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

After an earthquake or an industrial chemical release, a timely and effective response is crucial and can prevent or significantly reduce the risk of casualties. To this end, first responders and rescue teams have been equipped with state-of-the-art tools and specialised instruments to improve their capabilities in terms of accuracy, rapid location, and reduction of false alarms. The European Union-funded Search and Rescue project (Emerging technologies for the Early location of Entrapped victims under Collapsed Structures and Advanced Wearables for risk assessment and First Responders Safety in SAR operations) has designed, implemented and tested a highly compatible open architecture platform for first responders in a pilot case study of a chemical incident. An analysis of major chemical accidents classified by the eMars database (Major Accident Reporting System, established by the European Seveso Directive) was carried out; it has determined the types of companies that have suffered chemical accidents with the highest number of injuries and fatalities. Based on this previous analysis, a chemical spill pilot study was devised to test advanced user equipment systems and backup applications, improving first responders’ decision-making and providing a common, dynamic operational perspective of the disaster. The Lean Method was used to evaluate processes, identify waste, test new solutions and, finally, increase the value of the product and service produced.


Introduction
Multiple casualty incident (MCI) management by prehospital emergency medical systems is a complex issue of increasing concern.The existence of multiple cascading effects, limited knowledge of the situation and need for coordination amongst several responders are time-dependent factors that need to be dealt with one by one and solved to avoid potentially serious consequences (Kadri et al. 2013;Acinas and Patricia 2007).
Emergency incident management, using the coordination systems of all responding teams involved, is one of the most important factors of complexity and a serious challenge for emergency medical teams and other emergency professionals (Piraina and Trucco 2022).To this end, prehospital emergency teams have been equipped with stateof-the-art tools and specialised instruments to improve decision-making, precision, rapid location of victims and safety and to reduce false alarm rates (S&R-Search and Rescue Project 2023).
This study aims to develop an approach based on improving emergency management capacity and adaptability to prevailing and/or unpredictable circumstances by applying it at the scene of the incident.This framework is suitable for modelling the capabilities of out-of-hospital emergency services (OES) in different operational contexts and critical scenarios.It is also particularly useful for the assessment of industries with chemical risk by insurance companies, taking into account the infographic prioritisation of industries with a higher risk of suffering accidents with injuries and fatalities based on the 30 years of record of serious chemical incidents in the EMars database.
Part of the problem affecting emergency management is undoubtedly the physical and operational relationships amongst different emergency response units, including medical teams, State Security Forces, fire fighters and Civil Protection; this vital coordination is one of the most important factors of complexity and becomes a real challenge for effective synchronisation of first responders.Since it is impossible for a single organisation to provide all necessary skills and resources to respond to a disaster, cooperation amongst stakeholders is essential for the execution of an effective emergency response (Cedergren et al. 2018).
The integration of technological, human and organisational components is fundamental for emergency management capacity and it is crucial to understand the behaviour of organisations, the roles and responsibilities within them and resources that can be deployed, as well as internal and external information flows and other means of coordination (Piraina and Trucco 2022).
This study aims to address these problems by promoting an approach to emergency management based on improving coordination, communication and safety capacity by implementing the Lean methodology framework (Dickson et al. 2009;de Barros et al. 2021).

Methodology
The methodological sequence of this case study is shown in Fig. 1.
In order to give an adequate response to the question, "How to minimise or alleviate the consequences of a chemical incident, to optimise risk analysis and address emergency scenarios following disasters", the European H2020 Search and Rescue (S&R) project came into being.This 3-year project saw the development of technological tools, which were evaluated using the Lean methodology and suggested improvements in the following different areas when responding to this kind of emergency: (1) in communication channels during chemical incidents, (2) in the safety of responders and (3) in victim rescue times.
Currently, at community level, the protocol for action in the event of chemical incidents follows the following communication and emergency response or intervention flowchart (Figs. 2, 3).
In this protocol, the areas for improvement that were detected are (1) at the pre-response stage-drafting of a risk map of chemical incidents for the region and (2) at the response stage during the course of the incident-communication, safety of responders and faster rescue times.
To work on these improvements, different Information and Communication technologies (ICTs) are being developed as part of the S&R project, funded by the European Commission, with the participation of different emergency professionals, universities and technological and communication companies from different countries in Europe.Their aim is to develop technologies that can be used in chemical incidents: (1) a communication platform called CON-CORDE (Angelidis et al. 2022), which includes a decisionmaking system, monitoring of rescuers via GPS, alarm systems with chemical gas sensor and environmental risk notification, (2) smart uniform for rescuers with vital signs sensor and GPS (Girald et al. 2021), (3) chemical gas sensor, (4) drones, (5) smartwatch, (6) paediatric immobiliser system and (7) virtual reality glasses for training in this type of incident.
Assessment was carried out using performance, efficiency and usability indicators, first in laboratories and then under real conditions involving seven simulations, or Use Cases, carried out in different European cities.In Spain, the Use Case was carried out in December 2022 in the former Oncology Hospital in Villaviciosa de Odón (Madrid) and consisted of an earthquake causing a  To assess the potential risk of chemical incidents in the region per industry, a risk map was developed using the eMARS database (EUROPA-EMARS Dashboard-European Commission 2023).This analysis consisted of assessing chemical incidents involving the highest number of fatalities and direct injuries.A descriptive cross-sectional study was conducted for the period January 1980 to December 2020.The impact of chemical accidents at EU facilities and others registered in the eMARS database was analysed, taking into account the highest number of injuries and fatalities caused by severe registered accidents.
In the following infographics, we have listed the companies with highest risk to lowest risk of having fatalities and injuries in chemical incidents, based on the above analysis.These data would be of value for being considered by insurance in order to assess the risks of the chemical activity of the companies, based on the experience of previous serious chemical incidents (Chapter 30.Development of a Chemical Risk Map of the Madrid Community Using the Descriptive Analysis of the Seveso Directive's EMars Database-Nova Science Publishers 2023) (Figs. 4,5).
A risk map was drawn up for the Community of Madrid, based on different industries in the area and their possible release of toxic substances causing the worst-case scenario taken from the eMARS database and list of industries registered in the Civil Protection Regulations for the Community of Madrid (Chapter 30.Development of a Chemical Risk Map of the Madrid Community Using the Descriptive Analysis of the Seveso Directive's EMars Database-Nova Science Publishers 2023).
On the other hand, during the pilot study, different observers/evaluators from different technologies were deployed to report on improvements obtained over standard protocols, mainly in the three areas described above: (1) communication, (2) safety of responders and (3) rescue (Chalaris et al. 2021).

Communications during Multiple Casualty Incidents
Firstly, for standard operations, the Community of Madrid's SUMMA 112 emergency service is divided into three response areas, each with its own communications channel, in this case referred to as SECTOR 1, SECTOR 2 and SECTOR 3. When a response to an emergency that is classified as a Multiple Casualty Incident (MCI), the flow of communications, emergency needs and information to be transmitted are obviously much higher than usual and the communications system often collapses, so separate channels are used to avoid collapsing the channels normally used for each sector.
Once the emergency situation and Multiple Casualty Incident have been declared, a role solely assigned to the Officer on Call, an independent team is organised by the Emergency Operations Centre (EOC) to handle the incident, made up of a doctor, nurse and Emergency Medical Technicians (EMTs), also referred to as the Incident Management Team (IMT), each with their own respective roles.
As for communications, firstly one member from the IMT informs all resources in route or during the operation that an emergency response procedure has been activated, involving switching communications to its own channel, Channel 1 (assigned for all resources in route), and all those involved have to acknowledge notification to the EOC.
The only Officer who may communicate and liaise with the other Officers and the EOC is the Chief Medical Officer (CMO) to ensure that a single decision-maker has all the necessary information at their fingertips.
First, the CMO, after receiving information from the Officers belonging to the other emergency services (Police and Fire Brigade) at the Advanced Command Post (ACP) must transmit the following information to the rest of the Officers via the handheld radio transmitter: -To the EOC: the information available on the type, characteristics and possible number of casualties.-To the Triage Officer: when triage can begin and whether or not the triage area is safe for its carrying out.The person in charge of minor casualties initially goes along on this mission.-To the Resources Officer: to find suitable access and evacuation routes and to locate possible resources to be used in the emergency.
For their part, the first Officers must exchange information with the CMO via the handheld radio transmitters and convey the following: a summary of all communications/information transmitted during the Multiple Casualty Incident.
In a Multiple Casualty Incident (MCI), specific communication channels are used to handle the situation in order to avoid collapsing the usual working channels, namely: -SUMMA Channel 01: channel for all resources in route to the incident, and for all resources on site, other than those performing Officer duties.This is referred to as the 'Listening Channel'.-SUMMA Channel 02: channel for Officers involved in the emergency, i.e. all those wearing identification waistcoats: Advanced Medical Post Officer, Triage Officer, Green Victim Supervisor and Resource Officer.These officers may only convey information to the Chief Medi-1 3 cal Officer (CMO), who is the only valid interlocutor with the EOC.-SUMMA Channel 03: channel for managing hospital assignment, for the EOC nurse to communicate with the Chief Medical Officer (CMO) for allocating beds.
All clinical data are transmitted and a suitable hospital is assigned.
These communication channels are used until all casualties have been stabilised and/or taken to their

Industrie type
Ranking of industries generating proportionally the highest number of fatalities corresponding hospitals.Once finished, all units return to their normal working channels.The problem with this method of communication via TETRA channels is that each channel is independent and not simultaneous.The Chief Medical Officer (CMO) and staff must use one channel after the other, without being able to communicate between or intercept them, plus the fact that the quality of communication, on being oral, is usually bad, and far less precise than when written and/or accompanied    Amongst some of the potential improvements to SUM-MA112's response value stream would be to implement tools for use at the Emergency Operations Centre (EOC) to enable early CBRN incident detection; initial acceptance to do so would improve triggering of the specific protocol, help optimise response times and increase the safety of responders; such tools would allow for transversal communication flows and offer adequate information at different response phases, so essential for ensuring smooth procedural continuity; coordinating early intervention by simultaneously communicating with other response teams, equipping SUMMA112 with CBRN risk detection systems, providing early information on detected risks and improving systems for detecting exceptional risks are actions to be seriously considered in the future for a perfect response using high-quality criteria (Fig. 6).

Pilot study description
In Spain, a case study (Use Case 7) was carried out at the end of 2022 in the Old Oncology Hospital in Villaviciosa de Odón (Madrid).SUMMA 112 and a Rescue and Detection Team with dogs carried out an earthquake drill for two different scenarios.The first consisted of a search-and-rescue operation for victims in collapsed structures following an earthquake.Subsequently, a second scenario showed a hypothetical ammonia and chlorine release.All the professionals involved participated in a voluntary way.They received and signed an inform consent following the requirements of Law 14/2007, of July 3, 2007, on biomedical research, of Organic Law 3/2018, of December 5, 2018, on Personal Data Protection and guarantee of digital rights, and the regulations that develop them.
Thirty minutes after the start of the incident, the gas detection monitor warned of the presence of flammable gas.As a result of the earthquake, a gas leak occurred in a warehouse, causing deflagration followed by an explosion.The ammonia leak was caused by a burst refrigeration pipe.This ammonia leak was simulated using liquefied gas, causing a The new technological tools tested in this project included the CONCORDE communication platform (Angelidis et al. 2022), which provided the EOC and medical staff with real-time information on everything that was happening at the scene of the incident.This communication system collected information on both the victims and on what happened at the scene.On this platform, different roles were assigned, allowing for a better response to the emergency situation.The "High Commander" was based at the EOC using the programme with a laptop computer, being the first person responsible and the one who registered the incident in the system; they also allowed access to the rest of the participants and teams involved in the emergency.At the scene of the incident, the "Field Commander", using a tablet computer, coordinated the entire operation from the working area.Both roles, from their different positions, received real-time information from the "Triage Runner", the person in charge of making a rapid assessment of the vital signs of the casualties and prioritising them for evacuation (Fig. 7).
Similarly, both the High Commander and the Field Commander were able to communicate with the other responders, one of whom was wearing a smartwatch with an emergency communication app to provide messaging and hazard alert functions, as well as an emergency notification service to alert civilians of hazards and send directions to the population on appropriate exit routes from the disaster area and safe points of assistance.The responders also tested and validated a smart textile uniform (Girald et al. 2021), which sent real-time information to the High Commander and Field Commander, as well as a smart paediatric immobilisation device (Giraldi et al. 2023).The latter was used to carry a baby located under debris, guaranteeing its safety, avoiding further risks and preventing future sequelae.
On the other hand, the use and integration within the Concorde system of scanning performed by a rescue professional carrying a six-gas monitor connected to the Concorde handheld application was tested, the monitor consisting of several chemical sensors, the appropriate ones being used to detect ammonia and carbon monoxide from human activities.This type of monitor increased personal protection levels, including safer entry into semi-enclosed or enclosed spaces and detection of gas leaks at the scene of the incident.The simulated gases detected were ammonia and carbon monoxide (Search and Rescue H2020 Project 2023).

Results
When applying new technologies to a CBRN incident, the areas for improvement detected during a CBRN disaster by the emergency services of the Community of Madrid were taken into account.The identification of shortcomings was carried out by analysing both the initial phases, prior to the response protocol, as well as during the incident response phase.This improvement of capabilities in the face of CBRN disasters increases the resilience of the emergency health service that serves the population and thus the entire affected community.
Disaster risk reduction is a common concern for all states and the extent to which emergency services and countries can improve and effectively implement disaster policies and measures, in the context of their respective circumstances and capabilities, aligns with the ultimate goal of increasing global disaster resilience (What is the Sendai Framework for Disaster Risk Reduction?2023).
Improvements to a CBRN incident under this Search and Rescue initiative were achieved by implementing the Concorde platform, a state-of-the-art software tool that facilitated coordination and decision-making processes during the crisis and improved small-and medium-scale medical emergency responses, both local and regional, from responders, officers and managers alike.This coordination amongst those involved in the emergency involved immediate feedback from the monitored results of the rescuers' smart uniforms, both during the first response phase of the earthquake and afterwards (the smart uniform includes the vital signs sensor, under the personal protective equipment against CBRN risks).The platform synchronises with the chemical gas detector, smartwatch and GPS.Warning alerts can be immediately issued and transversally shared for zones where toxic concentrations of carbon monoxide are dangerous.
Using the "Assess" screen of the Concorde communication platform, information was collected on the health condition of the casualties attended, providing triage-correlated results with standardised severity colours (in accordance with the score after algorithmic analysis of injuries), including the identification of casualties (when conscious, assigning an identification number in all cases).
The results of this pilot study show the improvements when using technological tools in the processes involved in coordination, search and rescue and medical assistance during CBRN incidents.Coordination improved, reducing response times compared to using TETRA communication, zoning and warning times also decreased, and the safety of responders, communication between different teams, interdisciplinary collaboration and inter-organisational information exchange on the ground, as well as with the EOC, all saw a definite improvement.As a result, response times in rescuing victims are reduced, significantly improving casualty assistance and medical care.
The on-the-ground application of the Concorde software platform improved coordination, communication and decision-making during emergencies at both small-scale (intraorganisational) and large-scale levels, encompassing local and community zoning.This is made possible thanks to the real-time collection of incident data via sensors incorporated into the rescuers' smart uniform, also by Global Positioning System (GPS) geolocation of rescuers, as well as casualties and potential hazards, such as CBRN risks, allowing immediate risk assessment for responders to be evaluated from the EOC.
The Concorde communication platform helped us to immediately convey information to the EOC and all main players in real time as to what was happening during the emergency, thereby improving communication, response safety and decision-making by first responders, optimising victim rescue times and providing a shared, dynamic operational approach to the earthquake and its subsequent chemical release.
In terms of user-friendliness, all participants who tested this device rated the platform positively, saying it provided a lot of information in real time and has an intuitive, easy to use interface.
The smartwatch, worn by the first responder wearing the smart uniform, has a built-in emergency communication application by Bluetooth that offers messaging, vital signs monitoring and warning functions, all interfacing with the Concorde platform, providing added safety for first responders that was previously unavailable during a CBRN emergency.In terms of usability, the responders who tested this device agreed that it is the perfect size and weight.
The gas detector present in the first responder's smart uniform is the optimal solution for detecting ammonia, propane, carbon monoxide, oxygen, chlorine and carbon dioxide, allowing the zoning of hazardous areas and informing all responders of their location; geolocation of a CBRN atmosphere and communication to all teams simultaneously, was previously very difficult without this device.In terms of user-friendliness, those who tested this device suggested that it should be lighter in weight to improve usability.
The inbuilt mobile GPS tracker included in the responder's smart phone, remotely tracks and synchronises in real time to the Concorde platform, correctly transmitting data and increasing safety for responders that was previously unavailable during a CBRN emergency.In terms of ease of use during the pilot study, the device was found to provide real-time location of both victims and responders.
The smart uniform equipped with body sensors also improved results compared to what we had before: previously, during a CBRN incident, there was no possibility to geolocate personnel involved in the emergency in a risk area, nor did we have access to vital signs (heart rate, respiratory rate, blood pressure, oxygen saturation, electrocardiogram and temperature) and were therefore unable to transmit in real time the electrophysiological, biomechanical and environmental data that we can now send directly to the Concorde application using the sensors in the smart uniform, which is why it offers far more protection for personnel in terms of chemical injuries.In terms of usability, responders who tested this device found it comfortable and easy to use, giving a sense of real protection (Fig. 8).
The child rescue system is a device designed to meet the needs of first responders, based on an aluminium profile structure which is lightweight and very robust, adjusting to the height and weight of the casualty, so the child can be conveniently transported.Compared to devices designed for transporting adults, this is a definite improvement when transporting minors.In terms of ease of use, responders who tested this device considered the child rescue system to be safe, although they recommended a smaller size for hard-to-reach areas.They considered the weight of the device suitable for carrying and easy to handle and use (Fig. 9).
In the short term, better coordination and response of intervening teams at a natural and complicated disaster zone, with a chemical risk domino effect (Piraina and Trucco 2022), was assessed, compared to the usual previous working procedures and communication systems.The integrated version of CONCORDE EMS, within the SnR platform, has contained all the functionalities that end users identified and rated as very important during the CONCORDE piloting and -The applications, services and back-end portals provided decision support capabilities to the out-of-hospital emergency service.Ad hoc web portals and additions to stakeholder systems and back-offices provided a common, uniform and ubiquitous platform to collect, analyse and share real-time data from sensors, head triage and smart uniform to support management decisions.Certified security access allowed the various stakeholders to access the services provided by the stakeholders.The results of the pilot and testing can be assessed in depth in this link (Aumayr et al. 2021).It has implemented common, accepted and validated standard operating procedures, which have promoted more efficient multi-national and multi-organisational disaster response actions and are fully compatible with existing standard operating procedures (SOPs) in health emergency organisations, EU Member States and international organisations, technological framework and interoperability concepts.

Arguments
Modelling of emergency management capacity as a method of planning emergency management operations and related information flows is crucial when dealing with a multi-casualty incident from an inter-organisational perspective.This pilot S&R case study used the simulation model to consider the benefits of integrating new technologies.It involved the development of a person-centric, technologydriven solution to support and simplify collaborative planning for optimal first responder performance and disaster recovery.The simulation model was widely used in this case, given the difficulty of finding results from an experimental analytical point of view due to the limited number of multiple-casualty incidents of this type (Piraina and Trucco 2022); both advantages and disadvantages were found.
The chemical sensors, gas detectors, uniform, smartwatch and integrated mobile GPS tracker used in the project study and implemented during the pilot study showed a definite increase in safety levels of responders and improved communication with the EOC and rest of those involved.
These devices allowed monitoring of vital signs, remote geolocation of casualties, responders and chemical hazards, a definite advantage that was previously unavailable at such short notice during responses to this type of emergency Real-time cross-communication of data using the Concorde platform also enabled recommendation of adequate triage per casualty and the possibility of giving the different Officers involved in the incident vital information regarding risks, survivability and other data concerning the allocation of resources on the ground.
Proof of concept and superiority demonstrates that use of the new technologies implemented in this pilot project compares meaningfully and has definite advantages over current methods and solutions being used; this rationale stems from the positive feedback from responders and excellent results regarding multi-casualty incident coordination, accurate triage application and effectiveness of interdisciplinary communication on the ground.However, it should be noted that the use of Concorde in other types of disasters involving different emergency services requires the assignment of clear roles and responsibilities, good coordination of operational synchronisation and the smooth flow of information received by those involved in the incident; these are just some of the difficulties to face when deploying emergency services as critical infrastructure and collaboration therewith (Piraina and Trucco 2022) As previously mentioned, a key aspect in managing a CBRN incident is early risk detection and reporting thereof to the EOC, where a series of decisions are taken, including the official declaration of a Multiple Casualty Incident and mobilisation of specific second response units (CBRN Unit), implementing the aforesaid technologies helps improve safety of responders and reduce response times by enabling the detection of a CBRN threat in under 5 min.By geolocating victims, responders and the CBRN threat itself via GPS; such technology improves the quality of assistance given, improving communication with the ICP and facilitating decision-making via the Concorde platform.
Our results are consistent with those found in the study by (Zambrano Cancañón et al. 2019), demonstrating that the application of the Lean method in medical assistance increases the quality of services provided, reduces time, offers a complete solution for users, optimises the efficient use of resources and reduces risk situations for emergency professionals and volunteers.
Our findings are also consistent with the conclusions reached by Dickson in his work published in Annals of Emergency Medicine (Dickson et al. 2009), which show that the principles of Lean methodology can lead to changes in behaviour and substantial improvements in the quality of emergency assistance.However, the latter paper states that improvements are not universal and are affected by leadership and the involvement of frontline workers, suggesting the importance of team leaders and workers themselves in improving and changing the process to obtain better results, as well as suitable follow-up with positive reinforcement of the measures implemented in line with the aforesaid methodology to guarantee that process improvement is sustained over time.

Limitations
In order to prospectively confirm Dickson's previous statements, results would need to be reviewed in later pilot studies and with a different type of scenario belonging to the so-called CBRN category.This has been partially mitigated by recruiting local emergency personnel from the different fire, medical, and police services involved in the project in the seven case studies, although results have been obtained that imply improvement at all levels contemplated in said study.These results, however, would benefit from long-term tracking and evaluation, following the dynamics of continuous quality improvement.

Conclusion
This case study may serve as a reference for emergency services in different contexts involving different groups, both for operational response in disasters and to support emergency planning and risk analysis.The results of this study support new ways of delivering value-based medical assistance that focuses on each individual and professional by implementing ICT healthcare solutions in disasters and finally contributing to societal resilience to disasters.Through the lean method, we have found critical points for improvement.Effective performance and communication between the actors involved in disasters, supported by new technologies, allows for improvement in the resolution and safety of this type of incident.
These technologies help emergency services to improve the results of their interventions, reducing the impact of disasters on the environment, structures, and people.
It is vital the special surveillance and assurance of buildings and surroundings that present a higher risk in case of a Chemical incident, considering that these types of structures can be very close to population centres.

Fig. 1
Fig. 1 Methodology diagram used in the case study

Fig
Fig. 3 Incident coordination tetra radio communication flowchart

Fig. 4
Fig. 4 List of companies and their fatalities chemical incident rates

Fig. 5
Fig. 5 List of industries and their rate of injured people in the curse of chemical incidents Officer (CMO) declares CBRN incident • Awareness and risk assessment • Gather information reported • Incident Management Team (IMT) • Nurse coordinators alert to referral hospitals Until CMO declares finalisation of incident • Continuous risk assessment to sources in the field • Booking specific Hospital beds • Ensures patient traceability regarding patient safety Zoning 5 to first 15 min after the incident has begun • Hot zone (intervention) • Warm zone (relief): casualty concentration área, emergency treatment and sanitary decontamination stations • Cold zone: advanced medical post • Value the weather conditions, if changes, the CMO in the Advance Command Post (ACP) consider re-evaluating the zones Communications From minute 0 till the incident is declared finalised • Essential process • More flow of communications and information • Specific radio channels (little information) Essential during all the phases • Technical support specialised in communications • Field communications vehicle Risk analysis.Detection of toxic agent Risk analysis: minute 0 • Early suspicion • Asses the 5 signs of a CBRN incident • Report to the CMO Detection of the toxic agent: When personnel with PPE entry into the area • : minute 5 until several hours • First triage (dual).'Walk or cannot walk' • Second triage.Priority of assistance: START triage • Second triage in warm zone in casualty concentration área Triage can last from minute 5 till the end of incident • ETS: specific treatment and antidotes Contamination control point CBRNDS From the first 20 min to several hours • Measure the contamination • Warm zone • SUMMA112 decontaminates the victims • PPE is needed Stabilisation Evacuation priority From the minute 20 to several hours • Third triage: priority of evacuation • Cold zone • Usual PPE Reducing effects on population and environmentFrom the minute that the sources approach and incident and apply waste management protocolsFrom the minute 20, when set up the Sanitary Decontamination Station • Foot baths are required • Waste collection Company of action: a first response involving organisational tasks and medical assistance and a second response, CBRN specific, involving specific decontamination, agent neutralisation and treatment, as detailed in Table1.•Following the Lean Healthcare method, we have created a step map to display what happens at each step and stage that a contaminated patient affected by a CBRN incident goes through, from the time they are affected until they arrive at the hospital for final treatment.Once an incident occurs, all initial processes are primarily aimed at reducing harm to casualties and improving their survival rate.Reducing response times, improving the safety of responders and patients, guaranteeing the quality of care and prioritising evacuation to appropriate centres are fundamental objectives in this process.

Fig. 8
Fig. 8 Rescuer in smart uniform sensing at height whilst providing assistance

Table 1
CBRN incident response key points . It should also be pointed out that Concorde has been designed to meet the specific needs of different emergency services (Final Report Summary-CONCORDE (Development of Coordination Mechanisms During Different Kinds of Emergencies) | FP7 | CORDIS | European Commission 2023).A method for implementing new technologies in disasters has been developed in line with value-based healthcare standards and integration of technical solutions into current emergency procedures in Europe.