# Ambulance Commanders’ Reluctance to Enter Road Tunnels in Simulated Incidents and the Effects of a Tunnel-Specific e-Learning Course on Decision-Making: Web-Based Randomized Controlled Trial

## TL;DR

A study found that an e-learning course for ambulance commanders did not improve their decision-making in simulated road tunnel emergencies, possibly due to lack of actionable information and tunnel-specific plans.

## Contribution

This study introduces a novel method for assessing commander decision-making in tunnel incidents and highlights the limitations of e-learning in this context.

## Key findings

- None of the participants correctly answered the question on entering the tunnel system in the 1-month assessment.
- The e-learning course was not associated with more correct answers or faster decision-making compared to the control group.
- Interviews revealed issues related to lack of information, limited risk knowledge, and the need for mitigation tools like maps.

## Abstract

The optimal response to a major incident in a road tunnel involves efficient decision-making among the responding emergency services (fire and rescue services, police, and ambulances). The infrequent occurrence of road tunnel incidents may entail unfamiliarity with the tunnel environment and lead to uncertain and inefficient decision-making among emergency services commanders. Ambulance commanders have requested tunnel-specific learning materials to improve their preparedness.

We aimed to assess decision-making among ambulance commanders in simulated road tunnel incidents after they had participated in a tunnel-specific e-learning course designed to support timely and correct decisions in this context.

We conducted a web-based intervention study involving 20 participants from emergency medical services in Sweden who were randomly allocated to a test or control group. The control group (n=10, 50%) received a lecture on general incident management, while the intervention group (n=10, 50%) completed an e-learning course consisting of 5 modules focused on tunnel structure, safety, and collaboration in response. The participants took part in 2 simulation-based assessments for ambulance commander decision-making in major road tunnel incidents 1 month and 6 months after their allocated study intervention. In each simulation, the participants decided on the best course of action at 15 independent decision points, designed as multiple-choice questions. The primary outcome was the correct response to the question regarding how to appropriately enter the road tunnel. The secondary outcome measurements were correct or incorrect responses and the time taken to decide for each of the 15 decisions. Limited in-depth follow-up interviews were conducted with participants (n=5, 25%), and collected data were analyzed using qualitative content analysis.

All 20 participants completed the first simulation, and 16 (80%) completed the second. The main finding was that none (0/20, 0%) of the participants correctly answered the question on entering the tunnel system in the 1-month assessment. There were no significant differences between the groups (P=.59; 2-sample test of proportions) in the second assessment. The e-learning course was not associated with more correct answers at the first assessment, including accounting for participant factors (mean difference between groups: –0.58 points, 95% CI –1.88 to 0.73; P=.36). The e-learning course was also not associated with a shorter time to completion compared to the nonintervention group in either assessment. Interviews identified 3 categories linked to the main outcome: information (lack of), risk (limited knowledge and equipment), and mitigation (access to maps and aide-mémoire).

Participation in a tunnel-specific e-learning course did not result in a measurable change in ambulance commanders’ decision-making behavior during simulated road tunnel incidents. The observed hesitation to enter the road tunnel system may have several plausible causes, such as the lack of actionable intelligence and tunnel-specific plans. This novel approach to assessing commander decision-making may be transferable to other educational settings.