Design, Facilitation, and Evaluation of Tabletop Exercises for Prehospital Mass Casualty Preparedness: Scoping Review.

Background: Tabletop exercises (TTXs) are commonly used to enhance prehospital readiness for mass casualty incidents (MCIs). However, evidence on their design, facilitation, and evaluation remains scattered. TTXs simulate organized interactions at 3 levels: among individual responders and response protocols, within interdisciplinary teams, and across organizations and systems. While existing reviews cover tabletop simulation generally, they do not specifically focus on the prehospital MCI interface or assess whether evaluation methods match the exercise objectives. Objective: This scoping review aimed to explore how TTXs are designed, facilitated, and evaluated in prehospital MCI preparedness. It classified outcomes using the Kirkpatrick Evaluation Model and analyzed how evaluation methods align with the purpose of each exercise. Methods: We performed a scoping review following Arksey and O'Malley's framework, with enhancements from Levac et al, along with PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) and PRISMA-S (PRISMA Extension for Reporting Literature Searches) guidelines. Searches across PubMed, Embase, Scopus, PsycINFO, CINAHL, the Cochrane Library, ClinicalTrials.gov, Google Scholar, and references were limited to English peer-reviewed and gray literature published from 2015 to May 2026. Eligible studies focused on TTXs related to prehospital disaster or MCI preparedness and reported measurable educational, clinical, or system outcomes. The review protocol was registered beforehand on Protocols.io. Two reviewers (PP and AA) independently screened records, extracted data, and classified outcomes using Kirkpatrick levels, with an added level 2+ (Applied Learning) category for structured performance evaluation during exercises. Results: Thirteen studies from 9 countries were included. They were categorized into a preliminary 3-tier typology called the TTX Design Spectrum, representing increasing levels of interaction: algorithm-rehearsal exercises (n=2) focused on individual responders' interaction with triage protocols, scenario-based decision-training exercises (n=7) aimed at multidisciplinary team decision-making under realistic conditions, and systems integration exercises (n=4) centered on interagency coordination and system-level preparedness. Facilitation varied by exercise purpose, from standardized assessment-focused approaches to expert-led and multidisciplinary facilitation. Evaluation primarily targeted Kirkpatrick level 1: Reaction (n=10), level 2: Learning (n=10), and level 2+ (Applied Learning) (n=8), with fewer studies examining level 3: Behavior (n=2) or level 4: Results (n=3). Operational frameworks were reported more consistently than formal educational design or assessment frameworks. Additionally, natural disaster scenarios and evidence from resource-limited settings were underrepresented. Conclusions: TTXs for prehospital MCI preparedness should be viewed as a collection of related exercise types rather than a single, uniform intervention. This review introduces an initial typology called the TTX Design Spectrum, along with the level 2+ (Applied Learning) classification, which operationalizes the distinction between in-training performance and behavioral transfer. These tools aim to help align exercise purpose, facilitation, and evaluation strategies. Future research should focus on validating this typology, enhancing follow-up assessments of behavioral transfer, and adapting TTX design for natural disaster and resource-limited settings.