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Background: Mixed reality training encourages experiential learning to enhance skill acquisition and improve knowledge for medical first responders. The essential learning components for mixed reality innovations in the context of mass casualty incident training have yet to be explored. This modified Delphi study aimed to identify learning components for mixed reality training for mass casualty incident first responders.

Methods: A modified Delphi method was undertaken comprising of three stages. In stage one, a literature search was conducted to generate statements regarding learning components for mixed reality training in mass casualty incidents. In stage two, participants rated the statements and contributed further ideas in relation to whether statements should be revised, added, or removed. In stage three, participants re-appraised their ratings in view of the group consensus. A consensus rating of 75% was set a priori. Descriptive statistical analysis was undertaken following each survey round.

Results: In stage one, a total of 34 statements were derived from the literature. Eighteen experts were invited to participate. Of these, 14 provided ratings in stage two (response rate, 78%) and 8 provided ratings in stage three (response rate, 57%). Consensus was achieved for 27 of 34 statements (79%) in the first survey, and 29 of 30 statements (97%) in the second survey. Written comments from participants emphasised the importance of context in relation to the learner, the trainer, and the mixed reality system technology.

Conclusions: This study identified learning components that achieved consensus for mixed reality training for mass casualty incident first responders. The learner experience, collaborative interaction, system adaptability, and training environment were important components for mixed reality training. Skills development and learner engagement were given higher priority than knowledge improvement or retention. These findings can be used to inform the planning and development of future trainings that use mixed reality modalities.

Mixed reality offers an innovative approach to training complex medical skills in mass casualty incident simulations. This pre-post test study aimed to describe mixed reality feature priorities for mass casualty incident simulation from the end-users’ perspective and to explore the extent to which priorities changed following implementation. A mixed reality training program was developed to improve medical first responders’ triage skills in mass casualty incidents. Five European emergency medical service end-user organizations were asked to prioritize mixed reality training features in five content areas: the live training system, equipment, debriefing dashboard, analytics and statistics, and the manikin. The baseline (T1) survey was completed in late-2022. Six field trials were carried out between June 2023 and January 2024. The follow-up (T2) survey and group discussions were completed in early-2024. Follow-up responses tended to be more polarizing, with fewer features rated as must have (T1, 54.1%; T2, 46.4%), and more features rated as should have (T1, 19.6%; T2, 23.9%), could have (T1, 17.6%; T2, 18.4%), and won’t have (T1, 6.4%; T2, 10.7%). Prior to implementation, end-user organizations prioritized mixed reality simulation features that promoted realism. Following implementation end-users were more pragmatic, assigning higher ratings to features that aligned with the required learning goals and objectives for mixed reality mass casualty incident triage training. Changes in end-users’ priorities demonstrate a need to evaluate mixed reality simulation feature priorities before, during, and after implementation to ensure relevant feature selection and technology development.

BACKGROUND: The optimal response to a major incident in a road tunnel involves efficient decision-making among the responding emergency services (fire and rescue services, police, and ambulances). The infrequent occurrence of road tunnel incidents may entail unfamiliarity with the tunnel environment and lead to uncertain and inefficient decision-making among emergency services commanders. Ambulance commanders have requested tunnel-specific learning materials to improve their preparedness.

OBJECTIVE: We aimed to assess decision-making among ambulance commanders in simulated road tunnel incidents after they had participated in a tunnel-specific e-learning course designed to support timely and correct decisions in this context.

METHODS: We conducted a web-based intervention study involving 20 participants from emergency medical services in Sweden who were randomly allocated to a test or control group. The control group (n=10, 50%) received a lecture on general incident management, while the intervention group (n=10, 50%) completed an e-learning course consisting of 5 modules focused on tunnel structure, safety, and collaboration in response. The participants took part in 2 simulation-based assessments for ambulance commander decision-making in major road tunnel incidents 1 month and 6 months after their allocated study intervention. In each simulation, the participants decided on the best course of action at 15 independent decision points, designed as multiple-choice questions. The primary outcome was the correct response to the question regarding how to appropriately enter the road tunnel. The secondary outcome measurements were correct or incorrect responses and the time taken to decide for each of the 15 decisions. Limited in-depth follow-up interviews were conducted with participants (n=5, 25%), and collected data were analyzed using qualitative content analysis.

RESULTS: All 20 participants completed the first simulation, and 16 (80%) completed the second. The main finding was that none (0/20, 0%) of the participants correctly answered the question on entering the tunnel system in the 1-month assessment. There were no significant differences between the groups (P=.59; 2-sample test of proportions) in the second assessment. The e-learning course was not associated with more correct answers at the first assessment, including accounting for participant factors (mean difference between groups: -0.58 points, 95% CI -1.88 to 0.73; P=.36). The e-learning course was also not associated with a shorter time to completion compared to the nonintervention group in either assessment. Interviews identified 3 categories linked to the main outcome: information (lack of), risk (limited knowledge and equipment), and mitigation (access to maps and aide-mémoire).

CONCLUSIONS: Participation in a tunnel-specific e-learning course did not result in a measurable change in ambulance commanders' decision-making behavior during simulated road tunnel incidents. The observed hesitation to enter the road tunnel system may have several plausible causes, such as the lack of actionable intelligence and tunnel-specific plans. This novel approach to assessing commander decision-making may be transferable to other educational settings.

Background: Recent trends indicate that the frequency of major incidents (MIs) is increasing. Healthcare systems are vital actors in societies’ responses to MIs. Well-prepared healthcare systems may mitigate the effects of MIs. Disaster preparedness is based on region-specific risk and vulnerability analyses (RVAs). Hospital incident command groups (HICGs) are commonly formed per hospital’s contingency plan MI to aid in disaster response. Acquiring situational awareness and decision-making in the face of uncertainty are known challenges for HICGs during MIs. However, the remoteness of rural hospitals presents unique challenges.

Aim: The aim of this study was to explore HICG leaders’ perceptions of disaster preparedness in rural hospitals.

Methods: A qualitative study with semi-structured, focus group, and individual interviews was used. The data were analyzed through inductive content analysis.

Results: The analysis generated the main category, HICGs’ confidence in handling major incidents and four categories. These were Uncertainty and level of recognition (containing two subcategories); Awareness of challenges and risks (containing two subcategories); Factors that facilitate preparedness, response, and leadership (containing three subcategories); and Prerequisites for decision-making (containing three subcategories and four subcategories).

Conclusions: HICG leaders generally perceived their hospital’s disaster preparedness as adequate. However, preparedness was found to be influenced by several factors. The findings revealed a complex interplay of factors influencing preparedness and response, particularly highlighting challenges related to geographical isolation and resource constraints. Effective preparedness requires a comprehensive understanding of local contexts, hospital capabilities, and risks, which directly impacts training, decision-making, and resource allocation. Addressing the identified vulnerabilities necessitates targeted interventions focused on situational awareness, decision-making, collaboration, and training.

Clinical trial number: Not applicable.

Objective: Measuring the effectiveness of mass casualty incident (MCI) scenario training is challenging due to simultaneously assessing individual skills, team dynamics, decision-making under pressure and adaptability. Existing instruments often focus too narrowly on individual skills, overlooking the comprehensive range of skills needed for effective prehospital disaster response. This study aims to develop and validate a comprehensive self-Assessment tool for prehospital disaster response skills during initial MCI scenario training.

Design: The instrument was developed and validated using a comprehensive methodology. This included literature reviews to identify the construct, ensuring content validity through expert evaluation and conducting field trials in MCI scenario training to evaluate the instrument under simulated conditions that approximated real-life incidents. The instrument's psychometric properties were assessed using exploratory factor analysis (EFA) and Horn's parallel analysis, as well as Cronbach's α and item-Total correlation analysis.

Setting: Two field trials conducted with participants in Sweden during 2023 and 2024. Participants 75 students from a bachelor's programme at a Swedish university were recruited to participate in the field trials. The programme featured one semester of comprehensive theoretical and practical training in disaster medicine, including MCI response and management. 88 instruments were collected during the field trials.

Results: Overall Cronbach's α score was 0.86, indicating high internal consistency for the instrument. EFA and Horn's parallel analysis revealed a five-factor model accounting for 52.3% of the total variance: incident control and management; systematic examination procedures; risk assessment and management; stress response and impact; and triage procedures. Cronbach's α for all factors indicated good internal consistency (range: 0.74-0.85).

Conclusions: The instrument addresses a critical gap by offering a comprehensive self-evaluation tool for disaster response skills. The robust psychometric properties indicate its potential for practical implication. Future studies should explore its application in diverse training settings and populations to enhance its utility and generalisability. A comprehensive development and validation methodology ensured the high content validity of the instrument.

This study examines a Mixed Reality (MR) simulation aiming to train first responders for mass casualty incidents (MCIs). The focus is on how trainees and instructors use workarounds to address uncertainties, and technical glitches during the simulation. Advancements in MR offer new approaches to MCI training, either replacing or complementing traditional methods. Using observations, audio and video recordings, and interviews, we analysed interactions through Goffman's concepts of ‘frame,’ ‘footing,’ and ‘rules of irrelevance. Findings show that participants in this MR simulation use a range of workarounds, to deal with glitches that arise in the training system and uphold the simulation, bridging gaps between real-world tasks and the MR simulation. Workarounds can be understood through the participants' framings of the situation, and how they shifted footings and frames. Findings demonstrated the importance of considering which representation from real-world work practices needs to be included in the simulation to ensure workarounds do not hinder the intended learning objectives. To mitigate this risk, organisers, instructors, and trainees must develop and deepen their competencies and understanding of the pedagogical underpinnings of simulation practice. These insights underscore the importance of viewing MR simulations as distinct practices with their own logic and conditions.

Background: Hazardous chemicals are essential for modern society but the use and transportation of them bears the risk of major incidents. Past incidents have revealed the importance of preparation and training of emergency medical service (EMS) personnel when responding to these incidents. However, studies have shown the level of preparedness to be insufficient. There is a lack of knowledge as to how EMS personnel perceive their preparedness and response when facing chemical incidents.

Aim: The aim of this study was to qualitative investigate working procedures regarding chemical incidents among a cohort of EMS personnel.

Method: Seventeen ambulance nurses from rural and urban areas were individually interviewed using four different realistic scenarios (vignettes). The transcribed text from the interviews was analyzed using qualitative content analysis.

Result: The results were derived into two categories with underlying sub-categories: a struggle to organize the onsite work situation (insufficient managerial support, limited resources, trust in rescue services, difficult decision making, stressful responsibilities); and decontamination—a demanding and risky situation (risk management, work in protective gear, aggravating circumstances). Participants often lack real life experience in facing a chemical incident and training that improves preparedness and the ability to respond adequately.

Conclusion: Chemical incidents pose many challenges for EMS personnel, but with proper training efforts many of these challenges could be solved. This study has shown the need for more accessible chemical incident training targeting EMS personnel: especially focusing on risk assessment; managerial support; resource management; equipment; and decontamination, including stress management and decision-making. Research in the area of chemical incidents is sparse and there remains much to understand concerning work procedures during chemical incidents.

Background: In significant events like chemical, biological, radiological, nuclear, and explosive (CBRNE) incidents, additional expertise in specific chemical substances becomes essential. Train-the-trainer programmes are used to increase knowledge and skills in a variety of fields and have been shown to be a cost-effective training method, eliminating the necessity of bringing in external experts or requiring participants to travel outside their region. Care in Hazardous Environments (CiHE) is one example of a course which comprises basic multi-disciplinary training together with personnel from rescue, police, and emergency medical services to prepare them to handle chemical and radioactive nuclear incidents. The train-the-trainer programme described in this study contains both theoretical and practical components, intended for instructors who will lead training on CiHE incidents. This study aimed to evaluate trainers’ level of knowledge before and after a train-the-trainer programme, as well as their thoughts about becoming an instructor i.e. the pedagogical competence for the Care in Hazardous Environments course.

Methods: A pre- and post-test, along with an evaluation of open-ended response options were employed to assess the effectiveness of the train-the-trainer programme for teaching the basic course (CiHE). A total of 49 participants were enrolled in the programme.

Results: Participants showed significant improvement in chemical, radiological and nuclear (CRN) response knowledge in two of the eight questions between the pre- and post-tests. The two questions that improved pertained to chemical substances and basic principles of radiation protection. Instructors trained in the train-the-trainer programme are intended to bring new knowledge, incorporate a rarely discussed topic into instruction regularly, and de-stigmatise CRN incidents by helping raise the minimum competency levels in their respective organisation.

Conclusion: An effective response to CBRNE events begins with readiness. First responders must be prepared and possess knowledge of both CRN components as well as protective gear to keep themselves and others safe at the incident scene. This study shows the importance of the train-the-trainer programme in continuing to educate police, and personnel from rescue and emergency medical services in CiHE, enable them to collaboratively prepare to handle CRN incidents.

Objective: Despite participating in scenario training, many medical first responders (MFRs) perceive themselves as inadequately prepared to respond to mass casualty incidents (MCIs). The objective of this study was to conduct a comprehensive examination of traditional MCI scenario training methods, focusing on their inherent strengths and limitations. An investigation into the perceptions of MFRs who had participated in MCI scenario training was carried out to identify potential areas for improvement and provide recommendations for refining MCI training protocols.

Design: Qualitative inductive approach using semistructured interviews that took place between October 2021 and February 2022. Data were analysed with qualitative content analysis.

Setting: MCI scenario training involving four organisations (three emergency medical services and one search-and-rescue organisation) tasked with responding to MCIs, collectively representing four European Union countries.

Participants: 27 MFRs (17 emergency medical services personnel and 10 search-and-rescue volunteers) were recruited to participate in the study.

Results: Two categories and seven associated subcategories (shown in parentheses) were identified as influencing the learning outcomes for MFRs: Training in a context mirroring real-world incidents (conducting incident scene risk assessment, realistic representation in casualties, incorporating scenario variety into the curriculum, interagency collaboration, role alignment when training incident site management) and use of a pedagogical framework (allowing for mistakes, the importance of post-training evaluation).

Conclusions: This study reaffirms the value of traditional MCI scenario training and identifies areas for enhancement, advocating for realistic scenarios, interagency collaboration, improved incident site management skills and thorough post-training evaluation. It suggests a shift in MCI training conceptualisation and delivery. The potential of virtual reality technologies as a valuable addition to training methods is explored, with a note on the need for further research to ascertain the long-term effectiveness of these technologies. However, the selection of a training method should consider programme goals, target population and resources.