Community members simulate an influx of critically injured patients outside a local medical center in Wrangell, Alaska.


Few people think about emergencies as often as Heidi Aylsworth, Shannon Freitas, and their colleagues at SEARHC, the SouthEast Alaska Regional Healthcare Consortium. A network of over 100 healthcare providers in Alaska’s mountainous Southeast, SEARHC works to connect 27 remote communities to healthcare services for more accessible, equitable care across the region.  

Scattered across rugged terrain in the nation’s largest rainforest, SEARHC’s mostly island communities vary widely in size, location, and access to transportation. Some, like Alaska’s capital Juneau, are serviced by ferry and commercial flights, while others are accessible only by seaplanes that are often grounded by storms, fog, wind, and other navigational hazards. All of SEARHC’s locations face unpredictable weather conditions that can suspend supply chains and cut off support. 

The isolation of many SEARHC sites sets them apart from small rural hospitals in other states, says Freitas, SEARHC’s director of safety. “Almost everything we do is dependent on air travel. In the lower 48, if you have a very small rural clinic or Critical Access Hospital, you almost always have the road system. Our locations don’t have that. Everything is highly dependent on commercial air service and medevac flights.” 

“When you live in a remote location, you think about this all the time, because resources aren’t always available,” says Aylsworth, SEARHC SVP and chief strategy and business development officer. “Testing our systems and having the confidence that they work has huge value for our teams and communities.”  

Finding the gaps 

When she and Freitas set out to test their system and find the gaps, they needed the right partner. Aylsworth came to SEARHC from Swedish Medical Center in Seattle, where a team that is now part of Tegria ran healthcare simulation exercises. She knew that simulation drills involving realistic clinical scenarios would help SEARHC communities identify their own strengths, gaps, and vulnerabilities. By providing deliberate practice and real-time feedback, healthcare simulations result in rich contextual learning that’s easier to recall under pressure. 

SEARHC connected with Tegria in 2018 about onsite simulation drills. Soon, a plan emerged for weeklong exercises in four SEARHC sites: Sitka, Klawock, Haines, and Wrangell. Then the COVID-19 pandemic hit, pushing out the timeline. The delay had a silver lining, though—it gave the Tegria team more time to learn about the Southeast Alaskan sites and get to know their SEARHC counterparts. 

Learning about each community was an important part of Tegria’s process leading up to the onsite exercises, says Ian Doten, MD, medical director for Tegria’s Clinical Operations. “We had a lot of time to get to know them, because we were planning to go up there before the pandemic. This became an opportunity for partnership with a trusted colleague.” 

While the pandemic delayed the project, it also highlighted the need for well-defined Crisis Standards of Care to guide decision-making during emergencies. “One of the things that COVID brought out is the need for Crisis Standards of Care, which is something that a lot of physicians and hospitals don’t talk about much,” says Freitas. “This was an opportunity to bring that out and see how that would play out in a real mass casualty event.” 

Practicing mass casualty incident (MCI) protocols is especially important for small facilities with tight physical quarters and limited supplies and personnel. These small hospitals and clinics can become overwhelmed after an event like a plane crash, says Doten. “An MCI is relative, and for a small hospital, just 5 or 6 patients coming in at one time it could stress their system and their environment.” 

The exercises 

By spring 2022, the teams were ready to resume the project. Tegria’s team—Dr. Doten, Senior Manager of Clinical Operations Michelle Walters, RN, Certified Healthcare Simulation Expert Christina Mason, RN, and Certified Healthcare Simulation Operations Manager Ben Wilson—set out for Sitka to conduct the first exercise, an MCI drill simulating a plane crash. To simulate an influx of critically injured patients that could result from an actual crash, community members were made up to resemble real patients with acute conditions, from head wounds to broken limbs.  

During each two-hour drill, the site’s clinical staff worked through the steps involved in treating every simulated patient in real time. Afterward, a “hotwash” debrief gave participants the chance to talk through problems that came up. Working through a realistic, all-hands-on-deck simulation allowed staff and community responders to slow down and think through every aspect of emergency operations. 

The best simulations are multidisciplinary, involving staff from across an organization, says Theresa Demeter, Tegria managing director of Clinical Operations. “It’s fully multidisciplinary.  Anyone who has responsibility during the event participates very realistically in the simulation. It might be ED clinicians, or security; it might be the first responders. In a mass casualty incident, they all have a role.” 

Because simulation requires full engagement, it sparks a different type of critical thinking, communication, and problem solving. “Having the staff actually move a person in a realistic way, when they have realistic injuries, and they have to consider all of those things, forces them to slow down and think about what they’re doing,” says Freitas. “When you don’t have a full simulation, when you’re doing a tabletop discussion or using foam people, everyone just wants to get the task done, versus actually figuring out if they can get the task done.” 

Participants in Sitka’s simulation drill practice bedside procedures.


Pandemic-weary hospital staff still need emergency planning support, though many are more prepared than they were a few years ago. Plenty of hospitals set up their Hospital Incident Command System (HICS) during COVID, so their leaders might assume their emergency operations are sound, notes Walters. “I think a lot of sites learned what some of their gaps are during the pandemic, but there are so many different types of emergencies. What if it’s a plane crash or car crash? What if you lose communication and power? Those situations are completely different and have a different feel.”  

Immediate results, ongoing improvement 

The first drill in Sitka and the second in Klawock helped the sites address inefficient paper charts that slowed or stalled patient care. This was no surprise to Freitas. “I knew the charts were too long, and during the drills we saw that they weren’t even opened,” she says. “Dr. Doten helped us slim down the charts to just what was needed and eliminate the extra stuff.” 

The streamlined charts were used during the second two drills in Haines and Wrangell. “We got the chance to learn between each drill and keep making improvements,” Freitas says. “And we’re still getting feedback, so we’ll keep making improvements to the charts.”  

When communication problems showed up during each site’s drill, the simulation and debrief enabled teams to work through solutions. “With communication during an emergency, everyone defaults to radio—‘Get me a radio. Where’s the cache of radios?’ Most locations had radio problems, which was something that the sites needed to see and work through,” Freitas notes. 

Every site found opportunities to improve communication, says Walters. “Communication is always an issue that comes up. No communication is ever 100 percent perfect. They did a really good job, but radios are one of those things that people just don’t use very often.” 

The drills also highlighted the resourcefulness of the tightly-knit communities. Staff practiced using notecards and whiteboards for quick, effective patient tracking. “Haines surprised me—they had the best patient tracking system of all,” says Freitas. “They used a notecard with the patient identifier, the chief complaint, the triage code, and that was it. It was so simple, but it demonstrated how well they work with their resources.” 

All the sites showed resilience, flexibility, and strong teamwork. “They did fantastic, and it makes sense,” says Freitas. “They’re used to wearing multiple hats and working with limited resources. In Haines and in Klawock, the way they set up their flow for their patients just worked beautifully for their small space and small staff.”  

SEARHC plans to partner with Tegria to conduct more MCI exercises at additional sites next year. In the meantime, learnings from the 2022 drills will spill over into each site’s daily operations, notes Demeter. “We’re practicing mass casualty incidents, but there will be other improvements that will benefit day-to-day activity in terms of better processes.” 

While the drills were simulated, the excitement and relief felt by participants was 100 percent real. “For me, success is finishing the exercise and seeing a bunch of smiling faces,” says Freitas. “These things can be very stressful. There’s a lot of anxiety building up. If at the end of it they felt they spent their time well and feel more cohesive as a team, that’s what makes it a success.” 

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