Assessment of hospital surge capacity using the MACSIM simulation system: a pilot study

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

PURPOSE

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

METHOD

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

RESULTS

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

CONCLUSION

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

The implication of a translational triage tool in mass casualty incidents: part three: a multinational study, using validated patient cards

BACKGROUND

Mass casualty incidents (MCI) pose significant challenges to existing resources, entailing multiagency collaboration. Triage is a critical component in the management of MCIs, but the lack of a universally accepted triage system can hinder collaboration and lead to preventable loss of life. This multinational study uses validated patient cards (cases) based on real MCIs to evaluate the feasibility and effectiveness of a novel Translational Triage Tool (TTT) in primary triage assessment of mass casualty victims.

METHODS

Using established triage systems versus TTT, 163 participants (1575 times) triaged five patient cases. The outcomes were statistically compared.

RESULTS

TTT demonstrated similar sensitivity to the Sieve primary triage method and higher sensitivity than the START primary triage system. However, the TTT algorithm had a lower specificity compared to Sieve and higher over-triage rates. Nevertheless, the TTT algorithm demonstrated several advantages due to its straightforward design, such as rapid assessment, without the need for additional instrumental interventions, enabling the engagement of non-medical personnel.

CONCLUSIONS

The TTT algorithm is a promising and feasible primary triage tool for MCIs. The high number of over-triages potentially impacts resource allocation, but the absence of under-triages eliminates preventable deaths and enables the use of other personal resources. Further research involving larger participant samples, time efficiency assessments, and real-world scenarios is needed to fully assess the TTT algorithm's practicality and effectiveness in diverse multiagency and multinational contexts.

Determining surgical surge capacity with a hybrid simulation exercise

Background

To help test and improve surgical surge capacity, mass casualty incident (MCI) exercises generate valuable information. Both large scale table-top exercises (TTX) and full-scale exercises (FSX) have limitations if you want to test an organisation's capability and structure. A hybrid exercise incorporating the advantages of TTX and FSX is a possible way forward, but is no standardised exercise method, yet. This study aims at evaluating the exercise results to determine the feasibility of a hybrid TTX/FSX exercise for an organization's capability and structure.

Methods

A hybrid MCI simulation using moulaged figurants and simulation cards was designed, where the emergency department of a level 1 trauma centre receives 103 casualties over 4 h. After registration and triage, all casualties are expected to be resuscitated in real time and are transferred for further treatment inside the hospital (radiology, operating theatres, intensive care unit (ICU)/postop and wards). When reaching operation theatre, ICU or ward, figurants are replaced by simulation cards. Observers ensured that those procedures performed were adequate and adhered to realistic times. Use of resources (materials, drugs etc.) were registered. Primary endpoint was average time spent in the emergency department, from time of arrival, to transfer out. Secondary endpoints were related to patient flow and avoidable fatalities.

Results

The hospital managed to deal with the flow of patients without collapse of existing systems. Operating theatres as well as ICU and ward beds were available at the end of the exercise. Several details in the hospital response were observed that had not been noticed during previous TTX.

Conclusion

FSX have a valuable role in training, equipping, exercising, and evaluating MCI management. Hybrid simulations combining both FSX and TTX may optimise resource utilisation and allow more frequent exercises with similar organisational benefit.

Use of simulation models when developing and testing hospital evacuation plans: a tool for improving emergency preparedness

BACKGROUND

In recent decades, analyses of hospitals evacuations have generated valuable knowledge. Unfortunately, these evacuation case studies often lack crucial details and policies that would be helpful in evacuation preparedness. The aim of this study was to use a simulation model to illustrate how it can aid emergency planners in the development, testing, and revising of hospitals evacuation plans. This study includes evacuation exercises at two emergency hospitals in Region Stockholm, Sweden.

METHODS

A scientifically validated simulation system for "table top" exercises was used for interactive training of hospital medical staff, prehospital staff and collaborating agencies. All participants acted in their usual professionals' roles. The exercises were run in real-time and mirrored actual hospital resources with the aid of moveable magnetic symbols illustrating patients, staff and transport, presented on whiteboards. During the exercises, observers and independent instructors documented actions taken and post-exercise surveys were conducted to obtain reactions and compare results.

RESULTS

The simulation system allowed the emergency planner to test the whole evacuation process, making it possible to train and evaluate the important functions of management, coordination, and communication. Post-exercise surveys explored participants perception of the exercises. Analysis of open-ended questions included areas for improvement and resulted in five main categories: (1) management and liaison; (2) communication; (3) logistics; (4) medical care and patient prioritisation; and (5) resource utilisation.

CONCLUSIONS

This study has shown that "table top" exercises using a validated simulation system can serve to guide emergency planners when developing evacuation plans, procedures, and protocols as well in training of all medical staff. The system also served to train adaptive thinking, leadership, communication, and clarification of critical functions.

Hospital preparedness for major incidents in Sweden: a national survey with focus on mass casualty incidents

INTRODUCTION

Mass-casualty incidents, MCI, pose a constant threat on societies all over the world. It is essential that hospital organizations systematically prepare for such situations. A method for repeated follow-up and evaluation of hospital disaster planning is much needed.

AIMS

To evaluate Swedish hospitals´ disaster preparedness with focus on MCI through a web-based survey to highlight areas in need of improvement to ensure better preparedness and resilience.

MATERIALS AND METHODS

An online survey was sent to all Swedish emergency hospitals (n = 87, 49 emergency hospitals). One respondent per hospital answered questions about the hospital's disaster planning, training, key functions, and preparedness. The survey was developed based on current knowledge on key areas of interest for all-hazard preparedness, including the WHO's guidelines. The survey was open between September 6th and November 1st, 2021.

RESULTS

39 hospitals (34 emergency hospitals) from 18/21 regions participated. Main findings included marked differences between regions and hospital types regarding contingency plans, organization, formal education for key functions, disaster training and triage systems.

CONCLUSIONS

Generally, Swedish hospitals cover most key areas in disaster preparedness, but no hospital appears to have a full all-hazards coverage, which leaves room for improvement. There are large variations between the different hospitals' preparedness, which need to decrease. Several hospitals expressed a need of national guidelines for developing equivalent contingency plans. The study-method could be used for monitoring compliance with current laws and guidelines.

A method for detailed determination of hospital surge capacity: a prerequisite for optimal preparedness for mass-casualty incidents

BACKGROUND

Defined goals for hospitals' ability to handle mass-casualty incidents (MCI) are a prerequisite for optimal planning as well as training, and also as base for quality assurance and improvement. This requires methods to test individual hospitals in sufficient detail to numerically determine surge capacity for different components of the hospitals. Few such methods have so far been available. The aim of the present study was with the use of a simulation model well proven and validated for training to determine capacity-limiting factors in a number of hospitals, identify how these factors were related to each other and also possible measures for improvement of capacity.

MATERIALS AND METHODS

As simulation tool was used the MACSIM® system, since many years used for training in the international MRMI courses and also successfully used in a pilot study of surge capacity in a major hospital. This study included 6 tests in three different hospitals, in some before and after re-organisation, and in some both during office- and non-office hours.

RESULTS

The primary capacity-limiting factor in all hospitals was the capacity to handle severely injured patients (major trauma) in the emergency department. The load of such patients followed in all the tests a characteristic pattern with "peaks" corresponding to ambulances return after re-loading. Already the first peak exceeded the hospitals capacity for major trauma, and the following peaks caused waiting times for such patients leading to preventable mortality according to the patient-data provided by the system. This emphasises the need of an immediate and efficient coordination of the distribution of casualties between hospitals. The load on surgery came in all tests later, permitting either clearing of occupied theatres (office hours) or mobilising staff (non-office hours) sufficient for all casualties requiring immediate surgery. The final capacity-limiting factors in all tests was the access to intensive care, which also limited the capacity for surgery. On a scale 1-10, participating staff evaluated the accuracy of the methodology for test of surge capacity to MD 8 (IQR 2), for improvement of disaster plans to MD 9 (IQR 2) and for simultaneous training to MD 9 (IQR 3).

CONCLUSIONS

With a simulation system including patient data with a sufficient degree of detail, it was possible to identify and also numerically determine the critical capacity-limiting factors in the different phases of the hospital response to MCI, to serve as a base for planning, training, quality control and also necessary improvement to rise surge capacity of the individual hospital.

Modelling Granular Process Flow Information to Reduce Bottlenecks in the Emergency Department

Increasing demand and changing case-mix have resulted in bottlenecks and longer waiting times in emergency departments (ED). However, many process improvement efforts addressing the bottlenecks have limitations, as they lack accurate models of the real system as input accounting for operational complexities. To understand the limitation, this research modelled granular procedural information, to analyse processes in a Level-1 ED of a 1200-bed teaching hospital in the UK. Semi-structured interviews with 21 clinicians and direct observations provided the necessary information. Results identified Majors as the most crowded area, hence, a systems modelling technique, role activity diagram, was used to derive highly granular process maps illustrating care in Majors which were further validated by 6 additional clinicians. Bottlenecks observed in Majors included awaiting specialist input, tests outside the ED, awaiting transportation, bed search, and inpatient handover. Process mapping revealed opportunities for using precedence information to reduce repeat tests; informed alerting; and provisioning for operational complexity into ED processes as steps to potentially alleviate bottlenecks. Another result is that this is the first study to map care processes in Majors, the area within the ED that treats complex patients whose care journeys are susceptible to variations. Findings have implications on the development of improvement approaches for managing bottlenecks.

An Overview of Hospital Capacity Planning and Optimisation

Health care is uncertain, dynamic, and fast growing. With digital technologies set to revolutionise the industry, hospital capacity optimisation and planning have never been more relevant. The purposes of this article are threefold. The first is to identify the current state of the art, to summarise/analyse the key achievements, and to identify gaps in the body of research. The second is to synthesise and evaluate that literature to create a holistic framework for understanding hospital capacity planning and optimisation, in terms of physical elements, process, and governance. Third, avenues for future research are sought to inform researchers and practitioners where they should best concentrate their efforts. In conclusion, we find that prior research has typically focussed on individual parts, but the hospital is one body that is made up of many interdependent parts. It is also evident that past attempts considering entire hospitals fail to incorporate all the detail that is necessary to provide solutions that can be implemented in the real world, across strategic, tactical and operational planning horizons. A holistic approach is needed that includes ancillary services, equipment medicines, utilities, instrument trays, supply chain and inventory considerations.

A preliminary study for selecting the appropriate AI-based forecasting model for hospital assets demand under disasters

Purpose

Hospitals recently search for more accurate forecasting systems, given the unpredictable demand and the increasing occurrence of disruptive incidents (mass casualty incidents, pandemics and natural disasters). Besides, the incorporation of automatic inventory and replenishment systems – that hospitals are undertaking – requires developed and accurate forecasting systems. Researchers propose different artificial intelligence (AI)-based forecasting models to predict hospital assets consumption (AC) for everyday activity case and prove that AI-based models generally outperform many forecasting models in this framework. The purpose of this paper is to identify the appropriate AI-based forecasting model(s) for predicting hospital AC under disruptive incidents to improve hospitals' response to disasters/pandemics situations.

Design/methodology/approach

The authors select the appropriate AI-based forecasting models according to the deduced criteria from hospitals' framework analysis under disruptive incidents. Artificial neural network (ANN), recurrent neural network (RNN), adaptive neuro-fuzzy inference system (ANFIS) and learning-FIS (FIS with learning algorithms) are generally compliant with the criteria among many AI-based forecasting methods. Therefore, the authors evaluate their accuracy to predict a university hospital AC under a burn mass casualty incident.

Findings

The ANFIS model is the most compliant with the extracted criteria (autonomous learning capability, fast response, real-time control and interpretability) and provides the best accuracy (the average accuracy is 98.46%) comparing to the other models.

Originality/value

This work contributes to developing accurate forecasting systems for hospitals under disruptive incidents to improve their response to disasters/pandemics situations.

Disaster preparedness: A concept analysis and its application to the intensive care unit

OBJECTIVES

The aim of the study is to understand the concept of disaster preparedness in relation to the intensive care unit through the review and critique of the peer-reviewed literature.

REVIEW METHOD USED

Rodgers' method of evolutionary concept analysis was used in the study.

DATA SOURCES

Healthcare databases included in the review were Cumulative Index to Nursing and Allied Health Literature, Public MEDLINE, Scopus, and ProQuest.

REVIEW METHODS

Electronic data bases were searched using terms such as "intensive care unit" OR "critical care" AND prep∗ OR readiness OR plan∗ AND disaster∗ OR "mass casualty incidents" OR "natural disaster" OR "disaster planning" NOT paed∗ OR ped∗ OR neonat∗. Peer-reviewed articles published in English between January 2000 and April 2020 that focused on intensive care unit disaster preparedness or included intensive care unit disaster preparedness as part of a facility-wide strategy were included in the analysis.

RESULTS

Eighteen articles were included in the concept analysis. Fourteen different terms were used to describe disaster preparedness in intensive care. Space, physical resources, and human resources were attributes that relied on each other and were required in sufficient quantities to generate an adequate response to patient surges from disasters. When one attribute is extended beyond normal operational capacities, the effectiveness and capacity of the other attributes will likely be limited.

CONCLUSION

This concept analysis has shown the varied language used when referring to disaster preparedness relating to the intensive care unit within the research literature. Attributes including space, physical resources, and human resources were all found to be integral to a disaster response. Future research into what is required of these attributes to generate an all-hazards approach in disaster preparedness in intensive care units will contribute to optimising standards of care.

The Berlin Acute Trauma Care Instrument Set (BATMIN) - A Selected Combination of Surgical Instruments for Damage Control and Hemostasis Surgery in Severe Acute Trauma

A lack of sterile surgical instrument sets for damage control surgeries of severely injured patients became evident in a series of in-hospital mass casualty trainings in the German capital of Berlin. Moreover, the existing instrument trays contained mostly specialized instruments for elective interventions and were not well composed for the treatment of poly-traumatized patients. After a literature search on the most common injury patterns in Mass Casualty Incidents (MCIs), an expert group of surgeons from different disciplines designed an optimized instrument set. A set of 194 instruments was assembled and distributed into two containers. These 2 sets were subjected to a 6-month trial phase in our hospital, and the evaluation of usability was subsequently analyzed through feedback forms administered to the staff. After analysis of the feedback sheets, only minor alterations had to be incorporated. The Berlin Acute Trauma Care Instrument Set (BATMIN) was then made available by the state of Berlin to Berlin Hospitals providing acute trauma care. Out of the need to be prepared for mass casualties, we created an instrument set suitable for the damage control surgery of severely injured patients in individual care and MCIs.

Disaster Preparedness and Professional Competence Among Healthcare Providers: Pilot Study Results

The preparedness of a hospital for mass-casualty incident and disaster response includes activities, programs and systems developed and implemented before the event. These measures are designed to provide the necessary medical care to victims of disasters, and to minimize the negative impact of individual events on medical services. Up until now, there has been no systematic survey in Poland concerning the readiness of hospitals, as well as medical personnel, to deal with mass-casualty incidents. Consequently, little is known about the knowledge, skills, and professional competences of healthcare workers. The objective of this pilot study was to start an exploration and to collect data on the competences of healthcare workers, in addition to assessing the preparedness of hospitals for mass-casualty incidents. Utilizing an anonymous survey of a random sample, 134 healthcare providers were asked to respond to questions about the competencies they needed, and hospital preparedness during disaster response. It turned out that the test subjects evaluate their own preparedness for mass-casualty incidents and disasters better than the preparedness of their current place of work. The pilot study demonstrated that a properly designed questionnaire can be used to assess the relationship between hospital and staff preparedness and disaster response efficiency. Evaluation of the preparedness and effectiveness of disaster response is a means of finding and removing possible gaps and weaknesses in the functioning and effective management of a hospital during mass-casualty incidents.

The impact of mass casualty incidents on intensive care units

OBJECTIVES

Mass casualty incidents occur worldwide and have the capacity to overwhelm local healthcare facilities. There has been much research into how these events are managed in the prehospital environment and in the emergency department. However, there is a paucity in research addressing the impact that mass casualty incidents have on adult intensive care units. This review seeks to identify what literature is available that addresses the impact that mass casualty incidents have on intensive care units.

REVIEW METHOD USED

Integrative Review Data sources: Electronic databases MEDLINE, CINAHL, PubMed and Scopus.

REVIEW METHODS

Electronic databases were searched using terms such as "Intensive Care Unit" OR "Intensive Care" OR "Critical Care" OR "ICU" AND "Mass Casualty Incidents" OR "MCI" OR "Mass Casualty Event" OR "Mass Casualty Management" OR "Disaster". Articles that were published in the preceding 10 years in English as case studies or addressing real world events were included. Editorials, theoretical papers and research involving paediatrics were excluded from the results.

RESULTS

Seven articles met the search criteria. Results identified four key areas in ICU that were impacted by mass casualty incidents. These areas include the impact on facilities, on resources, on staff and of training on the management of mass casualty incidents.

CONCLUSIONS

This review has demonstrated a paucity in research and reporting practices on the impact that mass casualty incidents have on intensive care units. The returned articles have identified four areas that were seen as influencing management of real-world mass casualty incidents. By increasing reporting and research into factors that impact mass casualty incident management in intensive care units, policy and training can be enhanced to ensure better preparedness for future incidents.