Editorial note: This blog details an app developed by Pete Hulme and colleagues. Although this is now a commercial product we think the origin story, development path and product may be of interest to the EM/CC community. St Emlyn’s has no financial interest in the product.
The 22nd May 2017 was a night none of us in Virchester will ever forget. That night I was on call in the paediatric emergency department during the Manchester Arena terror attack that saw 22 people killed and over 800 injured.1
The attack took place at 22:31 at the end of an Ariana Grande concert and within minutes the less badly injured patients started self-presenting to the ED. We quickly declared a Major Incident and instigated the trust’s major incident plan. Part of that plan was to call in additional staff and the official way to do that would have been cascade phone calls through switchboard. However, we had concerns that this would be time consuming and inefficient2. Switchboards can be rapidly overloaded with phone calls during major incidents and are not an efficient way of contacting or coordinating large numbers of clinical staff. Fortunately, we had already set up a consultant WhatsApp group that we used for urgent communications and so this is what we used on the night.
WhatsApp use is now supported by the NHS (provided the appropriate security settings are in place)3 and has been shown to be effective in different medical situations such as burns, smoking cessation, STEMIs needing PCI, paediatric fractures and during the recent WannaCry ransomware attack. 4–8
Using WhatsApp generally worked for us that night in alerting enough ED consultants to cope with all the patients we saw, but it was not perfect.
In the days after the incident I reflected on the event and although we had been lucky on this occasion I had concerns. Some of my colleagues did not get the WhatsApp messages as they had either gone to bed, had their phones on silent or had them automatically muted after a certain time. Talking to colleagues I realised that if the attack had happened half an hour or an hour later (the average UK bedtime is 10:43 9) many people would have been asleep and/or their phones on silent. This would inevitably had led to a slower and less comprehensive response (we’re all big fans of sleep at St. Emlyn’s and like an early night to make up for all our on-calls!)10,11
Another difficulty encountered on the night of the Manchester Arena attack was the stress of answering the many WhatsApp messages pinging back and forth whilst at them same time trying to prepare the department for the expected patients and also simultaneously treating some of the walking wounded patients who were already starting to arrive.
To be involved in a future major incident is clearly a source of anxiety to all and recent research shows many junior doctors don’t feel well prepared for future major incidents and that this hasn’t improved over the last few years. 12
All of these issues kept thinking that there had to be a better way than this to contact staff in a major incident.
2017 was a tumultuous year for the UK (although not as bad as 2020 is shaping up with the Covid-19 pandemic). There were numerous terrorist attacks in London and the Manchester Arena attack was one of several incidents that year.13 In addition to those attacks the NHS had been hit by the WannaCry ransomware attack14 just days before the Manchester Arena incident, there was also the Grenfell Tower Fire disaster15 and the Beachey Head toxic gas major incident16.
A Technical Solution
It’s a common misperception and mistranslation (popularised in a speech by US President JF Kennedy in 1959)17 that the Chinese word for crisis is composed of ‘danger’ and ‘opportunity’. For me personally these crises and increased ‘dangers’ that we faced as a nation in the UK in 2017 led me to the ‘opportunity’ of coming up with a better method for contacting staff in a major incident.
The solution was a smartphone app that could alert people to emergencies whilst their phone was on silent or Do Not Disturb mode; imaginatively named ‘The Major Incident App’. The idea being that a single message sent to an app would allow multiple users to reply yes or no to their availability to respond and to give an estimated time of arrival. The responses would be sent to a website where another user could coordinate the response deciding who should attend immediately and who should come in later thus liberating the on site team to continue their major incident preparations without the distractions of coordinating staffing.
One of the great things about working at Manchester Foundation Trust (other than all my amazing friends and colleagues in the ED of course!) has been the Newly Appointed Consultants course. For one day a month over the course of a year we are released from clinical work to learn more about management and leadership skills. We are also supported to complete a quality improvement project, and I used this opportunity to work on the app, completing a minimal viable product (MVP) specification for the app and then sourcing quotes from tech companies. With some guidance from the chief executive of the trust (at the time Prof. Bob Pearson) I applied for funding from the Wouldn’t it be Good IF campaign supported by the Innovation Factor and Mimit. 18,19 After a Dragon’s Den20 style pitch I received half of the money and then received the other half from the Manchester Foundation Trust proof of concept fund.
Together with a colleague James Corden from TrusTech (https://www.trustech.org.uk/) we came up with a more detailed specification and then we became the ‘Dragons’ as app development companies came to pitch their ideas and quotes to us. This was a surreal moment for me having people pitching and demonstrating all kinds of apps that they had developed like a tracking app for sailing races and apps for discounts at restaurants. After careful consideration we chose the Manchester based app development company QuayTech Enterprises21 as they have a good track record of working with the NHS and had worked on another successful medical app designed to prepare patients for majoe surgery ERAS+22.
Hows the app works
To start a new major incident alert you have to log into the app website then put in the details. We wanted the website to be as easy to use as possible hence the big red ‘Click here to create a new Incident’ button on the home page.
Next you type the incident details message in METHANE form and say what help you require.
Press ‘Send’ and 25 ED consultants will be hearing this annoying tone until they acknowledge the alert and send a response about their availability and estimated time of arrival. The alert is loud and thus far has always attracted attention.
The app user will then receive a message like the one below and respond ‘Yes’ or ‘No’ to their availability and give an estimated time of arrival. The responses are fed back to the main website and out of the available staff the number needed are chosen to attend the incident.
What did I learn?
The biggest thing I would take away from this experience is that if you’ve got an idea that you believe in for something that will improve healthcare keep plugging away despite setbacks. I felt like giving up several times for example when getting funding applications rejected. It required me to tackle my tecnophobe traits, and to be persistent (as it’s taken three years to get to this point).
I learned a lot about working with industry and selecting an excellent partner in QuayTech who took the original vision and then helped mould that into something that was achievable within our time and budget constraints to deliver a realistic and achievable MVP for launch. They were always really available, helpful and patient with me and that relationship is vital to success in a project like this. The journey is not yet over and we have further developments to come. One new development has been partnering with the Transplant team at Manchester Foundation Trust and incorporating the critical alert (override do not disturb function) into a contact App the transplant team have developed so patients waiting for a transplant will get the same loud critical alert night or day when an organ becomes available. So far over 300 patients are using the app and hopefully this will improve contact times for them too.
Despite a few teething problems along way the Major Incident App has finally been launched and successfully tested in Virchester. It was used for the first time for a real incident last week and the average response time of 1.3 minutes for 22 consultants was significantly better than previous incidents (paper coming soon). Hopefully it’ll never be used again for an incident like Manchester Arena but we’re confident that we’ve got a tool that will improve our response times in major incidents and hopefully improve outcomes for our patients.
As the app’s only just been developed it’s only available to staff in Virchester at the moment but if you’re interested in finding out more drop me an email [email protected] or contact [email protected] .
Also any of you transplant surgeons interested in finding out more about the transplant app again please send us an email!
*I’ve got a declaration of interest with the app. I potentially may benefit from an undisclosed percentage share of the Intellectual property rights subject to agreement with my hospital.
- 1.https://en.wikipedia.org/wiki/Manchester_Arena_bombing . Wikipedia. https://en.wikipedia.org/wiki/Manchester_Arena_bombing . Published April 16, 2020. Accessed April 16, 2020.
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- 3.https://digital.nhs.uk/data-and-information/looking-after-information/data-security-and-information-governance/information-governance-alliance-iga/information-governance-resources/information-governance-and-technology-resources. digital.nhs.uk. https://digital.nhs.uk/. Published April 16, 2020. Accessed April 16, 2020.
- 4.https://www.escardio.org/The-ESC/Press-Office/Press-releases/whatsapp-use-by-argentina-ambulances-associated-with-faster-heart-attack-treatment. Escardio. https://www.escardio.org/. Published April 16, 2020. Accessed April 16, 2020.
- 5.Durmaz S, Ergin I, Durusoy R, Hassoy H, Caliskan A, Okyay P. WhatsApp embedded in routine service delivery for smoking cessation: effects on abstinence rates in a randomized controlled study. BMC Public Health. 2019;19(1):387. doi:10.1186/s12889-019-6727-z
- 6.Stahl I, Katsman A, Zaidman M, Keshet D, Sigal A, Eidelman M. Reliability of Smartphone-Based Instant Messaging Application for Diagnosis, Classification, and Decision-making in Pediatric Orthopedic Trauma. Pediatric Emergency Care. June 2019:403-406. doi:10.1097/pec.0000000000001211
- 7.https://www.digitalhealth.net/2017/10/nhs-could-have-fended-off-wannacry-disruption-says-nao-report/. https://www.digitalhealth.net. https://www.digitalhealth.net/. Published April 16, 2020. Accessed April 16, 2020.
- 8.Martinez R, Rogers AD, Numanoglu A, Rode H. The value of WhatsApp communication in paediatric burn care. Burns. June 2018:947-955. doi:10.1016/j.burns.2017.11.005
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- 10.May N. https://www.stemlynsblog.org/sleep-hygiene/. St Emlyns Blog. https://www.stemlynsblog.org. Published April 16, 2020. Accessed April 16, 2020.
- 11.Smith N. https://www.stemlynsblog.org/we-can-improve-your-learning-with-no-effort-at-all-here-at-st-emlyns/. St Emlyns Blog. https://www.stemlynsblog.org. Published April 16, 2020. Accessed April 16, 2020.
- 12.Mawhinney J, Roscoe H, Stannard G, Tillman S, Cosker T. Preparation for the next major incident: are we ready? A 12-year update. Emerg Med J. 2019;36(12):762-764. doi:10.1136/emermed-2019-208436
- 13.https://news.sky.com/story/britains-year-of-terror-timeline-of-attacks-in-2017-11036824 . Sky News. news.sky.com. Published April 16, 2020. Accessed April 16, 2020.
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