P3A223: Mass Casualty Simulations for Evaluation of a Departmental Mass Casualty Plan

Background: Mass casualty incidents (MCI) are common in the United States and school shootings pose a particular threat to the pediatric population. In MCIs, emergency department (ED) evaluation and stabilization of victims requires multiple radiologic imaging modalities. At our urban, level I trauma pediatric hospital, our existing multi-disciplinary MCI simulations had not focused on the Radiology Mass Casualty Plan (RMCP). To evaluate and improve the RMCP, our Emergency Management team recruited emergency physicians, radiologists, radiology technologists, and software experts to conduct repeated simulations to evaluate, reassess, and improve the RMCP.

Methods: From 2021-2022, our multidisciplinary team conducted four joint ED-medical imaging simulations to revise the RMCP with a fifth simulation currently planned. The initial RMCP evaluation was a tabletop simulation using paper dolls to model patient prioritization through ED imaging procedures. The subsequent two drills utilized manikins of varied acuity in the ED trauma bays and moved them through imaging simulations in the CT scanner or portable X-rays/ultrasounds. The mass casualty notification paging system initiated each drill and then communication between technologists, radiologists and bedside physicians to communicate patient movement and critical results reporting was evaluated. The fourth drill used the same simulation set-up and evaluated the new role of Charge Attending Radiologist who facilitated communication of critical results, a new ED mass casualty EMR order-set and portable imaging notation of actionable findings by ED physicians. In July 2022, we conducted a whole-hospital MCI drill during which a CT mass casualty study was timed, and reporting processes were assessed. Following each drill, we held debriefings and After Action Reports assigned follow-ups used for continued process improvement.

Results: Each simulation identified different areas for improvement in the RMCP and used process improvement cycles. We implemented technology changes including physical equipment additions, ED study annotations to portable films and EMR improvements including a creation of a mass casualty orderset with a streamlined CT mass casualty protocol. Our mass casualty notification system was updated to include the radiologists. We modified the Charge Attending Radiologist’s role and subsequently improved inter-disciplinary communication of critical results.

Conclusion: Preparation for pediatric MCIs is a key component of emergency preparedness. Though the overall frequency of events is increasing, the frequency at any single institution is rare, and thus simulations are a useful tool to evaluate departmental mass casualty plans. Our drills uncovered many areas for improvement in our RMCP and allowed us to address weaknesses and improve the efficiency of the plan. We implemented creative solutions to technology barriers such as point of care annotation of studies by the interpreting bedside provider. Repeated simulations and revisions of the RMCP allowed us to try proposed solutions and improve communication and efficiency with each subsequent simulation.