Evaluation of the decision-making process within the table-top exercise of the Terror and Disaster Surgical Care (TDSC®) course

Abstract

Purpose: The threat of terror is omnipresent in Europe and the number of attacks worldwide is increasing. The target of attacks in Europe is usually the civilian population. Incalculable dangerous situations at the scene of the event and severe injury patterns such as complex gunshot and explosion injuries with a high number of highly life-threatening people present rescue forces, emergency physicians and subsequently hospitals with medical, organizational as well as tactical and strategic challenges. The Terror and Disaster Surgical Care (TDSC^®) course trains clinical decision-makers to meet these challenges of a TerrorMASCAL in the first 24-48 h.

Methods: A table-top exercise was developed for the TDSC^® course as a decision training tool, which was prospectively evaluated in six courses. The evaluation took place in 3 courses of the version 1.0, in 3 courses in the further developed version 2.0 to different target values like, e.g., the accuracy of the in-hospital triage. Furthermore, 16 TDSC^® course instructors were evaluated.

Results: For the evaluation, n = 360 patient charts for version 1.0 and n = 369 for version 2.0 could be evaluated. Overall, the table-top exercise was found to be suitable for training of internal clinical decision makers. Version 2.0 was also able to depict the action and decision-making paths in a stable and valid manner compared to the previous version 1.0. The evaluation of the instructors also confirmed the further value and improvement of version 2.0.

Conclusion: With this prospective study, the table-top exercise of the TDSC^® course was tested for decision stability and consistency of the participants' decision paths. This could be proven for the selected target variables, it further showed an improvement of the training situation. A further development of the table-top exercise, in particular also using digital modules, will allow a further optimization. http://www.bundeswehrkrankenhaus-ulm.de.

Keywords: Decision-making; Disaster; Evaluation; Preparedness; Simulation game; Table-top exercise; Terror.

Fig. 1

The game board from the table-top exercise is shown above. Number 1 represents the screening area, where patients are first screened and categorized. From here, patients are taken to the emergency area/treatment area red (number 2) with a connection to the radiology department (number 3) for further treatment prioritization after a primary survey and appropriate diagnostics, if necessary. In the further course, depending on the previous examination results and capacities, the patients are taken to the operating room (number 4) or to the intensive care unit (number 7). Following surgery, monitoring is required from the patient in the recovery room (number 5). Patients with mild injuries or patients not triaged in red can be cared for in the emergency department/treatment area yellow (number 6) or in the ward block (number 8). Patients triaged green are cared for in the treatment area green (number 9) [9]

Fig. 2

Average age of the TDSC course participants of the game version 2.0 with application on the x-axis: age and on the y-axis number of participants. 92% (n = 44 of 48) of the course participants were over 34 years old, the most represented group was the 35–39-year-old group with n = 13, i.e., 27%, the minimum age was in the 25–29-year-old group with two course participants, the maximum age was defined by one course participant who stated that he was over 60 years old

Fig. 3

Training level of the participants, left version 2.0, right version 1.0. The percentages of the respective training level of the participants are shown. In version 2.0, the proportion of residents was 6%, of specialists 11%, of senior physicians 73%, of chief physicians 10%. In version 1.0, the percentage of residents was 8%, of specialists 26%, of attendings 53%, of chiefs 13%

Fig. 4

Composition of specialties, left for exercise 2.0, right for version 1.0. For version 2.0, 72% of participants were from orthopedics and trauma surgery, 14% from anesthesiology, 7% additional training in clinical emergency medicine, 3% vascular surgery, 2% internal medicine, 2% other specialties. For version 1.0, the proportion of the specialty of trauma surgery and orthopedics was 39%, anesthesiology 41%, other specialties with n = 6 were composed of ENT n = 1, neurosurgery n = 1, visceral surgery n = 1 vascular surgery n = 1, internal medicine n = 1, health economics n = 1

Fig. 5

Hit accuracy of the triage categories in comparison of the table-top exercise version 2.0–1.0: x-axis: patients as they were imported in chronological order within the scenario, y-axis: hit accuracy of the triage category in percent, the mean value is shown on the far right. Full color bars (green, red, yellow, blue) represent the results for version 2.0, saded bars (green, red, yellow, blue) for version 1.0

Fig. 6

Location of patient cards relative in percent depending on the respective total number of patient cards (n = 369 for version 1.0, n = 360 for version 2.0) at the end of the game. The picture is very similar between exercise version 2.0 and 1.0

Fig. 7

Selected diagnostics of patients in percent. In the game version 2.0 n total = 183. In the game version 1.0 n total = 247. x-axis: diagnostics, y-axis percentage frequency

Fig. 8

Selected form of therapy in the patient charts relative. x-axis therapy type, y-axis therapy in percent. Game version 2.0: DCS n = 31, TASC n = 74; game version 1.0: DCS n = 18, TASC n = 62