Mass Casualty Emergency Preparedness Training Through an Academic-Practice Partnership

Abstract

Mass casualty incidents overwhelm a health care system's resources. Stakeholders developed a pediatric mass casualty simulation with an unfolding timeline. A post-simulation debriefing identified opportunities to improve patient triage, interprofessional communication, and resource mobilization. Participants agreed that the simulation was effective, influenced their clinical behavior, and supported triage in clinical practice. [J Contin Educ Nurs. 2025;56(3):95–97.]

A mass casualty incident (MCI) is an event that overwhelms the local health care system, with the number of casualties quickly exceeding resources. Limited research exists on pediatric MCIs specifically. Proper emergency response planning for an MCI ensures that resources are allocated appropriately and efficiently. Planning for an MCI for pediatric patients is essential because of high-mortality events such as school shootings, school transportation accidents, and natural disasters (^{Costa et al., 2021}). Planning for a pediatric MCI is complicated by the complex needs specific to the population, including family reunification; appropriate communication with family members, the media, and school systems; and the identification of victims (^{Costa et al., 2021}). Tabletop simulation has proven to be a helpful tool in planning for MCIs (^{Moss & Gaarder, 2022}). It is a low-cost, highly effective exercise designed to help facilitate discussion and appropriate allocation of resources (^{Moss & Gaarder, 2022}).

The simulation approach in the study was enhanced by using paper patients, escalating scenarios, and remote communication. The Jump-START Pediatric Triage MCI tool is used to triage pediatric patients in an MCI scenario (^{Tan et al., 2023}). Literature has shown that the Jump-START system is a highly effective way to triage pediatric patients (^{Cicero et al., 2016}). It categorizes patients into four treatment categories: expectant (black), delayed (yellow), immediate (red), and minor (green) (^{Cicero et al., 2016}). This system was implemented during the simulation and was applied to paper pediatric patients. In addition to using various forms of technology, the simulation event focused on the coordination of an interdisciplinary team, a vital aspect of a mass casualty response (^{Costa et al., 2021}). The simulation we developed to identify gaps in knowledge also created the opportunity for an academic-practice partnership, fostering collaboration among undergraduate nursing students, nursing faculty, and hospital staff. This study provided an opportunity for staff and students to triage pediatric patients appropriately, improve interdisciplinary communication among roles, and create a plan to effectively mobilize resources for an MCI.

Method

Sample

Simulation participants included students, faculty, emergency room triage nurses, an emergency department (ED) manager, physicians, administrators, the director of trauma services for the hospital, and clinical nurse specialists from the larger statewide hospital system. Additionally, the trauma team members and emergency services providers from a nationally ranked children's hospital within the statewide hospital system attended remotely. The selection of participants was based on the participants' roles in a potential MCI; thus, nurses and leadership from the ED as well as trauma team members were heavily involved. It was important for the sample to include participants from multiple disciplines, as this allowed us to better understand the full scope of the multidisciplinary policies and procedures that could be implemented in an MCI. The participants came from two different facilities, with participants from one facility joining the simulation via Zoom (Zoom Communications). Between the two facilities, 29 participants were included in the study.

Simulation

This study was planned and conducted through a larger Midwestern statewide hospital system in collaboration with a large Midwestern school of nursing. Faculty members of the school of nursing, school of medicine, and school of social work were included in the simulation exercise. The simulation, developed over several months, presented a pediatric MCI and was based on gaps in surrounding communities and on observation of recent media events. The objectives of the simulation were to assess the ability of hospital staff and facilities to respond to this event, assess resource mobilization, and identify opportunities for improved response.

This simulation was formatted as a timed event with a tabletop discussion. The event included a prebriefing and a detailed summary of the objectives and roles before the simulation, the MCI scenario, and a debriefing/discussion after the event. During the scenario, patients were presented using patient triage cards, and nurses triaged each patient using the JumpSTART method onto larger whiteboards. Hospital and university health science school participants were chosen via convenience sampling to support broader discipline representation. Hospital team participants included members of the ED nursing team, administrative team, trauma team, clinical operations team, and children's hospital ED and trauma teams. University health science school participants were chosen for the simulation from school of nursing faculty, nursing honors students, and school of social work faculty. The children's hospital ED and trauma team members were integrated into the event through online video conferencing. The debriefing with all participants after the conclusion of the event was structured and centered around opportunities for improvement.

The Team Emergency Assessment Measure (TEAM) tool (^{Cooper et al., 2010}) has been found to be a valid, reliable and feasible observational tool for the assessment of team performance. The TEAM tool was used before and after the event to gauge outcomes. The survey consisted of Likert scale-type questions and an open comment section. A larger team debriefing was conducted in the days after the event to obtain feedback and review results. Evaluation of data was performed by the nursing faculty and the local hospital ED administrative team.

Results

Of the 29 study participants, 22 consented to participate in the table-top simulation. Participants were predominantly female (59%), 32% were members of hospital leadership, 52% held a graduate degree as their highest level of education, and 72% were White. Before the event, the participants were asked specific questions about their perspectives and knowledge related to team collaboration during the pediatric simulation. Results from the Likert-scale questions indicated that 50% of participants were confident in their skills and that they knew how to use simulation activities. After the video-recorded simulation, 19 of the 29 participants completed the postevent survey. All respondents agreed or strongly agreed that the simulation event and education were effective learning activities, the content would help them triage patients in clinical practice, and the simulation would impact their future behavior in actual practice.

Qualitative data were also obtained from study participants during and after the simulation. Response frequencies showed prominent topics of concern that were not previously addressed by the hospital or understood by the participants: resources, communication, and operations (Table 1). The exemplifying statements suggest that the simulation was successful in identifying areas of improvement for the local hospital system.

Table 1
Participant Qualitative Statements

Theme	Illustrative examples
Resources	“No plans seemed to be in place, or at least identified, for how to obtain additional supplies for the ED areas if needed.”
	“May need to use other resources such as . . . local transport operations to take less critical patients to surrounding hospitals so that space and resources can be freed up during the event at hand.”
	“There could be potential for ‘mass casualty’ carts with supplies that are ready to go for a scenario such as this which can be wheeled to the triage center or others that are being utilized during the incident.”
Communication	“Communication with incident command and allocation of resources is critical, so all staff should be aware of who will be in direct contact with them at all times to transfer information to and from one source.”
	“Off-site pediatric clinics/schools need to be given warning regarding the situation as questions will swarm their communication lines as well as there being an influx of patients who will be seen after the event. Who does this?”
	“Need for media location and family location . . . . With pediatric situation, lots of questions about patient identification and parent reunification/notification.”
Operations	“Triage area . . . ambulance bay is a good choice as it is covered. Will require rapid turnover to get ambulances out of the way to make more room for those incoming.”
	“There did not appear to be a plan in place to decompress the ED, especially with boarded patients. Is there an emergency discharge plan? Who executes it?”
	“There must be a minor treatment area for walking wounded patients. All green tags were absorbed into the ED.
	Looking at patients in this drill, all green tags and many yellow tags did not need ED level emergency care. Where should this treatment area be located?”

Conclusion

This tabletop simulation event exposed some shortcomings of the local hospital ED. Participants realized that if a similar event occurred, the hospital system would not be able to handle issues efficiently. One participant said they would need to communicate with team members from the storeroom to pull extra supplies once notified of an MCI. Also, lower-acuity patients already admitted to the ED would need to be moved to a different area of the hospital or discharged to make room for the massive influx of new patients. Communication is also vital, and paramedics' communication of triage information to the ED is extremely important so that the ED has as much information as possible about incoming patients and can anticipate some needs before the patients arrive. The consensus was that team members in the ED believe there is work to be done to be prepared for such an event, but that the simulation helped them identify areas that need improvement. Therefore, this simulation could be a useful tool to educate new nurses hired for the ED on the protocols and procedures for MCIs and can also be used for the adult population as there is a START Adult Triage Algorithm to guide adult MCIs (^{Franc et al., 2021}).

References

Cicero, M. X., Overly, F., Brown, L., Yarzebski, J., Walsh, B., Shabanova, V., Auerbach, M., Riera, A., Adelgais, K., Meckler, G., Cone, D. C., & Baum, C. R. (2016). Comparing the accuracy of three pediatric disaster triage strategies:Asimulation-based investigation. Disaster Medicine and Public Health Preparedness, 10(2), 253–260. 10.1017/dmp.2015.171

Cooper, S., Cant, R., Porter, J., Sellick, K., Somers, G., Kinsman, L., & Nestel, D. (2010). Rating medical emergency teamwork performance: Development of the Team Emergency Assessment Measure(TEAM). Resuscitation, 81(4), 446–452. 10.1016/j.resuscitation.2009.11.027

Costa, V. S. L. P., Stéfani, G. M., Ferenhof, H. A., Lima, F. S., & Cola, M. (2021). Children's health care in mass-casualty incidents:Asystematic literature review. Prehospital and Disaster Medicine, 36(6), 739–746. 10.1017/s1049023x21001060

Franc, J. M., Kirkland, S. W., Wisnesky, U. D., Campbell, S., & Rowe, B. H. (2021). METASTART:Asystematic review and meta-analysis of the diagnostic accuracy of the simple triage and rapid treatment(START) algorithm for disaster triage. Prehospital and Disaster Medicine, 37(1), 106–116. 10.1017/s1049023x2100131x

Moss, R., & Gaarder, C. (2022). Exercising for mass casualty preparedness. British Journal of Anaesthesia, 128(2), e67–e70.

Tan, Y. T., Shin, C. K. J., Park, B., Bharath, A., Wing, R., Monteilh, C., Sanseau, E., Boswell, B., Pearce, J. I., Luetje, M., Enriquez, B., Cicero, M., & Thomas, A. (2023). Pediatric emergency medicine didactics and simulation: JumpSTART secondary triage for mass casualty incidents. Cureus. 10.7759/cureus.40009

The authors thank David L. Rodgers, EdD, EMT-P, NRP, FAHA, Director, Interprofessional Simulation Center, and Assistant Professor of Clinical Medicine, Indiana University School of Medicine, and Stephen Carey, South Central Region Manager, Environment of Care, Life Safety & Emergency Management, Indiana University Health, for their support in planning and execution of the simulation event.