Development of Multiple Trauma Activation Training for Surgical Services

Mass casualty incidents (MCIs) create a large influx of patients, are becoming more prevalent, and require adequate training for healthcare personnel. Multiple Trauma Activation (MTA)- specific protocols promote awareness and effective responses and increase access to healthcare. Intermountain Medical Center (IMED) in Murray, UT, needs an MTA protocol and MTA training material for surgical services. The lack of an MTA-specific protocol has the potential to impact patient care. This project aimed to develop an MTA protocol and training material for surgical services employees to increase their preparedness competency in response to a large influx of critical surgical patients during a MCI. This quality improvement project aimed to increase emergency preparedness of surgical services during a MCI. The Emergency Preparedness Information Questionnaire (EPIQ) is a validated tool to measure the emergency preparedness of nurses. We created an adapted EPIQ tailored toward surgical services. The pre-MTA training online survey included an adapted EPIQ, General Self-Efficacy Score (GSE), and participant demographics. MTA protocol and training material was developed with 23 content experts and presented to 70 surgical services employees. The post-MTA training online survey included the adapted EPIQ and training feedback of pilot MTA training. Participants' competency level was increased after MTA training (p = <.001). Seventy employees attended the MTA pilot training; 61 provided demographic information, 60 completed the GSE, and 50 completed the pre-and post-EPIQ. GSE demonstrated a high self-efficacy score across all roles measured. Most participants identified time commitment for future training as a weekday workshop or a 2-hour lecture. The most preferred training modalities identified were face-to-face and simulation. MTA pilot training increased emergency preparedness competency for participants. More specific MTA role training is needed to ensure an efficient MCI response by surgical services.

1 Development of Multiple Trauma Activation Training for Surgical Services Rachael Anne Hubertz, Jia-Wen Guo College of Nursing: The University of Utah NURS 7703: DNP Scholarly Project III April 14, 2023 2 Abstract Background: Mass casualty incidents (MCIs) create a large influx of patients, are becoming more prevalent, and require adequate training for healthcare personnel. Multiple Trauma Activation (MTA)specific protocols promote awareness and effective responses and increase access to healthcare. Intermountain Medical Center (IMED) in Murray, UT, needs an MTA protocol and MTA training material for surgical services. The lack of an MTA-specific protocol has the potential to impact patient care. This project aimed to develop an MTA protocol and training material for surgical services employees to increase their preparedness competency in response to a large influx of critical surgical patients during a MCI. Methods: This quality improvement project aimed to increase emergency preparedness of surgical services during a MCI. The Emergency Preparedness Information Questionnaire (EPIQ) is a validated tool to measure the emergency preparedness of nurses. We created an adapted EPIQ tailored toward surgical services. The pre-MTA training online survey included an adapted EPIQ, General Self-Efficacy Score (GSE), and participant demographics. MTA protocol and training material was developed with 23 content experts and presented to 70 surgical services employees. The post-MTA training online survey included the adapted EPIQ and training feedback of pilot MTA training. Results: Participants’ competency level was increased after MTA training (p = <.001). Seventy employees attended the MTA pilot training; 61 provided demographic information, 60 completed the GSE, and 50 completed the pre-and post-EPIQ. GSE demonstrated a high self-efficacy score across all roles measured. Most participants identified time commitment for future training as a weekday workshop or a 2-hour lecture. The most preferred training modalities identified were face-to-face and simulation. Conclusion: MTA pilot training increased emergency preparedness competency for participants. More specific MTA role training is needed to ensure an efficient MCI response by surgical services. Keywords: Multiple trauma activation protocol, surgical services, training, education, mass casualty incident 3 Development of Multiple Trauma Activation Training for Surgical Services Problem Description Mass casualty incidents (MCIs) include natural disasters such as hurricanes, tornadoes, and earthquakes and manufactured disasters such as bombings and mass shootings. MCIs are becoming more common, requiring systems in place and adequate training for medical personnel in Multiple Trauma Activation (MTA)—a large influx of critical patients in a short amount of time (Gabbe et al., 2022; Moran, Blecker, et al., 2021). Day-to-day protocols are insufficient for effectively managing MCIs due to increased resource strain. This can compromise the quality of trauma care, thus creating a need to develop and test MCI-specific protocols to minimize loss of life and maximize patient outcomes (Haverkort et al., 2017; Moran, Blecker, et al., 2021; Moran, Zimmerman, et al., 2021). During an MCI, the ability to get critical patients to surgery quickly is the most effective intervention at saving lives, rather than a facility’s surge management plan for bed availability (Gabbe et al., 2022; Greater New York Hospital Association, 2019; Lake, 2018). Intermountain Medical Center (IMED) in Murray, Utah, is one of three trauma-one centers in Utah and the second-largest hospital in Utah (Hospital Management, 2022). IMED is the flagship hospital campus for Intermountain Health, with 504 beds, serving the intermountain west (Hospital Management, 2022). The MTA protocol for IMED focuses heavily on the triage process for the Emergency Department and the patient surge plan for the intensive care units and the medical floors. An annual simulation test of the facility’s MTA protocol involves the emergency department, transfusion services, Life Flight, and local emergency medical services, including the fire department, ambulances, and the police department. Within this facility’s MTA protocol, the information specific to the operating room directs the charge nurse to place all non-emergent surgical cases on hold and to await further details regarding the prioritization of need for the operating space (Evertsen et al., 2021). This lack of direction and explicit protocol for surgical services can cause a problem with the facility’s response to an MTA, significantly impacting the operating room response time, preparation, and readiness to accept trauma victims in an MCI. 4 For patients who are unstable and need immediate intervention before being transferred to the intensive care unit or a medical floor, the operating room is the next step after triage in the emergency department. Preparing the operating room for emergent cases requires the synchronization of several departments to ensure the proper staff and equipment are available and ready to mobilize—these departments include the operating room, central processing, anesthesia department, and the postanesthesia care unit. Central processing is a precious and necessary element of surgical procedures to secure the essential sterile supplies needed in any procedure. Collecting supplies for a surgical procedure takes time, and several people to make it run smoothly. Close communication and a protocol that includes explicitly central processing during an MTA will contribute to an efficient surgical response to a large influx of critical surgical patients. During an MTA, central processing is responsible for a crucial role in cleaning surgical equipment and returning it to service as soon as possible to streamline the throughput to surgery time, thus saving more lives in an MTA (Lake, 2018). The anesthesia department comprises anesthesiologists and anesthesia monitoring technicians who provide critical care for acutely ill patients during surgical procedures. The MTA protocol at IMED currently does not account for the anesthesia team members and their roles outside of being notified of an event. The post-anesthesia care unit cares for patients directly after surgery before transferring them to the medical floor. In situations where the intensive care units are experiencing high volumes of patients, critical surgical patients will be brought to the post-anesthesia care unit until space is available in intensive care units. IMED needs a policy, processes, education, and exercises to ensure a successful response by surgical services by integrating surgical plans into the facility MTA response (Hick et al., 2020). Available Knowledge The United States is witnessing an epidemic of MCIs, with mass shootings being the most common (Hollister et al., 2021). As of July 2, 2022, over 200 mass shootings had already occurred in the United States in 2022 alone, killing 343 people and injuring an additional 1,391 people (Ledur et al., 2022). Conventional traumatic MCIs, such as natural disasters or major road accidents, tend to result in 5 lower rates of emergent operative intervention. However, violent events designed to kill or injure as many people as possible have a markedly increased rate of necessary emergent surgical intervention (Hick et al., 2020). In addition, many victims of gunshot wounds require emergent surgery for stabilization; with mass shootings becoming more commonplace, surgical services need to be prepared for MTAs involving gunshot wounds (Sarani et al., 2021). Trauma training is vital in educating healthcare providers about acutely injured patients. In addition, the increasing frequency of mass casualty disaster events has required a readiness for more large-scale events (Quick, 2018). However, a study conducted in Canada to measure the preparedness level of their trauma centers for MCIs found that very few centers mandated training of personnel for MCIs, including trauma one centers—no trauma one center required physicians to be trained. In addition, only 15% required nurses and other healthcare providers to be trained in an MCI response (Cameron et al., 2021). The findings of this study, combined with the increasing frequency of MCIs, highlight the need for development training for those involved in an MCI response. Rationale Mass casualty preparedness is a complex process requiring a multidisciplinary approach; through effective planning, trauma systems should be positioned to deliver an optimal response when faced with an MCI (Gabbe et al., 2022). During an MCI response, the ability to provide life-saving surgical interventions to critically unstable patients effectively improves patient outcomes (Gabbe et al., 2022; Greater New York Hospital Association, 2019; Lake, 2018). Disaster-related training is necessary to improve the preparedness and confidence of healthcare personnel in response to an MCI (Labrague et al., 2018). To achieve this goal, the employees of surgical services need training on the MTA protocol and how they can efficiently and effectively respond to an MCI. This project creates a surgical-specific MTA protocol and provides training to surgical services employees addressing their respective roles and responsibilities during an MTA. The proposal to increase the preparedness competency of surgical services employees related to an updated MTA protocol focuses on the importance of building knowledge and translating it into actions 6 that improve health systems. The Knowledge to Action (KTA) framework was chosen for this project because it provides a process that aligns well with this project as it integrates the concepts of knowledge creation and action. Within the KTA framework, (A) a problem is identified, (B) review, selection, and adaptation of knowledge for the appropriateness of the intended audience, (C) assess barriers and facilitators to knowledge use, (D) selection, tailor, and implement interventions, (E) monitor knowledge, (F) evaluation of outcomes, and (G) a plan created to sustain knowledge (Rycroft-Malone & Bucknall, 2010). The problem identified in this project is the lack of an MTA protocol and training material specific to surgical services (KTA-A). Therefore, knowledge development (MTA training material) is tailored to the healthcare partners’ local context, including nurses, scrub techs, anesthesia techs, orderlies, and central processing staff (KTA-B). The MTA training material delivery method will be assessed for future adaption (KTA-B). In assessing the need for MTA training, barriers and facilitators to training delivery will be identified (KTA-C). The knowledge tool produced is MTA training for operating room staff which has been tailored to engage and inform all staff roles in surgical services (KTA-D). Monitoring knowledge use is performed by examining the pre- and post-adapted EPIQ evaluation to determine the effectiveness of pilot training, the time commitment for participants, and the areas of improvement for the training materials (KTA-E). Evaluation of outcomes is based on the pre- and postself-reported preparedness competency level via the adapted EPIQ (KTA-F). To sustain knowledge, we propose annual MTA training for surgical services employees, which is out of the scope of this DNP project (KTA-G). Specific Aims This DNP project aimed to develop training material for the revised MTA protocol for surgical services employees to increase their preparedness competency in responding to a large influx of critical surgical patients during an MCI. Objectives of this project included: 1. Develop MTA training material based on surgical services MTA protocol 7 a. Revise existing facility protocol to include content specific to surgical services b. Create computerized MTA training material c. Address bias in trauma care 2. Assess the surgical services employee’s preparedness for MTA training a. Assess the emergency preparedness competency level of surgical services employees during an MTA b. Assess common barriers and facilitators to the training modality 3. Pilot test MTA training for a portion of surgical services staff a. Implement training for up to 100 surgical services employees b. Evaluate time commitment to complete MTA training c. Evaluate a necessary improvement of the material d. Evaluate emergency preparedness competency of surgical services employees during an MTA Methods Context This project took place at IMED in Murray, Utah. IMED is located in the Salt Lake City metropolitan area. IMED is one of three trauma-one centers in Utah and the second-largest hospital in the state. IMED is instrumental in providing medical treatment to Utah and neighboring Mountain West states that lack the specialized care offered by IMED. The departments involved in this project compose surgical services, which include the Operating Room (OR), Same Day Surgery (SDS), Post-Anesthesia Care Unit (PACU), and Central Processing (CP). These departments are made up of doctors, nurses, technicians, and orderlies. The healthcare partners from the departments involved in this project include nursing leadership, registered nurses (RN), surgical scrub technicians, anesthesia monitoring technicians (AMT), central processing technicians, OR core technicians, orderlies, and health unit coordinators (HUC). 8 IMED has an MTA protocol for the facility; it specifies that each department is responsible for its response to the event. However, IMED had no MTA protocol or training material for surgical services. The Nurse Leadership in several surgical services departments expressed interest in outlining a specific protocol for a surgical response to an MCI requiring MTA. Additionally, the updated 2022 guidelines for IMED’s trauma recertification put forth by the American College of Surgeons requires an MTA surgical response in the hospital’s mass casualty plan. The surgical response must outline the critical personnel, means of contact, and coordination of procedures (American College of Surgeons, 2022). Increased preparedness competency and a specific protocol aim to improve the efficiency and effectiveness of the surgical response. Heightened efficiency in care will allow surgical services to provide surgical intervention for a more significant number of patients more quickly, aiding in the emergency department’s ability to care for more patients efficiently. By streamlining the care process, this project addresses social determinants of health by increasing patient access to high-quality surgical care during an MTA. Increased access to surgical intervention will also uphold the goal of mass casualty response, which is to provide the greatest good for the greatest amount of people (Briggs, 2017). Manufactured MCIs are often extremely violent events targeting racial, cultural, ethnic, and LGBTQ+ groups at an increasing rate (Williams et al., 2022). Because of this, there is a greater likelihood for patients requiring emergent life-saving surgical intervention during a mass casualty incident to be minorities and vulnerable populations. This project provides an MTA protocol to streamline the care provided to a surge of critical patients but also includes education on implicit bias in healthcare delivery and provides tools for employees to deliver equitable care aiming to decrease health disparities in surgical services. Addressing implicit bias in surgical services employees aims to promote empathic care, enhance healthcare delivery, and improve surgical outcomes (Spruce, 2018). Intervention The objectives of this pilot training project included developing training material (Appendix A) based on the updated MTA protocol for surgical services (Appendix B), assessing the preparedness level of surgical services employees, and pilot testing the training for a portion of surgical services employees. 9 A pre-training survey was administered using an adapted Emergency Preparedness Information Questionnaire (EPIQ) (Appendix C) tailored to focus on surgical services’ roles in an MCI to assess the preparedness level of surgical services employees. The adapted EPIQ was administered before and after the MTA pilot training. The General Self-Efficacy scale (Appendix D) was included in their pre-training surveys to evaluate the participants’ perceived efficacy. Additionally, before the pilot training, demographic data was collected of the participants, including their age, biological sex, race, ethnicity, job title, years of experience in their current role, and overall years of experience in surgical services (Appendix E). There were a total of 23 content experts involved in this project: two Nurse Educators, eight Surgical Services Managers (one in CP, one in SDS, one in PACU, five in OR), one AMT supervisor, one CP Coordinator, one CP Supervisor, one HUC, one OR Charge Nurses, one RN Practice Coordinator, one Senior Orderly, three senior OR nurses, one Surgical Services Consultant, the IMED Trauma Services Manager, and the IMED Emergency Management Coordinator. Content experts were chosen based on their years of experience in surgical services, trauma care, and leadership within their respective departments. Collaboration with content experts resulted in the revision of the MTA protocol (Appendix B) to include a surgical services response with details on the employee notification process and roles and responsibilities of employees and leadership in surgical services. The MTA training material (Appendix A) was developed based on the revised protocol and reviewed by content experts before implementation. The pilot training includes education on MCIs, how they can result in an MTA, facility MTA response, employee notification process during an MTA, the roles and responsibilities of each staff member, communication with the Incident Command Center, patient flow, and debriefing after an MTA. The training also includes education on bias in trauma care and how to counteract bias to improve patient care. After the pilot training was presented, a post-survey included a post-EPIQ (Appendix C), a knowledge assessment of participants’ roles during an MTA, and training feedback (Appendix F). The training feedback assessed for facilitators, barriers, and improvement to training and modality. All surveys were 10 administered using the research electronic data capture (REDCap) online surveys for data collection, a secure HIPAA-compliant system. Study of the Intervention The EPIQ is a tool designed and studied by the Emergency Preparedness Self-Assessment Survey Task Force formed by the Wisconsin Nurses Association (Wisniewski et al., 2004). When used in various studies, this tool has shown that nurses tend to self-report a low level of competency preparedness for emergencies (Wisniewski et al., 2004). In this quality improvement project, we used an adapted EPIQ to measure surgical services employees’ emergency preparedness levels before and after MTA training was completed. These scores were analyzed to determine whether the MTA training increased emergency preparedness. Demographics were collected for each participant, including age, biological sex, race, ethnicity, job title, years of experience in their current role, and overall experience in surgical services. Additionally, a survey was collected after the training to assess needs, barriers, facilitators, pre-/post-training knowledge of roles and responsibilities during an MTA, and general training feedback. All the data was collected using the research electronic data capture (REDCap), a secure HIPAA-compliant system. In addition to descriptive demographics of MTA training participants, expected outcomes of the intervention include a comparison of the emergency preparedness level pre- and post-MTA training and effectiveness of the MTA training through assessment of knowledge of MTA roles and responsibilities of the participants. Measures Gina Dennik-Champion, Wisconsin Nurses Association Executive Director, granted permission to use the EPIQ tool in this project. Through extensive feedback from content experts, the EPIQ was adapted for use in this project to measure the emergency preparedness of surgical services employees. The adapted EPIQ contains 21 statements related to the detection of and response to an event; the incident command center and the employee’s role; ethical issues in triage; decontamination; communication/connectivity; psychological issues; special populations; accessing critical resources; and 11 overall familiarity of emergency preparedness for a large-scale event. The participant answers each statement using a 5-point Likert-type scale from Very Familiar (1) to Not Familiar (5), resulting in a lower score on the EPIQ, indicating a higher level of emergency preparedness competency. Participants were also asked to complete a General Self-Efficacy scale of 10 items describing their perceived self-assessment of their ability to adapt to daily obstacles and stressful life events (Schwarzer & Jerusalem, 1995). The participant answers each statement using a 4-point Likert-type scale from Not at all true (1) to Exactly true (4); a higher score indicates the individual perceives themselves to have more self-efficacy than someone with a lower score. The participants’ pre- and post-survey results were linked using three questions to construct an anonymous survey identification number. This number comprises the last two numerical digits of their home address, the last two digits of their birth year, and the last two digits of their employee identification number. Constructing this anonymous identification number allowed us to collect and link data using the research electronic data capture (REDCap) online surveys without using protected health information. Analysis The quantitative data were analyzed using descriptive statistics, including demographics, pre-and post-EPIQ scores, GSE scores, and knowledge of MTA role responsibilities. In addition, participants completed a pre-and post-training quiz to evaluate the participant’s understanding of their role responsibilities during an MTA. A one-way ANOVA test was used to measure the mean GSE scores among the different role groups. The groups included were those with at least two individuals (Orderly, RN, and Scrub Tech); AMT was excluded due to only one individual in this group. The adapted EPIQ measures the participant’s emergency preparedness competency level before and after training. Differences between the pre-and post-training EPIQ scores of the participants were analyzed using a parametric independent t-test. In addition, a non-parametric Wilcoxon test was used to analyze the pre-post-training EPIQ scores due to the varied distribution of data. 12 Differences between the pre-and post-training MTA role responsibilities quiz were analyzed using a chi-squared test to measure an association between the individual’s roles and their knowledge improvement regarding MTA role responsibilities. Scores for the MTA role quiz were graded as pass/fail—those who answered all questions correctly passed, while those who answered at least one question incorrectly were scored as fail. In addition, those who failed their pre-training MTA role quiz and passed their post-training MTA role quiz were measured as being improved from baseline. Post-training feedback collected will compose the qualitative data and will be summarized by using content analysis to identify themes or patterns. Ethical Considerations This quality improvement project was not subject to University of Utah institutional review board oversight. Therefore, there were no conflicts of interest concerning this study. Results The initial steps of this intervention involved an extensive literature review in identifying current knowledge and tools available for multiple trauma activation in surgical services in response to an MCI. Most previous research has been conducted in pre-hospital and emergency department settings. The content experts and I reviewed the existing facility MTA policy and procedures at IMED to include a protocol specific to surgical services. Feedback was collected from a Surgical Services consultant, leadership in SDS, OR, PACU, and CP to include the elements necessary to incorporate in a surgical services response during an MCI. As the MTA protocol was being written, surveys for data collection were also developed. Surveys for training participants included demographics, General Self-Efficacy Scale, adapted EPIQ, MTA role responsibilities, and training feedback. The EPIQ was selected as a tool to measure the emergency preparedness competency of surgical services employees. The original EPIQ was distributed to the leadership in surgical services and content experts to gather feedback on the adaptation of the questionnaire to fit the specific audience and setting. The General-Self Efficacy scale was used to measure the perception of self-efficacy and roles in surgical services. Finally, participants were asked to 13 identify their roles and responsibilities in an MTA pre- and post-training to evaluate the effectiveness of knowledge dissemination during the training. Of the 70 surgical services employees who attended the MTA training, 61 completed the demographics survey (Table 1), 50 completed both the pre-and post-EPIQ (Table 2), 60 completed the Self-Efficacy Scale (Table 3), and 49 submitted training feedback (Table 4, Table 5, Figure 1). In addition, participants were asked three questions to create a unique identification number to link data sets from pre- and post-training surveys. Data sets with incomplete survey responses were not included in the analysis. Most participants who attended the MTA pilot training identified themselves as white (n=51), non-Hispanic (n=49), and female (n=41). Over half of the participants acknowledged their role as surgical services nurses (n=36). At the same time, the rest were a mixture of scrub techs (n=15) and orderlies (n=9), one participant was an AMT, and no central processing employees were present. Additionally, more than half of the participants (n=39) reported having less than two years of experience in surgical services (Table 1). Post-training EPIQ data demonstrated significantly lower scores than the pre-training EPIQ scores p-value was <.001 for the paired t-test and Wilcoxon test (Table 2). Of the 60 participants who completed the General Self-Efficacy Scale, there was little difference between orderlies, nurses, and scrub technicians (Table 3). The role quiz data from pre- to post-training scores demonstrated a p-value of .397 among the roles measured. Feedback regarding the pilot training was primarily positive, although many desired additional information and training on the subject matter (Table 4). The most preferred modality for future training was face-to-face (i.e., traditional classroom), simulation, and educational videos (Table 5). Participants also identified their top three preferences of time commitment to future MTA training as a one-day weekday workshop, 2-hour lecture, and a 2–3-day workshop/conference, respectively (Figure 1). 14 Discussion Summary Mass casualty preparedness requires a multidisciplinary approach with effective planning to deliver an optimal response (Gabbe et al., 2022). As demonstrated in previous literature, providing lifesaving surgical interventions during an MCI improves patient outcomes (Gabbe et al., 2022; Greater New York Hospital Association, 2019; Lake, 2018). This project aimed to create an MTA protocol and develop MTA training for surgical services employees to increase their emergency preparedness competency in effectively responding during an MCI. This project allowed us to measure the emergency preparedness of some surgical services employees before and after completing the MTA pilot testing by using an adaptation of the EPIQ tool. A particular strength of this project is that the training materials we developed were specially created for a specific audience and their responsibilities. This protocol would not be generalizable to other departments in a healthcare facility as it is written. Surgical services are an incredibly specialized environment and require protocols and training to be as such in order to be applicable. As this is tailored for surgical services, this project may be adapted for other institutions to be included in their MTA planning. Another strength is that the direct application of this protocol has the potential to increase access to healthcare for critically injured patients during an MCI with the possibility of saving lives. The training was designed to be short, with crucial phrases and instructions for each role of surgical services employees. Interpretation There was a significant improvement measured in the emergency preparedness of surgical services employees after completing the MTA pilot training compared to their scores before the training. This improvement in EPIQ scores after the completion of emergency education or training is similar to those in previous studies using either the original EPIQ or an adaptation (Garbutt et al., 2008; Georgino et al., 2015; Ghazi Baker, 2021). However, those other studies mainly looked only at measuring the 15 emergency preparedness of nurses, whereas this project included other healthcare personnel roles in surgical services. The GSE scores of the participants who attended the MTA pilot training were similar and did not differ much between the roles. The GSE has a minimum score of 0 and a maximum score of 40, with a higher score indicating more perceived self-efficacy. We created the role quiz administered to each participant before and after MTA training based on the MTA protocol and training materials presented in the pilot training. Therefore, we anticipated seeing an improvement in the scores when comparing the pre-and post-training scores. When comparing the scores using a chi-squared test, however, we determined no improvement after the pilot training. These findings contradict the outcome measured with the adapted EPIQ. This result is possibly due to the EPIQ's reliability and validity in measuring emergency preparedness, while the role quiz we created has not been tested for reliability and validity. Limitations This project was developed specifically for surgical services at IMED, limiting its generalizability to other departments. This project may be adapted for surgical services in other facilities but will likely need adaptation to the local context for full workability. Although based on the training material, the role quiz is not a validated tool and may not be an exemplary process for measuring competency and knowledge level. The role quiz, if to be used again, should be modified. The timing of the quiz may factor into information recall. It may be better to complete the role quiz immediately after their respective role is covered in training rather than after training on all roles has been discussed. Although the sample size was about one-third of surgical services employees, several roles were either not present at the training or were not represented by enough participants to include their scores in the data analysis. For example, no representatives from central processing, including core technicians, were present at the pilot training. There was only one AMT who attended and completed the training surveys. Without all roles attending the MTA pilot training, only three of the six roles discussed in the 16 presentation received the training. The training was also only held once on a weekday morning—those who work evenings, nights, and weekends did not receive the training. Conclusions We are confident that this project met its goal of creating an MTA protocol and training materials for surgical services and improving the emergency preparedness of those who participated in the pilot training. However, little research has been completed on the emergency preparedness of surgical services employees, and more is needed. Additional MTA training is needed for all surgical services employees, emphasizing hands-on simulation to improve knowledge use. The creation of written materials, such as pocket reference guides outlining MTA protocol roles, could also be beneficial to enhance learning. Nurse educators at IMED will champion this project to ensure the protocol is included in annual training, at a minimum, with the potential of more frequent training. In addition, this protocol should be revisited annually by the surgical services leadership to ensure the information is current and aligns with the facility MTA protocol. We further recommend this training to be mandatory for all surgical services roles on at least an annual basis, as is already practice for mock code, to ensure a swift response should an MCI occur. 17 Acknowledgments Content experts who contributed to this project include Jeff Jorgensen, Katie Johnson, Tim Phasaka, Carmen McGarry, Nicole Long, Rhonda Chilson, Hailey Bello, Annie Lyman, Courtney Miller, Chantay Stringham, Brandon Jones, Richard Jensen, Ryan Dahl, Diana Robinson, Colleen Allen, Stephanie Smith, Lauren Aland, Aubrey Hills, Mary Christensen, Jennifer Martinez, Jon Worthen, Shawn Evertsen, and Jo Loter. 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Mass shootings in 2022: U.S. sees more than 300 so far. The Washington Post. https://www.washingtonpost.com/nation/2022/06/02/mass-shootings-in2022/ Moran, M. E., Blecker, N., Gothard, M. D., & George, R. L. (2021). A Critical Pathway for Mass Casualty Incident Preparedness. Journal of Trauma Nursing, 28(4), 275–280. https://doi.org/10.1097/JTN.0000000000000597 20 Moran, M. E., Zimmerman, J. R., Chapman, A. D., Ballas, D. A., Blecker, N., & George, R. L. (2021). Staff perspectives of mass casualty incident preparedness. Cureus, 13(6), e15858. https://doi.org/10.7759/cureus.15858 Quick, J. A. (2018). Simulation Training in Trauma. Missouri Medicine, 115(5), 447–450. Rycroft-Malone, J., & Bucknall, T. (2010). Models and frameworks for implementing evidence-based practice: Linking evidence to action. Chichester, West Sussex. Sarani, B., Smith, E. R., Shapiro, G., Nahmias, J., Rivas, L., McIntyre, R., Robinson, B. R. H., Chestovich, P. 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Emergency preparedness competencies: Assessing nurses’ educational needs. JONA: The Journal of Nursing Administration, 34(10), 475–480. 21 Tables and Figures Table 1 Demographics Characteristic Gender Female Male Age Mean (SD) Range Ethnicity Non-Hispanic or Latino/a Hispanic or Latino/a Race White Asian African American Other Years of Experience in Surgical Services <1 1-2 3-5 >5 Years of Experience in Current Role <1 1-2 3-5 >5 Total (N = 61) AMT (n = 1) Orderly (n = 9) RN (n = 36) Scrub Tech (n = 15) 41 (67.2%) 20 (32.8%) 0 (0.0%) 1 (100.0%) 6 (66.7% 3 (33.3%) 26 (73.3%) 10 (27.8%) 9 (60.0%) 6 (40.0%) 30.8 (10.1) 18-65 44 44-44 23.6 (4.0) 23-30 32.1 (8.3) 22-59 32 (14.3) 18-65 49 (87.5%) 1 (100.0%) 0 (0.0%) 8 (88.9%) 28 (90.3%) 12 (80.0%) 1 (11.1%) 3 (9.7%) 3 (20.0%) 1 (100.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 9 (100.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 28 (84.8%) 13 (86.7%) 2 (6.1%) 1 (3.0%) 2 (6.1%) 1 (6.7%) 0 (0.0%) 1 (6.7%) p 0.421 0.063 0.764 7 (12.5%) 0.987 51 (87.9%) 3 (5.2%) 1 (1.7%) 3 (5.2%) 0.122 14 (23.0%) 19 (31.1%) 10 (16.4%) 18 (29.5%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (100.0%) 5 (55.6%) 3 (33.3%) 0 (0.0%) 1 (11.1%) 9 (25.0%) 10 (27.8%) 7 (19.4%) 10 (27.8%) 0 (0.0%) 6 (40.0%) 3 (20.0%) 6 (40.0%) 0.231 18 (29.5%) 21 (34.4%) 10 (16.4%) 12 (19.7%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 (100.0%) 5 (55.6%) 3 (33.3%) 0 (0.0%) 1 (11.1%) 11 (30.6%) 13 (36.1%) 7 (19.4%) 5 (13.9%) 2 (13.3%) 5 (33.3%) 3 (20.0%) 5 (33.3%) Note: Participants were asked to complete a demographics survey before undergoing the MTA pilot training. 22 Table 2 Comparison of EPIQ score pre- and post-MTA Training Score Pre-EPIQ Post-EPIQ N Mean SD 50 50 3.57 2.07 0.93 0.79 t df 13.90 49 Paired t-test p-value < .001 Wilcoxon p-value < .001 Note: Participants completed the adapted EPIQ before and after the MTA pilot training session. A lower score indicates a higher level of emergency preparedness. Due to the data distribution, we used a Wilcoxon test to verify the paired t-test outcome. The paired t-test and Wilcoxon test demonstrated the pre- and post-values to be statistically significant and improve after the intervention. 23 Table 3 General Self-Efficacy (GSE) Summary Score Total (N=60) Orderly (n=9) RN (n=36) Scrub Tech (n=15) Mean (SD) Range 32.4 (3.9) 23-40 32 (2.8) 29-38 32.6 (3.8) 27-40 32.3 (4.9) 23-38 p 0.922 Note: Participants completed the General Self-Efficacy (GSE) scale to determine if there was a difference in selfefficacy between the roles completing the pilot training. We only included groups with two or more people who completed the GSE, as there was only one AMT in attendance who completed the surveys that data was not included. 24 Table 4 Themes in Training Feedback Total (N=61) n=48 25 Percent of Responses More information on subject matter 18 37.5% More interaction 4 8.33% 1 n=49 28 2.08% 57.14% Want more information on subject 10 20.41% Training too short 5 10.20% Not interactive enough 5 10.20% Dry/boring subject Case Scenario Discussion 1 1 2.04% 2.04% Unsure if prepared for MTA Surveys too long 1 1 2.04% 2.04% n=49 29 69.05% Themes Suggestions for Improvement No opinion No Survey Elements Disliked by Participants No opinion Elements Liked by Participants Relevant new information to practice 52.08% Quote “Liked everything”; “None”; “N/A”; “Doesn’t need improvement”; “Enjoyed the topic”; “All was great” “A longer more in depth session would be helpful”; “Take home pamphlet of paper of information”; “More info on triaging”; “More info on bias”; “Videos demonstrating MTA process”; “Need follow up info and training”; “Patient scenarios” “More hands-on activities”; “Breakout session with each role”; “Simulation training” “Take away the survey” “Liked everything”; “None”; “N/A”; “Nothing, it was great!”; “Can’t think of anything” “More detail on specifics”; “Some information was not relevant to my job duties”; “Not enough info”; “Would like some scenarios as examples”; “Too broad, needs more time and details”; “Need follow up info and training” “Too short for content”; “Talked too fast”; “Quick overview” “Not long enough” “More images for visual learning”; “Not interactive” “More encouragement and time for questions throughout the presentation” “Dry, a little boring” “A real-life story to apply this to see where is best to improve and what was done correctly” “Don’t feel prepared to handle MTA still” “The survey doesn’t seem total applicable to the learning material” “A lot of information about everyone’s role” 25 Clear, direct, concise, and well organized No opinion 12 24.49% 8 16.33% “Engaging and interesting content that was relevant to me”; “Group based, everyone worked together to determine knowledge based information”; “It relates to what we do”; “Knowing my responsibilities”; “I really didn’t know anything about this before and I feel a lot more prepared now”; “Great information” “Direct and to the point”; “Well designed slides and flow”; “Easy phrases to remember, easy locations and steps provided to follow”; “Clear instruction”; “Clear, short, and to the point. The information was spot in with what we need to do and each role was described perfectly” “None”, “N/A” Note: After completing the MTA pilot training, participants were asked to provide feedback, including what they liked and disliked and suggestions for improvement. The major themes are summarized with direct quotes from participants. 26 Table 5 Preferred Training Modality Modality Face-to-face First 31 Second 21 Third 3 Simulation 23 24 5 Web-based course 1 6 18 Video conference 2 2 7 Self-instruction 0 3 7 Videos 2 3 19 Note: Participants were asked to rank their first, second, and third preferred methods of training formats from the following: Face-to-face (i.e., traditional classroom); Simulation; Online Web-based Courses; Video Conferencing (i.e., Zoom or Webinar meeting); Self Instruction (i.e., self-study booklet with post-test, Pamphlet, Pocket Reference Cards); Videos. In total, 60 participants provided feedback regarding their preferred training modality. 27 Table 6 Chi-Squared Test Pre/Post-MTA Training Role Quiz Total N=45 No Improvement Improvement Role Orderly n=8 2 6 RN n=25 13 12 Scrub Tech n=12 6 6 Chi-squared df p 1.85 2 .397 Note: The role quiz was created based on the MTA protocol and pilot training material. Participants completed this quiz before and after attending the pilot training. Therefore, the scores of those groups with two or more individuals are included in the analysis. 28 Figure 1 Time Commitment for Future Training 60 50 43 40 37 40 30 33 27 23 20 17 20 7 10 0 54 53 Academic Course 2-3 Day Workshop 2-hour Lecture Yes 6 Evening Workshop Weekend Workshop Weekday Workshop No Note: Participants were asked the following options as “Yes” or “No” to determine the amount of time they would commit to future MTA training: Take a course for an academic semester; Attend a 2–3-day workshop/conference; Participate in a 2-hour lecture or web-based training; Attend an evening workshop; Attend a one-day weekend workshop; Attend a one-day weekday workshop. 29 Appendix A: Multiple Trauma Activation Training Slides MULTIPLE TRAUMA ACTIVATION: SURGICAL SERVICES PROTOCOL Rachael Hubertz, BSN, BSW, RN November 15, 2022 PRE-TRAINING SURVEY Definition of MTA Facility Response OBJECTIVES Surgical Response Roles and Responsibilities Aftermath Bias in Trauma Care 30 CASE SCENARIO Utah State Fair shooting CODE TRAUMA ALERT —MULTIPLE TRAUMA ACTIVATION BACKGROUND & PURPOSE MCI vs MTA MTA Protocol Staff, Space, & Stuff FACILITY ACTIVATION & NOTIFICATION PROCESS MTA decided by ED Census evaluated for Surge Plan Level CODE TRAUMA ALERT —MULTIPLE TRAUMA ACTIVATION 31 INCIDENT COMMAND CENTER Emergency Department Coordination Logistics Communication SURGICAL SERVICES RESPONSE MOBILIZE STAFF MAKE ROOMS AVAILABLE OBTAIN ADDITIONAL RESOURCES LEADERSHIP ROLES Cancel Cases Notify Anesthesiologists Call in staff Communication Staff support 32 OR STAFF ROLES AMTs Core Techs HUC Nurses Orderlies Scrub Techs STAFFING COORDINATOR Coordinate staff Liaison with OR front desk Assign teams Waiting room attendant AMT Stock Anesthesia Carts Obtain trauma supplies Glide scopes available Difficult airway cart Ultrasound Fluid warmers and Belmonts Trach towers 33 CORE TECHS/CP Trauma carts Core Tech stationed at trauma OR Extra supplies Rapid turnover Cleaning equipment & sterilizers ED TRAUMA BAY MAINTAIN COMMUNICATION ASSIST WITH THORACOTOMY HUC ASSIST OR CHARGE RN LOG PATIENT INFORMATION ASSIGN OPERATING ROOMS BED ASSIGNMENTS 34 NURSES Rooms are trauma ready Open Supplies Set up Cell Savers Get Neptunes Turn over rooms Assist Orderlies Return patients Supply stretchers to ED Rooms are stocked ORDERLIES Assist with opening Turn over rooms Blood runners Patient transport SCRUB TECHS Set up trauma rooms Trauma bay Turning over rooms Assist Orderlies 35 EQUIPMENT LOCATIONS Belmonts Cell Savers Neptune Suction Crash Carts Contact Precaution Carts MH Cart Glide Scopes Difficult Airway Cart Ultrasounds High demand MTP Based on need Determined by lead Trauma Surgeon TIME OUT 36 PATIENT FLOW/MORGUE HOLDING Patients requiring surgery • Held in ED • Leadership aid in flow Deceased patients • Temporarily held in a designated OR AFTERMATH Debrief and Support Increased Surgery Load Employee Assistance Program Procedures completed in stages (EAP) Additional staff after the event BIAS IN TRAUMA CARE Bias  Health Disparities How to Counteract Personal Awareness Acknowledgement Empathy Advocacy Education 37 POST-TRAINING SURVEY REFERENCES Bucknor-Ferron, P., & Zagaja, L. (2016). Five strategies to combat unconscious bias. Nursing2022 , 46(11), 61–62. https://doi.org/10.1097/01.NURSE.0000490226.81218.6c Evertsen, S., Brown, C., & Davis, M. (2021). Multiple trauma activation: Intermountain medical center trauma services . Intermountain Healthcare. Gabbe, B. J., Veitch, W., Mather, A., Curtis, K., Holland, A. J. A., Gomez, D., Civil, I., Nathens, A., Fitzgerald, M., Martin, K., Teague, W. J., & Joseph, A. (2022). Review of the requirements for effective mass casualty preparedness for trauma systems. A disaster waiting to happen? British Journal of Anaesthesia, 128(2), e158–e167. https://doi.org/10.1016/j.bja.2021.10.038 Greater New York Hospital Association. (2019). Mass casualty incident response toolkit . https://www.gnyha.org/tool/mass -casualty-incident-response-toolkit Haverkort, J. J. M., de Jong, M. B., Foco, M., Gui, D., Barhoum, M., Hyams, G., Bahouth, H., Halberthal, M., & Leenen, L. P. H. (2017). Dedicated mass -casualty incident hospitals: An overview. Injury, 48(2), 322–326. https://doi.org/10.1016/j.injury.2016.11.025 Hick, J. L., Nelson, J., Fildes, J., Kuhls, D., Eastman, A., & Dries, D. (2020). Triage, trauma, and today’s mass violence events. Journal of the American College of Surgeons , 230(2), 251–256. https://doi.org/10.1016/j.jamcollsurg.2019.10.011 Hollister, L. M., Zhu, T., Edwards, N., Good, B., & Hoeppner, S. (2021). Mass casualty mini drills on trauma surgery department staff knowledge: An educational improvement study. of Trauma Nursing | JTN , 28(2), 135–141. https://doi.org/10.1097/JTN.0000000000000571 Journal Lake, C. C. (2018). A day like no other: A case study of the Las Vegas mass shooting . Nevada Hospital Association. https://drive.google.com/file/d/1CxbLHiWJwL9ZRbWddbaPv15NN6YiNFEc/view?usp=embed_facebook Moran, M. E., Blecker, N., Gothard, M. D., & George, R. L. (2021). A critical pathway for mass casualty incident preparedness. Journal of Trauma Nursing , 28(4), 275–280. https://doi.org/10.1097/JTN.0000000000000597 Moran, M. E., Zimmerman, J. R., Chapman, A. D., Ballas, D. A., Blecker, N., & George, R. L. (2021). Staff perspectives of mas s casualty incident preparedness. Cureus, 13(6), e15858. https://doi.org/10.7759/cureus.15858 Wisniewski, R., Dennik-Champion, G., & Peltier, J. W. (2004). Emergency preparedness competencies: Assessing nurses’ educational needs. 34(10), 475–480. JONA: The Journal of Nursing Administration , Note: The pilot MTA training was created based on the updated MTA protocol for surgical services. This training was presented via in-person PowerPoint lecture to 70 surgical services employees. Appendix B: Multiple Trauma Activation Protocol for Surgical Services 38 Intermountain Medical Center – Multiple Trauma Activation: Protocol for Surgical Services PURPOSE Intermountain Medical Center’s trauma response teams are activated on a tiered system based on the severity of the injury. The Multiple Trauma Activation is intended to mobilize internal IMED staff to respond to care for multiple trauma patients arriving simultaneously when resource capacity is exceeded. This protocol details the MTA response by surgical services in conjunction with other IMED departments. ACTIVATION AND NOTIFICATION PROCESS The decision for activation of the Multiple Trauma process will be made by the ED Charge Nurse, in consultation with an Emergency Department physician when time permits, based on the number and acuity of trauma patients arriving, along with the status of the ED and trauma services. There is not a pre-determined number of patients needed for activation. The Hospital census will be evaluated as part of the Pre-Surge process to determine if activation of the Hospital Surge Plan is needed. The Hospital Operator will use the overhead paging system to announce the following: Code Trauma Alert – Multiple Trauma Activation Each hospital department and physician group involved will be individually responsible for calling in additional resources as deemed appropriate for their area to meet the needs of the patients in their respective areas. This protocol details the Surgical Services’ response to an MTA. Additional steps may be outlined in each surgical services department in separate documents as deemed necessary by those departments (i.e., Surgical Center, SDS, PACU, CP, Pharmacy). The Emergency Department will be responsible for contacting Surgeons, Pharmacy, Radiology, Phlebotomy, and Transfusion Services. 39 INCIDENT COMMAND CENTER Located just outside the Emergency Department (southwest corner of ED, LL1). Will communicate with other departments for coordination of facility response. MTP May not be possible depending on the situation, prioritization will be based on need and determined by the Lead Trauma Surgeon. PATIENT FLOW Patients needing surgery will be held in the ER until surgery is ready, brought into the OR if the anesthesiologist is present, and monitored until the surgeon arrives. Leadership will aid in communicating patient flow locations for patients postoperatively (PACU, SDS, Floors, Units) as outlined in the IMED Surge Plan. TIME OUT PROCESS As with other Trauma 1 procedures, the standard timeout process is deferred to allow life-saving measures taken to be taken promptly. Signatures for consent forms will likely not be available. The timeout completed before the incision will be initiated and led by the surgeon to ensure the entire OR team agrees on the procedure taking place for the patient. EQUIPMENT LOCATIONS  Belmont’s o  South Hallway near AMT office Cell Savers o Cell Saver Storage next to OR 14 40   Crash Carts o North: Next to North Team Manager’s Office o Central: Across the hall from the South PACU entrance o PACU: Next to the Northwest entrance Glide Scopes o  Difficult Airway Carts o   In the hall across from OR 25 Contact Precautions Carts o Next to North Team Manager’s Office o Across from Scope Room MH Cart o  Central: Across the hall from the South PACU entrance Neptune Suction o  Near OR 18/19 & 23 (1 each), AMT office (1), Anesthesia Workroom (4), Cath Lab (2). Anesthesia Workroom Ultrasounds o Anesthesia Workroom MORGUE FLOW/HOLDING AREA Designate an OR for the temporary holding area of deceased patients while awaiting morgue availability. Remove large equipment from the room and relocate the boom and anesthesia machine as far out to the perimeter of the room as possible to maximize the area. RESCHEDULING CANCELLED PROCEDURES 41 MTA procedures will likely be completed in several phases to provide immediate stability measures to the greatest number of patients promptly. As elective surgeries are rescheduled, the patient load in the OR will likely be increased for some time after the MTA has been completed due to the delayed phases of the trauma patient. This increased patient load will require additional staff until the surge has stabilized. DEBRIEF AND SUPPORT Debrief will be provided for all staff members after an MTA with leadership and an EAP representative. Additional support is available for all staff members through EAP. SURGERY CHARGE RN / LEADERSHIP RESPONSIBILITIES 1. Collect data about the situation a. Communicate information regarding the situation to the hospital operator, other departments, cores, SDS, and PACU 2. Notify the leadership on call (if not on duty) who will then proceed to the hospital to assist the charge RN in managing the situation and communicating with the Incident Command Center 3. Cancel all electives cases 4. Maintain communication with the Incident Command Center to ascertain the number of patients expected, the type, and extent of injuries 5. Determine the number of anesthesiologists and surgery staff available immediately and on-call (refer to DSS), report to the Incident Command Center and OR staff in the trauma bay(s) a. Notify all employees on-call to report to the OR ASAP 6. Initiate the employee notification system/waterfall list 7. Notify the following personnel (with estimates of the number of patients, time of arrival, and types of injuries expected) who will initiate the employee notification system/waterfall list for 42 their department and then report to the hospital. If the text system is unavailable, all employees’ contact information is kept at the OR front desk a. Central Processing Manager b. 1st call Anesthesiologist and Chief of Anesthesia (on-call surgeons are notified by ED HUC) c. PACU Nurse Manager d. AMT Supervisor 8. Designate two or more RN/Tech to report to the trauma bay(s) 9. Contact the Security Officer on duty to obtain a handheld two-way radio that will be issued for communication with the hospital operator and the Incident Command Center 10. Assign rooms for surgical procedures 11. Designate the RN Educators or available Leadership as OR Staffing Coordinator 12. Have oncoming staff report to the hall of learning to await instruction 13. Two leadership staff should be stationed in the surgery conference room a. Monitor the radio b. Communicate with the Incident Command Center c. Keep an ongoing assessment of the department’s status d. Communicate with nursing supervisors and patient flow e. Assign personnel as needed f. Ensure food and drinks are obtained and available for surgical staff g. Alert EAP of the situation PACU CHARGE RN / LEADERSHIP RESPONSIBILITIES 1. The RN Manager (if not on duty) will proceed to the hospital 2. Notify the SDS RN Manager 43 3. Collect data about the situation 4. Maintain ongoing communication with other surgical services areas, nursing supervisors, and patient flow 5. Initiate the employee notification system/waterfall list, assigning unit assistants to call in on-call staff and additional staff as needed 6. Monitors and reports the number of a. Staff nurses on duty b. Staff expected to arrive c. Beds immediately available d. Patients in progress and probable times of recovery e. Additional equipment or supplies that may be needed 7. Arranges for the immediate transfer of stabilized patients 8. After stable patients are transferred, the leadership can determine the availability of sending helping hands RNs to the ICUs and ED SDS CHARGE RN / LEADERSHIP RESPONSIBILITIES 1. SDS RN Manager will be contacted by OR RN Manager/Shared Leader 2. The RN Manager (if not on duty) will proceed to the hospital 3. Collect data about the situation 4. Maintain ongoing communication with other surgical services areas 5. Initiate employee notification system/waterfall list, assigning a staff member to call in additional staff personnel 6. Staff will inform each patient that surgery has been canceled, coordinate family management, collect family belongings, and discharge patients 7. Alter workflow as outlined in the Surge Plan as needed 44 8. SDS has 29 patient rooms available to use as overflow as needed CENTRAL PROCESSING RESPONSIBILITIES 1. The CP person in charge of the core, supply, and processing areas when an MTA is called should: a. Collect data about the situation b. Maintain communication with the other surgical services areas 2. Notify the Leadership call person (if not on duty) who will proceed to the hospital and take charge of Central Processing 3. Leadership will assume the responsibility of determining how many additional staff members will be required 4. Notify the Clinical Inventory leader and coordinate staff needs 5. Initiate the employee notification system/waterfall list 6. Assign one person in each core to coordinate supplies, equipment, and instruments needed 7. Assign staff to begin creating additional trauma carts (Ex-Lap, Thoracotomy, Vascular, Craniotomy) 8. Request a status report from all cores and the CP department regarding a. Personnel available b. General stock items c. Fluids d. Elevator status 9. Report to the OR Charge RN for a case list and distribute it to cores 10. Give proper instructions to CP staff to prioritize needs within the department to meet the needs required by the situation 11. Be prepared to contact outside equipment personnel to facilitate repairs and replacements 45 12. Check to see if equipment or instrumentation needs to be borrowed from another institution, and coordinate/facilitate the process STAFF ROLES AND RESPONSIBILITIES     STAFFING COORDINATOR o Coordinate department staff to address needs as they arise o Liaison between OR front desk and staff awaiting assignments o Keep track of who has been assigned specific tasks o Assign teams to setup trauma rooms (ex-Lap, Crani, CV) o Assign a staff member to the OR Waiting with an interpreter tablet NURSES o Make sure rooms are stocked and trauma ready o Assist Techs in opening trauma carts o Set up Cell Savers and push around to each trauma room o Make sure each trauma room has a Neptune o Assist in turning over rooms o May need to assist Orderlies in their duties SCRUB TECHS o Set up trauma rooms o May be asked to staff the trauma bay o Assist in turning over rooms o May need to assist Orderlies in their duties ORDERLIES o Collect all patients whose surgeries have been canceled and return them to their room/SDS 46   o Supply stretchers to ED (stretchers may be taken from Surgery, Radiology, and SDS) o Ensure rooms are stocked and trauma ready o Assist RNs and Techs in collecting and opening supplies o Assist in turning over rooms o Assign designated blood runners o Assist in patient transport AMT o Ensure all anesthesia carts are stocked and trauma ready o Obtain supplies for I-stats, central lines, and arterial lines in each trauma room o Have glide scopes available near trauma rooms o Ensure the difficult airway cart is stocked o Obtain ultrasonic imaging devices o Ensure fluid warmers and Belmont’s are prepped and ready o Get trach towers ready CENTRAL PROCESSING/CORE TECHS o Ensure trauma carts are stocked and ready for patient arrival to the OR (Ex-Lap, Thoracotomy, Vascular, Craniotomy, etc.) o Bring extra trauma carts up to cores most likely to use each type (Ex-Lap in the west, Craniotomy in the North, Thoracotomy/Cardiovascular in the South) o Remove case carts for scheduled cases from the cores, relocate to the ACR o A staff member will be stationed at each OR involved in the MTA if possible o Core par-level supply carts should be delivered to the core of ready access to extra supplies o Processing areas should be prepared for rapid turnover of instruments and equipment o Cleaning equipment and sterilizers should be cleared from routine use as soon as possible o Communicate to the clinical inventory team the status of high-use trauma supplies. 47 o Clinical inventory team to assist with keeping cores stocked with high-use trauma supplies   OR HUC o Assist Charge RN in contacting on-call employees, be sure to communicate MTA o Log patient information as it is received o Assign operating rooms for surgical procedures o Assist with bed assignments ED TRAUMA BAY – OR REPRESENTATIVES o Maintain communication with Charge RN and Trauma Surgeons to ensure the operating room is prepared for incoming surgical patients o Assist with thoracotomy as needed Definitions AMT- Anesthesia Monitoring Tech CP- Central Processing ED- Emergency Department HUC- Health Unit Coordinator IMED- Intermountain Medical Center MH- Malignant Hyperthermia MTA- Multiple Trauma Activation MTP- Mass Transfusion Protocol OR- Operating Room PACU- Post Anesthesia Care Unit RN- Registered Nurse SDS- Same-Day Surgery 48 Appendix C: Adapted EPIQ Survey 49 50 Note: This project's adapted EPIQ was created to be tailored to surgical services employees. Participants completed this survey before and after attending the MTA pilot training. 51 Appendix D: General Self-Efficacy Scale Survey Note: The General Self-Efficacy scale measures perceived self-efficacy. Scores range from 10 (low) to 40 (high). 52 Appendix E: Demographics Survey 53 54 Note: The first survey for participants to complete before the MTA pilot training included demographics and the role quiz. When answering “In the event of a Multiple Trauma Activation, what is your role?” participants were then directed to select all their roles/responsibilities based on their selected role. 55 Appendix F: Post-Training Feedback Survey 56 Note: The post-training survey included questions on the desired modality and time commitment of training, what participants liked, and disliked, suggestions for improvement, and the post-training role quiz.