This groundbreaking study used a cross-sectional intervention approach, which consisted of two fundamental phases: preparation and implementation.
Setting
The primary response-related departments of the Security Forces Hospital program in Riyadh [Emergency department (ED), Wards, Intensive Care Unit (ICU), Operating room (OR)].
The Security Forces Hospital (SFH) – Riyadh is a government tertiary hospital with approximately 550 beds and over 250,000 patients who visit the ED annually. Twenty-three students volunteered to act as standardized patients (SPs). The 2021 updated hospital disaster plan was in use at the time of the study. Standard operating procedures with a surge capacity plan were evaluated in the primary response-related departments, whereas the physical movement of SPs occurred exclusively in the ED.
Participants
-
a.
Players (trainees): 141 front-line hospital receivers participated in the drill; the ED staff actively participated in the disaster drill, with 47 individuals involved. This group included 22 nurses, 12 physicians, three paramedics, five administrators (covering patient eligibility), and five security guards. The drill coordinator requested the heads of response-related departments, such as OR, ICU, and wards, to assign on-duty staff (89 personnel) to test the surge capacity plan for each department. This plan evaluates four elements: staff, stuff, structure, and systems. Five individuals from different medical and administrative departments activated the hospital incident operation room. The sample of players involved in the training was collected randomly using probability sampling, specifically stratified random sampling.
-
b.
Instructors, controllers, and evaluators: Five instructors and controllers from the drill control team were responsible for the scenario injects (or master event list), actors’ (SPs) actions, and players’ organization. Six EMS student volunteers assisted the control team in their tasks. Fifteen evaluators contributed to the drill; five were invited from three different government sectors (King Saud University, King Abdul-Aziz Medical City, and King Fahad Medical City), all with previous experience in emergency and disaster medicine education.
-
c.
Actors: 23 volunteers (13 paramedics and 10 nurses) acted as standardized patients (SPs) in this drill. Each SP’s occupation and prior experience were recorded. Before conducting the drill, the ED Director sent invitation letters to Prince Sultan College-Riyadh (medical services) and the hospital office (nursing internship training) to select volunteers to act as SPs. All SPs (actors) consented to participate before the functional drill. Attendance was compulsory for all actors once recruited.
The study was approved by the institutional research board of King Abdullah bin Abdulaziz University Hospital at Princess Nourah bint Abdulrahman University (IRB. Log. NO 23-0173E).
Drill development
Phase 1: the preparatory phase
This phase was established by six members of the disaster subcommittee with experience in emergency and disaster medicine. The experts set the drill’s goals and parameters according to the latest hospital risk assessment report, hospital resources, and the backgrounds and skills necessary for performing the roles and activities specified in the drill.
The first author developed the following three stages for Phase 1:
Stage one for Phase 1 is about verifying the requirements to set up a drill or the conditions needed for conducting exercises. Before preparing training, one needs to be sure that specific criteria are met, such as the following [31,32,33]:
-
Availability of an emergency management organizational structure with a disaster response plan (Hospital Incident Command Structure).
-
The items that must be investigated during the drill.
-
A risk scenario that considers potential dangers, weaknesses, and resources.
-
A site where there is little risk to participants and where the physical and environmental circumstances are appropriate for simulating emergencies and.
-
Necessary logistical support and institutional financial resources.
Stage two for phase 1
The organization process integrates and coordinates the work of different teams in developing the drill, which is conducted by the drill coordinator and includes a specific structure (Fig. 1 shows the organization structure).
Organizational structure. EMS: Emergency Medical Services, HICT: Hospital Incident Command Team
In Fig. 1, each position has tasks of responsibility, including technical and logistical aspects of the emergency drill. The technical design section is responsible for the master event list that explains the inject with action time, event input, action required by responsible parties/departments, duration for each inject/event during the scenario, and resource requirements.
Situation reports with timelines were also prepared for the media, relatives, and the local emergency operation center. Finally, the technical team wrote the scenario according to the abovementioned processes [31, 32].
Stage three of Phase 1 (preparedness) involved preparing evaluation instruments, training SPs, and creating the simulation cards.
-
A.
Instrument preparation
The technical design team prepared the evaluation forms under the supervision of the drill coordinator. Five different forms were used to evaluate the functional drill’s primary goals.
The first form involved collecting general feedback from the player, facilitator, and evaluator on the drill. The form evaluates the following items: the organization of the drill, the realism of the scenario itself, the orientation lectures before the functional drill, the level of facilitators, the hospital’s interdisciplinary approach, and the effect of utilizing standardized patients with MAC-SIM cards.
The second form evaluated the ED team’s performance in the triage zone and treatment (red, yellow, and green) areas, the security team’s response, communication flow, and the emergency operation center with the HICT (hospital incident command team) by external and internal evaluators.
The third form involved evaluating the performance of the ED team using actors (SPs) in the ED areas. It specifically focused on the accuracy and efficiency of the triage team’s triage, the time patients spent waiting for examination by the ED team, and the time it took to transfer patients from the ED. It also included an open-ended question about how to improve the drill design.
Instructors also assessed the actors’ performance (fourth form) to determine if they achieved the scenario’s objectives, understood their roles and behaviors, and adapted their physiological parameters to the players response management.
The last form pertained to the surge capacity protocol plan for response-related departments such as the ED, ICU, OR, and wards.
The first form was modified from the Public Health Emergency Exercise Toolkit [30]; the second combines the Ministry of Health (MOH) and the County of Los Angeles Department of Health Services Emergency Medical Disaster Services drills forms [31]. Three experts in disaster medicine education prepared for this study and validated the third and fourth forms. Ten paramedic students not included in the SP team participated in the pilot study for the third survey. The last questionnaire was developed around a questionnaire piloted and published by the medical response to major incidents and disaster course [16, 18].
An ED key treatments list was created for patients, primarily focusing on (A) airway, (B) breathing, (C) circulation, and (O) other treatments, such as immobilizing fractures and dressing wounds. The list indicated the start time for completing each required treatment. It was placed at each bedside so that healthcare providers could document their patients’ main treatment, including examination and planning for surgery and therapy.
-
B.
Standardized patient training and moulage trials
Two simulation techniques were used: standardized patients (SPs) and MAC-SIM to identify victim symptoms and signs.
Individuals with previous training in disaster medicine or drill experience were known as experienced SPs. The term “inexperienced SP” refers to SPs who have never been in a drill or received training in disaster medicine.
The drill design team delivered an orientation session before the drill, explaining scenario objectives, details with a master event list, and storyboards with MAC-SIMs for each SP. At the following meeting, the disaster medicine expert instructed the actors (SPs) on simulation techniques (such as acting and assessing participant reactions). The storyboards described the outcome of the patient’s situation and whether he received treatment or not. Ten days before the drill, two moulage experts applied the makeup descriptions to the makeup collector cards for each SP. Moulage experts from the medical field were invited to vividly describe wounds or illnesses on SPs to create highly realistic scenarios.
-
C.
Mass card simulation
The MAC-SIM is a validated system developed for assessing and comparing various triage methods in major event responses [18]. The actors (SPs) wear simulation cards around their necks to represent their signs, symptoms, and physiological parameters in line with their reactions to the healthcare provider’s medical response.
The physiological parameters (Airway, Breathing, Circulation, and Disability) used by Advanced Trauma Life Support are employed to depict the patient’s condition along the edges of the card [18].
Instructors can adjust the criteria based on the time since the injury and whether any therapies were provided. The card includes a transparent symbol system at the center (Fig. 2), making it easy to represent the various injuries combined with SP moulage. Additionally, the card includes the patient’s starting position, age, and gender. Two sizes of cards are available: a larger one for attaching to casualty actors during field exercises and a smaller one for simulation use. The technical leader provided the instructor with information about each patient:
A Mass Casualty Simulation card (MAC-SIM)
-
The entire and definite diagnosis of all injuries.
-
The proper time for various maneuvers to be performed to reduce the risk of complications and fatality.
-
Results in the best-case scenario, i.e., if the patient had recovered fully and all appropriate treatments had been administered.
-
Possibility of need for ventilator treatment.
-
Trauma scores to correlate results with Injury Severity Score (ISS).
Storyboards with cards were prepared for 23 cases: five reds, 12 yellows, and six greens. The green cases were deemed self-evacuation casualties by private cars to the ED entrance.
Phase 2: the implementation phase
Stage one: orientation session
The drill coordinator team held a one-hour orientation lecture ten days before the drill. The lecture covered the objectives of the drill, organizational structures, and critical information from the disaster manual. The presentation was delivered to response-related departments, focusing on the ED team. The presentation also included essential information that needed to be understood before the drill, such as an ED floor map, the ED surge capacity plan, ward discharge criteria, and safety plans in the event of an incident. The instructors introduced a tool for treating disaster victims and the primary (start) and secondary triage procedures. Finally, the hot wash and after-action reports procedures were explained.
Stage two: conducting the drill
On December 19, 2022, at 11 a.m., a functional drill was conducted inside the hospital. The scenario involved a building collapsing during a graduation ceremony, resulting in over 60 casualties. The renal dialysis area was utilized as the incident scene.
When the initial report of the disaster was made from the regional command center, it took 17 min to be clarified in which time the ED standby level was activated. Six self-evacuated victims left the incident scene by private vehicle during the standby period. After receiving confirmation that 17 urgent and immediate cases had been transported to the hospital, the ED director-initiated level two of the disaster plan. Each patient evacuated by ambulance to the hospital’s ED was transferred from the renal dialysis area to the ED. Ten evaluators were assigned to different areas, such as the command control room, triage, and treatment areas. Four of these evaluators checked the physiological parameters of each victim to ensure they were consistent with the treatment or life-saving procedures received during the drill. Additionally, five head nurses were allocated to departments such as the ICU, wards, and OR to assess the surge capacity plan in each department. After the last patient arrived at the ED, the coordinating chief announced that the external disaster drill was over with the remainder of the drill focused on the internal responses. The entire simulation lasted two and a half hours and focused on the ED response and internal communication within and between hospital departments.
Thirty minutes after the drill ended, the drill coordinator, players, and the evaluation team participated in a one-hour hotwash session and completed the forms for the drill feedback. Standardized Patients (SPs) also joined instructors for a brief discussion to address the positive and negative aspects. One week after the drill, the after-action report was sent to the medical administration and disaster committee.
Analysis Method
Data were analyzed using IBM SPSS version 25 (Statistical Package for the Social Sciences). Two types of analyses were employed: reliability tests and non-parametric Kruskal-Wallis tests. The reliability test involves using Cronbach’s alpha to measure the consistency of a questionnaire, mainly through Likert-scale questions.
Add Comment