Evaluating the Effectiveness of the Chemical-Mass Casualty Incident Response Education Module (C-MCIREM): A Pilot Simulation Study With a Before and After Design

Background With the occurrence of a number of major disasters around the world, there is growing interest in chemical disaster medicine. In South Korea, there is a training program for mass casualty incidents (MCI) and backup by legal regulations by the Framework Act on the Management of Disasters and Safety. However, there is no program focusing on chemical disasters. Thus, the authors newly created a program, the Chemical-Mass Casualty Incident Response Education Module (C-MCIREM) in September 2019. This was a pilot study to verify the educational effect of the program. Method A pre/post study was conducted of a chemical MCI training program based on simulation. A total of 25 representative and qualified participants were recruited from fire departments, administrative staff of public health centers, and healthcare workers of hospitals in the Gyeonggi-do province of South Korea. They participated in a one-day training program. A knowledge test and confidence survey were provided to participants just before training, and again immediately following the training online. The authors compared improvements of pre/post-test results. In the tabletop drill exercise, quantified qualitative analyses were used to measure the educational effect on the participants. Results In the knowledge test, the mean (standard deviation) scores for all 25 participants at baseline and after training were 41.72 (15.186) and 77.96 (11.227), respectively (p < 0.001). In the confidence survey for chemical MCI response for all 25 participants, all the sub-items concerning personal protective equipment selection, antidote selection, antidote stockpiling and passing on knowledge to colleagues, zone setup and decontamination, and chemical triage were improved compared to the baseline score (p < 0.001). The tabletop exercise represented a prehospital setting and had 11 participants. The self-efficacy qualitative survey showed pre- and post-exercise scores of 64/100 and 84/100 respectively. For a hospital setting exercise, it had 14 participants. The survey showed pre/post-exercise scores of 26/100 and 73/100 respectively. Twenty-two (88%) participants responded to the final satisfaction survey, and their overall mean scores regarding willingness to recommend this training program to others, overall satisfaction with theoretical education, overall satisfaction with tabletop drill simulation, and opinion about whether policymakers need this training were all over 8 out of 10 respectively. Conclusion C-MCIREM, the newly created chemical MCI program, provided effective education to the selected 25 participants among Korean chemical MCI responders in terms of both knowledge and practice at a single pilot trial. Participants were highly satisfied with the educational material and their confidence in disaster preparedness was clearly improved. In order to prove the universal educational effect of this C-MCIREM in the future, more education is needed.


Introduction
With the occurrence of a number of major disasters around the world over the past 40 years , including the   1  2  2  3  4  2 which the "proposed chemical mass casualty triage system" proposed by Cone et al. and the concept of "validating signs and symptoms of irritant gas syndrome agent (IGSA) exposure" proposed by Culley et al. were merged and applied to overcome the shortcomings of the START triage, which is the existing traumabased disaster classification at the prehospital or hospital stage, and to determine the appropriate treatment for severe patients and the priority of antidote provision (Appendices/ Tables 4, 5 and Appendices/ Figure 4) [21,23]. Finally, to evaluate the effectiveness of C-MCIREM and contribute to the improvement of education quality through future updates, we developed a survey for assessment of overall educational satisfaction.

Study Design, Selection of Participants, and Study Period
To confirm increases in knowledge, confidence, and competency in practical terms of disaster response personnel after C-MCIREM training, a pilot simulation study with a before and after the design was conducted (Appendices/ Figures 3, 4 and Appendices/ Figures 6-8). Participants' inclusion criteria were determined as those who voluntarily agreed to the training participation request among representative qualified paramedics who actually have worked at emergency medical service field, administrators of public health centers, and DMATs those who were assigned a role of deploying to the field according to the relevant national disaster law in Gyeonggi-do. The number of participants was determined based on the minimum number of participants for existing KDLS-Field and KDLS-Hospital education tabletop map training simulations (11 for the prehospital phase and 14 for the hospital phase) [17,18]. On September 17, 2019, a total of 25 participants were recruited from fire departments (n = 5), public health centers (n = 4), and hospitals (n = 16) in Gyeonggi-do, South Korea, and received 7 hours of training in 1 day according to the C-MCIREM education timetable (Appendices/ Table 3 and Appendices/ Table 6).

Data Collection
All data in this study were collected and analyzed retrospectively from the pilot study of C-MCIREM education that had already been implemented. Data from all theory tests, confidence surveys, and satisfaction surveys were collected using an online Google survey with the consent of the participants. Knowledge tests and confidence surveys related to chemical MCI had a before and after design and results were collected online. In the tabletop map drill exercise, both quantitative and qualitative analyses were used to measure the educational effect on the teams made up of participants. There were 14 instructors consisting of the chief operating instructor who oversaw knowledge and tabletop map training, the tabletop training instructor, and 12 assistant training instructors (Appendices/ Table 3). These 14 instructors were composed of disaster medical experts who completed both KDLS-Field and KDLS-Hospital, the national disaster education of the Republic of Korea, and were certified as disaster medical instructors in the country. They got acquainted with C-MCIREM programs beforehand by NEMC and researchers. The researchers set the ratio of instructor to the participant to be 2:1 in order to closely observe whether participants perform exactly what they need to do and to provide feedback. Of the 14, seven were disaster managers at NEMC, and seven were medical staff at hospitals. In addition, as those who participated in the production of C-MCIREM, they operated C-MCIREM before this pilot training and were trained in their role as instructors under the coordination of the chief operating instructor. In addition, the chief operating instructor was an emergency medicine (EM) specialist doctor at the hospital and a person who has authorized as an educational member of the KDLS education operational council under NEMC which empowered for his authority in the C-MCIREM production. In the tabletop map drill, all 14 instructors acted as rating staff in each allocated sector to evaluate and comment on the performance of team training using quantitative and qualitative methods, according to the tabletop map drill evaluation sheets for the prehospital team and hospital team (Appendices/ . The confidence survey related to chemical MCI and the survey for overall education assessment used an 11-point Likert scale, with a score of 0 being least favorable, 5 being neutral, and 10 being most favorable. This survey was conducted along with pre-and post-knowledge tests in the same format before and data were collected through Google survey.

Flowchart of C-MCIREM Training
The overall process of C-MCIREM training was summarized as a flowchart ( Figure 1).

FIGURE 1: Flowchart of C-MCIREM Training
Prehospital and hospital phase tabletop map drills proceed at the same time and be closely assessed by 14 instructors.

Scenario for the Tabletop Map Drill
In the tabletop map drill scenario, a large amount of hydrofluoric acid (HF) has leaked due to an explosion caused by a fire at a cell phone manufacturing plant in Bucheon, Gyeonggi-do, South Korea. At least 20 patients exposed to on-site hydrofluoric acid have been reported to the fire department emergency situation room.

Distribution of the Total of 25 Participants and Rule of Operation in the Tabletop Map Drill
Both the prehospital team and the hospital team, consisting of a total of 25 people, received a total of 25 minutes of training time for tabletop map drills after the opening of the scenario. Initially, there were seven participants in the prehospital team training area and 18 participants in the hospital team. After opening the scenario, the chief operating instructor informed the hospital team that four participants should be dispatched to the prehospital team as a hospital DMAT. Therefore, 11 personnel in the prehospital team and 14 in the hospital team were trained. After opening the scenario, the tabletop map training instructor inserted a total of 20 virtual patient cards with various exposure severities to HF at intervals into the prehospital team. The chief operating instructor increased hospital surges by inserting 20 triaged as minimal virtual patient cards that were not assigned to the prehospital team to the hospital team. The hospital team proceeded with treatment when the virtual patient card transferred from the prehospital team arrived at the hospital. The results of the survey on knowledge, confidence, and satisfaction for individuals were kept private to the trainees in the field, but the results of the quantitative evaluation of the tabletop map drill as teamwork were released after a debriefing of the participant taking the role of the incident commander and hospital incident commander of each team at the end of each session in the field, along with the comments of the rating staff.

Measurement Method of Knowledge Test Results
The knowledge test consisted of three categories: disaster administration, disaster medicine, and preparedness and response to the chemical disaster. Baseline knowledge was measured before C-MCIREM training and a test was conducted after theory training to measure the improvement in knowledge ( Table 1, Figure 2).   Statistical analyses were performed using the paired t-test.

Comparison of Characteristics of the 25 Participants
The information variables of the total of 25 participants were age, sex, career (years), profession, and motivation for participation in the training (Appendices/   IQR, interquartile range from 25% to 75%; Pre, pre-training; Post, post-training; Statistical analyses were performed using the Kruskal-Wallis test. ADM, administration; EMT, emergency medical technician; IQR, interquartile range from 25% to 75%; Pre, pre-training; Post, post-training; Statistical analyses were performed using the Kruskal-Wallis test.

Measurement Method of Confidence Survey Score Results for Chemical Multiple Casualty Incident Responses
The confidence survey scores obtained using an 11-point Likert scale for multiple casualty chemical incident response in the total of 25 participants were compared between baseline and after training ( Table 3).

Measurement Method of Tabletop Map Drill Test Results
After the demonstration by the instructor, the participants were divided into a prehospital team and a hospital team and performed a total of two tabletop map drills. According to the tabletop map drill evaluation sheets for prehospital and hospital teams in C-MCIREM, the results evaluated by a total of 14 instructors have scored pre-and post-training, and compared using a quantitative method ( Tables 4, 5).  (2) c. Debriefing including the type of disaster (2) d. Debriefing including casualty scale (2) e. Debriefing including the status of transport to hospital for the total patient population (2) 14. Time

Measurement Method of Survey for Overall Education Assessment
After finishing the tabletop map training exercise, a survey of overall education assessment was implemented online and the results were analyzed quantitatively (

Statistical Analysis
Data were reported as the mean and standard deviation (SD) in the parametric test or the median and interquartile range (IQR) from 25% to 75% (Q1/Q3) with minimum to maximum (Min/Max) in the non-parametric test for continuous variables and number (%) for categorical variables. Continuous variables were analyzed using the Kruskal-Wallis test and categorical variables were analyzed using Fisher's exact test. In all analyses, p < 0.05 was taken to indicate statistical significance. Statistical analyses were performed using Rex Excel-based statistical analysis software (version 3.0.3; RexSoft Inc., Seoul, South Korea).

Comparing characteristics of the total of 25 participants
The characteristics of the 25 participants were compared according to institution and profession ( Tables 1,  2

Prehospital Team
In the quantitative measurement of qualitative analysis of tabletop map training drill simulation in the prehospital team composed of 11 participants, the total scores in the pre-and post-training drills were 64/100 and 84/100, respectively ( Table 4). On qualitative analysis, the prehospital team showed improvements after training in Early on-site disaster declaration; Activation of disaster response system; On-site zone and facility setup; Casualty status board setup; Decontamination; Response to the media; Debriefing to the media; and Team score and overall proficiency ( Table 4). The prehospital team had satisfactory assessments on both pre-and post-training drills for Use of regional chemical hazard surveillance map; Triage; Re-triage; and Time relevance (Table 4). However, there were no improvements following training for On-site initial mass triage; or Management of patients triaged as minimal. In addition, the score for Transport to the hospital was worsened in the post-training drill with a value of −4 due to two cases of improper transport to the hospital for patients triaged as immediate (−2 per case) compared to the value of −2 in the pre-training drill due to failure of transport to hospital for patients triaged as minimal (−2), where seven patients triaged as minimal were transported to one hospital at a time ( Table 4).

Hospital Team
In the quantitative measurement of qualitative analysis of tabletop map training drill simulation in the hospital team composed of 14 participants, the total scores in the pre-and post-training drills were 26/100 and 73/100, respectively ( Table 5). On qualitative analysis of pre-and post-training drills, the hospital team showed improvements for: Declaration of transition to hospital disaster system; Decontamination; Initial patient zoning in ED; Expansion of ED and setup of HICS facility; Securing ED beds; Securing disaster reserve beds and available hospital facilities; Manpower reinforcement in the ED; Securing available resources; Time constraint action in treating severe patients; Operation of bottleneck areas by HICS commander; Debriefing to the media; Appropriateness of treatment and resource utilization; and Team score and overall proficiency. The hospital team had satisfactory assessments on both pre-and post-training drills for Early hospital disaster declaration; and the Operation of bottleneck areas by the ED director ( Table  5). However, there was no improvement after training for Enhancing security; or Re-triage (Table 5). Moreover, the post-training assessment decreased for: Use of regional chemical hazard surveillance map and antidote preparedness with a value of 2 satisfying items of zone setup and decontamination tent setup considering the wind direction compared to the pre-training drill with a value of 3 satisfying items of zone setup, determining the PPE level to wear by the regional chemical hazard surveillance map, and instructions for hospital preparedness of antidote by the regional chemical hazard surveillance map ( Table 5). After preand post-training exercise debriefings, Rater 11 commented that the medical staff in charge of the nonemergency zone should ask the HICS commander to reinforce personnel, to resolve patient congestion and that the medical staff in charge of the emergency zone should quickly identify patients who have finished surgery and admit them to the ICU ( Table 5).

Survey results for overall education assessment
Twenty-two participants out of the total 25 (88%) responded to the survey regarding the overall assessment of the training program and showed at least over 8 out of 10 in the mean value ( Table 6).

Discussion
This pilot training with the C-MCIREM achieved an increase in knowledge for a total of 25 participants, increased confidence in preparing and responding to chemical MCI, and increased disaster medical response capabilities through tabletop map drill disaster exercises, as determined by quantitative and qualitative methodologies. In particular, in the case of the knowledge test, there was no gap between groups according to characteristics or organization, which confirmed that this training program was delivered evenly and effectively. In the final questionnaire, the participants gave the training program a high satisfaction score. As a pilot study, this training program had only 25 participants (11 for the prehospital phase and 14 for the hospital phase), the minimally required number for KDLS-Field and KDLS-Hospital training programs. Future studies with increased numbers of participants are expected to provide a more objective evaluation of the effectiveness of the training program. In particular, it is not possible to judge statistical significance with a single training session. Conducting C-MCIREM training at least three times would allow comparison of the quantitative scores for each team and, therefore, the educational effect of tabletop map training would be amenable to statistical analysis.
In this C-MCIREM pilot training program, post-decontamination chemical triage at the prehospital stage was divided between DMATs and EMTs (Appendices/ Figure 4). This was because of the limitation of the special legal scope of the job among Korean EMTs [47]. According to the Emergency Response Manual in Disaster Fields published by the Ministry of Health and Welfare in 2016, the DMAT team adopts the Sort, Assess, Life-saving interventions, Treatment and/or transport (SALT) multi-injury severity classification method as the basis for patient classification, but the START method can also be used in combination for individual patients [17,18]. On the other hand, EMTs cannot apply SALT, which requires life-saving intervention, because the scope of their work is limited according to the Korean Medical Service Act and Emergency Medical Service Act. Therefore, in this training program, only START triage was adopted at the prehospital stage after decontamination [17,18,47].
EMTs, who account for the largest proportion of emergency personnel who are the first to encounter patients in a hazardous chemical exposure accident, can provide no treatment other than simple trauma treatment and only classify and transfer patients. Therefore, patients are unable to receive life-saving antidote treatment until arrival at the hospital. This was reflected in this C-MCIREM training program (Appendices/ Figure 4). Prehospital Disaster medical response practitioners and participants in this C-MCIREM pilot training program answered question #6 (Policymakers should also receive this training program) with a mean (SD) score of 8.91 (1.192). This reflects the opinion of field operatives that such legislative obstacles should be improved. Under the premise that they have appropriate knowledge and skills to respond to each hazardous chemical and a regular evaluation system is in place, adjusting the scope of work for EMTs to permit active treatment in the field through regular medical guidance would have a positive effect on the prognosis of patients. Such legal and institutional differences can be adjusted according to local circumstances in different countries, and so they will not have a significant impact on the universal applicability of C-MCIREM training programs, but such differences in national and regional systems and laws should not be overlooked.
A chemical hazard surveillance map applying the concept of hazard vulnerability assessment was produced and used in the simulation for prehospital and hospital disaster preparedness and response (Appendices/Supplement list). Using this map, with local data of hazardous chemical materials, disaster response health care personnel can set up zones, determine decontamination methods, determine PPE levels, and make decisions regarding antidote preparation and use. Although this chemical hazard surveillance map was created based on regional data from Bucheon, a city in Gyeonggi-do, South Korea, its scope can be expanded to other countries, which is a major advantage of this C-MCIREM map training method.
In addition to the MASS triage/START Triage, which is the existing trauma-based disaster classification, the participants newly experienced the chemical disaster response triage presented in the past disaster medical literature [20,21,23]. Thus, in this training assuming chemical MCI, participants set up the zone, selected the appropriate PPE and decontamination method and priority, and learned how to use antidote correctly. The authors evaluate this as a major achievement of the C-MCIREM program.
However, global social distancing and restrictions on group members due to the 2020 COVID-19 pandemic became obstacles to the continued implementation of this C-MCIREM training program with the existing platform. In the future, theoretical training should be converted to an online platform, and the number of participants should be limited so that instructors and trainees can participate in the tabletop map drill exercise only after COVID-19 vaccination, where offline training is indispensable. To ensure effective and safe education, it is necessary to develop operational plans that take into account reality, such as converting to the original education format after the achievement of herd immunity.
This study had some limitations in that it was a one-off pilot study. The sample size of the total participants was small at 25. However, in tabletop map simulation training, after the instructor's demonstration, the well-organized curriculum, scoring system, and feedback system through a total of two repetitions maximized the advantages of indirect education, such as simulation, with low cost and high efficiency. The authors expect that, as more training is provided in the future, the degree of completion of training itself will increase. Indeed, the authors are proceeding with the future study to compare the result of this pilot study to the result of the study which will meet the sample size criteria after multiple education completion.

Conclusions
In this study, the C-MCIREM education program created with the support of Gyeonggi-do, the National Municipality of South Korea, was implemented as a pilot trial. In addition to the existing MASS/START disaster triage, pre-decontamination triage and post-decontamination chemical triage were reflected in knowledge and tabletop map drill training. In addition, zone setup, PPE selection, antidote selection, and basic supportive care were also reflected in the overall education for chemical disaster response. The C-MCIREM including chemical disaster tabletop map drill exercise had clear educational benefits, both individually and as a team, and clearly strengthened the disaster preparedness confidence of the participants including the overall satisfaction of the education. In order to prove the universal educational effect of this C-MCIREM in the future, more education is needed.  (2) c. Type of disaster (2) d. Transition to a disaster response system (2) 3. On-site initial      Table 1. Basic information of total 25 participants (  3. Supplementary Figure 1. Knowledge education by chief operating instructor in C-MCIREM ( Figure 6)