Exercising for mass casualty preparedness

Managing a mass casualty, lessons learned

PURPOSE OF REVIEW

Mass casualty incidents (MCIs) strain available healthcare resources requiring unusual actions. Within a trauma system, hospitals receiving patients from an MCI have a defined key role in the care of the casualties and their preparedness is critical for patient outcome. The aim of this review is to address recent relevant literature to highlight important elements necessary for an adequate hospital response to an MCI.

RECENT FINDINGS

That disaster preparedness is a prerequisite for success during an MCI is undisputable. Key components in the hospital response to an MCI like triage, communication, leadership, security, and surge capacity are areas that still need attention. There has been an increased focus on optimal treatment of children and their families, and the psychosocial support for patients and staff involved.

SUMMARY

The complexity and unpredictability of MCIs demands a predefined strategy within every hospital. This strategy should include increased attention to the specific needs for children, physical security and psychological support but not at the expense of frequent training of staff. Involvement of dedicated clinical leadership both during disaster preparedness planning, training and during actual MCIs is irreplaceable.

A full response chain surge capacity test of a small rural hospital, prehospital resources and collaborating organisations

BACKGROUND

Increased surge capacity is key in mass casualty incidents. Rural hospitals face other challenges in terms of transport capacity and available resources. The aim was to examine if a simulation system previously used to test surge capacity at large hospitals, could be used to test surge capacity at a small rural hospital.

METHOD

A qualitative study was conducted to assess surge capacity at a small rural hospital using a previously validated simulation system. The simulation system was adopted to the Norwegian trauma system and local context. New simulated patient cards were developed, inspired by traffic victims. A tunnel accident scenario involving a bus, a heavy goods vehicle and a motorcyclist was used. Test staff ensured that real consumption of time and resources were followed. 98 persons representing 16 organisations, participated. A post-test survey was collected.

RESULTS

Access to the scene and transport resources were bottlenecks in the initial phase. The emergency department and lack of surgeons and anaesthetic doctors in the trauma team became the first and most prominent in-hospital surge capacity limiting factors. Operating theatre reached surge capacity, but never exceeded. The intensive care unit avoided depletion of beds/staff/ventilators due to transfer of patients to the trauma centre. Surge capacity was enhanced by obtaining staff, blood and equipment from the trauma centre. Water lock systems and replenishment routines for chest tube trays was inadequate. Blood supply was insufficient in the initial phase and a lack of overview of blood products was identified. Some communication gaps and deficiencies in victim identification were detected. The hospital participants evaluated the method as useful in assessing hospital surge capacity. Half of the participants requested increased time to learn the system pre-test. The inclusion of several organisations in the mass casualty incident exercise was appreciated and ranked high as a simulation training.

CONCLUSION

The simulation system provided detailed data to determine surge capacity and capacity-limiting factors in the mass casualty incidents response at a rural hospital and performed as a training tool for staff. Methods to improve pre-test simulation system knowledge should be examined. Broad inclusion of cooperating organisations was found beneficial.

Mass Casualty Emergency Preparedness Training Through an Academic-Practice Partnership

Mass casualty incidents overwhelm a health care system's resources. Stakeholders developed a pediatric mass casualty simulation with an unfolding timeline. A post-simulation debriefing identified opportunities to improve patient triage, interprofessional communication, and resource mobilization. Participants agreed that the simulation was effective, influenced their clinical behavior, and supported triage in clinical practice. [J Contin Educ Nurs. 2025;56(3):95-97.].

A national study of in-hospital preparedness for Mass Casualty Incidents and disasters

PURPOSE

The current geopolitical situation and climate changes accentuate the importance of health preparedness. The aim was to examine the in-hospital preparedness for Mass Casualty Incidents (MCI) and Major Incidents (MI) on a national level.

METHOD

A web-based, cross-sectional study of in-hospital preparedness for MCI/MI in Norway. All hospitals with trauma function were included with 3 defined representatives, excluding hospitals without trauma function. The survey consisted of 63 questions covering: MCI/MI organisation, education, plans, Surge Capacity, triage and supply management.

RESULTS

The study had a response rate of 97/112 (87%), representing 35/38 (92%) of the included hospitals. Contingency responsible respondents (CRR) reported that 27/34 (80%) of the hospitals had a contingency responsible function/role and 29/34 (85%) had a Disaster Preparedness Committee. Among CRR, formal MCI/MI education 5/34 (15%) and MCI/MI training 9/34 (26%) was completed. Further, 87/97 (90%) had an all-hazard contingency plan. MCI/MI exercise within the last 2 years was reported by 63/97 (65%). Surge Capacity was assessed within the last 5 years at 6/35 (17%) of the hospitals. MCI/MI material storage was reported by 56/97 (58%).

CONCLUSION

Many key aspects of contingency work were found to be well-established. MCI/MI education and training for roles/functions was missing in most hospitals. Areas of improvement detected included Surge Capacity and emergency storage. The results suggest a need for national minimum standards and requirements. National in-hospital MCI/MI preparedness could be monitored by a web-based survey, providing information of pan-European relevance.

Exploring medical first responders' perceptions of mass casualty incident scenario training: a qualitative study on learning conditions and recommendations for improvement

OBJECTIVE

Despite participating in scenario training, many medical first responders (MFRs) perceive themselves as inadequately prepared to respond to mass casualty incidents (MCIs). The objective of this study was to conduct a comprehensive examination of traditional MCI scenario training methods, focusing on their inherent strengths and limitations. An investigation into the perceptions of MFRs who had participated in MCI scenario training was carried out to identify potential areas for improvement and provide recommendations for refining MCI training protocols.

DESIGN

Qualitative inductive approach using semistructured interviews that took place between October 2021 and February 2022. Data were analysed with qualitative content analysis.

SETTING

MCI scenario training involving four organisations (three emergency medical services and one search-and-rescue organisation) tasked with responding to MCIs, collectively representing four European Union countries.

PARTICIPANTS

27 MFRs (17 emergency medical services personnel and 10 search-and-rescue volunteers) were recruited to participate in the study.

RESULTS

Two categories and seven associated subcategories (shown in parentheses) were identified as influencing the learning outcomes for MFRs: Training in a context mirroring real-world incidents (conducting incident scene risk assessment, realistic representation in casualties, incorporating scenario variety into the curriculum, interagency collaboration, role alignment when training incident site management) and use of a pedagogical framework (allowing for mistakes, the importance of post-training evaluation).

CONCLUSIONS

This study reaffirms the value of traditional MCI scenario training and identifies areas for enhancement, advocating for realistic scenarios, interagency collaboration, improved incident site management skills and thorough post-training evaluation. It suggests a shift in MCI training conceptualisation and delivery. The potential of virtual reality technologies as a valuable addition to training methods is explored, with a note on the need for further research to ascertain the long-term effectiveness of these technologies. However, the selection of a training method should consider programme goals, target population and resources.

Evaluation of prehospital preparedness for major incidents on a national level, with focus on mass casualty incidents

PURPOSE

To investigate prehospital preparedness work for Mass Casualty Incidents (MCI) and Major Incidents (MI) in Norway.

METHOD

A national cross-sectional descriptive study of Norway's prehospital MI preparedness through a web-based survey. A representative selection of Rescue and Emergency Services were included, excluding Non-Governmental Organisations and military. The survey consisted of 59 questions focused on organisation, planning, education/training, exercises and evaluation.

RESULTS

Totally, 151/157 (96%) respondents answered the survey. The results showed variance regarding contingency planning for MCI/MI, revisions of the plans, use of national triage guidelines, knowledge requirements, as well as haemostatic and tactical first aid skills training. Participation in interdisciplinary on-going life-threatening violence (PLIVO) exercises was high among Ambulance, Police and Fire/Rescue Emergency Services. Simulations of terrorist attacks or disasters with multiple injured the last five years were reported by 21/151 (14%) on a regional level and 74/151 (48%) on a local level. Evaluation routines after MCI/MI events were reported by half of the respondents (75/151) and 70/149 (47%) described a dedicated function to perform such evaluation.

CONCLUSION

The study indicates considerable variance and gaps among Prehospital Rescue and Emergency Services in Norway regarding MCI/MI preparedness work, calling for national benchmarks, minimum requirements, follow-up routines of the organisations and future reassessments. Implementation of mandatory PLIVO exercises seems to have contributed to interdisciplinary exercises between Fire/Rescue, Police and Ambulance Emergency Service. Repeated standardised surveys can be a useful tool to assess and follow-up the MI preparedness work among Prehospital Rescue and Emergency Services at a national, regional and local level.

Training nurses in an international emergency medical team using a serious role-playing game: a retrospective comparative analysis

BACKGROUND

Although game-based applications have been used in disaster medicine education, no serious computer games have been designed specifically for training these nurses in an IEMT setting. To address this need, we developed a serious computer game called the IEMTtraining game. In this game, players assume the roles of IEMT nurses, assess patient injuries in a virtual environment, and provide suitable treatment options.

METHODS

The design of this study is a retrospective comparative analysis. The research was conducted with 209 nurses in a hospital. The data collection process of this study was conducted at the 2019-2020 academic year. A retrospective comparative analysis was conducted on the pre-, post-, and final test scores of nurses in the IEMT. Additionally, a survey questionnaire was distributed to trainees to gather insights into teaching methods that were subsequently analyzed.

RESULTS

There was a significant difference in the overall test scores between the two groups, with the game group demonstrating superior performance compared to the control group (odds ratio = 1.363, p value = 0.010). The survey results indicated that the game group exhibited higher learning motivation scores and lower cognitive load compared with the lecture group.

CONCLUSIONS

The IEMT training game developed by the instructor team is a promising and effective method for training nurses in disaster rescue within IEMTs. The game equips the trainees with the necessary skills and knowledge to respond effectively to emergencies. It is easily comprehended, enhances knowledge retention and motivation to learn, and reduces cognitive load.

A Call to Action: Why Anesthesiologists Must Train, Prepare, and Be at the Forefront of Disaster Response for Mass Casualty Incidents

Disasters, both natural and man-made, continue to increase. In Spring 2023, a 3-hour workshop on mass casualty incidents was conducted at the Society for Pediatric Anesthesia-American Academy of Pediatrics Annual conference. The workshop used multiple instructional strategies to maximize knowledge transfer and learner engagement including minididactic sessions, problem-based learning discussions in 3 tabletop exercises, and 2 30-minute disaster scenarios with actors in a simulated hospital environment. Three themes became evident: (1) disasters will continue to impact hospitals and preparation is imperative, (2) anesthesiologists are extensively and comprehensively trained and their value is often underestimated as mass casualty incident responders, and (3) a need exists for longitudinal disaster preparedness education and training over the course of a career. In this special article, we have sought to further define the problem and evidence, the capacity of anesthesiologists as leaders in disaster preparedness, and the rationale for preparation with current best practices to guide how best to move forward.

Consensus Statement No. 434: Simulation in Obstetrics and Gynaecology

OBJECTIVE

To provide a comprehensive and current overview of the evidence for the value of simulation for education, team training, patient safety, and quality improvement in obstetrics and gynaecology, to familiarize readers with principles to consider in developing a simulation program, and to provide tools and references for simulation advocates.

TARGET POPULATION

Providers working to improve health care for Canadian women and their families; patients and their families.

OUTCOMES

Simulation has been validated in the literature as contributing to positive outcomes in achieving learning objectives, maintaining individual and team competence, and enhancing patient safety. Simulation is a well-developed modality with established principles to maximize its utility and create a safe environment for simulation participants. Simulation is most effective when it involves interprofessional collaboration, institutional support, and regular repetition.

BENEFITS, HARMS, AND COSTS

This modality improves teamwork skills, patient outcomes, and health care spending. Upholding prescribed principles of psychological safety when implementing a simulation program minimizes harm to participants. However, simulation can be an expensive tool requiring human resources, equipment, and time.

EVIDENCE

Articles published between 2003 and 2022 were retrieved through searches of Medline and PubMed using the keywords "simulation" and "simulator." The search was limited to articles published in English and French. The articles were reviewed for their quality, relevance, and value by the SOGC Simulation Working Group. Expert opinion from relevant seminal books was also considered.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

INTENDED AUDIENCE

All health care professionals working to improve Canadian women's health, and relevant stakeholders, including granting agencies, physician/nursing/midwifery colleges, accreditation bodies, academic centres, hospitals, and training programs.

RECOMMENDATIONS

[Hospital disaster planning in south-western Germany. A survey of 214 clinics]

Background

Due to legal regulations in Germany, public acute and emergency (A&E) hospitals-along with responsible authorities, emergency medical services, and other institutions such as the state medical associations-are committed to participate in civil protection. This participation includes the need to create and update emergency plans for external and internal crises and to take part in disaster drills. In fact, so far there is only little literature to prove whether and to what extent hospitals fulfill their obligations on this topic.

Objectives

Using a standardized survey, the state of emergency planning in hospitals in Baden-Wuerttemberg was evaluated.

Materials and methods

Based on a listing provided by the Hospital Society of Baden-Wuerttemberg (BWKG), all 214 hospitals in Baden-Wuerttemberg were identified. The standardized questionnaire inquired about specific characteristics of the emergency plan, the availability and knowledge of this plan by the hospital workforce and other local institutions that take part in civil protection and, finally, participation in disaster drills were queried.

Results

Of the 214 hospitals in Baden-Wuerttemberg, 135 (63%) provided information using the questionnaire. Except for one hospital, all other clinics indicated having a special emergency plan ready. In most cases (79.3%), both external (e.g., mass casualty incidents) and internal (e.g., fire, failure of technical equipment) crises are covered. In the vast majority of cases (94%), the hospitals also indicated that they regularly update their emergency plan, whereby the frequency of updates varied markedly. Three quarters of the hospitals said that they also regularly simulate the use of the emergency plan in disaster drills. In two thirds of the cases, external forces such as emergency medical services or the fire department also take part in these drills along with the hospitals themselves. In some cases, knowledge gained from the drills was incorporated into the emergency plan or led to improvements in staff training.

Conclusions

The willingness of public hospitals to establish comprehensive disaster planning and to take part in related drills seems to have improved noticeably in recent years. However, there is still the need for improvement in keeping the concepts up to date at some hospitals. Especially smaller hospitals showed deficits in emergency planning, particularly concerning preparedness for internal crises, resulting from failure of technical equipment. More regular drills should be used to test existing concepts and to familiarize employees with the processes on a routine basis.

Fifteen-minute consultation: An overview of major incidents

Major incidents are rare but require a large amount of preparation, co-ordination and communication across different emergency services and specialities. This ensures that casualties are efficiently managed within the constraints of limited clinical resources. This article aims to provide a brief understanding of what constitutes as a major incident, how it is declared and the chain of command in communication and action, focusing specifically on the paediatric process. It also aims to highlight important considerations that could potentially be missed (eg, the mental health impact, forensic evidence and so on).

Development and Evaluation of Innovative and Practical Table-top Exercises Based on a Real Mass-Casualty Incident

PURPOSE

The aim of this work was to develop a table-top exercise (TTX) program for mass-casualty incident (MCI) response based on a real incident to evaluate the program.

METHODS

The TTX program was developed based on the 8 TTX design steps. Convenience sampling was adopted to recruit recently graduated physicians in China. After the TTX training, the participants completed a self-designed questionnaire, as well as the Simulation Design Scale (SDS) and Educational Practices in Simulation Scale (EPSS).

RESULTS

In total, 148 valid questionnaires were collected. The difficulty score of the TTX program was 3.69 ± 0.8. The participants evaluated the program highly, with a score of 4.72 ± 0.54 out of 5. Both the SDS and the EPSS had average scores higher than 4.5. Guided reflection/feedback (M = 4.68, SD = 0.41) and fidelity (M =4.66, SD = 0.57) were the 2 highest-rated SDS subscales. For the EPSS, diverse ways of learning and collaboration were the 2 highest-rated subscales. Multivariate stepwise regression analysis showed that the participants' evaluations of the TTX training course were related to the EPSS score, the difficulty rating, the evaluation of the instructional props, and the degree of participant involvement (F = 24.385, P < 0.001).

CONCLUSIONS

A TTX program for MCIs was developed based on the 2014 Shanghai New Year Crush. The TTX kit is practical and sophisticated, and it provides an effective strategy for MCI training.

Mass casualty medicine: time for a 21st century refresh

Mass casualty events are on the rise globally, as we face increasing pressures from scarcity of resources, population growth, systemic inequalities, geopolitical instabilities, and polarised discourse. Although they are rare events for an individual practitioner, they are going to happen to someone, somewhere, this week, this month, this year. And whilst they are often the last consideration for healthcare systems under constant pressures from daily routine work, individuals, departments, hospitals, and systems have to step up effectively in times of crisis. Failure to do so can lead to suboptimal outcomes for casualties, and even perceived failures can have crippling consequences on staff, families, and communities for years.