Mass Casualty Drills Research Articles

Evaluation of the hospital emergency plan based on an exercise for a mass casualty incident

The hospital emergency plan is an important tool for hospitals in the management of amass casualty incident. It is alegal requirement for hospitals to have such plans in place and to carry out drills. Emergency drills are auseful tool for the training of staff and for the evaluation of existing structures. The emergency plan of the University Hospital Würzburg (UKW) was evaluated during adisaster drill based on predefined drill objectives. The procedures according to the emergency plan of the UKW were practiced during alarge-scale disaster exercise. The exercise objectives were defined as: testing the management structure, deployment of personnel, physical organization, triage, patient flow and communication. Several exercise objectives were defined in advance. An anonymized questionnaire was used to evaluate the achievement of the exercise objectives. When properly trained and practiced the UKW emergency plan is generally well-suited to managing amass casualty event. Improvements need to be made in the communication structure, responsibilities in the treatment areas and staff knowledge of the existing emergency plans and available material. Mass casualty drills are agood tool for the evaluation of hospital emergency plans. Acritical and decisive element for success is the existence of aclear management and communication structure. Agood knowledge of the available material, the contents of the emergency plan and the consistent application of the procedures defined in this plan are essential for acoordinated course of action. This can be achieved by means of regular and mandatory training sessions.

Virtual simulation of mass casualty drills: using breakout rooms to simulate physical locations

Virtual simulation of mass casualty drills: using breakout rooms to simulate physical locations

Developing a Multi-Focal Mass Casualty Drill to Test Surge Capacity of Prehospital and Community Hospital Resources

Developing a Multi-Focal Mass Casualty Drill to Test Surge Capacity of Prehospital and Community Hospital Resources

Evolution of a mass casualty drill design team: A program evaluation.

The number of mass casualty incidents (MCIs) is increasing. While many healthcare systems have not experienced an MCI, the need for preparedness is ever present. The unique challenges of MCI preparedness require the use of simulation, which has been found to be an effective model for training in medical environments. To determine common discussion points when a multidisciplinary team designed and implemented in situ MCI simulation drills to enhance our emergency preparedness plan. This was a retrospective qualitative evaluation of the multidisciplinary mass casualty drill design team's weekly meeting minutes documents. These documents provided insight into the evolution of a mass casualty drill design team and the advancement of our emergency response plan. Continuous discussions surrounding resource restraints helped to inform the emergence of the three themes, which were "Staff," "Space," and "Stuff." These three themes were further broken down into different subthemes, but there was a continued focus on resource scarcity. Our results indicate the use of an MCI drill design team and in situ simulations assisted in better understanding of how hospital departments struggled with resource scarcity and provided opportunities to strengthen the emergency preparedness response plan. Incorporating a multidisciplinary mass casualty drill design team helped to ensure different perspectives and department needs were acknowledged and addressed through the in situ simulation trainings.

An Island-Wide Disaster Drill to Train the Next Generation of Anesthesiologists: The SIAARTI Academy Experience

Anesthesiologists play a pivotal role in mass-casualty incidents management. Disaster medicine is part of the anesthesiologist's core skills; however, dedicated training is still scarce and, often, it does not follow a standardized program. We designed and delivered a crash course in disaster medicine for Italian anesthesiology residents participating in the nationwide program, Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) Academy Critical Emergency Medicine 2019. Residents totaling 145, from 39 programs, participated in a 75-minute workstation on the principles of disaster management. Following this, each participant was involved in a full-scale mass-casualty drill. A plenary debriefing followed to present simulation data, maximize feedback, and highlight all situations needing improvement. Overall, participant performance was good: Triage accuracy was 85% prehospital and 84% in-hospital. Evacuation flow respected triage priority. During the debriefing, residents were very open to share and reflect on their experiences. A narrative qualitative analysis of the debriefing highlights that many participants felt overwhelmed by events during the exercise. Participants in coordination positions shared how they appreciated the need to switch from a clinical mindset to a managerial role. This was an invaluable experience for anesthesiology trainees, providing them with the skill set to understand the fundamental principles of a mass-casualty response.

A novel use of telemedicine during a hospital mass casualty drill

During a mass casualty disaster drill at NewYork-Presbyterian’s Lower Manhattan Hospital in April 2019, the Emergency Department (ED) used telemedicine to see low-acuity ‘walking wounded’ patients. This telemedicine service is provided every day as ED Express Care Service and staffed by off-site, board-certified Emergency Medicine attending physicians. This novel use of the ED Express Care Service allowed the ED to provide timely, safe, quality care while expanding resources and ED capacity through rapid assessment, treatment and discharge of the low-acuity patients.

Operation continued care: A large mass-casualty, full-scale exercise as a test of regional preparedness

BackgroundOur regional trauma organization, which comprises 7 trauma centers, 30 acute care hospitals and free-standing emergency departments, and 42 emergency medical services agencies, conducted possibly the largest mass-casualty drill to date, totaling 445 victims at 3 sites involving 11 hospitals and 25 agencies and organizations. MethodsThe drill was preceded by a tabletop exercise 4 months beforehand called Operation Continued Care Full-Scale Exercise, which consisted of simulated terrorist events at 3 sites to wound 445 moulaged patients. Four law enforcement and 5 fire and emergency medical services departments and 16 supporting organizations and agencies were involved in transporting patients to 11 different hospitals. The 7 objectives for the event addressed coordinating emergency operations, sustaining adequate communications, updating regional bed status, processing resource requests, triaging patients, tracking patients, and patient identification. ResultsOf the 445 transported patients, 270 (60%) were entered correctly into the state patient tracking system; 68 (25.2%) upgrades and 34 (12.6%) downgrades from scene triage categories were noted. Multiple opportunities for improvement were identified, with major weaknesses noted in communication and coordination from event sites to the regional trauma organizations and hospitals. ConclusionThe size and complexity of the drill provided experience and knowledge to facilitate future disaster preparedness and highlighted weaknesses in communication and coordination. Large, multijurisdictional, multiagency exercises provide opportunities to stress, evaluate, and improve regional disaster preparedness.

Mass casualty drill with paper blood products.

Mass casualty drill with paper blood products.

(10) The Mass-Casualty Drill at the National University Hospital: Simulating the Madrid Bombing Scenario in Singapore

(10) The Mass-Casualty Drill at the National University Hospital: Simulating the Madrid Bombing Scenario in Singapore

Expanding the Health Care Response to Mass Violence.

For Joseph Ibrahim, MD, the first wake-up call came last year at an Orlando Magic basketball game. The trauma medical director of Orlando Regional Medical Center (ORMC) was sitting in the stands at the Amway Center when he looked around at the crowd of thousands and imagined a mass casualty incident. “Being the only level I [Trauma] Center in this area, we’re responsible for every single person in here,” he recalled thinking to himself. It later struck him that Orlando—with its proximity to Disney World—was a prime target for a mass shooting or bombing. Ibrahim’s fears were realized when the deadliest mass shooting in modern US history unfolded in the early morning hours of June 12 at Orlando’s Pulse nightclub, located 2 blocks from ORMC. But by then, the hospital’s trauma and emergency staff were prepared. Three months before this real-life tragedy, ORMC staged its annual community-wide mass casualty drill. In prior years, the drills have simulated scenarios including a bombing, a rally that became violent, and an airplane crash. This year’s mock disaster—an active shooter incident at a local school with 500 injuries—included all of central Florida’s 15 hospitals, the Federal Bureau of Investigation (FBI), local law enforcement, emergency medical services (EMS), fire personnel, and ORMC’s Air Care Team, which provides transportation and in-flight stabilization for trauma patients. Ibrahim recently pushed to add trauma simulations on a more regular basis, and these smaller drills have been taking place 3 times a month. As 44 injured patients streamed in during 2 waves on the night of the Pulse nightclub shooting, these and other preparations undertaken by the hospital for mass casualties paid off, Ibrahim said: “For the most part, the big needs—anesthesia, operating rooms [and other] space, blood, and people to care for [patients]—were taken care of, and I think it was in large part due to the drills that we had performed.” Jay Kaplan, MD, vice chair of emergency services for Ochsner Health System in New Orleans and president of the American College of Emergency Physicians (ACEP), called the hospital’s response “amazing.” “Within a very short period of time they had 6 trauma surgeons [and] 8 emergency physicians caring for patients,” he said. Surgeons performed 28 operations on Sunday alone. Thirty-five patients survived and, as reported in the media, the 9 patients who did not survive died soon after reaching the hospital, indicating that they had arrived with fatal wounds. Ibrahim said that local EMS reached out to express gratitude for being included in the hospital’s drills. “I’ve had a lot of feedback saying they’re really happy that we did those drills because they knew how to step in and how to best help,” he said. By all accounts, ORMC is an example of how trauma centers and communities should prepare for mass shootings and other intentional mass casualty events. The 2013 Boston Marathon bombing, after which only 3 of 264 patients died, has been cited as another well-coordinated and highly successful response.... Language: en

Challenges of Mass Casualty Management at a Regional Trauma Centre in Sub-Saharan Africa

Background: Mass Casualty incidents usually overwhelm the capabilities of any centre. It is an event whose nature is undetermined, unexpected and disrupts the normal trauma care in a hospital. Hospitals have established protocols to deal with mass casualty when it arises. Objectives: We sought to profile the presentations of mass casualty incidents and challenges in management in a regional trauma Centre in North-West Nigeria. Methodology: A retrospective look at the records of mass casualty presentations in our centre over a 12-month period (January-December 2011) was done. A mass casualty event in our setting is the presentation to our facility of eight or more patients from the same cause at the same. Results: There were a total of 18 mass casualty presentations with an average of 1.5 per month. There were a total of 236 victims including those brought in dead (BID). Males were 203 (86%) and females 33 (16%) with an M:F ratio of 6:1. Majority of the victims 222 (94%) were above 16 years and all the victims had a common mechanism of injury which was Road traffic crashes. One hundred and forty-three (61%) of the victims sustained lacerations and bruises while 31 (13%) were polytraumatized. Sixty-two (26%) of the victims were BID’S from the scenes of the Road Crashes. The outcome was that 131 (75%) of the victims were treated and discharged while 41 (24%) were admitted for further management. Two (1%) patients died during resuscitation and within 24 hours. Conclusion: Mass casualty presentations are a regular event in our centre hence there is the need for the establishment of a protocol and regular mass casualty drills to cope with future occurrences.

Paramedic Accuracy Using SALT Triage After a Brief Initial Training

Objective. To determine paramedics’ understanding of and accuracy using SALT (sort–assess–lifesaving interventions–treatment/transport) triage, a proposed national guideline for primary triage during mass-casualty incidents, immediately and four months after training. Methods. A 20-minute lecture on SALT triage was provided to all paramedics (n = 320) from a single county during mandatory continuing education. Triage concepts were reemphasized during a 10-minute small-group lecture throughout the study period as part of standard refresher training. After the initial training, all paramedics were asked to complete a posttest consisting of three general knowledge questions about SALT triage and 10 patient scenarios in which they had to assign a triage category. The same test was administered four months after the original educational session. Demographic and job experience information was also obtained. Responses were scored and matched for each paramedic and compared using paired t-test. Results. A total of 290 (91%) paramedics completed the initial posttest. They correctly answered an average (± standard deviation) of 10.7 ± 2.3 of the 13 questions (82%). For the 10 patient scenarios, they correctly triaged an average of 8.1 ± 2.0 patients. A total of 159 paramedics completed both tests. Sixty-seven percent had more than 10 years of emergency medical services (EMS) experience; 72% had prior mass-casualty drill experience; 51% had prior actual mass-casualty experience; and 23% had heard of SALT triage prior to the training. There were no statistically significant differences in initial test scores for any of these demographic groups. For those subjects who completed both tests, the mean overall score for the initial test was 10.9 ± 1.9 (84%) and for the later test was 11.0 ± 1.9 (85%) (p < 0.770; 95% confidence interval [CI] –0.3 to 0.3). For the 10 patient scenarios, the paramedics correctly triaged an average of 8.3 ± 1.7 patients on the initial test and 8.3 ±1.4 patients on the later test (p < 0.565; 95% CI –0.4 to 0.2). Conclusion. Following a short didactic course, paramedics were able to accurately perform SALT triage during a written scenario. Four months after the training, they had retained their understanding of and accuracy using SALT triage. It appears that a brief educational tool was effective for training EMS providers in SALT triage.

A Randomized, Double‐blind, Sham‐controlled Trial Comparing Two Screening Devices for Radiation Contamination

This exploratory study compared the screening ability of a newly introduced radiation detection portal with a traditional Geiger counter for detection of radiation contamination in the setting of a mass casualty training exercise. Following a pretrial evaluation of interobserver reliability for Geiger counter use, 30 volunteers were randomly assigned to don gowns containing three disks, each of which was either a sham resembling the radioactive samples or an actual cesium-137 sample; each subject participated a minimum of four times with different gowns each time. Each subject underwent standard radioactivity screening with the Geiger counter and the portal. Interobserver reliability was excellent between the two Geiger counter screeners in the pretrial exercise, correctly identifying 101 of 102 sham and radioactive samples (κ = 0.98; 95% confidence interval [CI] = 0.94 to 1.00). For radioactively labeled subjects across all bodily locations, the portal (43/61, or 70.5%; 95% CI = 58.1% to 80.5%) was less sensitive than the Geiger counter screening (61/61, or 100%; 95% CI = 92.9% to 100%), which resulted in a portal false-negative rate of 29.5%. For radiation detection in the posterior thorax, the portal radiation screening (4/19, or 21.1%; 95% CI = 8% to 43.9%) was less accurate than the Geiger counter (19/19, or 100%; 95% CI 80.2% to 100%). In contrast, there were no major differences between the portal and the Geiger counter for radiation detection at the left shoulder, right shoulder, or sham (nonradiation) detection. There were no false-positive detections of the sham-labeled subjects for either device, yielding a specificity of 100% for both screening modalities. Geiger counter screening was more sensitive than, and equally specific to, radiation detection portal screening in detecting radioactively labeled subjects during a radiation mass casualty drill.

Simulation in a Disaster Drill: Comparison of High‐fidelity Simulators versus Trained Actors

High-fidelity patient simulation provides lifelike medical scenarios with real-time stressors. Mass casualty drills must construct a realistic incident in which providers care for multiple injured patients while simultaneously coping with numerous stressors designed to tax an institution's resources. This study compared the value of high-fidelity simulated patients with live actor-patients. A prospective cohort study was conducted during two mass casualty drills in December 2006 and March 2007. The providers' completion of critical actions was tested in live actor-patients and simulators. A posttest survey compared the participants' perception of "reality" between the simulators and live actor victims. The victims (n = 130) of the mass casualty drill all had burn-, blast-, or inhalation-related injuries. The participants consisted of physicians, residents, medical students, clerks, and paramedics. The authors compared the team's execution of the 136 critical actions (17 critical actions x 8 scenarios) between the simulators and the live actor-patients. Only one critical action was missed in the simulator group and one in the live actor group, resulting in a miss rate of 0.74% (95% confidence interval [CI] = 0.01% to 4.5%). All questionnaires were returned and analyzed. The vast majority of participants disagreed or strongly disagreed that the simulators were a distraction from the disaster drill. More than 96% agreed or strongly agreed that they would recommend the simulator as a training tool. The mean survey scores for all participants demonstrated agreement that the simulators closely mimicked real-life scenarios, accurately represented disease states, and heightened the realism of patient assessment and treatment options during the drill with the exception of nurse participants, who agreed slightly less strongly. This study demonstrated that simulators compared to live actor-patients have equivalent results in prompting critical actions in mass casualty drills and increase the perceived reality of such exercises.

Impact of Disaster Drills on Patient Flow in a Pediatric Emergency Department

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)-accredited hospitals must conduct disaster drills twice a year, with one incorporating a mass casualty incident to the emergency department (ED). The authors found no studies describing the potential negative impact on the quality of care real patients in the ED receive during these drills. The objective was to determine the impact that mass casualty drills have on the timeliness of care for nondisaster patients in a pediatric ED. Since 2001, nine disaster drills involving mass casualties to the ED were conducted at the authors' institution. The authors studied 5-, 10-, and 24-hour blocks of time surrounding these events and defined quality measures as the timeliness of care in terms of length of stay (LOS) in ED, time-to-triage, and time-to-physician. Drill dates were compared with control dates (the same weekday on the following week). Paired t-tests were used to compare outcomes of interest between drill and control days. Nine drill days and nine control days were studied. There was no statistically significant difference between drill dates and control dates in average time-to-triage and time-to-emergency physician and average ED LOS. Admitted patients spent less time in the ED during drill dates. Disaster drills at this institution do not appear to significantly affect the timeliness of care to nondisaster drill ED patients. Attention should be paid to the quality of care "real" patients receive to ensure that their care is not jeopardized during an artificial stress to the system during a disaster drill.

Hospital Collaboration with Public Safety Organizations on Bioterrorism Response

Objective. To identify hospital characteristics that predict collaboration with public safety organizations on bioterrorism response plans andmass casualty drills. Methods. The 2003 and2004 Bioterrorism andMass Casualty Supplements to the National Hospital Ambulatory Medical Care Survey examined collaboration with emergency medical services (EMS), hazardous materials teams (HAZMAT), fire departments, andlaw enforcement. The sample included 112 geographic primary sampling units and1,110 hospitals. Data were weighted by inverse selection probability, to yield nationally representative estimates. Characteristics included residency andmedical school affiliation, bed capacity, ownership, urbanicity andJoint Commission accreditation. The response rate was 84.6%. Chi-square analysis was performed with alpha set at p < 0.05. Logistic regression modeling yielded odds ratios with 95% confidence intervals. Results. During a bioterrorism incident, 68.9% of hospitals would contact EMS, 68.7% percent law enforcement, 61.6% fire departments, 58.1% HAZMAT, and42.8% all four. About 74.2% had staged mass casualty drills with EMS, 70.4% with fire departments, 67.4% with law enforcement, 43.3% with HAZMAT, and37.0% with all four. Predictors of drilling with some or all of these public safety organizations included larger bed capacity, nonprofit andproprietary ownership, andJCAHO accreditation. Medical school affiliation was a negative predictor of drilling with EMS.Conclusions. The majority of hospitals involve public safety organizations in their emergency plans or drills. Bed capacity was most predictive of drilling with these organizations. Medical school affiliation was the only characteristic negatively associated with drilling.

The Advanced Health and Disaster Aid Network: A Light-Weight Wireless Medical System for Triage

Advances in semiconductor technology have resulted in the creation of miniature medical embedded systems that can wirelessly monitor the vital signs of patients. These lightweight medical systems can aid providers in large disasters who become overwhelmed with the large number of patients, limited resources, and insufficient information. In a mass casualty incident, small embedded medical systems facilitate patient care, resource allocation, and real-time communication in the advanced health and disaster aid network (AID-N). We present the design of electronic triage tags on lightweight, embedded systems with limited memory and computational power. These electronic triage tags use noninvasive, biomedical sensors (pulse oximeter, electrocardiogram, and blood pressure cuff) to continuously monitor the vital signs of a patient and deliver pertinent information to first responders. This electronic triage system facilitates the seamless collection and dissemination of data from the incident site to key members of the distributed emergency response community. The real-time collection of data through a mesh network in a mass casualty drill was shown to approximately triple the number of times patients that were triaged compared with the traditional paper triage system.

Managing Bioterrorism Mass Casualties in an Emergency Department: Lessons Learned From a Rural Community Hospital Disaster Drill

Bioterrorism represents a threat for which most emergency departments (EDs) are ill prepared. In order to develop an evidence-based plan for ED and hospital management of contaminated patients, a review was conducted of the most effective strategies developed during the severe acute respiratory syndrome (SARS) epidemic, as well as Centers for Disease Control and Prevention and military guidelines on biowarfare. Six basic steps were identified: 1) lock down the hospital and control access to the ED; 2) protect emergency care personnel with appropriate personal protective equipment; 3) decontaminate and triage patients; 4) isolate patients; 5) treat patients with appropriate medications or measures, including decontamination of wounds; and 6) use restrictive admission and transfer guidelines. By emphasizing these six basic concepts, a rural ED passed an annual state-run bioterrorism mass-casualty drill. The drill provided health care personnel with the knowledge and skills necessary to prepare for future bioterrorism casualties. These same concepts could also be used to manage highly virulent viral or bacterial outbreaks.

The Pope Air Force Base Aircraft Crash and Burn Disaster

This report describes the initial hospital and burn center management of a mass casualty incident resulting from an aircraft crash and fire. One hundred thirty soldiers were injured, including 10 immediate fatalities. Womack Army Medical Center at Fort Bragg, North Carolina, managed the casualties and began receiving patients 15 minutes after the crash. As a result of repetitive training that included at least two mass casualty drills each year, the triage area and emergency department were cleared of all patients within 2 hours. Fifty patients were transferred to burn centers, including 43 patients to the US Army Institute of Surgical Research. This constitutes the largest single mass casualty incident experienced in the 57-year history of the Institute. All patients of the US Army Institute of Surgical Research survived to hospital discharge, and 34 returned to duty 3 months after the crash. The scenario of an on-ground aircraft explosion and fire approximates what might be seen as a result of an aircraft hijacking, bombing, or intentional crash. Lessons learned from this incident have utility in the planning of future response to such disasters.

A Burn Mass Casualty Event Due to Boiler Room Explosion on a Cruise Ship: Preparedness and Outcomes

The purpose of this study was to review our experience with a mass casualty incident resulting from a boiler room steam explosion aboard a cruise ship. Experience with major, moderate, and minor burns, steam inhalation, mass casualty response systems, and psychological sequelae will be discussed. Fifteen cruise ship employees were brought to the burn center after a boiler room explosion on a cruise ship. Eleven were triaged to the trauma resuscitation area and four to the surgical emergency room. Seven patients were intubated for respiratory distress or airway protection. Six patients had >80 per cent burns with steam inhalation, and all of these died. One of the 6 patients had 99 per cent burns with steam inhalation and died after withdrawal of support within the first several hours. All patients with major burns required escharotomy on arrival to trauma resuscitation. One patient died in the operating room, despite decompression by laparotomy for abdominal compartment syndrome and pericardiotomy via thoracotomy for cardiac tamponade. Four patients required crystalloid, 20,000 mls/m2-27,000 ml/m2 body surface area (BSA) in the first 48 hours to maintain blood pressure and urine output. Three of these four patients subsequently developed abdominal compartment syndrome and died in the first few days. The fourth patient of this group died after 26 days due to sepsis. Five patients had 13-20 per cent bums and four patients had less than 10 per cent burns. Two of the patients with 20 per cent burns developed edema of the vocal cords with mild hoarseness. They improved and recovered without intubation. The facility was prepared for the mass casualty event; having just completed a mass casualty drill several days earlier. Twenty-six beds were made available in 50 minutes for anticipated casualties. Fifteen physicians reported immediately to the trauma resuscitation area to assist in initial stabilization. The event occurred at shift change; thus, adequate support personnel were instantaneously to hand. Our mass casualty preparation proved useful in managing this event. Most of the patients who survived showed signs of post-traumatic stress syndrome, which was diagnosed and treated by the burn center psychology team. Despite our efforts at treating large burns (>80%) with steam inhalation, mortality was 100 per cent. Fluid requirements far exceeded those predicted by the Parkland (Baxter) formula. Abdominal compartment syndrome proved to be a significant complication of this fluid resuscitation. A coordinated effort by the facility and preparation for mass casualty events are needed to respond to such events.