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Competency in Chaos: Lifesaving Performance of Care Providers Utilizing a Competency-Based, Multi-Actor Emergency Preparedness Training Curriculum

  • Lancer A. Scott (a1), Derrick A. Swartzentruber (a2), Christopher Ashby Davis (a2), P. Tim Maddux (a2), Jennifer Schnellman (a3) and Amy E. Wahlquist (a4)...



Providing comprehensive emergency preparedness training (EPT) to care providers is important to the future success of disaster operations in the US. Few EPT programs possess both competency-driven goals and metrics to measure performance during a multi-patient simulated disaster.


A 1-day (8-hour) EPT course for care providers was developed to enhance provider knowledge, skill, and comfort necessary to save lives during a simulated disaster. Nine learning objectives, 18 competencies, and 34 performance objectives were developed. During the 2-year demonstration of the curriculum, 24 fourth-year medical students and 17 Veterans Hospital Administration (VHA) providers were recruited and volunteered to take the course (two did not fully complete the research materials). An online pre-test, two post-tests, course assessment, didactic and small group content, and a 6-minute clinical casualty scenario were developed. During the scenario, trainees working in teams were confronted with three human simulators and 10 actor patients simultaneously. Unless appropriate performance objectives were met, the simulators “died” and the team was exposed to “anthrax.” After the scenario, team members participated in a facilitator-led debriefing using digital video and then repeated the scenario.


Trainees (N = 39) included 24 (62%) medical students; seven (18%) physicians; seven (18%) nurses; and one (3%) emergency manager. Forty-seven percent of the VHA providers reported greater than 16 annual hours of disaster training, while 15 (63%) of the medical students reported no annual disaster training. The mean (SD) score for the pre-test was 12.3 (3.8), or 51% correct, and after the training, the mean (SD) score was 18.5 (2.2), or 77% (P < .01). The overall rating for the course was 96 out of 100. Trainee self-assessment of “Overall Skill” increased from 63.3 out of 100 to 83.4 out of 100 and “Overall Knowledge” increased from 49.3 out of 100 to 78.7 out of 100 (P < .01). Of the 34 performance objectives during the disaster scenario, 23 were completed by at least half of the teams during their first attempt. All teams except one (8 of 9) could resuscitate two simulators and all teams (9 of 9) helped prevent anthrax exposure during their second scenario attempt.


The 1-day EPT course for novice and experienced care providers recreated a multi-actor clinical disaster and enhanced provider knowledge, comfort level, and EPT skill. A larger-scale study, or multi-center trial, is needed to further study the impact of this curriculum and its potential to protect provider and patient lives.

ScottLA, SwartzentruberD, DavisCA, MadduxPT, SchnellmanJ, WahlquistAE. Competency in Chaos: Lifesaving Performance of Care Providers Utilizing a Competency-Based, Multi-Actor Emergency Preparedness Training Curriculum. Prehosp Disaster Med. 2013;28(4):1-12.


Corresponding author

Correspondence: Lancer A. Scott, MD, FACEP Division of Emergency Medicine and Pediatric Emergency Medicine Medical University of South Carolina MSC 300 115 MUH 169 Ashley Ave. Charleston, SC 29425 USA E-mail


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1.Tokuda, Y, Kikuchi, M, Takahashi, O, Stein, GH. Prehospital management of sarin nerve gas terrorism in urban settings: 10 years of progress after the Tokyo subway sarin attack. Resuscitation. 2006;68(2):193-202.
2.Barkemeyer, BM. Practicing neonatology in a blackout: the University Hospital NICU in the midst of Hurricane Katrina: caring for children without power or water. Pediatrics. 2006;117(5 Pt 3):S369-S374.
3.Currier, M, King, DS, Wofford, MR, Daniel, BJ, Deshazo, R. A Katrina experience: lessons learned. Am J Med. 2006;119(11):986-992.
4.Edwards, TD, Young, RA, Lowe, AF. Caring for a surge of Hurricane Katrina evacuees in primary care clinics. Ann Fam Med. 2007;5(2):170-174.
5.Hamm, LL. Personal observations and lessons from Katrina. Am J Med Sci. 2006;332(5):245-250.
6.Kline, DG. Inside and somewhat outside Charity. J Neurosurg. 2007;106(1):180-188.
7.Leder, HA, Rivera, P. Six days in Charity Hospital: two doctors’ ordeal in Hurricane Katrina. Compr Ther. 2006;32(1):2-9.
8.Ciraulo, DL, Frykberg, ER, Feliciano, DV, et al. A survey assessment of the level of preparedness for domestic terrorism and mass casualty incidents among Eastern Association for the Surgery of Trauma members. J Trauma. 2004;56(5):1033-1039; discussion 1039-1041.
9.Bartley, BH, Stella, JB, Walsh, LD. What a disaster?! Assessing utility of simulated disaster exercise and educational process for improving hospital preparedness. Prehosp Disaster Med. 2006;21(4):249-255.
10.Galante, JM, Jacoby, RC, Anderson, JT. Are surgical residents prepared for mass casualty incidents? J Surg Res. 2006;132(1):85-91.
11.Martin, SD, Bush, AC, Lynch, JA. A national survey of terrorism preparedness training among pediatric, family practice, and emergency medicine programs. Pediatrics. 2006;118(3):e620-e626.
12.Miller, GT, Scott, JA, Issenberg, SB, et al. Development, implementation and outcomes of a training program for responders to acts of terrorism. Prehosp Emerg Care. 2006;10(2):239-246.
13.Scott, JA, Miller, GT, Issenberg, SB, et al. Skill improvement during emergency response to terrorism training. Prehosp Emerg Care. 2006;10(4):507-514.
14.Sklar, DP, Richards, M, Shah, M, Roth, P. Responding to disasters: academic medical centers’ responsibilities and opportunities. Acad Med. 2007;82(8):797-800.
15.Coico, R, Kachur, E, Lima, V, Lipper, S. Guidelines for preclerkship bioterrorism curricula. Acad Med. 2004;79(4):366-375.
16.Waeckerle, JF, Seamans, S, Whiteside, M, et al. Executive summary: developing objectives, content, and competencies for the training of emergency medical technicians, emergency physicians, and emergency nurses to care for casualties resulting from nuclear, biological, or chemical incidents. Ann Emerg Med. 2001;37(6):587-601.
17.Association of American Medical Colleges. Training future physicians about weapons of mass destruction. In: Report of the Expert Panel on Bioterrorism Education. Washington, DC: Association of American Medical Colleges; 2008.
18.National Research Council. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: The National Academies Press, 2007.
19.Scott, LA, Carson, DS, Greenwell, IB. Disaster 101: a novel approach to disaster medicine training for health professionals. J Emerg Med. 2010;39(2):220-226.
20.Association of American Medical Colleges. Number of US medical schools teaching selected topics 2004-2005. Accessed November 1, 2008.
21.Rico, E, Trepka, M, Zhang, G, et al. Knowledge and attitudes about bioterrorism and smallpox: a survey of physicians and nurses. Miami, FL: Miami-Dade County Health Department, Office of Epidemiology and Disease Control. Epi Monthly Report. 2002;3(7):1-7.
22.Lanzilotti, SS, Galanis, D, Leoni, N, Craig, B. Hawaii medical professionals assessment. Hawaii Med J. 2002;61(8):162-173.
23.Gershon, RR, Canton, AN, Magda, LA, DiMaggio, C, Gonzalez, D, Dul, MW. Web-based training on weapons of mass destruction response for emergency medical services personnel. Am J Disaster Med. 2009;4(3):153-161.
24.Chen, J, Wilkinson, D, Richardson, RB, Waruszynski, B. Issues, considerations and recommendations on emergency preparedness for vulnerable population groups. Radiat Prot Dosimetry. 2009;134(3-4):132-135.
25.Subbarao, I, Lyznicki, JM, Hsu, EB, et al. A consensus-based educational framework and competency set for the discipline of disaster medicine and public health preparedness. Disaster Med Public Health Prep. 2008;2(1):57-68.
26.Williams, J, Nocera, M, Casteel, C. The effectiveness of disaster training for health care workers: a systematic review. Ann Emerg Med. 2008;52(3):211-222, 22 e1-e2.
27.Improving Patient Safety Through Simulation Research. Agency for Healthcare Research and Quality (US) web site. Accessed March 23, 2013.
28.Hsu, EB, Jenckes, MW, Catlett, CL, et al. Training to hospital staff to respond to a mass casualty incident. Evid Rep Technol Assess. (Summ) 2004(95):1-3.
29.Scott, LA. Disaster 101: a novel approach to health care students’ disaster medicine and emergency preparedness training. Disaster Med Public Health Prep. 2009;3(3):139-140.
30.Scott, L, Ross, A, Schnellmann, J, Wahlquist, A. Surge Capacity: CHPTER and the South Carolina Healthcare Worker Preparedness. The Journal of the South Carolina Medical Society. 2011;107:74-77.
31.Barbera, JA, Yeatts, DJ, Macintyre, AG. Challenge of hospital emergency preparedness: analysis and recommendations. Disaster Med Public Health Prep. 2009;3(2 Suppl):S74-S82.
32.The George Washington University Institute for Crisis Disaster and Risk Management. VHA-EMA Certification Program, Healthcare Emergency Management Professional Certification Program, Final Program Recommendations. Accessed March 23, 2013.
33.Subbarao, I, Bond, WF, Johnson, C, Hsu, EB, Wasser, TE. Using innovative simulation modalities for civilian-based, chemical, biological, radiological, nuclear, and explosive training in the acute management of terrorist victims: A pilot study. Prehosp Disaster Med. 2006;21(4):272-275.
34.Agency for Healthcare Research and Quality. Tool for Evaluating Core Elements of Hospital Disaster Drill. AHRQ Publication No 08-0019. Rockville, Maryland USA; 2008.
35.King, HB, Battles, J, Baker, DP, et al. Team STEPPS: Team Strategies and Tools to Enhance Performance and Patient Safety (Performance and Tools). Accessed March 23, 2013.
36.Markenson, D, DiMaggio, C, Redlener, I. Preparing health professions students for terrorism, disaster, and public health emergencies: core competencies. Acad Med. 2005;80(6):517-526.
37.Smith, P, Ragan, T. Instructional design, 3rd ed. New York: John Wiley & Sons; 2005.
38.Krathwohl, D, Bloom, B, Masia, B. Taxonomy of educational objectives; the classification of educational goals. New York: Longman, Green; 1964.
39.Bloom, B, Engelhart, M, Furst, E, Hill, W, Krathwohl, D. Taxonomy of educational objectives: the classification of educational goals. New York: Longmans, Green; 1956.
40.Diehr, P, Martin, D, Koepsell, T, Cheadle, A. Breaking the matches in a paired /-test for community interventions when the number of pairs is small. Statistics in Medicine. 1995;14(13):1491-1504.
41.Ruhe, DS, Byfield, GV. Audiovisual aids for disaster and military medicine in the medical schools. J Med Educ. 1954;29(81):59-62.
42.Kohn, LT, Corrigan, J, Donaldson, MS. To err is human: building a safer health system. Washington, DC: National Academy Press; 2000.
43.Howard, SK, Gaba, DM, Fish, KJ, Yang, G, Sarnquist, FH. Anesthesia crisis resource management training: teaching anesthesiologists to handle critical incidents. Aviat Space Environ Med. 1992;63(9):763-770.
44.Wiener, EL, Kanki, BG, Helmreich, RL. Cockpit resource management. San Diego: Academic Press; 1993.
45.Murray, DJ, Boulet, JR, Kras, JF, Woodhouse, JA, Cox, T, McAllister, JD. Acute care skills in anesthesia practice: a simulation-based resident performance assessment. Anesthesiology. 2004;101(5):1084-1095.
46.Wayne, DB, Didwania, A, Feinglass, J, Fudala, MJ, Barsuk, JH, McGaghie, WC. Simulation-based education improves quality of care during cardiac arrest team responses at an academic teaching hospital: a case-control study. Chest. 2008;133(1):56-61.
47.Wayne, DB, Butter, J, Siddall, VJ, et al. Mastery learning of advanced cardiac life support skills by internal medicine residents using simulation technology and deliberate practice. J Gen Intern Med. 2006;21(3):251-256.
48.Rosenthal, ME, Adachi, M, Ribaudo, V, Mueck, JT, Schneider, RF, Mayo, PH. Achieving housestaff competence in emergency airway management using scenario based simulation training: comparison of attending vs housestaff trainers. Chest. 2006;129(6):1453-1558.
49.Tsai, TC, Harasym, PH, Nijssen-Jordan, C, Jennett, P. Learning gains derived from a high-fidelity mannequin-based simulation in the pediatric emergency department. J Formos Med Assoc. 2006;105(1):94-98.
50.Shavit, I, Keidan, I, Hoffmann, Y, et al. Enhancing patient safety during pediatric sedation: the impact of simulation-based training of nonanesthesiologists. Arch Pediatr Adolesc Med. 2007;161(8):740-743.
51.DeVita, MA, Schaefer, J, Lutz, J, Wang, H, Dongilli, T. Improving medical emergency team (MET) performance using a novel curriculum and a computerized human patient simulator. Qual Saf Health Care. 2005;14(5):326-331.
52.Franc-Law, J, Ingrassia, P, Ragazzoni, L, Corte, F. The effectiveness of training with an emergency department simulator on medical student performance in a simulated disaster. CJEM. 2010;12(1):27-32.
53.Gordon, JA, Shaffer, DW, Raemer, DB, Pawlowski, J, Hurford, WE, Cooper, JB. A randomized controlled trial of simulation-based teaching versus traditional instruction in medicine: a pilot study among clinical medical students. Adv Health Sci Educ Theory Pract. 2006;11(1):33-39.
54.Morgan, PJ, Cleave-Hogg, D, Desousa, S, Lam-McCulloch, J. Applying theory to practice in undergraduate education using high fidelity simulation. Med Teach. 2006;28(1):e10-e15.
55.Ten Eyck, RP, Tews, M, Ballester, JM. Improved medical student satisfaction and test performance with a simulation-based emergency medicine curriculum: a randomized controlled trial. Ann Emerg Med. 2009;54(5):684-691.
56.Wong, G, Jenkins, C, Yao, TJ, Irwin, M. A trend toward improved learning of cardiovascular pathophysiology in medical students from using a human patient simulator: results of a pilot study. Adv Physiol Educ. 2007;31(4):372.
57.Small, SD, Wuerz, RC, Simon, R, Shapiro, N, Conn, A, Setnik, G. Demonstration of high-fidelity simulation team training for emergency medicine. Acad Emerg Med. 1999;6(4):312-323.
58.Reznek, M, Smith-Coggins, R, Howard, S, et al. Emergency medicine crisis resource management (EMCRM): pilot study of a simulation-based crisis management course for emergency medicine. Acad Emerg Med. 2003;10(4):386-389.
59.Kobayashi, L, Shapiro, MJ, Gutman, DC, Jay, G. Multiple encounter simulation for high-acuity multipatient environment training. Acad Emerg Med. 2007;14(12):1141-1148.
60.Andreatta, PB, Maslowski, E, Petty, S, et al. Virtual reality triage training provides a viable solution for disaster-preparedness. Acad Emerg Med. 2010;17(8):870-876.
61.Eaves, RH, Flagg, AJ. The U.S. Air Force pilot simulated medical unit: a teaching strategy with multiple applications. J Nurs Educ. 2001;40(3):110-115.
62.Decker, SI, Galvan, TJ, Sridaromont, K. Integrating an exercise on mass casualty response into the curriculum. J Nurs Educ. 2005;44(7):339-340.
63.Vincent, DS, Burgess, L, Berg, BW, Connolly, KK. Teaching mass casualty triage skills using iterative multimanikin simulations. Prehosp Emerg Care. 2009;13(2):241-246.
64.Coule, PL, Schwartz, RB. The national disaster life support programs: a model for competency-based standardized and locally relevant training. J Public Health Manag Pract. 2009;15(2 Suppl):S25-S30.
65.Fritz, PZ, Gray, T, Flanagan, B. Review of mannequin-based high-fidelity simulation in emergency medicine. Emerg Med Australas. 2008;20(1):1-9.
66.LeRoy Heinrichs, W, Youngblood, P, Harter, PM, Dev, P. Simulation for team training and assessment: case studies of online training with virtual worlds. World J Surg. 2008;32(2):161-170.
67.Schumacher, J, Runte, J, Brinker, A, Prior, K, Heringlake, M, Eichler, W. Respiratory protection during high-fidelity simulated resuscitation of casualties contaminated with chemical warfare agents. Anaesthesia. 2008;63(6):593-598.
68.Schultz, CH, Koenig, KL, Whiteside, M, Murray, R. Development of national standardized all-hazard disaster core competencies for acute care physicians, nurses, and EMS professionals. Ann Emerg Med. 2012;59(3):196-208.e1.
69.Kyle, RR, Via, DK, Lowy, RJ, Madsen, JM, Marty, AM, Mongan, PD. A multidisciplinary approach to teach responses to weapons of mass destruction and terrorism using combined simulation modalities. J Clin Anesth. 2004;16(2):152-158.
70.Lerner, E, Schwartz, R, Coule, P, Pirrallo, R. Use of SALT triage in a simulated mass-casualty incident. Prehosp Emerg Care. 2010;14:21-25.
71.Summerhill, EM, Mathew, MC, Stipho, S, et al. A simulation-based biodefense and disaster preparedness curriculum for internal medicine residents. Med Teach. 2008;30(6): Schultz CH, Koenig KL, Whiteside M, Murray R. Development of national standardized all-hazard disaster.
72.Gillett, B, Peckler, B, Sinert, R, et al. Simulation in a disaster drill: comparison of high-fidelity simulators versus trained actors. Acad Emerg Med. 2008;15(11):1144-1151.
73.Wallace, D, Gillett, B, Wright, B, Stetz, J, Arquilla, B. Randomized controlled trial of high fidelity patient simulators compared to actor patients in a pandemic influenza drill scenario. Resuscitation. 2010;81(7):872-876.


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Competency in Chaos: Lifesaving Performance of Care Providers Utilizing a Competency-Based, Multi-Actor Emergency Preparedness Training Curriculum

  • Lancer A. Scott (a1), Derrick A. Swartzentruber (a2), Christopher Ashby Davis (a2), P. Tim Maddux (a2), Jennifer Schnellman (a3) and Amy E. Wahlquist (a4)...


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