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.

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.

Swedish emergency hospital surgical surge capacity to mass casualty incidents.

BACKGROUND: In Sweden the surgical surge capacity for mass casualty incidents (MCI) is managed by county councils within their dedicated budget. It is unclear whether healthcare budget constraints have affected the regional MCI preparedness. This study was designed to investigate the current surgical MCI preparedness at Swedish emergency hospitals. METHODS: Surveys were distributed in 2015 to department heads of intensive care units (ICU) and surgery at 54 Swedish emergency hospitals. The survey contained quantitative measures as the number of (1) surgical trauma teams in hospital and available after activating the disaster plan, (2) surgical theatres suitable for multi-trauma care, and (3) surgical ICU beds. The survey was also distributed to the Armed Forces Centre for Defence Medicine. RESULTS: 53 hospitals responded to the survey (98%). Included were 10 university hospitals (19%), 42 county hospitals (79%), and 1 private hospital (2%). Within 8 h the surgical capacity could be increased from 105 to 399 surgical teams, while 433 surgical theatres and 480 ICU beds were made available. The surgical surge capacity differed between university hospitals and county hospitals, and regional differences were identified regarding the availability of surgical theatres and ICU beds. CONCLUSIONS: The MCI preparedness of Swedish emergency care hospitals needs further attention. To improve Swedish surgical MCI preparedness a national strategy for trauma care in disaster management is necessary.