropriate opportunity

• contribute to the post activity report (PAR).

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Figure 3

Assessment of operating theatre team.

When the OTs deem that a catastrophic outcome would result, this briefing would normally come from the most experienced member of the OT team to ensure that there is no impression that the OTs have in any way unfairly dealt with the treating team.

At the start of the HOSPEX activity, each member of the OT team is introduced to all of the clinical personnel on the activity. At the conclusion of the activity which generally lasts about 36 h, all personnel attend a presentation from the OT team to ensure that the lessons identified are known to all. Following the conclusion of the HOSPEX, an informal oral presentation is made by the OT team to the CO of 2 GHB and his staff. A formal PAR is produced by the team project officer and officially is returned to the CO 2 GHB by the CO of 3 HSB, ensuring that the training lessons learnt are known to the responsible management teams of the full-time and reserve elements who will form the deployable Role 2 E facility.

Lessons learnt

A number of potential problems in equipment, timing of assessment and procedures have been identified. These are summarised in Table 1. Finally, we have reconfirmed the critical role of a hospital clinical director in mass casualty events, clinical governance and day-to-day clinical decision making.16

Future developments

CO 2 GHB has a significant interest in testing the allied health areas in 2 GHB and examining the performance of 2 GHB command and control under exercise conditions. Developing common pathways with medical personnel from the other services and potential coalition partners is underway. During the second HOSPEX in 2013, a number of Royal Australian Navy (RAN) and US Navy personnel provided support to 2 GHB. The first HOSPEX activity in 2014 had members from the New Zealand Army field hospital and health services attending as observers. As the RAN commissions its new landing helicopter dock ships which provide the RAN with a significant new seaborne surgical capacity, we envisage that HOSPEX will become an activity shared with the RAN. Given the likelihood that the ADF will be operating in a joint service coalition environment particularly in the health sphere, HOSPEX has the potential to provide a means of ensuring that there is a common demonstrated delineation of clinical privilege and current scope of practice across all three Australian services, our regional allies and civilian personnel.

HOSPEX-type exercises with the civilian Australian Medical Assistance Teams, who are likely to work in conjunction with ADF personnel, identified for deployment to natural disasters is another potential development. There are geographical and financial barriers to such exercises, but given the widespread location of the companies within 3 HSB there are opportunities to provide this using this reserve unit rather than the full-time 2 GHB.

Testing the primary medical care Role 1 elements of 1 CHB using a purpose-designed HOSPEX-type macrosimulation exercise is another potential task for 3HSB and may make the exercise truly macrosimulation across the entire military casualty/health system.