Mass Casualty Incident Training Research Articles

The Jerusalem tribune collapse incident: Challenges in the management of a pediatric mass casualty incident.

Children comprise up to 30-50 percent of all disaster victims. Pediatric disaster medicine is a poorly established field, and most protocols are designed without adequate emphasis on the special needs of the pediatric population. During the 2021 Shavuot holiday in Israel, the collapse of temporary steel bleachers in a partially constructed synagogue resulted in a mass casualty incident (MCI) with a majority of pediatric casualties. This study analyzed the differences in post-incident casualty management, treatment, and outcomes in three Jerusalem medical centers. Multicenter retrospective data were collected from two tertiary level 1 trauma centers and one secondary hospital in Jerusalem. The data included demographics, triage scores, injury mechanisms, medical workups, and the management of the pediatric patients. A total of 171 children and adolescents aged 9-18 years presented to three centers. In two institutions, the triage was performed by a senior emergency medicine physician, and in the third institution, by a senior trauma physician. Different protocols were applied, resulting in significant differences in triage, identification and documentation, admission strategies, adherence, and analgesic treatment. Most patients presented with orthopedic injuries (115/171, 67 percent). A small number had head, chest, abdominal, and multisystem injuries (11, 5, 2, and 2 percent, respectively). Pediatric MCI management presents specific challenges. The lack of consistency in triage, registry, and management highlights the need for robust pediatric MCI training programs.

Mixed Reality–Exploring the Requirements of Realism in the Context of Mass Casualty Incident Training

Introduction:The occurrence of mass casualty incidents is increasing globally. Training is an essential cornerstone in achieving disaster preparedness, yet studies show that medical first responders perceive their level of readiness to face disaster incidents as inadequate. As real-world disaster training exercises can be characterized as resource-intensive in terms of cost and time, virtual training environments have been highlighted as a potential alternative to mass casualty incident training. In order to increase the preparedness of medical first responders, a deeper understanding of their requirements in the context of disaster training exercises is needed.Method:Individual, contextual interviews were conducted with a total of 26 medical first responders from four European emergency service organizations: Hellenic Rescue Team (Greece), Summa 112 (Spain), Sanitätspolizei Bern (Switzerland), and Johanniter Österreich (Austria). The interviews were analyzed using qualitative content analysis.Results:The preliminary results indicate that real-world disaster training exercises have limitations regarding realism. The participants described a need to train in an environment that accurately represents what they might face amidst a real-world incident site. This included the recreation of potential environmental dangers that had to be taken into consideration before approaching the incident site. The participants also highlighted the importance of realistic representations of injuries and reactions from the victims during training. The limited possibilities to provide a realistic training environment that corresponds to the set requirements lead to the participants feeling less prepared to face a real-world mass casualty incident.Conclusion:Medical first responders’ need for increased realism in real-world disaster training exercises deserves attention. Training solutions that could potentially increase the level of preparedness needs to be taken into consideration. How the degree of realism in Virtual or Mixed Reality based training platforms affects the perception of preparedness among medical first responders warrant further research.

Exposure to a Virtual Reality Mass-Casualty Simulation Elicits a Differential Sympathetic Response in Medical Trainees and Attending Physicians.

Previous studies have demonstrated the use of virtual reality (VR) in mass-casualty incident (MCI) simulation; however, it is uncertain if VR simulations can be a substitute for in-person disaster training. Demonstrating that VR MCI scenarios can elicit the same desired stress response achieved in live-action exercises is a first step in showing non-inferiority. The primary objective of this study was to measure changes in sympathetic nervous system (SNS) response via a decrease in heart rate variability (HRV) in subjects participating in a VR MCI scenario. An MCI simulation was filmed with a 360º camera and shown to participants on a VR headset while simultaneously recording electrocardiography (EKG) and HRV activity. Baseline HRV was measured during a calm VR scenario immediately prior to exposure to the MCI scenarios, and SNS activation was captured as a decrease in HRV compared to baseline. Cognitive stress was measured using a validated questionnaire. Wilcoxon matched pairs signed rank analysis, Welch's t-test, and multivariate logistic regression were performed with statistical significance established at P <.05. Thirty-five subjects were enrolled: eight attending physicians (two surgeons, six Emergency Medicine [EM] specialists); 13 residents (five Surgery, eight EM); and 14 medical students (six pre-clinical, eight clinical-year students). Sympathetic nervous system activation was observed in all groups during the MCI compared to baseline (P <.0001) and occurred independent of age, sex, years of experience, or prior MCI response experience. Overall, 23/35 subjects (65.7%) reported increased cognitive stress in the MCI (11/14 medical students, 9/13 residents, and 3/8 attendings). Resident and attending physicians had higher odds of discordance between SNS activation and cognitive stress compared to medical students (OR = 8.297; 95% CI, 1.408-64.60; P = .030). Live-actor VR MCI simulation elicited a strong sympathetic response across all groups. Thus, VR MCI training has the potential to guide acquisition of confidence in disaster response.

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

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. 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). 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). 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.

Dynamic Communication Quantification Model for Measuring Information Management During Mass-Casualty Incident Simulations.

ObjectiveTo develop a new model to quantify information management dynamically and to identify factors that lead to information gaps.BackgroundInformation management is a core task for emergency medical service (EMS) team leaders during the prehospital phase of a mass-casualty incident (MCI). Lessons learned from past MCIs indicate that poor information management can lead to increased mortality. Various instruments are used to evaluate information management during MCI training simulations, but the challenge of measuring and improving team leaders’ abilities to manage information remains.MethodThe Dynamic Communication Quantification (DCQ) model was developed based on the knowledge representation typology. Using multi point-of-view synchronized video, the model quantifies and visualizes information management. It was applied to six MCI simulations between 2014 and 2019, to identify factors that led to information gaps, and compared with other evaluation methods.ResultsOut of the three methods applied, only the DCQ model revealed two factors that led to information gaps: first, consolidation of numerous casualties from different areas, and second, tracking of casualty arrivals to the medical treatment area and departures from the MCI site.ConclusionThe DCQ model allows information management to be objectively quantified. Thus, it reveals a new layer of knowledge, presenting information gaps during an MCI. Because the model is applicable to all MCI team leaders, it can make MCI simulations more effective.ApplicationThis DCQ model quantifies information management dynamically during MCI training simulations.

Mass Casualty Incident (MCI) training in a metropolitan university hospital: short-term experience with MAss Casualty SIMulation system MACSIM®.

The aim of this study was to test and validate a new hospital Mass Casualty Incident (MCI) training using MACSIM® (MAss Casualty SIMulation) system adapted to the specifications and MCI plan of a single hospital. The original MCI training format called MACSIM-PEMAF (Piano di Emergenza per il Massiccio Afflusso di Feriti, i.e., hospital disaster plan for massive influx of casualties) was developed for the Italian Society for Trauma and Emergency Surgery (SICUT) in 2016. It uses MACSIM®, a simulation tool for the training and assessment of healthcare professionals in MCI management. Between 2016 and 2018 the course was held several times at a university hospital in the Milan metropolitan area. The MACSIM® tool was used to reproduce different MCI scenarios with actual hospital resources. During the simulations, participants acted in their usual professional functions, testing both the local MCI plan as well as the individuals' knowledge and skills. Course effectiveness was validated by a pre- and post-curse self-assessment questionnaire. MACSIM-PEMAF was tested over 7 courses, with a total of 258 participants. Pre- and post-course questionnaires showed a significant improvement for hospital staff in self-reported perceptions of knowledge and skills in MCI management. In total, on a 1-10 scale, all the staff increased their competencies from a value of 4.4 ± 2.5 to 7.5 ± 1.9 (p < 0.001). MACSIM-PEMAF demonstrated efficacy in fulfilling the requirements of Italian law for PEMAF implementation, testing local resources and resilience, as well as increasing the self-reported perception of the hospital staff ability to respond to a MCI.

Periodic Refresher Emails for Emergency Department Mass Casualty Incident Plans.

This mass casualty incident (MCI) curriculum is intended for use as refresher content in the months between more formal education, such as hands-on MCI training and drills. The target audience for each topic varies, but the majority of them apply to all disciplines such as direct patient care roles (emergency room technicians, nurses, paramedics, advanced practice practitioners, resident physicians, attending physicians, etc.) and emergency department clerks/coordinators. Topics intended for only one or more discipline are labeled as such. See curriculum chart or email schedule (Appendix AI) for details. This curriculum is intended for use as weekly refresher emails spanning up to a 30-week period. There have been an increasing number of mass casualty events occurring throughout the country in recent years, many of which involve penetrating trauma. Education surrounding response to an MCI is broad and has many complex and ever-changing aspects that require staff to be updated on the most current information. This curriculum is intended to maintain a knowledge base of MCI processes to mitigate degradation of necessary knowledge between hands-on MCI training. The educational strategies used in this curriculum include short weekly refresher emails and optional external links for further reading. This content was evaluated for efficacy by administering electronic knowledge tests at baseline, mid-way (at 16 weeks), and at the end of the curriculum (32 weeks) via email. Additionally, brief content questions were asked in person while staff members were on shift throughout the entire study period, and a post-study survey was administered in order to obtain staff opinions on email length and training processes in general. Scores for the knowledge tests were slightly higher at the end of the 32 weeks compared to baseline. Subjective feedback was positive overall at the end of the testing period. Training and maintaining knowledge of roles and concepts of mass casualty incidents is vital since such events will never happen when expected. Short refresher emails allow educators to use spaced repetition and interleaving methods which have been shown to be a helpful adjunct to maintain knowledge, skills, and attitudes learned in more formal training.1,2. Mass casualty incident, emergency department, decontamination, blast injury, media relations, biological agents, reprocessing, crisis standard of care, SALT (Sort, Assess, Lifesaving Interventions, Treatment/Transport) triage, personal protective equipment, disaster carts, airways, passive security, family reunification.

The Value of Functional Exercise in Pediatric Mass- Casualty Incident Training.

Hospital staff in Taiwan practice mass casualty incident (MCI) management through full-scale exercise (FSE). However, FSE is generally resource-intensive and time-consuming. As an alternative, functional exercise (FE) may be more cost-effective with a similar effect in certain aspects. Hence, we aimed to evaluate the FE value in MCI training. We investigated whether FE can increase the familiarity of pediatric MCI response and the effect in different groups. A new emergency operation plan (EOP) of nontraumatic pediatric MCI was developed in 2018 for our Children's Hospital. An FE was conducted to assess the plan. In addition to the emergency department staff, head nurses, supervisors, and physicians of Children's Hospital also participated in the exercise. Pre- and post-exercise questionnaires were designed, and participants were asked to evaluate their familiarity with pediatric MCI response pre- and post-exercise. Participants' reading experience of the new EOP, previous training level, occupation position, and whether they were using a computer during the exercise were also noted in the questionnaires. Data were analyzed using paired t-test and Fisher's exact test. Among 49 participants, 16 participants completed the pre- and post-exercise questionnaires. The post-exercise familiarity score was found to be significantly higher than that of pre-exercise (p < 0.05). There were no significant differences among the relationships between familiarity increase and participants' reading experience of the new EOP, previous training level, occupation position, and whether they were using a computer during the exercise. FE can significantly increase the familiarity of the hospital staff with pediatric MCI response and may be applied as a new training method of hospital disaster preparedness.

A Surprise Mass Casualty Incident Simulation: Does It Improve Knowledge or Is It Just a Bit of Fun?

Introduction:We opened a national conference in Australia with a surprise mass casualty simulation scenario of a van versus multiple persons outside the conference venue. The purpose of this exercise was to increase awareness of, and preparation for, mass casualty incident (MCI) events for the conference delegates who were paramedics, emergency department nurses, and doctors.Aim:The aim of the research is to understand whether a surprise MCI simulation is a useful way to increase knowledge and motivate preparedness.Methods:A survey hosted on Qualtrics was circulated to delegates via email. The survey was designed by the research team and had 38 questions about demographics and respondents’ experience with MCIs, as well as their perceptions of the simulation exercise. The questions were a mixture of 5-point Likert scales, multiple choice, and short answers.Results:The majority of respondents were clinicians (n = 66, 76%) and those who worked in emergency departments or the prehospital setting (n = 75, 86%). While the majority had not responded to an MCI in the past 5 years (n = 67, 77%), more than half (n = 50, 57%) had undertaken MCI training during this time. Overall, a vast majority of respondents found the simulation to be a worthwhile exercise that increased knowledge and preparedness. An overwhelming majority also reported that the simulation was relevant to practice, of high quality, and a useful way to teach about major incidents.Discussion:Our surprise major incident simulation was a fun and effective way to raise awareness and increase knowledge in prehospital and emergency department clinicians about MCI response. This approach to simulation can be easily replicated at relatively low cost and is, therefore, a useful solution to training a group of multidisciplinary health professionals outside of the workplace.

Practicing What You Preach

Introduction:During a mass casualty incident (MCI) seminar in Rome, Italy a survey was used to gauge the self-efficacy and confidence of the participants in managing an MCI. Following the course, a follow-up presentation was held by the Torino EMS Medical Director to evaluate and debrief the Torino Railway incident that occurred one day prior. Students partook in a seminar on MCI management, as well as a debriefing of the Turin Railway accident in which they evaluated the skills used by teams on the scene to manage the incident.Methods:Medical students partook in a seminar to learn to manage an MCI scene, as well as a debriefing of the Turin Railway accident. Following both seminars, the students were given a survey to assess their sense of self-confidence in managing such a situation.Results:The mean level of self-efficacy prior to the MCI training (M=3.43, SD+0.42) increased after the training (M=3.71, SD+0.37) and remained at the same higher level (M=3.71, SD+0.51) after the medical students were exposed to the details of the Turin train accident. The overall difference between the mean self-efficacy scores in the three time frames was not found to be significant. The mean level of confidence in managing MCIs prior to the training (M=2.83; SD+0.89) increased after the training (M=3.56; SD+0.53) and remained higher following the presentation of the Turin train accident, despite a slight decrease (M=3.52, SD+0.63).Discussion:The participants’ surveys showed an increase in their self-efficacy and confidence following the course and follow-up presentation. It is our professional recommendation that real-life events be used in such seminars to increase self-efficacy and confidence. The topic will continue to be evaluated further.

A Simplified Mass Casualty Incident Training for Medical Students

Background: Medical students have the ability to play an important role in institutional response to a mass casualty incident (MCI). However, while previous studies have shown a strong desire among students to take part in MCI response, a lack of training has left them unprepared to confidently respond to such an event. Currently, simpler models are needed to increase the prevalence of MCI response training in medical school curricula. Our goal was to develop a sustainable curriculum to prepare medical students to respond in MCIs by combining didactic instruction and interactive simulationbased training. Methods: In 2017, a group of first-through-fourth year medical students designed and carried out a one-day MCI curriculum involving a one-hour didactic lecture on emergency management and triage as well as one hour of scenario-based exercises involving two mock mass casualty incidents. In order to analyze the impact of this event, students were asked to fill out pre- and post-training surveys. Results: Out of 45 participating medical students from all levels of training, 37 filled out the pre- and post-event surveys. Prior to the event, 17% (n=35) of the attendees reported that they were aware of the University of Michigan’s Mass Casualty Incident Protocol (MCIP), and 51% (n=35) reported they would be ‘likely’ or ‘very likely’ to respond to an MCI. After the event, 74% (n=35) of the students reported awareness of the MCIP, while 74% (n=35) also stated they would be likely or very likely to respond to an MCI. Of these participants, 85% (n=34) ‘agreed’ or ‘strongly agreed’ that the simulation environment was conducive to learning, and 91% (n=35) similarly agreed or strongly agreed that the simulations improved understanding of the MCIP and triage principles presented during the lectureportion of the training. Conclusion: Combined didactic- and scenario-based training is a simple tool to promote medical student preparedness for an MCI. In order to train a group of self-selected medical students to be involved in MCI response, future efforts to refine this training model should focus on the promotion of interprofessional involvement. Keywords: MASS CASUALTY INCIDENT RESPONSE, MEDICAL STUDENT, TRIAGE, TRAINING, SIMULATION, CURRICULUM

LO094: Mass casualty incident training for rural Canadian municipalities: a mobile education unit initiative

Introduction / Innovation Concept: The Shock Trauma Air Rescue Society (STARS®) is a charitable, non-profit organization that is dedicated to providing a safe, rapid, highly specialized emergency medical transport system for the critically ill and injured. The STARS® Mobile Education Unit (MEU) is comprised of a high fidelity simulation suite that mimics a hospital emergency room, installed in a specially equipped motorhome (SEM) that can wirelessly operate a high fidelity human mannequin. The MEU provides an excellent opportunity to combine continuing medical education for resuscitation and MCI management. At present, no formal MCI education process exists in Saskatchewan. Curriculum, Tool, or Material: The Saskatchewan STARS® MEU delivers a phased MCI education initiative to rural and regional centers within the province. The educational initiative is sub-divided into three stages: 1. pre-exercise knowledge translation using a flipped classroom approach, 2. on-site tabletop exercise (TTX) and, 3. high-fidelity simulation session with a review of MCI management principles . Sites perform a Hazard Vulnerability Analysis (HVA) following stage 2 and the highest identified site-specific risks are utilized during the development of the simulated scenarios for stage 3. During stage 2, participants also complete a pre and post-exercise survey. The survey evaluates the educational component, the tabletop exercise component and the perceived pre and post tabletop exercise competencies for the management of MCI. In the pilot project, two regional sites completed the tabletop exercise. The pre-exercise survey evaluated perceived MCI and disaster preparedness for the region. Only 8% and 25% of participants at each site respectively, reported that their disaster plan had been trialed in tabletop, full exercise or real activation within the past three years. Participants strongly agreed that the tabletop exercise was a valuable experience (86% and 88% respectively). More robust data will become available as the initiative transitions out of the pilot stage to formal operations. Conclusion: A formal MCI training program implemented through the STARS® MEU for rural Saskatchewan municipalities enables participants and their organizations to both review and enhance their current emergency management plans. This initiative will aim to establish a foundation for future collaboration at the provincial and national level for rural MCI training and preparedness.

Mass casualty incident training in a resource-limited environment (Br J Surg 2012; 99: 356–361)

Mass casualty incident training in a resource-limited environment (<i>Br J Surg</i> 2012; 99: 356–361)

Mass casualty incident training in a resource-limited environment

A mass casualty incident (MCI) occurs when a disaster involves a large number of injured people, overwhelming the capacity of local emergency medical services. This article describes the planning and execution of a MCI workshop created for use in Sierra Leone, a low-income country. Surgeons OverSeas (SOS), an international non-governmental organization, partnered with the Sierra Leone Office of National Security and Connaught Hospital to develop a 2-day MCI workshop designed to meet needs specific to their resource-limited environment. Pre- and post-course questionnaires were completed. Day 1 consisted of didactic teaching focused on triage principles, resource deployment, communication/operations and tabletop drills. On day 2 a mock MCI with performance assessments by independent observers was staged, followed by post-event debriefing. Pre-course questionnaires identified the following deficits: lack of triage training (29 per cent), and transportation (19 per cent) and communication (17 per cent) shortfalls. Only 11 per cent could define MCI. During the drill, on-scene and hospital triage was accurate in 28 (93 per cent) and 23 (77 per cent) of 30 casualties respectively. Systematic deficiencies identified included: transport issues, no accurate system for tracking victims, and undersized triage areas. Participants identified interagency coordination (63 of 136 responses; 46·3 per cent) and triage (32 of 136; 23·5 per cent) as the most valuable lessons learned. Pre-existing MCI programmes based on first-world logistics do not account for challenges encountered when caring for casualties in resource-constrained settings. Logistical training, rather than medical skills or knowledge, was identified as the educational priority.

(A23) Mass Casualty Incident and Terrorist Attack Preparedness of German Hospitals and Physicians Compared to Austria, Switzerland, the USA and a Worldwide Collective

ContextBecause of worldwide increase of catastrophes and recent terrorist attacks, hospitals and physicians are devoting increased attention to disaster and mass casualty incident (MCI) preparedness not only outside but also inside hospitals. In case of a terrorist attack physicians have to cope with injuries caused by conventional, biological, chemical, or radioactive weapons.ObjectiveThe aim of this study was to evaluate the current state of preparedness of German hospitals and physicians in case of an MCI or terrorist attack and to compare those results to the preparedness of hospitals and physicians from Austria, Switzerland, the United States of America and a worldwide collective.Materials and MethodsUsing an online questionnaire, we interviewed 1343 physicians in Germany, Austria, Switzerland, the US and a worldwide collective. The replies were analyzed statistically with the Shapiro-Walk test and the Mann-Whitney-U test.Resultsin Germany physicians are less prepared than their colleagues worldwide for disasters inside and outside hospitals. 48,4% of German physicians (37% worldwide) did not know their area of responsibility as a physician in case of an “internal” emergency (fire, water pipe burst, power cut), even though 30,2% of German physicians (29,1% worldwide) have already had a real emergency in their hospital. Only 65,3% of physicians in Germany (75,5% worldwide) knew their area of responsibility in case of an MCI; MCI training was given less often in Germany (42,7%) than worldwide (64,3%). Most physicians in every country were unaware of injury patterns and treatment strategies in patients following bombings or nuclear, chemical and biological contamination.ConclusionsHospital Physicians are insufficiently prepared for internal emergencies and MCIs. There is a need for more drills in hospitals. In spite of the recent threat of terrorist attacks, the physicians' emergency training should be modified to accommodate the increased risk of catastrophes and terrorist attacks.

Effectiveness of Hospital Staff Mass-Casualty Incident Training Methods: A Systematic Literature Review

Recently, mass-casualty incident (MCI) preparedness and training has received increasing attention at the hospital level. To review the existing evidence on the effectiveness of disaster drills, technology-based interventions and tabletop exercises in training hospital staff to respond to an MCI. A systematic, evidence-based process was conducted incorporating expert panel input and a literature review with the key terms: "mass casualty", "disaster", "disaster planning", and "drill". Paired investigators reviewed citation abstracts to identify articles that included evaluation of disaster training for hospital staff. Data were abstracted from the studies (e.g., MCI type, training intervention, staff targeted, objectives, evaluation methods, and results). Study quality was reviewed using standardized criteria. Of 243 potentially relevant citations, 21 met the defined criteria. Studies varied in terms of targeted staff, learning objectives, outcomes, and evaluation methods. Most were characterized by significant limitations in design and evaluation methods. Seventeen addressed the effectiveness of disaster drills in training hospital staff in responding to an MCI, four addressed technology-based interventions, and none addressed tabletop exercises. The existing evidence suggests that hospital disaster drills are effective in allowing hospital employees to become familiar with disaster procedures, identify problems in different components of response (e.g., incident command, communications, triage, patient flow, materials and resources, and security) and provide the opportunity to apply lessons learned to disaster response. The strength of evidence on other training methods is insufficient to draw valid recommendations. Current evidence on the effectiveness of MCI training for hospital staff is limited. A number of studies suggest that disaster drills can be effective in training hospital staff. However, more attention should be directed to evaluating the effectiveness of disaster training activities in a scientifically rigorous manner.