Crisis-Optimized Patient Tracking: A Novel Approach for Mass Casualty Incident Management in Emergency Departments.

BackgroundTriage plays a crucial role in the emergency department (ED) management of mass casualty incidents (MCIs) when resources are limited. This study aimed to compare the performance of simple triage and rapid treatment (START) with that of the Taiwan Triage and Acuity Scale (TTAS) for the ED triage of victims following an earthquake-related MCI.MethodsWe retrospectively reviewed the records of victims presenting at our ED with earthquake-related injuries within 24 h of a large-scale earthquake. TTAS was initially used at our ED for this event, and START was performed by retrospectively reviewing the patient records in a blinded manner. Area under the receiver operating characteristic curve (AUC), sensitivity, and specificity of START and TTAS were determined for predicting ED discharge.ResultsWe enrolled 105 patients (predominantly women, 60.0%; median age, 45.0 years) in this study; most of them presented with traumatic injuries and were initially triaged as TTAS level III (78.1%), followed by TTAS level II (11.4%). Although the majority of the victims (81.0%) were discharged, four deaths occurred. A moderate agreement in differentiating emergency from nonemergency patients was observed between START and TTAS. Furthermore, both the triage systems showed similar predictions for ED disposition (START AUC/sensitivity/specificity: 0.709/82.35%/55.00%; TTAS AUC/sensitivity/specificity: 0.709/90.59%/45.00%).ConclusionsThe present study demonstrated that START and TTAS have similar triage accuracy and ability to predict ED disposition. Our findings demonstrate that START may be used as an alternative to TTAS for the ED triage of victims following earthquake-related MCIs.

Simple triage and rapid treatment protocol for emergency department mass casualty incident victim triage

To compare emergency department triage nurses' time to triage and accuracy of a simulated mass casualty incident (MCI) population using a computerized version of CTAS or START systems. This pilot study was a prospective trial using a convenience sample. A total of 20 ED triage nurses, 10 in each arm of the study, were recruited. The paper-based questionnaire contained nine simulated MCI vignettes. An expert panel arrived at consensuses on the wording of the vignettes and created a standard triage score from which to compare the study participants. Linear regression and chi-squared test were used to examine the time to triage and accuracy of triage, respectively. The mean triage time for computerized CTAS (cCTAS) and START were 138 seconds/patient and 33 seconds/patient, respectively. The effect size due to triage method was 108 seconds/patient (95% CI 83-134 seconds/patient). The cumulative triage accuracy for the cCTAS and START tools were 70/90 (77.8%) and 65/90 (72.2%), respectively. The percent difference between cumulative triage was 6% (95% CI -19-8%). Triage nurses completed START triage 105 seconds/patient faster when compared to cCTAS triage and a similar level of accuracy between the two methods was achieved. However, when the typing time is taken into consideration cCTAS took 45 seconds/patient longer. The use of either CTAS or START in the ED during a MCI may be reasonable but choosing one method over another is not justified from this investigation.

AudienceThe target audience is any medical professional who requires training in mass casualty incident (MCI) triage. This could apply to pre-hospital specialists, nurses, medical students, residents, and physicians.IntroductionEmergency medicine specialists must be able to triage patients quickly, especially in an MCI scenario. The simple triage and rapid treatment (START) system allows providers to categorize patients according to the urgency with which patients must access limited resources. Providers should be comfortable utilizing the START triage system before an MCI or disaster so that they can be prepared to implement it if necessary. This exercise uses simulation and gamification as instructional strategies to encourage knowledge of and comfort with the START triage system for emergency providers.Educational ObjectivesBy the end of this exercise, learners should be able to (1) recite the basic START patient categories (2) discuss the physical exam signs associated with each START category, (3) assign roles to medical providers in a mass casualty scenario, (4) accurately categorize patients into triage categories: green, yellow, red, and black, and (5) manage limited resources when demand exceeds availability.Educational MethodsGamification is the use of elements of game design in non-game contexts.1 Gamification was implemented in this scenario by assigning participants to roles and teams, while creating an engaging, fun, and competitive environment. The exercise also uses low fidelity simulation (without simulation equipment) to encourage learners to practice using the START triage system in a low stakes environment.2 It is possible for the learners to be divided into two groups that each have the same patients, resources, and objectives. The team that finishes triaging all patients first would be declared the winner. However, in our implementation, we completed the exercise as a single group of learners and patients.Research MethodsLearners were given a survey at the end of implementation and also given the opportunity to discuss feedback with the instructors in a group discussion after completing the exercise. There was no formal assessment completed after the exercise.ResultsInformal feedback was collected at the end of the exercise. Residents and medical students all enjoyed the experience. The feedback was overwhelmingly positive. All participants providing feedback stated they would enjoy participating in the exercise again and suggested that it is implemented annually for review of triage topics. We also received informal feedback for suggested changes which we will discuss in this article. An optional, anonymous survey was given to participants at the end of the exercise. There were six responses. Of those surveyed, 100% of participants stated the effectiveness and value of the exercise was outstanding (a rating of five on a scale of one to five). Regarding the quality of the exercise, and whether the participants felt engaged, 100% of responses gave a rating of five. When asked to consider the relevance of the session, 100% of participants selected a score of five (“I loved this session”). Regarding whether the content was applicable to practice of emergency medicine, 80% of respondents stated the session was highly relevant and 20% of responses selected a score of mostly relevant. One question asked for points of improvement for the session to which there were no responses.DiscussionLearners were assigned roles in the exercise by the incident commander, fulfilling objective three. The START categories were discussed at the beginning of the exercise by the lead proctor (using PowerPoint) and then utilized throughout the exercise, thus accomplishing objectives one and two. The residents/students filling the triage roles were primarily responsible for fulfilling objective four; however, all participants assisted in categorization of patients throughout the exercise. Finally, objective five was addressed through the various social situations and complications that can be implemented during the exercise. We chose not to implement the additional “radiation contamination” scenario (details available in the article text) due to time constraints; however, this is an additional option to address objective five. The implementation was effective based on informal feedback from participants and proctors as well as evidenced by the responses to the anonymous survey. Learners found the aspects of resource management, review of START triage, repetition of the START triage system, and medical management of various types of trauma informative and meaningful. We received valuable feedback from both learners and proctors, which we will discuss in this article.TopicsMass casualty incident, disaster, START, gamification, simulation, emergency medicine, triage, triage category, contamination, teamwork, trauma, projectile trauma, penetrating injury, blunt trauma, intracranial hemorrhage, fracture, trauma in pregnancy, active shooter, radiation, radio communication.

Regarding survival and quality of life recent mass casualty incidents again emphasize the importance of early identification of the correct degree of injury/illness to enable prioritization of treatment amongst patients and their transportation to an appropriate hospital. The present study investigated existing triage algorithms in terms of sensitivity (SE) and specificity (SP) as well as its process duration in arelevant emergency patient cohort. In this study 500 consecutive air rescue missions were evaluated by means of standardized patient records. Classification of patients was accomplished by 19emergency physicians. Every case was independently classified by at least 3physicians without considering any triage algorithm. Existing triage algorithms Primary Ranking for Initial Orientation in Emergency Medical Services (PRIOR), modified Simple Triage and Rapid Treatment (mSTaRT), Field Triage Score (FTS), Amberg-Schwandorf Algorithm for Triage (ASAV), Simple Triage and Rapid Treatment (STaRT), Care Flight, and Triage Sieve were additionally carried out computer based on each case, to enable calculation of quality criteria. The analyzed cohort had an age of (mean± SD) 59± 25years, aNACA score of 3.5± 1.1 and consisted of 57% men. On arrival 8patients were deceased. Consequently, 492 patients were included in the analysis. The distribution of triage categories T1/T2/T3 were 10%/47%/43%, respectively. The highest diagnostic quality was achieved with START, mSTaRT, and ASAV yielding aSE of 78% and aSP ranging from 80-83%. The subgroup of surgical patients reached aSE of 95% and aSP between 85-91%. The newly established algorithm PRIOR exerted aSE of 90% but merely aSP of 54% in the overall cohort thereby consuming the longest time for overall decision. Triage procedures with acceptable diagnostic quality exist to identify the most severely injured. Due to its high rate of false positive results (over-triage) the recently developed PRIOR algorithm will cause overload of available resources for the severely injured within mass casualty incident missions. Non-surgical patients still are poorly identified by the available algorithms.

This is a combined independent study and simulation session designed to teach and drill Mass Casualty Incident (MCI) Triage and is intended for emergency medicine residents at all levels. The training of emergency medicine residents to assume leadership roles in disaster response is important. However, lack of accepted specific educational goals on the national level leads to significant variability between residencies. The purpose of this session is to train EM residents in the use of the Simple Triage and Rapid Treatment (START) and pediatric JumpSTART algorithms for triage in mass casualty incidents (MCIs) using an asynchronous model. By the end of this small group session, learners will be able to: 1) describe START triage for adult MCI victims; 2) describe JumpSTART triage for pediatric MCI victims; 3) demonstrate the ability to apply the START and JumpSTART triage algorithms in a self-directed learning environment; 4) demonstrate the ability to apply the START and JumpSTART triage algorithms in a simulated mass casualty scenario under time constraints; and 5) demonstrate appropriate use of acute life-saving interventions as dictated by the START and JumpSTART triage algorithms in a high-pressure simulated environment. This session utilizes an online independent study module that was created de novo for this specific purpose by the authors followed by a high-pressure in-person simulation session where learners practice applying the START triage model with multiple simulated patients under time constraint. Learner feedback was collected after completion of the session. Retention of learning objectives was tested at four months via multiple-choice quiz. The session was very well received by our residents, who appreciated the opportunity to practice applying START triage under pressure. The average score on the pretest was 49%. Response rates to the post-test were low, but residents scored an average of 73%, indicating a trend towards retention of learning objectives. Overall, the utilization of a de novo online learning module followed by simulation proved to be a well-received method of teaching MCI triage to emergency medicine residents. We consider this to be an effective way to train MCI Triage with minimal in-conference time utilization. We plan to implement this training annually to provide our residents with longitudinal reinforcement of this vital skill. Mass casualty, MCI, triage, START triage, JumpSTART Triage, disaster, disaster preparedness, disaster curriculum, prehospital, EMS.

We compared Sort, Assess, Lifesaving Intervention, Treatment/Transport (SALT) and Simple Triage and Rapid Treatment (START) triage methodologies to a published reference standard, and evaluated the accuracy of the START method applied by emergency medical services (EMS) personnel in a field simulation. Simulated mass casualty incident (MCI). Paramedics trained in START triage assigned each victim to green (minimal), yellow (delayed), red (immediate), or black (dead) categories. These victim classifications were recorded by investigators and compared to reference standard definitions of each triage category. The victim scenarios were also compared to the a priori classifications as developed by the investigators. MCI field simulation. Comparison of the correlation of START and SALT triage methodologies to reference standard definitions. Another outcome measure was the accuracy of the application of START triage by EMS personnel in the field exercise. The strongest correlation to the reference standard was SALT with an r = 0.860 (p < 0.001) and κ = 0.632 (p < 0.001). START and SALT triage systems agreed 100 percent on both black and green classifications. There were significant correlations between the field triage and both START and SALT methods (p < 0.001, respectfully). SALT had a significantly lower undertriage rate (9 percent [95%CI 2-15]) than both START (20 percent [95%CI 11-28]) and field triage (37 percent [95%CI 24-52]). There were no significant differences in overtriage rates. In our study, the SALT triage system was overall more accurate triage method than START at classi-fying patients, specifically in the delayed and immediate categories. In our field exercise, paramedic use of the START methodology yielded a higher rate of undertriage compared to the SALT classification.

A high influx of patients during a mass-casualty incident (MCI) may disrupt patient flow in an already overcrowded emergency department (ED) that is functioning beyond its operating capacity. This pilot study examined the impact of a two-step ED triage model using Simple Triage and Rapid Treatment (START) for pre-triage, followed by triage with the Canadian Triage and Acuity Scale (CTAS), on patient flow during a MCI simulation exercise. Hypothesis/Problem It was hypothesized that there would be no difference in time intervals nor patient volumes at each patient-flow milestone. Physicians and nurses participated in a computer-based tabletop disaster simulation exercise. Physicians were randomized into the intervention group using START, then CTAS, or the control group using START alone. Patient-flow milestones including time intervals and patient volumes from ED arrival to triage, ED arrival to bed assignment, ED arrival to physician assessment, and ED arrival to disposition decision were compared. Triage accuracy was compared for secondary purposes. There were no significant differences in the time interval from ED arrival to triage (mean difference 108 seconds; 95% CI, -353 to 596 seconds; P=1.0), ED arrival to bed assignment (mean difference 362 seconds; 95% CI, -1,269 to 545 seconds; P=1.0), ED arrival to physician assessment (mean difference 31 seconds; 95% CI, -1,104 to 348 seconds; P=0.92), and ED arrival to disposition decision (mean difference 175 seconds; 95% CI, -1,650 to 1,300 seconds; P=1.0) between the two groups. There were no significant differences in the volume of patients to be triaged (32% vs 34%; 95% CI for the difference -16% to 21%; P=1.0), assigned a bed (16% vs 21%; 95% CI for the difference -11% to 20%; P=1.0), assessed by a physician (20% vs 22%; 95% CI for the difference -14% to 19%; P=1.0), and with a disposition decision (20% vs 9%; 95% CI for the difference -25% to 4%; P=.34) between the two groups. The accuracy of triage was similar in both groups (57% vs 70%; 95% CI for the difference -15% to 41%; P=.46). Experienced triage nurses were able to apply CTAS effectively during a MCI simulation exercise. A two-step ED triage model using START, then CTAS, had similar patient flow and triage accuracy when compared to START alone.

Background: In the everyday life, a large number of pre-hospital emergency missions are including the injurers caused by traumatic events. Meanwhile, the immediate response to the injurers of the mass casualties is of particular importance due to their large number and also the distance to the medical centers. Using of a proper triage scale has a major role in prioritizing the injuries resulted from mass casualty events in order to treat and transfer them to health centers and also in the management of the scene and improving the quality of care of traumatic injuries. Therefore, the purpose of this study is to describe the various methods of triage in the scene, so that we can present a suitable triage scale for prioritizing injuries in mass casualty for pre-hospital emergency. Methods: This study is an overview one and is performed by using of databases and library resources and words including triage, pre-hospital emergency, mass casualty, crisis and emergency medical technician. Results: Based on the surveys, a variety of triage methods in the scene were found including Simple triage and rapid treatment (START), Jump start, triage sieve or Major Incident Medical Management and Support (MIMMS), Pediatric Triage Tape (PTT), Move, Assess, Sort, and Send (MASS), Care Flight, Sort, Assess, Lifesaving interventions, and Treatment and/or Transport (SALT), Revised Trauma Score (RTS), Pediatric Trauma score (PTS). Conclusion: In the literature, the use of different triage scales has been recommended in the crisis, the scene of the accident and trauma. By considering the context, structure and dispersion of mass casualty in the country, it isn’t known yet which one of these scales is operational and applicable. Therefore, for the patients in mass casualty, it is suggested that an appropriate and applicable triage scale should be designed for pre-hospital emergency operations. Key words: Triage in the scene, Pre-hospital emergency, Mass casualty

The objective of this study was to determine if modification of the Simple Triage and Rapid Treatment (START) system by the addition of an Orange category, intermediate between the most critically injured (Red) and the non-critical, non-ambulatory injured (Yellow), would reduce over- and under-triage rates in a simulated mass-casualty incident (MCI) exercise. A computer-simulation exercise of identical presentations of an MCI scenario involving a 2-train collision, with 28 case scenarios, was provided for triaging to two groups: the Fire Department of the City of New York (FDNY; n=1,347) using modified START, and the Emergency Medical Services (EMS) providers from the Eagles 2012 EMS conference (Lafayette, Louisiana USA; n=110) using unmodified START. Percent correct by triage category was calculated for each group. Performance was then compared between the two EMS groups on the five cases where Orange was the correct answer under the modified START system. Overall, FDNY-EMS providers correctly triaged 91.2% of cases using FDNY-START whereas non-FDNY-Eagles providers correctly triaged 87.1% of cases using unmodified START. In analysis of the five Orange cases (chest pain or dyspnea without obvious trauma), FDNY-EMS performed significantly better using FDNY-START, correctly triaging 86.3% of cases (over-triage 1.5%; under-triage 12.2%), whereas the non-FDNY-Eagles group using unmodified START correctly triaged 81.5% of cases (over-triage 17.3%; under-triage 1.3%), a difference of 4.9% (95% CI, 1.5-8.2). The FDNY-START system may allow providers to prioritize casualties using an intermediate category (Orange) more properly aligned to meet patient needs, and as such, may reduce the rates of over-triage compared with START. The FDNY-START system decreases the variability in patient sorting while maintaining high field utility without needing computer assistance or extensive retraining. Comparison of triage algorithms at actual MCIs is needed; however, initial feedback is promising, suggesting that FDNY-START can improve triage with minimal additional training and cost.

In reply

BackgroundTriage is an initial important step in emergency medical rescues for mass casualty incidents, and different triage systems are used in practice. However, quantitative analysis-based evidence comparing these triage systems in mass casualty incidents is limited.ObjectiveTo compare the performance of three triage systems, simple triage and rapid treatment (START), abbreviated scoring method for combat casualty (ASMcc), and sort assess lifesaving interventions treatment/transport (SALT) system, for simulated disaster patients, as assessed by medical undergraduate students.MethodsMedical undergraduates were recruited and randomly divided into three groups to evaluate the performance of the three triage systems by using simulated disaster patient cards. The triage time, accuracy, and overtriage and undertriage rates were analyzed among groups. Furthermore, a questionnaire survey was used to investigate the responses of the participants regarding learning, practice, and satisfaction among the three triage systems.ResultsA total of 30 participants were included in the study. The participants were male medical undergraduate students with a mean age of 20.73 ± 0.45 years. ASMcc had the highest accuracy of 75% with the lowest over-triage rate of 20%, SALT had the lowest undertriage rate of 19%, and START had the shortest triage time of 12.68 ± 4.96 min (all P &amp;lt; 0.05). Furthermore, the results of the questionnaire survey showed that START was easy to learn and recall with high efficiency and, among the three systems, had the highest satisfaction ratings from the participants.ConclusionThe results of the study showed that the three triage systems had their own characteristics and advantages, and they are all suitable for use in mass casualty incidents. Further studies involving more triage systems with data based on real conditions are recommended.

Introduction: In traumatic mass casualty incidents (MCIs), accurate triage is essential for prioritizing care and managing resources effectively. This study assesses the accuracy of the START (Simple Triage and Rapid Treatment) method across different responder variables, including occupation, experience, gender, and unit. Additionally, it compares the accuracy rates for each triage category and the time spent. The study further evaluates the execution rate of critical interventions, such as hemorrhage control and airway opening, which are essential steps within the START method. Methods: This study utilized AI-generated realistic images of injured patients to create a high-fidelity simulation environment. Participants included physicians, nurses, and emergency medical technicians (EMTs) with varying levels of experience (&lt;2 years, 2-5 years, &gt;5 years) and from different units (emergency department, non emergency, and fire stations). During the simulation, evaluators interacted face-to-face with participants, acting as standardized patients (SPs) to support the triage decision-making process. Participants assessed 30 simulated patients within a 30-minute timeframe, making triage color judgments based on START criteria. Bleeding control materials and nasopharyngeal airways were provided for simulated interventions. Results: On average, participants correctly assessed 28.04 cases, achieving a mean accuracy rate of 93.71%. The average time spent on triage was 845.28 seconds. Triage accuracy by color category was as follows: green (94%), yellow (96%), red (89%), and black (100%). Analysis by occupation and experience indicated that experienced participants and those in emergency-related roles performed more accurately, particularly in the red and black categories. Conclusion: This study highlights variability in START triage accuracy based on responder occupation and experience. The use of AI-generated injury images facilitated realistic training, suggesting that such simulations could enhance competency in triage skills, especially in hemorrhage and airway management. Enhanced training for responders from non-emergency units or with limited experience may lead to more consistent triage accuracy and improved MCI response.

Early appropriate allocation of resources for critically injured combat casualties is essential. This is especially important when inundated with an overwhelming number of casualties where limited resources must be efficiently allocated, such as during mass casualty events. There are multiple scoring systems utilized in the prehospital combat setting, including the shock index (SI), modified shock index (MSI), simple triage and rapid treatment (START), revised trauma score (RTS), new trauma score (NTS), Glasgow Coma Scale + age + pressure (GAP), and the mechanism + GAP (MGAP) score. The optimal score for application to the combat trauma population remains unclear. This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry from January 1, 2007 through March 17, 2020. We constructed univariable analyses to determine the area under the receiving operator characteristic (AUROC) for the scoring systems of interest. Our primary outcomes were early death (within 24 hours) or early massive transfusion, as defined by ≥3 units. There were 12,268 casualties that met inclusion criteria. There were 168 (1%) who died within the first 24 hours and 2082 (17%) that underwent significant transfusion within the first 24 hours. When assessing the predictive capabilities for death within 24 hours, the AUROCs were 0.72 (SI), 0.69 (MSI), 0.89 (START), 0.90 (RTS), 0.83 (NTS), 0.90 (GAP), and 0.91 (MGAP). The AUROCs for massive transfusion were 0.89 (SI), 0.89 (MSI), 0.82 (START), 0.81 (RTS), 0.83 (NTS), 0.85 (MGAP), and 0.86 (GAP). This study retrospectively applied seven triage tools to a database of 12,268 cases from the Department of Defense Trauma Registry to evaluate their performance in predicting early death or massive transfusion in combat. All scoring systems performed well with an AUROC >0.8 for both outcomes. Although the SI and MSI performed best for predicting massive transfusion (both had an AUROC of 0.89), they ranked last for assessment of mortality within 24 hours, with the other tools performing well. START, RTS, NTS, MGAP and GAP reliably identified early death and need for massive transfusion, with MGAP and GAP performing the best overall. These findings highlight the importance of assessing triage tools to best manage resources and ultimately preserve lives of traumatically wounded warfighters. Further studies are needed to explain the surprising performance discrepancy of the SI and MSI in predicting early death and massive transfusion.

This content can be used for trauma centers, emergency medicine residency programs, and emergency nursing. Mass casualty incidents (MCI) are becoming increasingly common and are occurring in locations that have not experienced them previously which adds to the challenge of readiness for emergency departments (EDs). Sporadic occurrences and limited resources add to the complexity of preparing for such an event. In advance of a large gathering in our metropolitan area, we developed and conducted a simulation to better prepare not only our residents, but our MCI planning committee, registered nurses (RNs) and emergency room technicians (ERTs) for an MCI.Emergency medicine is at the forefront of any hospital's response to an MCI. These events stretch the resources and force EDs to function differently than usual.1 Responding effectively is crucial to minimizing the morbidity and mortality of our patients while maximizing use of available resources. We can improve our level-headedness, efficiency, and department and hospital-level planning through simulation. This has particular implications for residency training with effects on education, preparedness, and wellness. The learners will (1) recognize state of mass casualty exercise as evidenced by verbalization or triaging by START (Simple Triage and Rapid Treatment) criteria, (2) triage several patients, including critically ill or peri-arrest acuities, according to START criteria, (3) recognize the need to limit care based on available resources, as evidenced by verbal orders or communication of priorities to team, and (4) limit emergency resuscitation, given limited resources, by only providing treatments and employing diagnostics that do not deplete limited time, staffing, and space inappropriately. A small-scale, high-fidelity simulation was created to replicate the pace and acuity of patients presenting in an MCI. Three critically injured patients with multiple gunshot wounds, represented by high-fidelity manikins with moulaged wounds, were presented over a 6-minute span. The team was allowed 10 minutes total to conduct life-saving measures, targeted evaluation, and disposition of the patients. The simulation was then adapted for use in a second institution's simulation center to replicate and validate the objectives given a different system. The learners were immediately verbally debriefed and feedback of the simulation, fidelity and appropriateness of the experience solicited. Unprompted, several of the learners volunteered that the efficacy of the experience was highly educational and valuable. Anonymized digital feedback was requested in the form of an online survey and was generally positive.The educational content was created by experts in simulation medicine and validated by content experts in the fields of Emergency Medicine, Trauma Surgery and Emergency Nursing. After the scenario ended, the learners were taken to a second room for debriefing by a trauma surgeon, an emergency medicine attending, and the nurse trauma educator. The actors were able to participate as secondary learners and were rotated out of simulation duties to participate in the debriefing. After this twenty-minute educational debrief, the learners were brought back to the simulation bay and were given a similar scenario. After this iteration, the team debriefed a second time. This hour schedule of cases and debrief was repeated a total of four times with a total of twelve individual learners. Suggestions and verbal feedback were noted for incorporation into appropriate committees or hospital departments. No formal assessment was done and inclusion was strictly on a voluntary basis. An evaluation of the session (on a Likert scale of 1-5) had six respondents which showed an average of 5 on how educational the session was, 4.8 on how realistic the session was, and 4.8 on how effective the session was. Simulation allows participants to safely gain practical experience in MCI management. The experience was well-received, and the learners verbalized increased confidence should they encounter an MCI in the future. We developed this simulation to give residents and nurses first-hand experience performing under high-stress, resource-limited conditions. We also had other learners observing the process which allowed for productive debriefing and planning for improvement. The ideas generated from this ultimately became part of the hospital's MCI response plan. The main takeaways were triage strategy and limited resource management. Mass casualty incident, mass gathering, penetrating trauma, high-fidelity simulation, team-based simulation, trauma center, hospital response planning.