# A full response chain surge capacity test of a small rural hospital, prehospital resources and collaborating organisations

## TL;DR

This study tested a simulation system to evaluate surge capacity at a small rural hospital during a mass casualty incident, identifying key challenges and benefits of multi-organization collaboration.

## Contribution

The study adapts and validates a simulation system for surge capacity testing in rural hospitals, highlighting unique challenges and training benefits.

## Key findings

- Emergency department and trauma team staffing were the main in-hospital surge capacity limitations.
- Transport and scene access were initial bottlenecks, while ICU avoided resource depletion through patient transfers.
- Multi-organization involvement improved training effectiveness and identified communication gaps.

## Abstract

Increased surge capacity is key in mass casualty incidents. Rural hospitals face other challenges in terms of transport capacity and available resources. The aim was to examine if a simulation system previously used to test surge capacity at large hospitals, could be used to test surge capacity at a small rural hospital.

A qualitative study was conducted to assess surge capacity at a small rural hospital using a previously validated simulation system. The simulation system was adopted to the Norwegian trauma system and local context. New simulated patient cards were developed, inspired by traffic victims. A tunnel accident scenario involving a bus, a heavy goods vehicle and a motorcyclist was used. Test staff ensured that real consumption of time and resources were followed. 98 persons representing 16 organisations, participated. A post-test survey was collected.

Access to the scene and transport resources were bottlenecks in the initial phase. The emergency department and lack of surgeons and anaesthetic doctors in the trauma team became the first and most prominent in-hospital surge capacity limiting factors. Operating theatre reached surge capacity, but never exceeded. The intensive care unit avoided depletion of beds/staff/ventilators due to transfer of patients to the trauma centre. Surge capacity was enhanced by obtaining staff, blood and equipment from the trauma centre. Water lock systems and replenishment routines for chest tube trays was inadequate. Blood supply was insufficient in the initial phase and a lack of overview of blood products was identified. Some communication gaps and deficiencies in victim identification were detected. The hospital participants evaluated the method as useful in assessing hospital surge capacity. Half of the participants requested increased time to learn the system pre-test. The inclusion of several organisations in the mass casualty incident exercise was appreciated and ranked high as a simulation training.

The simulation system provided detailed data to determine surge capacity and capacity-limiting factors in the mass casualty incidents response at a rural hospital and performed as a training tool for staff. Methods to improve pre-test simulation system knowledge should be examined. Broad inclusion of cooperating organisations was found beneficial.

The online version contains supplementary material available at 10.1186/s13049-025-01372-9.