Skill improvement during emergency response to terrorism training

Preparing medical first responders for crises: a systematic literature review of disaster training programs and their effectiveness

BACKGROUND

Adequate training and preparation of medical first responders (MFRs) are essential for an optimal performance in highly demanding situations like disasters (e.g., mass accidents, natural catastrophes). The training needs to be as effective as possible, because precise and effective behavior of MFRs under stress is central for ensuring patients' survival and recovery. This systematic review offers an overview of scientifically evaluated training methods used to prepare MFRs for disasters. It identifies different effectiveness indicators and provides an additional analysis of how and to what extent the innovative training technologies virtual (VR) and mixed reality (MR) are included in disaster training research.

METHODS

The systematic review was conducted according to the PRISMA guidelines and focused specifically on (quasi-)experimental studies published between January 2010 and September 2021. The literature search was conducted via Web of Science and PubMed and led to the inclusion of 55 articles.

RESULTS

The search identified several types of training, including traditional (e.g., lectures, real-life scenario training) and technology-based training (e.g., computer-based learning, educational videos). Most trainings consisted of more than one method. The effectiveness of the trainings was mainly assessed through pre-post comparisons of knowledge tests or self-reported measures although some studies also used behavioral performance measures (e.g., triage accuracy). While all methods demonstrated effectiveness, the literature indicates that technology-based methods often lead to similar or greater training outcomes than traditional trainings. Currently, few studies systematically evaluated immersive VR and MR training.

CONCLUSION

To determine the success of a training, proper and scientifically sound evaluation is necessary. Of the effectiveness indicators found, performance assessments in simulated scenarios are closest to the target behavior during real disasters. For valid yet inexpensive evaluations, objectively assessible performance measures, such as accuracy, time, and order of actions could be used. However, performance assessments have not been applied often. Furthermore, we found that technology-based training methods represent a promising approach to train many MFRs repeatedly and efficiently. These technologies offer great potential to supplement or partially replace traditional training. Further research is needed on those methods that have been underrepresented, especially serious gaming, immersive VR, and MR.

Assessment of the effectiveness of a course in major chemical incidents for front line health care providers: a pilot study from Saudi Arabia

BACKGROUND

Mass chemical exposure emergencies are infrequent but can cause injury, illness, or loss of life for large numbers of victims. These emergencies can stretch and challenge the available resources of healthcare systems within the community. Political unrest in the Middle East, including chemical terrorist attacks against civilians in Syria and increasing chemical industry accidents, have highlighted the lack of hospital preparedness for chemical incidents in the region. This study aimed to evaluate the effectiveness of a course designed to empower frontline healthcare providers involved in mass casualty incidents with the basic knowledge and essential operational skills for mass chemical exposure incidents in Saudi Arabia.

METHODS

A mixed-methods approach was used to develop a blended learning, simulation enhanced, competency-based course for major chemical incidents for front line healthcare providers. The course was designed by experts from different disciplines (disaster medicine, poisoning / toxicology, and Hazard Material Threat - HAZMAT team) in four stages. The course was piloted over five days at the Officers Club of the Ministry of Interior (Riyadh, Saudi Arabia). The 41 participants were from different government health discipline sectors in the country. Pre- and post-tests were used to assess learner knowledge while debriefing sessions after the decontamination triage session and simulation-enhanced exercises were used for team performance assessment.

RESULTS

The overall knowledge scores were significantly higher in the post-test (69.47%) than the pre-test (46.3%). All four knowledge domains also had significant differences between pre- and post-test results. There were no differences in the pre and post-test scores for healthcare providers from the different health disciplines. A one-year post-event survey demonstrated that participants were satisfied with their knowledge retention. Interestingly, 38.3% had the opportunity to put this knowledge into practice in relation to mass chemical exposure incidents.

CONCLUSION

Delivering a foundation level competency-based blended learning course with enhanced simulation training in major chemical incidents for front line healthcare providers may improve their knowledge and skills in response to such incidents. This in turn can improve the level of national preparedness and staff availability and make a crucial difference in reducing the health impacts among victims.

Impact of Clinician Personal Protective Equipment on Medical Device Use During Public Health Emergency: A Review

The aim of this systematic review is to evaluate the impact of personal protective equipment (PPE) on medical device use during public health emergency responses. We conducted a systematic literature search of peer-reviewed journals in PubMed, Web of Science, and EBSCO databases. Twenty-nine of 92 articles published between 1984 and 2015 met the inclusion criteria for the review. Although many medical device use impacts were reported, they predominantly fell into 3 categories: airway management, drug administration, and diagnostics and monitoring. Chemical, biological, radiological, and nuclear (CBRN)-PPE increased completion times for emergency clinical procedures by as much as 130% and first attempt failure rates by 35% (anesthetist) versus 55% (non-anesthetist). Effects of CBRN-PPE use depend on device, CBRN-PPE level, and clinician experience and training. Continuous clinical training of responders in CBRN-PPE and device modifications can improve safety and effectiveness of medical device use during public health emergency response.

60 Seconds to Survival: A Multisite Study of a Screen-based Simulation to Improve Prehospital Providers Disaster Triage Skills

OBJECTIVES

Paramedics and emergency medical technicians (EMTs) perform triage at disaster sites. There is a need for disaster triage training. Live simulation training is costly and difficult to deliver. Screen-based simulations may overcome these training barriers. We hypothesized that a screen-based simulation, 60 Seconds to Survival (60S), would be associated with in-game improvements in triage accuracy.

METHODS

This was a prospective cohort study of a screen-based simulation intervention, 60S. Participants included emergency medical services (EMS) personnel from 21 EMS agencies across 12 states. Participants performed assessments (e.g., check for pulse) and actions (e.g., reposition the airway) for 12 patients in each scenario and assigned color-coded triage levels (red, yellow, green, or black) to each patient. Participants received on-screen feedback about triage performance immediately after each scenario. A scoring system was designed to encourage accurate and timely triage decisions. Participants who played 60S included practicing EMTs, paramedics, and nurses as well as students studying to assume these roles. Participants played the game at least three times over 13 weeks.

RESULTS

In total, 2,234 participants began game play and 739 completed the study and were included in the analysis. Overall, the median number of plays of the game was just above the threshold inclusion criteria (three or more plays) with a median of four plays during the study period (interquartile range [IQR] = 3-7). There was a significant difference in triage accuracy from the first play of the game to the last play of the game. Median baseline triage accuracy in the game was 89.7% (IQR = 82.1%-94.9%), which then increased to a median of 100% at the last game play (IQR = 87.5%-100.0%; p < 0.001). There was some variability in median triage accuracy on fourth through 11th game plays, ranging from 95% to 100%, and on the 12th to 16th plays, the median accuracy was sustained at 100%. There was a significant decrease in the rate of undertriage: from 10.3% (IQR = 5.1%-18.0%) to 0 (IQR = 0%-12.5%; p < 0.001).

CONCLUSION

60 Seconds to Survival is associated with improved in-game triage accuracy. Further study of the correlation between in-game triage accuracy and improvements in live simulation or real-world triage decisions is warranted.

Existing Approaches to Chemical, Biological, Radiological, and Nuclear (CBRN) Education and Training for Health Professionals: Findings from an Integrative Literature Review

OBJECTIVES

This review was conducted to explore the literature to determine the availability, content, and evaluation of existing chemical, biological, radiological, and nuclear (CBRN) education programs for health professionals.

METHODS

An integrative review of the international literature describing disaster education for CBRN (2004-2016) was conducted. The following relevant databases were searched: Proquest, Pubmed, Science Direct, Scopus, Journals @ OVID, Google Scholar, Medline, and Ichuschi ver. 5 (Japanese database for health professionals). The search terms used were: "disaster," "chemical," "biological," "radiological," "nuclear," "CBRN," "health professional education," and "method." The following Medical Subject Headings (MeSH) terms, "education," "nursing," "continuing," "disasters," "disaster planning," and "bioterrorism," were used wherever possible and appropriate. The retrieved articles were narratively analyzed according to availability, content, and method. The content was thematically analyzed to provide an overview of the core content of the training.

RESULTS

The literature search identified 619 potentially relevant articles for this study. Duplicates (n=104) were removed and 87 articles were identified for title review. In total, 67 articles were discarded, yielding 20 articles for all-text review, following 11 studies were retained for analysis, including one Japanese study. All articles published in English were from the USA, apart from the two studies located in Japan and Sweden. The most typical content in the selected literature was CBRN theory (n=11), followed by studies based on incident command (n=8), decontamination (n=7), disaster management (n=7), triage (n=7), personal protective equipment (PPE) use (n = 5), and post-training briefing (n=3).

CONCLUSION

While the CBRN training course requires the participants to gain specific skills and knowledge, proposed training courses should be effectively constructed to include approaches such as scenario-based simulations, depending on the participants' needs. Kako M , Hammad K , Mitani S , Arbon P . Existing approaches to chemical, biological, radiological, and nuclear (CBRN) education and training for health professionals: findings from an integrative literature review. Prehosp Disaster Med. 2018;33(2):182-190.

Bomb blast in a tertiary care hospital, the challenges faced during management of victims in a resource limited country

Introduction

A bomb blast in a hospital results in a many fold increase in the casualties. The affected health care in the region is the next challenge faced by the administration of the city. We discuss the challenges faced after a bomb blast in the civil hospital of Quetta, Pakistan on 8 August 2016.

Methods

A retrospective review of the medical records of patients who were transferred by air to the Aga Khan University Hospital Karachi over a period of 86 h after the blast in Quetta.

Results

Seventy-five patients were received in three separate waves; those received in the first wave were sicker than the following waves. Errors in triage and communication which could have been prevented were identified.

Conclusion

Security of hospitals needs to be improved to avoid such incidents in future. The teams involved in the management of these incidents should be trained about triage and communication and its importance. There is need for designated trauma centers to take care of these incidents.

The Past, Present, and Future of Simulation-based Education for Pediatric Emergency Medicine

The pediatric emergency medicine (PEM) environment is well suited for simulation-based activities, be they educational interventions for PEM learners, evaluations of the interface between health providers and the environment that they work in, or research investigations using simulation as a tool to answer specific clinical questions. As such, PEM has been among the leaders in the integration of this modality for clinical training. Traditionally, simulation has been used extensively for the dissemination of clinical training in the areas of clinical knowledge and its application, and the clinical, technical, and teamwork skills involved in PEM care. Increasingly, simulation is being used in novel applications, including breaking bad news, disclosure of error, family-centered care, quality and patient safety education, and system-level integration. The future will look to further identify, measure, and inform the integration of simulation with new and innovative adjuncts in the clinical environment, as well as to determine the optimal timing and use of simulation-based education to enhance the quality of care delivered to patients by the interprofessional and multidisciplinary team.

Willingness of the local health department workforce to respond to infectious disease events: empirical, ethical, and legal considerations

According to the Institute of Medicine, the local health department workforce is at the hub of the public health emergency preparedness system. A growing body of research has pointed to troubling attitudinal gaps among local health department workers, a vital response cohort, regarding willingness to respond to emergent infectious disease threats, ranging from naturally occurring pandemics to bioterrorism events. A summary of relevant literature on the empirical evidence, ethical norms, and legal standards applicable to the willingness of public health professionals to respond to an infectious disease emergency is presented. Recommendations are proposed for future work to be done to bring the relevant empirical, ethical, and legal considerations together to develop practical guidance for the local response to infectious disease emergencies.

Mapping the use of simulation in prehospital care - a literature review

Background

High energy trauma is rare and, as a result, training of prehospital care providers often takes place during the real situation, with the patient as the object for the learning process. Such training could instead be carried out in the context of simulation, out of danger for both patients and personnel. The aim of this study was to provide an overview of the development and foci of research on simulation in prehospital care practice.

Methods

An integrative literature review were used. Articles based on quantitative as well as qualitative research methods were included, resulting in a comprehensive overview of existing published research. For published articles to be included in the review, the focus of the article had to be prehospital care providers, in prehospital settings. Furthermore, included articles must target interventions that were carried out in a simulation context.

Results

The volume of published research is distributed between 1984- 2012 and across the regions North America, Europe, Oceania, Asia and Middle East. The simulation methods used were manikins, films, images or paper, live actors, animals and virtual reality. The staff categories focused upon were paramedics, emergency medical technicians (EMTs), medical doctors (MDs), nurse and fire fighters. The main topics of published research on simulation with prehospital care providers included: Intubation, Trauma care, Cardiac Pulmonary Resuscitation (CPR), Ventilation and Triage.

Conclusion

Simulation were described as a positive training and education method for prehospital medical staff. It provides opportunities to train assessment, treatment and implementation of procedures and devices under realistic conditions. It is crucial that the staff are familiar with and trained on the identified topics, i.e., intubation, trauma care, CPR, ventilation and triage, which all, to a very large degree, constitute prehospital care. Simulation plays an integral role in this. The current state of prehospital care, which this review reveals, includes inadequate skills of prehospital staff regarding ventilation and CPR, on both children and adults, the lack of skills in paediatric resuscitation and the lack of knowledge in assessing and managing burns victims. These circumstances suggest critical areas for further training and research, at both local and global levels.

Competency in chaos: lifesaving performance of care providers utilizing a competency-based, multi-actor emergency preparedness training curriculum

OBJECTIVE

Providing comprehensive emergency preparedness training (EPT) to care providers is important to the future success of disaster operations in the US. Few EPT programs possess both competency-driven goals and metrics to measure performance during a multi-patient simulated disaster.

METHODS

A 1-day (8-hour) EPT course for care providers was developed to enhance provider knowledge, skill, and comfort necessary to save lives during a simulated disaster. Nine learning objectives, 18 competencies, and 34 performance objectives were developed. During the 2-year demonstration of the curriculum, 24 fourth-year medical students and 17 Veterans Hospital Administration (VHA) providers were recruited and volunteered to take the course (two did not fully complete the research materials). An online pre-test, two post-tests, course assessment, didactic and small group content, and a 6-minute clinical casualty scenario were developed. During the scenario, trainees working in teams were confronted with three human simulators and 10 actor patients simultaneously. Unless appropriate performance objectives were met, the simulators "died" and the team was exposed to "anthrax." After the scenario, team members participated in a facilitator-led debriefing using digital video and then repeated the scenario.

RESULTS

Trainees (N = 39) included 24 (62%) medical students; seven (18%) physicians; seven (18%) nurses; and one (3%) emergency manager. Forty-seven percent of the VHA providers reported greater than 16 annual hours of disaster training, while 15 (63%) of the medical students reported no annual disaster training. The mean (SD) score for the pre-test was 12.3 (3.8), or 51% correct, and after the training, the mean (SD) score was 18.5 (2.2), or 77% (P < .01). The overall rating for the course was 96 out of 100. Trainee self-assessment of "Overall Skill" increased from 63.3 out of 100 to 83.4 out of 100 and "Overall Knowledge" increased from 49.3 out of 100 to 78.7 out of 100 (P < .01). Of the 34 performance objectives during the disaster scenario, 23 were completed by at least half of the teams during their first attempt. All teams except one (8 of 9) could resuscitate two simulators and all teams (9 of 9) helped prevent anthrax exposure during their second scenario attempt.

CONCLUSIONS

The 1-day EPT course for novice and experienced care providers recreated a multi-actor clinical disaster and enhanced provider knowledge, comfort level, and EPT skill. A larger-scale study, or multi-center trial, is needed to further study the impact of this curriculum and its potential to protect provider and patient lives.

A comprehensive systematic review of the use of simulation in the continuing education and training of qualified medical, nursing and midwifery staff

BACKGROUND

Simulation can be defined as a person, device or set of conditions made to resemble a real life situation. It is used in many high-risk industries particularly when reality is dangerous, critical events are rare and errors are costly in human and/or financial terms. The use of simulation in the UK is now considered an essential component of education programmes designed for healthcare practitioners. However the use of simulation in undergraduate education has been studied in depth but little is known about its use in postgraduate education.

OBJECTIVE

The aim of this systematic review was to establish: where and in which context is simulation an effective educational medium in post qualifying/continuing education; what is the benefit to learners of using simulation in respect of their knowledge, skills and confidence and what are the implications for future research in this area?

INCLUSION CRITERIA

This review looked for both quantitative and qualitative evidence in the form of primary research.The review focused on post qualification medical, nursing and midwifery staff undertaking educational development programmes utilising simulation. Types of interventions: the intervention explored in this review is simulation in the form of the re-creation of a patient centred scenario / event in a realistic context. The review explicitly excluded simulation designed to specifically to improve motor skills in isolation from context, such as part task trainers.

TYPES OF OUTCOME MEASURES

The outcome measures to be explored in this review were: demonstration of the application of knowledge to the simulated clinical situation; demonstrable improvement in knowledge of the environment and equipment; demonstration of risk assessment; safe working practice in relation to the clinical environment; recognition of own limitations and knowing when to call for help; effective communication; team working and leadership skills; evidence from learners in relation to the educational experience; evidence of increased learner confidence following simulated practice; evidence of improved patient outcome being assessed in relation to training SEARCH STRATEGY: The search strategy aimed to find both published and unpublished English language studies from 1998-2009. Databases systematically searched included: Medline, CINAHL, EMBASE, ERIC and the Dissertation Abstracts International Proceedings.

METHODOLOGICAL QUALITY

Papers were assessed for methodological quality independently by two of the review team. Critical appraisal of methodological quality of papers was undertaken using the Joanna Briggs Institute modules, Meta Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) and Qualitative Assessment and Review Instrument (JBI-QARI). Differences in judgment were resolved through discussion between the two reviewers of their differences and through the inclusion of a third reviewer if necessary in order to reach consensus. A fifth member of the team independently reviewed all included and excluded studies as a quality control mechanism.

DATA COLLECTION

The process of data extraction was undertaken independently by two reviewers using the JBI data extraction tools.

DATA SYNTHESIS

A statistical meta-analysis of the data was not possible due to the variation in outcome measures used in the papers. The findings are therefore presented descriptively using the specified outcome measures as a reporting framework.

RESULTS

The initial search identified 1522 papers. Thirty eight papers were considered to have met the inclusion criteria and were subsequently critically appraised for methodological quality. Thirty papers were considered to be of appropriate quality for inclusion in the review. These were predominantly experimental pre post test studies but they covered a wide range of healthcare workers and situations.

CONCLUSION

There is considerable evidence that suggests that simulation based educational programmes are consistently effective in improving the performance of doctors, nurses and midwives in educational contexts particularly in teamwork and communication. There is also evidence that practitioners value simulation as a learning and teaching strategy. There is however very little evidence to support the assumption that improvements in performance are translated into "real life" clinical settings and ultimately outcomes for service users.

IMPLICATIONS FOR PRACTICE

Although the evidence base provided by this review is relatively weak in terms of educational practice it would seem to have high face validity. The evidence has added coherence when seen in the context of educational theory and those planning educational programmes for healthcare practitioners should be cognizant of the potential benefits offered by simulation as part of a blended approach to learning.

IMPLICATIONS FOR RESEARCH

This review has identified a clear need to establish causative links between simulation based educational programmes and improvements in healthcare practice, by using experimental designs where simulation is compared with other educational interventions.

A simulation-based biodefense and disaster preparedness curriculum for internal medicine residents

AIMS

Disaster and bioterrorism preparedness is poorly integrated into the curricula of internal medicine residency programs. Given that victims may present to a variety of healthcare venues, including primary care practices, inpatient hospital wards, and intensive care units, we developed a curriculum to address this need.

METHODS

The curriculum consisted of four didactic sessions with supplemental readings covering biologic, chemical, and radiologic agents, as well as public health infrastructure. All 30 internal medicine resident participants also underwent a four hour training seminar at a high fidelity human simulation center. Instruction included the use of personal protective equipment (PPE)and participation in simulated scenarios utilizing technologically sophisticated mannequins with monitoring and interactive capability. Sessions were videotaped, reviewed with participants, and followed by self-evaluation and constructive feedback.

RESULTS

Compared to a control group of residents who did not undergo training, the participants' level of knowledge was significantly better, with mean objective test scores of 66.8%+/-11.8% SD vs. 50%+/-13.1% SD, p < 0.0001. Although there was a trend toward increasing knowledge with increasing level of training in the control group, this difference was not significant. Subjective preparedness was also significantly better in the intervention group (p < 0.0001). Objective improvements were not maintained after one year.

CONCLUSIONS

In this pilot study, a disaster-preparedness curriculum including simulation-based training had a positive effect on residents' knowledge base and ability to respond to disaster. However, this effect had diminished after one year, indicating the need for reinforcement at regular intervals.