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injuries to be resolved by trained medical personnel in an on the Victoria I Consensus response model. The statements
area that calls for operational and security requirements that and questions have binary and multiple answers, including the
a nonspecialized EMS could not provide. Consequently, the possibility of feedback. The survey was validated using a con-
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time gained can be directly related to survival. 17,18 To carry venience sample that includes 13 reviewers: 7 healthcare ex-
23
out these tasks, the Spanish model proposes that the EMAET perts in tactical medicine, 3 medical experts (with no expertise
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healthcare staff should include physicians, nurses, and EMTs. in tactical medicine), 1 person with no expertise in health care,
These personnel must have sufficiently extensive medical and 2 experts in scientific methodology. The predetermined
experience to make clinically critical decisions in very short variability of these professional profiles was planned to obtain
timeframes in areas with significant environment, human, and a wider validation of the survey. All these perspectives grant
resource limitations. adequate content, method, and comprehensibility of the ques-
tions and statements.
Our proposal to achieve this expertise recommends starting
with basic training programs, such as the Tactical Emergency Once the survey was validated, a panel of experts was selected,
Casualty Care, and later expanding to joint training with the defined by their updated evidence-based knowledge and expe-
collaborating police force. The goal is to maximize interoper- rience. 24,25 This new panel excluded the previous reviewers and
ability, thus achieving maximum coherence between the police included 61 experts who were surveyed anonymously. Vari-
priorities and health necessities of the local situation. To be ables such as sex or age were omitted because these were not
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able to assess the effectiveness of this model, joint training is considered of interest in the context of this research.
essential. These training sessions guarantee that on-site work is
undertaken in the same way it was previously. This allows real A maximum of three rounds 26,27 was scheduled to achieve
scenario problem-solving beyond the protocol, such as ballistic consensus consistency. After each round, the statistical data
protection equipment removal from an injured agent, the ac- from the initial responses were analyzed both quantitatively
tual casualty transfer between zones, or adapting to the rapid and qualitatively. These results were then added to the next
change of risk priorities instructed by the police commander. round in order to allow the experts to reaffirm or modify their
positions following the contributions of the other reviewers.
Considering the obvious differences between police tasks and
medical tasks, we do not intend each workforce to assume Using a 9-point Likert scale for each item, a high degree of con-
external competencies, but rather to merge capacities and nar- sensus was considered when the congruence of the responses
row the gap between two different jobs that have many dif- exceeded 75%. The statements below the 75% consensus
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ferent secondary objectives but a common main objective: the threshold were reiterated, as reflected in Figure 1. If there was
wounded. Therefore, it is quite clear that a police officer can- a lack of consensus by the end of the third round, the specific
not provide full emergency medical assistance without com- statement would be resolved by formal consensus by means
promising their own safety and security functions, in the same of an expert committee. Once the consensus was reached, the
way that healthcare personnel cannot provide health care in improvements suggested by the experts were reported to the
an insecure area without compromising safety. Therein lies the authors of the Victoria I Consensus. The objective was to ap-
importance of establishing joint working models that allow propriately enhance the response model and thus convert it
optimizing resources and priorities. In this manner, a police into a proposal applicable to all the different contexts of the
officer with basic healthcare training is able to initiate medi- national territory.
cal procedures that can be continued by specialized healthcare
personnel, who will also then conduct the victim on the right Results
path within the local healthcare system for the best possible
outcome. This interoperative integration from the moment of The first Delphi round was sent to a panel of 61 experts, 55
the injury to definitive treatment is assumed to increase the of whom answered from 11 different autonomous regions in
chances of survival of those affected. 8 Spain. Their professional categories and experience in mass
casualty incidents MCIs and IMCIs appear in Tables 1 and 2.
Section topics are reflected in Table 3, as well as the degree of
Research Question and Purpose of the Study
consensus, which was above agreement threshold in all sec-
The Victoria I Consensus document defines and recognizes a tions except 5 and 6. The main topic in section 5 is to define
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newly implemented role (i.e., EMAET) whose usefulness has a series of intervention levels in which to carry out specific
emerged after attacks such as that in Las Ramblas in Barce- actions. Section 6 aims to define a logical competence-based
lona. Despite the clear potential of the idea and its actual process according to the response tiers and interventions.
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applicability, more evidence needs to be considered about it
as a standard response to IMCIs in the Spanish context. To After analyzing the experts’contributions (synthetized in Table
reinforce the suitability of this approach, the aim of this study 3) by means of a standardized critical review, the conclusion
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was to submit the real possibilities of this response model to was that the main limitation of the proposed model was that it
a panel of national experts to assess the endorsement of the did not suit the reality of all the regions in Spain. The possibil-
proposal in the different areas of the country. ity of such a specific healthcare response was not available in
all areas, especially in those less densely populated. To resolve
this lack of consensus, specific recommendations were made for
Method
those places where the specialized teams’ response was delayed.
The chosen research design is a conventional Delphi method, 20,21 After adding this contribution, the second round was executed.
with the structure described by Yañez-Gallardo and Cuadra-
Olmos in 2008. The questionnaire was devised by the first This second round was sent to the 55 experts who answered the
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and second authors of this article, and the content was based first iteration. Of these, 52 responses were obtained, achieving a

96 | JSOM Volume 20, Edition 4 / Winter 2020