Setting

AREU serves an area of 24.864 km² and a population of approximately 10 million, ranging from very high-density urban areas (4 million in the urban area of Milan) to very rural and remote locations, and approximately 40% of the region is mountainous.

AREU directly manages, in a centralized fashion, training, operations, and governance of all prehospital emergency medical services operating in its territory. At any given day, AREU operates a fleet of 5 HEMS/SAR helicopters (2 operating during 24 hours a day, and 3 during daylight), 51 critical care physician-led response cars (staffed by a prehospital physician, a critical care nurse, and a driver technician) using a system similar to that described by Rehn in London, ^{Reference Rehn, Davies, Smith and Lockey11} 50 nurse-led cars (staffed by a critical care prehospital nurse and a driver technician), and more than 200 basic life support ambulances staffed by a team of 3 emergency medical technician equivalent operators, many of which are being operated by volunteers. Overall, these resources respond to more than 1 million calls every year. Clinicians (doctors and nurses) can choose to work a variable amount of their overall monthly clinical time in the prehospital system. Most physicians staffing ground emergency vehicles will operate an 80/20 ratio between hospital and prehospital time. HEMS, dispatch center clinicians, and managerial roles are full-time. The resources are managed by 4 interconnected dispatch centers (SOREU) spread around the region.

Curriculum Development and Didactic Tools

The content of training was based on core competencies required for disaster response published in the United States and internationally, ^{Reference Subbarao, Lyznicki and Hsu5,Reference Schultz, Koenig, Whiteside and Murray6} along with national and regional laws and internal standard operating procedures. The core of the training was the internal mass casualty management standard operating procedures.

The course was designed using a blended-learning approach. Course participants could access online course materials, including learning modules and the regional prehospital mass casualty plan, in a dedicated online platform designed using the Moodle Environment. Moodle (moodle.org) is an online Learning Management System (LMS) developed on pedagogical principles and used internationally by schools and universities for blended-learning and distance education. It allows educators to create private websites with online courses to achieve predetermined learning goals. Each participant received individual credentials allowing them to access the learning modules, interact with the faculty via dedicated forums, and complete the pretests and posttests.

The program learning objectives are: (1) principles of command and control, communications, and resource management; (2) principles of mass casualty triage and the START triage protocol; (3) on-scene roles, identification, and management; (4) Regione Lombardia and AREU Mass Casualty management standard operating procedures; and (5) inter-agency communications and relations (principles of fire-brigade and police operations). In detail, at distance online training included all theoretical knowledge, including law and ethics, triage, roles and responsibilities, including the first on scene, casualty clearing, medical posts, communications, and media management. Students could also choose up to 3 elective modules: hazardous materials (HazMat), urban search and rescue (USAR), and psychology aspects of disasters and mass casualty. During the live course scene, assessment and roles and responsibilities were covered in the form of a lecture, triage protocols were presented with a tabletop exercise, and 2 iterations of the ISEE exercise were run following a brief familiarization with the tool. The overall scientific program of the course is presented in Table 1.

Table 1.

Scientific educational program of the provider course

A, assessment; CS, computerizes simulation; Deb, debriefing; Dem, demonstration; L, lecture; ONF, online forum; PD, plenary discussion.

The initial curriculum and the train-the-trainer program were designed and delivered by the AREU mass casualty management office personnel, along with guest faculty from the Research Center in Emergency and Disaster Medicine (CRIMEDIM) and the European Master in Disaster Medicine. ^{Reference Della Corte, Hubloue and Ripoll Gallardo12}

Train-the-Trainer (Instructor) Course

A cohort of experienced prehospital providers from different areas of the region was selected as the initial instructor class. The selection was based on formal qualifications and professional experience and was managed in a centralized fashion. Each class member participated in an edition of the train-the-trainers workshop during which they were exposed to instruction on theories about adult learning, training methodologies, collaborative content development, and delivery and mentoring from experienced trainers. Instructors in training also familiarized with the new teaching tools (simulations) while being supported by expert external facilitators. Candidate instructors had to pass a final exam to qualify for the role.

Provider Training Event

The provider course is open to a mixed classroom of physicians, nurses, technicians, and drivers. Before attending the class, course participants are required to complete a 4-hour-long, distance-learning didactical module that exposes them to principles of mass casualty management and to the regional disaster response plan. Each edition of the live course lasts a working day (8 hours) and includes formal lectures and case-based discussions in the morning and computer-based simulation in the afternoon. Each course includes 4 to 5 instructors and circa 15 participants. Simulation sessions were designed with the following goals: training and exercising the command and control chain as well as communication and resource management skills. Each simulation session was run using the ISEE simulation software (ISEE Support, Wemmel, Belgium). ^{Reference Delooz, Debacker, Moens and Johannik13} The software allows users to re-create virtual worlds, where virtual resources can be portrayed and used to respond to a virtual emergency involving casualties. For this course, a specific virtual world was created and named “Lombardialand” (Figure 1). Starting from high definition regional cartography, all prehospital and hospital resources were introduced in the virtual world, including the exact number of ambulances and cars, helicopters, fire departments, law enforcements, and hospitals. Based on historical data, a number of possible MCI scenarios were designed (major highway car crash, railway accident, mass gathering, and industrial event), each with approximately 50 to 120 virtual casualties. During the simulation, course participants were assigned response roles as they would in real life and were expected to declare the major incident (METHANE), assess the scene, set up the incident command system, communicate, triage and care for the victims, plan the evacuation strategy, and utilize the available resources efficiently.

Figure 1.

The Lombardialand interactive virtual world. The base layer for the simulation exercises during the training course. It contains an accurate reproduction of the actual emergency resources of Regione Lombardia, Italy.

Summative Assessment

Each course participant was asked to complete a multiple-choice pretest before taking part in the course. At 30 days following the end of the live training, participants were asked to complete a 45-item multiple-choice summative assessment. This had a predetermined pass mark. Those who failed were allowed a re-test in the following 30 days.

Participant Feedback

After completion of the course, a 5-item Likert scale-based survey was used to obtain participant feedback on the training experience. The questions investigated the general domains and specific items: (1) learning objectives (course met the predetermined learning objectives); (2) faculty (the quality of teaching); (3) course organization (course logistics and organizational aspects such as technology, venue, and ancillary services); (4) perceived relevance (subjective perception of whether the overall training program has a direct transferability to the operational capacity of the trainee); and (5) overall assessment (global rating of the quality of the educational event). A free text section allowed them to provide positive and negative comments and improvement suggestions, and a final qualitative thematic analysis was performed. The free text feedback section was analyzed by themes, and items were grouped by section as positive feedback, negative feedback, and areas for improvement.

Economic Analysis

A cost analysis of the training program has been conducted using Levin’s framework for educational cost-effectiveness. First, all resources needed to run the training program, also called “ingredients,” are identified. Second, monetary values are placed on each ingredient. Third, the total cost of each ingredient is summed and expressed as a cost-per-learner. ^{Reference Levin and McEwan14,Reference Levin15} Cost categories were divided into: (1) equipment and learning materials, (2) personnel costs, (3) facility costs, (4) required client inputs, and (5) other program inputs. Ingredients are presented as suggested in the systematic review of cost in simulation-based medical education by Zendejas et al. ^{Reference Zendejas, Wang and Brydges16}

Statistical Analysis and Ethical Approval

Data were collected and analyzed in Excel spreadsheets (version 14.4; Microsoft, Redmond, WA). Data distributions are reported by average and standard deviation (SD) or median and interquartile ranges (IQRs). The AREU medical directorate considered the project protocol. It met local criteria for, and was considered as, an agency service evaluation and quality improvement project (Protocol number 0010223). No additional interventions were performed, and the study recorded only the frequency of events in normal training programs, with a view to service improvement. Therefore, ethical approval was not required. All the authors confirm that the standards of the Declaration of Helsinki were maintained during the delivery of the educational programs, and confidentiality was maintained.