JMIR Publications

ABSTRACT

Background:

Tabletop exercises (TTXs) are increasingly used to enhance prehospital preparedness for mass casualty incidents (MCIs). However, the evidence regarding their design, facilitation, and evaluation remains scattered. The field lacks a systematic framework to align exercise objectives with design choices and evaluation methods.

Objective:

This scoping review systematically maps how TTXs have been designed, implemented, and evaluated in prehospital MCI preparedness, with outcomes classified using the Kirkpatrick Evaluation Model, and identifies patterns of alignment between design and evaluation across the literature.

Methods:

We used Arksey and O'Malley's framework alongside PRISMA-ScR reporting guidelines. We searched PubMed, Embase, Scopus, PsycINFO, CINAHL, the Cochrane Library, and ClinicalTrials.gov for studies published from 2015 to 2025 that evaluated TTXs in prehospital disaster or MCI preparedness. Two reviewers independently screened records, extracted data, and classified outcomes using Kirkpatrick's Evaluation Model, including an additional Level 2+ (Applied Learning) subcategory for simulation-based performance. Through iterative cross-study comparisons, we developed five analytical constructs to identify patterns in exercise design, facilitation, and evaluation.

Results:

Eleven studies from seven countries met the inclusion criteria. Studies aligned along a TTX Design Spectrum with three levels: Algorithm Rehearsal (n=2), focusing on standardized triage protocol testing; Scenario-Based Decision Training (n=6), targeting multi-competency decision-making under realistic constraints; and Systems Integration Testing (n=3), assessing organizational coordination and policy-level outcomes. Five distinct facilitation modes were identified: Instructional Guide, Performance Coach, Standardization Agent, Expert-Led, and Multidisciplinary, each linked to specific exercise tiers. Kirkpatrick Level 1 (Reaction, n=8) and Level 2 (Learning, n=9) outcomes were most commonly evaluated. Seven studies assessed structured performance within the exercise environment (classified as Level 2+ (Applied Learning)), but only one study documented behavioral transfer to an actual MCI response (Level 3). Level 4 (Results) was achieved solely by Tier 3 studies. This Evaluation Depth Disparity highlights a systematic gap between exercise goals and evaluation methods across tiers. No studies addressed natural disaster scenarios, and geographic representation from high-burden, resource-limited settings was limited.

Conclusions:

TTXs for prehospital MCI preparedness are not a single uniform intervention but a range of exercise types with specific design needs and varying evaluation levels. The TTX Design Spectrum, the Level 2+ (Applied Learning) classification, and the Evaluation Depth Disparity framework offer tools for aligning exercise goals with facilitation methods and evaluation strategies. Future research should test these frameworks in larger samples and develop post-exercise techniques to capture real-world behavioral transfer. Researchers should also create TTX formats for natural disaster simulations.