Assessing and Improving Hospital Mass-Casualty Preparedness: A No-Notice Exercise

A Call to Action: Why Anesthesiologists Must Train, Prepare, and Be at the Forefront of Disaster Response for Mass Casualty Incidents

Disasters, both natural and man-made, continue to increase. In Spring 2023, a 3-hour workshop on mass casualty incidents was conducted at the Society for Pediatric Anesthesia-American Academy of Pediatrics Annual conference. The workshop used multiple instructional strategies to maximize knowledge transfer and learner engagement including minididactic sessions, problem-based learning discussions in 3 tabletop exercises, and 2 30-minute disaster scenarios with actors in a simulated hospital environment. Three themes became evident: (1) disasters will continue to impact hospitals and preparation is imperative, (2) anesthesiologists are extensively and comprehensively trained and their value is often underestimated as mass casualty incident responders, and (3) a need exists for longitudinal disaster preparedness education and training over the course of a career. In this special article, we have sought to further define the problem and evidence, the capacity of anesthesiologists as leaders in disaster preparedness, and the rationale for preparation with current best practices to guide how best to move forward.

Emergency Department Admission Rates, Waiting Times, and Mortality: An Observational Study in the Tertiary Center Most Proximal to Gaza During a Military Conflict

OBJECTIVES

Military conflicts may be ongoing and encompass multiple medical facilities. This study investigated the impact of a military conflict ("Protective Edge" PE) on emergency department (ED) function in a tertiary medical center.

METHODS

Visits to the ED during PE (July-August 2014) were compared with ED visits during July-August 2013 and 2015 with regard to admission rates, waiting times and 30-d mortality. Odds ratios (ORs) adjusted for confounders were used for the multivariable regression models.

RESULTS

There were 32,343 visits during PE and 74,279 visits during the comparison periods. A 13% decrease in the daily number of visits was noted. During PE, longer waiting times were found, on average 0.25 h longer, controlling for confounders. The difference in waiting times was greater in medicine and surgery. Admission rates were on average 10% higher during PE military conflict, controlling for confounders. This difference decreased to 7% controlling for the daily number of visits. Thirty-day mortality was significantly increased during PE (OR = 1.42; 95% CI: 1.18-1.70). ORs for mortality during PE were significantly higher in medicine (OR = 1.45; 95% CI: 1.15-1.81) and pediatrics (OR = 4.40; 95% CI: 1.33-14.5).

CONCLUSIONS

During an ongoing military conflict, waiting times, admission rates, and mortality were statistically significantly increased.

Collaborative Interprofessional Health Science Student Led Realistic Mass Casualty Incident Simulation

In collaboration, a health science university and a fire department offered a mass casualty incident (MCI) simulation. The purpose of this study was to evaluate a cross-section of student health care providers to determine their working knowledge of an MCI. Students were given a pretest using the Emergency Preparedness Information Questionnaire (EPIQ) and the Simple Triage and Rapid Transport (START) Quiz. The EPIQ instrument related to knowledge of triage, first aid, bio-agent detection, critical reporting, incident command, isolation/quarantine/decontamination, psychological issues, epidemiology, and communications. The START Quiz gave 10 scenarios. Didactic online content was given followed by the simulation a few weeks later. A posttest with the same instruments was given after the simulation. Participants were majority female (81.7%), aged between 25-34 (41.7%), and 61.7% (n = 74) had undergraduate or post-graduate degrees. The overall pretest mean was 2.92 and posttest mean was 3.64. The START Quiz found participants struggled to correctly assign triage levels. Students also experienced challenges correctly assigning patients to specific triage categories. Findings will assist educators to understand knowledge gaps, so revisions can be made to enhance learning in disaster management. Concentration in proper field triage is also a needed focus.

Establishment of a no-notice drill mode evaluation system for public health emergencies

OBJECTIVE

At present, there are some no-notice drill mode evaluation systems for public health emergencies in Chinese hospitals, which are the subjects of assessment in this study. However, there is a lack of CDC. This study builds a set of no-notice drill mode evaluation systems for public health emergencies that involve the CDC.

METHODS

The indexes for these systems were based on the performance of two no-notice drills for public health emergencies in Guangdong Province. Twenty experts were invited to screen the indicators during two rounds of the Delphi method to determine the weight of first- and second-level indexes through the analytic hierarchy process, and the weight of the third-level index was calculated using the percentage method.

RESULTS

After two rounds of expert consultation, we obtained four first-level indicators, twenty-six second-level indicators and eighty-six third-level indicators. According to the weight calculated by analytic hierarchy process, the weights of the first-level indicators are emergency preparation (0.2775), verification and consultation regarding an epidemic situation (0.165), field investigation and control (0.3925) and summary report (0.165). Sensitivity analysis shows that the stability of the index is good.

CONCLUSION

The no-notice drill mode evaluation system for public health emergencies constructed in this study can be applied to public health departments such as the CDC. Through promotion, it can provide a scientific basis for epidemiological investigation assessment.

The First 15 Minutes: A Novel Disaster Simulation Exercise

OBJECTIVE

The objective was to describe a feasible, multidisciplinary pediatric mass casualty event (MCE) simulation format that was less than 2 h within emergency department space and equipment constraints.

METHODS

This was a prospective cohort study of an MCE in situ simulation program from June-October 2019. Participants rotated through 3 modules: (1) triage, (2) caring for a critical patient in an MCE setting, and (3) being in a disaster leadership role. Triage accuracy, knowledge, self-evaluation of preparedness, and MCE skills by means of pre- and post-test surveys were measured. Wilcoxon matched pairs signed rank test scores and McNemar's matched pair chi-squared test were performed to evaluate for statistically significant differences.

RESULTS

Forty-six physicians (MD), 1 physician's assistant (PA), and 22 nurses participated over 4 simulation d. Among the MD/PA group, there was a statistically significant 7% knowledge increase (95% confidence interval [CI], 3%-11%). Nurses did not show a statistically significant knowledge difference (0.04, 95% CI, 0.04%, 14%). There was a statistically significant increase in triage and resource use preparedness (P < 0.01) for all participants.

CONCLUSION

This efficient, feasible model for a multidisciplinary ED disaster drill provides a multi-modular exposure while improving both MD and PA knowledge and all staff preparedness for MCE.

Exercising for mass casualty preparedness

Exercising for mass casualty incidents is mandated by governing organisations with the aim of maintaining readiness within the healthcare sector for the many challenges these incidents bring. This readiness is delivered through a combination of discussion-based and operation-based exercises that are targeted to the needs of both the individuals delivering care and the needs of the overall system of patient flow and treatment. Although exercising for disaster preparedness is resource intensive, it is the repetitive, iterative nature that allows for wide staff capture and exposure along with continual improvement of plans. Having been recently involved in exercising is also likely to increase the confidence of staff and makes them feel better prepared. Exercising should be tailored to the needs and likely challenges of each healthcare system. A cycle of design, challenge, and redesign should target areas of greatest need and greatest benefit. The conventional advice, when introducing exercising, is to start small and build up over time with repeated exercises that demonstrate increasing response capability. However, some organisations would benefit from an exercise that lays bare shortcomings and acts to galvanise change.

Reimagining health preparedness in the aftermath of COVID-19

Efficiency is an essential part of sustainable healthcare, especially in emergency and acute care (including surgical) settings. Waste minimisation, streamlined processes, and lean principles are all important for responsible stewardship of finite health resources. However, the promotion of efficiency above all else has effectively subordinated preparedness as a form of waste. Investment in preparedness is an essential part of resilient healthcare. The ongoing COVID-19 pandemic has exposed the gap between efficient processes and resilient systems in many health settings. In anticipation of future pandemics, natural disasters, and mass casualty incidents, health systems, and individual healthcare workers, must prioritise preparedness to be ready for the unexpected or for crises. This requires a reframing of priorities to view preparedness as crucial insurance against system failure during disasters, by taking advantage of lessons learnt preparing for war and mass casualty incidents.

Surge Capacity and Mass Casualty Incidents Preparedness of Emergency Departments in a Metropolitan City: a Regional Survey Study

BACKGROUND

Emergency departments (EDs) generally receive many casualties in disaster or mass casualty incidents (MCI). Some studies have conceptually suggested the surge capacity that ED should have; however, only few studies have investigated measurable numbers in one community. This study investigated the surge capacity of the specific number of accommodatable patients and overall preparedness at EDs in a metropolitan city.

METHODS

This cross-sectional study officially surveyed surge capacity and disaster preparedness for all regional and local emergency medical centers (EMC) in Seoul with the Seoul Metropolitan Government's public health division. This study developed survey items on space, staff, stuff, and systems, which are essential elements of surge capacity. The number of patients acceptable for each ED was investigated by triage level in ordinary and crisis situations. Multivariate linear regression analysis was performed on hospital resource variables related to surge capacity.

RESULTS

In the second half of 2018, a survey was conducted targeting 31 EMC directors in Seoul. It was found that all regional and local EMCs in Seoul can accommodate 848 emergency patients and 537 non-emergency patients in crisis conditions. In ordinary situations, one EMC could accommodate an average of 1.3 patients with Korean Triage and Acuity Scale (KTAS) level 1, 3.1 patients with KTAS level 2, and 5.7 patients with KTAS level 3. In situations of crisis, this number increased to 3.4, 7.8, and 16.2, respectively. There are significant differences in surge capacity between ordinary and crisis conditions. The difference in surge capacity between regional and local EMC was not significant. In both ordinary and crisis conditions, only the total number of hospital beds were significantly associated with surge capacity.

CONCLUSION

If the hospital's emergency transport system is ideally accomplished, patients arising from average MCI can be accommodated in Seoul. However, in a huge disaster, it may be challenging to handle the current surge capacity. More detailed follow-up studies are needed to prepare a surge capacity protocol in the community.

Emergency department registered nurses overestimate their disaster competency: A cross-sectional study

BACKGROUND

Major incidents continue to pose a threat to health care systems by overwhelming them with a sudden surge of patients. A major factor impacting a hospital's surge capacity is the skills, abilities, and knowledge of emergency department (ED) registered nurses (RN). The level of disaster nursing competency they possess affects patient safety and outcome. ED RNs' ability to accurately assess their competency and knowledge is imperative for mitigating the effect of major incidents. ED RN's perception of overall disaster preparedness has not been thoroughly addressed. The aim of this study was to assess emergency department registered nurses' self-perceived disaster preparedness.

METHOD

The study was a cross-sectional study per the STROBE checklist. A self-assessment questionnaire based on the results of a study identifying specific disaster nursing competencies for ED RNs was distributed to all ED RNs at six participating hospitals between January 10th to February 19th of 2019. A five-point Likert-type scale was used to assess competency.

RESULTS

ED RNs' disaster preparedness according to the Total Disaster Competency mean was low. Furthermore, the results indicate that ED RNs' significantly overestimate their disaster nursing competency when compared to the Total Disaster Competency mean. Additionally, this study identified factors such as experience and education were positively associated with disaster preparedness and self-assessment ability.

CONCLUSION

ED RNs' overestimate their disaster preparedness. However, ED RNs with experience and education may be better prepared. ED RNs with formal disaster education appeared to have better insight concerning their preparedness. Clinical experience, advanced levels of education, and training were positively associated with preparedness. Overestimating disaster competencies may negatively impact patient outcomes during a major incident.

Mass-Casualty Training Exercise Using High-Fidelity Computerized Simulators and Involving Time and Resource Limitation

PURPOSE

Training emergency department (ED) personnel in the care of victims of mass-casualty incidents (MCIs) is a highly challenging task requiring unique and innovative approaches. The purpose of this study was to retrospectively explore the value of high-fidelity simulators in an exercise that incorporates time and resource limitation as an optimal method of training health care personnel in mass-casualty care.

METHODS

Mass-casualty injury patterns from an explosive blast event were simulated for 12 victims using high-fidelity computerized simulators (HFCS). Programmed outcomes, based on the nature of injuries and conduct of participants, ranged from successful resuscitation and survival to death. The training exercise was conducted five times with different teams of health care personnel (n = 42). The exercise involved limited time and resources such as blood, ventilators, and imaging capability. Medical team performance was observed and recorded. Following the exercise, participants completed a survey regarding their training satisfaction, quality of the exercise, and their prior experiences with MCI simulations. The Likert scale responses from the survey were evaluated using mean with 95% confidence interval, as well as median and inter-quartile range. For the categorical responses, the frequency, proportions, and associated 95% confidence interval were calculated.

RESULTS

The mean rating on the quality of experiences related trainee survey questions (n = 42) was between 4.1 and 4.6 on a scale of 5.0. The mean ratings on a scale of 10.0 for quality, usefulness, and pertinence of the program were 9.2, 9.5, and 9.5, respectfully. One hundred percent of respondents believed that this type of exercise should be required for MCI training and would recommend this exercise to colleagues. The five medical team (n = 5) performances resulted in the number of deaths ranging from two (including the expectant victims) to six. Eighty percent of medical teams attempted to resuscitate the "expectant" infant and exhausted the O- blood supply. Sixty percent of medical teams depleted the supply of ventilators. Forty percent of medical teams treated "delayed" victims too early.

CONCLUSION

A training exercise using HFCS for mass casualties and employing limited time and resources is described. This exercise is a preferred method of training among participating health care personnel.

Hospital incident command groups' performance during major incident simulations: a prospective observational study

BACKGROUND

Hospital incident command groups' (HICG) performance may have a profound impact on hospital response to major incidents. Previous research has assessed hospital incident command group capacity as opposed to performance and factors associated to performance. The objective was to assess associations between decision-making and staff procedure skills of the hospital incident command group.

METHODS

This was a prospective observational study using performance indicators to assess hospital incident command groups' decision-making and performance. A total of six hospitals in Stockholm, Sweden, with their respective HICGs participated. Associations between decision-making skills and staff procedure skills during major incident simulations were assessed using measurable performance indicators.

RESULTS

Decision-making skills are correlated to staff procedure skills and overall HICG performance. Proactive decision-making skills had significantly lower means than reactive decision-making skills and are significantly correlated to staff procedure skills.

CONCLUSION

There is a significant correlation between decision-making skills and staff procedural skills. Hospital incident command groups' proactive decision-making abilities tended to be less developed than reactive decision-making abilities. These proactive decision-making skills may be a predictive factor for overall hospital incident command group performance. A lack of proactive decision-making ability may hamper efforts to mitigate the effects of a major incident.

An Exploration of Discrepancies and Concordances Between Hospital Disaster Directors and General Health Care Providers in Gyeonggi Province, South Korea: Quantitative Analysis of a Multicenter Cross-Sectional Survey Study

OBJECTIVE

The purpose of this study was to investigate differences in the perception of disaster issues between disaster directors and general health care providers in Gyeonggi Province, South Korea.

METHODS

The Gyeonggi provincial committee distributed a survey to acute care facility personnel. Survey topics included awareness of general disaster issues, hospital preparedness, and training priorities. The questionnaire comprised multiple choices and items scored on a 10-point Likert scale. We analyzed the discrepancies and characteristics of the responses.

RESULTS

Completed surveys were returned from 43 (67%) of 64 directors and 145 (55.6%) of 261 health care providers. In the field of general awareness, the topic of how to triage in disaster response showed the greatest discrepancies. In the domain of hospital level disaster preparedness, individual opinions varied most within the topics of incident command, manual preparation. The responses to "accept additional patients in disaster situation" showed the biggest differences (> 21 versus 6~10).

CONCLUSIONS

In this study, there were disaster topics with discrepancies and concordances in perception between disaster directors and general health care providers. The analysis would present baseline information for the development of better training programs for region-specific core competencies, knowledge, and skills required for the effective response.

A Simulated Mass Casualty Incident Triage Exercise: SimWars

INTRODUCTION

This multipatient simulation exercise encompasses triage by hospital medical providers during a mass casualty incident (MCI) involving gas line explosion with building collapse. The SimWars format allows two teams to participate in identical simulations coupled with active audience observation, followed by facilitated group discussion. The exercise requires real-time knowledge application of MCI management and helps learners develop a framework for rapidly classifying and dispositioning MCI patients.

METHODS

Two teams of provider pairs completed MCI triage of 12 simulated patients in 8 minutes with an objective of quickly and accurately dispositioning within hospital bed availability. Participants included emergency medicine and surgery physicians, with active observation by mixed provider audiences. Observers completed a checklist per patient (category: urgent/emergent/not emergent, disposition: bed type/location). At simulation conclusion, a 45-minute facilitated discussion compared observers' self-assessment of MCI patient management with the simulation teams' decisions. Finally, an expert panel discussed management decisions and MCI triage pearls.

RESULTS

Team performances (N = 4) and audience responses (N = 164) were similar on seven of 12 patients, allowing robust discussion. Participants completed an evaluation at exercise conclusion; 37% reported good/excellent ability to accomplish MCI initial triage and disposition before this exercise compared to 100% after, a statistically significant 63% increase. All postsurvey respondents agreed or strongly agreed that the exercise would change their MCI clinical practice.

DISCUSSION

The two-team format allows comparison of how different teams handle MCI triage, and active observation allows comparison of audience and team decision making.

Assessing and Improving Hospital Mass-Casualty Preparedness: A No-Notice Exercise

In recent years, mass-casualty incidents (MCIs) have become more frequent and deadly, while emergency department (ED) crowding has grown steadily worse and widespread. The ability of hospitals to implement an effective mass-casualty surge plan, immediately and expertly, has therefore never been more important. Yet, mass-casualty exercises tend to be highly choreographed, pre-scheduled events that provide limited insight into hospitals’ true capacity to respond to a no-notice event under real-world conditions. To address this gap, the US Department of Health and Human Services (Washington, DC USA), Office of the Assistant Secretary for Preparedness and Response (ASPR), sponsored development of a set of tools meant to allow any hospital to run a real-time, no-notice exercise, focusing on the first hour and 15 minutes of a hospital’s response to a sudden MCI, with the goals of minimizing burden, maximizing realism, and providing meaningful, outcome-oriented metrics to facilitate self-assessment. The resulting exercise, which was iteratively developed, piloted at nine hospitals nationwide, and completed in 2015, is now freely available for anyone to use or adapt. This report demonstrates the feasibility of implementing a no-notice exercise in the hospital setting and describes insights gained during the development process that might be helpful to future exercise developers. It also introduces the use of ED “immediate bed availability (IBA)” as an objective, dynamic measure of an ED’s physical capacity for new arrivals.

WaxmanDA, ChanEW, PillemerF, SmithTWJ, AbirM, NelsonC. Assessing and improving hospital mass-casualty preparedness: a no-notice exercise. Prehosp Disaster Med. 2017;32(6):662–666.