The effective and efficient coordination of emergent patient care at the point of injury followed by the systematic resource-based triage of casualties are the most critical factors that influence patient outcomes after mass casualty incidents (MCIs). The effectiveness and appropriateness of implemented actions are largely determined by the extent and efficacy of the planning and preparation that occur before the MCI. The goal of this work was to define the essential efforts related to planning, preparation, and execution of acute and subacute medical care for disaster burn casualties. This type of MCI is frequently referred to as a burn MCI.”
Key points
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Managing the Burn Mass Casualty Incident requires planning and a unique knowledge of where the resources are located.
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More resources are available (trauma services) when the disaster includes only burn injured patients (nightclub fire versus industrial plant explosion).
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If the disaster includes infrastructure damage such as an earthquake or a terrorist explosion, it may hinder patients coming to you or being able to transfer them to other facilities.
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The first line of defense is what you have at your facility to include what you can create by adapted spaces and reverse triage in the hospital with the aim of discharging those who can go home.
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Housekeeping staff play a vital role getting rooms cleaned if rapid discharge decisions need to be made to create more space. Involve them in the planning process.
Introduction
Due to their unpredictability and indiscriminate impact on either unprepared and seemingly risk-free populations or military populations, disasters of even local magnitude tend to be large-scale media events, and the associated responses to them are subject to intense media scrutiny. As a result, society’s exposure to mass casualty incidents (MCIs) and their associated management are commonly measured through a sensational and incomplete lens of media outlets. This skewed, remote, and occasionally distanced perspective can often lead to harsh unproductive critiques of observed actions viewed out of context, focused praise of certain isolated high-profile efforts, or harsh judgment of perceived failures with little science to judge operations, outcomes, or perspectives offered.
In contrast, the perspective of health care responders who become engulfed in the actual chaos of an unfolding disaster is real, dynamic, complicated, and inherently linked to emotion. The scope and scale of a given disaster, the quantity or quality of available resources, or the geopolitical implications of a particular event can vary widely. Each disaster response can be universally reduced to the aggregate actions of individuals who are called on to make complex, immediate, and high-stake decisions that ultimately contribute to the outcome. Although the process always begins with first responders, it systematically evolves and expands throughout the entire health care system, inclusive of 9-1-1 call systems, emergency medical systems (EMS), triage centers, initial receiving hospitals, and definitive care and postacute facilities, extending well into available rehabilitation and psychosocial support infrastructure. Disasters are fundamentally local community events that commonly grow to involve regions, nations, and sometimes even manifest global impact.
Disasters are local events. Therefore, sound community MCI planning is critical to effecting excellent patient outcomes. Capacity and capability are inherently resource-based. This requires the development and implementation of thoughtful, carefully crafted, and individually designed emergency plans that match potential needs with a progressive echelon of available or potentially available response assets.
Although first-responder personnel commonly consist of local EMS, fire, hazardous materials (HAZMAT), or rescue assets, training and available equipment often vary significantly between jurisdictions. Furthermore, the initial facilities that receive the first wave of patients may range from major regional referral medical centers to minimally staffed critical access hospitals and may even consist of temporary mobile shelters.
Given these known and anticipated variabilities in available resources, pre-incident planning is crucial. This planning contributes to the provision of consistent care delivered through the rational coordination of integrated system-level care networks. When disaster strikes, the first calls for help are funneled to the local 9-1-1 center (although 9-1-1 is the number used primarily in the United States and other countries, this number varies in other countries to include 9-9-9 and 1-1-2 being several of the more common).
Once the call is placed to the emergency communications center, the trigger point for all disasters with a medical component will rest on the shoulders of the local EMS system. Thus, the first wave of patients will be managed by EMS personnel (the First Responders ) and the emergency department physicians and nurses (the First Receivers ). It should be noted that casualty evacuation may take on many forms, including the use of privately owned and law enforcement vehicles. Nevertheless, a vast majority of patients are initially managed by first responders and all those with serious injuries are managed by the first receivers.
Introduction
Due to their unpredictability and indiscriminate impact on either unprepared and seemingly risk-free populations or military populations, disasters of even local magnitude tend to be large-scale media events, and the associated responses to them are subject to intense media scrutiny. As a result, society’s exposure to mass casualty incidents (MCIs) and their associated management are commonly measured through a sensational and incomplete lens of media outlets. This skewed, remote, and occasionally distanced perspective can often lead to harsh unproductive critiques of observed actions viewed out of context, focused praise of certain isolated high-profile efforts, or harsh judgment of perceived failures with little science to judge operations, outcomes, or perspectives offered.
In contrast, the perspective of health care responders who become engulfed in the actual chaos of an unfolding disaster is real, dynamic, complicated, and inherently linked to emotion. The scope and scale of a given disaster, the quantity or quality of available resources, or the geopolitical implications of a particular event can vary widely. Each disaster response can be universally reduced to the aggregate actions of individuals who are called on to make complex, immediate, and high-stake decisions that ultimately contribute to the outcome. Although the process always begins with first responders, it systematically evolves and expands throughout the entire health care system, inclusive of 9-1-1 call systems, emergency medical systems (EMS), triage centers, initial receiving hospitals, and definitive care and postacute facilities, extending well into available rehabilitation and psychosocial support infrastructure. Disasters are fundamentally local community events that commonly grow to involve regions, nations, and sometimes even manifest global impact.
Disasters are local events. Therefore, sound community MCI planning is critical to effecting excellent patient outcomes. Capacity and capability are inherently resource-based. This requires the development and implementation of thoughtful, carefully crafted, and individually designed emergency plans that match potential needs with a progressive echelon of available or potentially available response assets.
Although first-responder personnel commonly consist of local EMS, fire, hazardous materials (HAZMAT), or rescue assets, training and available equipment often vary significantly between jurisdictions. Furthermore, the initial facilities that receive the first wave of patients may range from major regional referral medical centers to minimally staffed critical access hospitals and may even consist of temporary mobile shelters.
Given these known and anticipated variabilities in available resources, pre-incident planning is crucial. This planning contributes to the provision of consistent care delivered through the rational coordination of integrated system-level care networks. When disaster strikes, the first calls for help are funneled to the local 9-1-1 center (although 9-1-1 is the number used primarily in the United States and other countries, this number varies in other countries to include 9-9-9 and 1-1-2 being several of the more common).
Once the call is placed to the emergency communications center, the trigger point for all disasters with a medical component will rest on the shoulders of the local EMS system. Thus, the first wave of patients will be managed by EMS personnel (the First Responders ) and the emergency department physicians and nurses (the First Receivers ). It should be noted that casualty evacuation may take on many forms, including the use of privately owned and law enforcement vehicles. Nevertheless, a vast majority of patients are initially managed by first responders and all those with serious injuries are managed by the first receivers.
Types of medical disasters
Burn injuries are one of the most challenging medical disaster scenarios. Burn MCI (BMCI) typically can be linked to 1 of 3 broad scenarios: a mass gathering, such as a theater, dinner, or nightclub with a sudden fire; natural disaster, such as wildfire or earthquake; or purposeful hostilities, such as terrorism, bomb blast, or an act of war. As an event becomes more complex, the variety of wounds and concomitant injuries will require a more diverse response. If there is concurrent damage to infrastructure that limits hospital care or limits transportation access, the problems and limitations may grow exponentially.
Despite the infrequent nature of medical disasters, their initial management and the subsequent surge in capacity that necessarily follows, quickly becomes the greatest challenge, and potential threat to a given hospital, health care system, or region. Learning from these events, whether civilian or military, offers opportunities for improvement in approach to trauma delivery across the nation and around the world. The purpose of this article was to review the basics of disaster planning, preparedness, response, and recovery in the aftermath of a medical disaster. Although the primary focus is BMCI, illustrative examples include natural disaster and infectious disease principles.
Content: why burn injuries?
Patients with significant burn injuries represent a small subset of patients; however, due to their complexity and injury severity, they impose a disproportionate impact on health care systems. A recent survey revealed that even seasoned practitioners, including experienced physicians, nurses, and paramedics, stated they were “uncomfortable with their knowledge, skills, and ability to care for a burn-injured patient.”
The capability to effectively manage and care for BMCI is a critical determinant of desirable outcomes in the care of patients with burn injuries. Given the scarcity of resources and the infrequency of BMCI events, it is reasonable to consider and plan for these events as worst-case scenarios in modern health care systems. Successful BMCI planning includes thorough examination of existing internal protocols, patient flow parameters, and the engagement of all pertinent stakeholders. Geography and lines of political jurisdiction are important planning factors, and close coordination and communication between various burn centers are essential for a successful response.
All-hazards, capability-based planning, surge capacity, and the standard of care
The critical phase of MCI planning involves initial patient assessment and management, individualized triage, and subsequent referral to accepting definitive care centers. Preparations for large-scale events must include plans to address surge resources on local, regional, and national scales. Capacity refers to the quantity of staff, space, and supplies (pharmaceuticals and equipment) available. Capability refers to the types of clinicians available to render appropriate care for the sick and injured, as well as the quality of equipment needed to perform certain procedures.
Key factors that determine capacity include commonly available routinely used resources in addition to key assets that can be flexed to specifically accommodate MCI needs, such as holding areas, outpatient facilities, conference rooms, and often the adaptation of temporary structures to serve this purpose. An important measure of scalable capacity is the ability to increase bed availability through flexing by 20% within 4 hours for the highest acuity patients.
Factors to consider in a capability analysis include available equipment and its asset typing, noninventory materials that have the potential for shipping and receiving, and available personnel with detailed credentialing information. In addition, an understanding of transportation assets, multijurisdictional, and multiagency are imperative.
Facility planning
Over the past 10 years, clinicians have gained a greater understanding in the assessment and management of MCIs with regard to the fine balance of staff, space, and supplies . By 2009, the surge planning had evolved to stratify surge capacity into 3 defined categories: Conventional, Contingency, and Crisis Surge Capacities .
Some mass casualty events can be managed with limited strain on existing health care resources. At times, surging requires only small modifications in staffing, hospital-based equipment, and treatment facility spaces. In these cases, traditional standards of care may remain intact.
In events where needs outstrip resources, traditional standards of care and expectations require modification. Contingency surge capacity measures may include such things as provision of medical care in otherwise nontraditional settings and/or by nontraditional practitioners. Staffing will still often include clinicians with traditional credentials but who may be unaccustomed with the specialized care that will need to be delivered. Supplies are commonly limited in these settings, and in some cases substitute medications or fluids may need to be used. The most unpredictable limitation is the availability of and access to supplies and specialty equipment, such as intravenous pumps and ventilators.
Crisis Surge Capacity implies that the practices of care may, by necessity, extend outside of what may be considered traditional standards of care. Although often required under these conditions, mitigation strategies should be enacted to alleviate them as soon as is reasonably possible. The pre-incident planning process provides an ideal opportunity to engage informed policymakers to define community care standards under various potential disaster scenarios, provide guidelines for acceptable care under resource-constrained conditions, and outline reasonable expectations for the infrastructure needed to manage any given disaster event.
Surge equilibrium
As a disaster scenario unfolds, there are trigger points that often mark event stabilization. The achievement of this state of relative balance (known as surge equilibrium, represented in Fig. 1 ) can be identified when sufficient numbers of patients have been transferred, discharged, or died. This inflection point creates conditions whereby patients with ongoing needs can be met on a steady and predictable basis by the staff, space, and supplies available for use. Effective and efficient transportation resources are often effective tools to enable relative patient decompression during a disaster by allowing rational triage of acutely injured or ill patients to appropriate receiving facilities and simultaneously shuttling supplies, personnel, and temporary treatment facilities to the disaster site.
Immediate bed availability, alternative staff resources, just-in-time training, and force multipliers
A core strategy for disaster process planning is implementation of an immediate bed availability (IBA) approach, which emphasizes the deliberate triage and discharge of affected patients to available medical resources with reliance on existing personnel to receive and treat the initial influx of patients from an MCI. Ideally, IBA tactics should be expected to generate 20% more resources with no more than 4 hours’ notice.
Strategies to surge staff include force multipliers through just-in-time (JIT) training by using personnel who have the aptitude to quickly learn, adapt, and assist. Cross-training before a disaster can effectively augment personnel pools in preparation for an MCI event, but for logistic reasons may not be a viable option for smaller organizations. Military surge strategies offer excellent examples of how to systematically leverage medical resources by flexing available manpower that may not be considered traditional clinical complements. JIT training paradigms can augment targeted capabilities over relatively short time frames and can provide large groups of caregivers led by specially trained medical team leaders, allowing systems to manage large numbers of acute care patients. Telemedicine platforms may also be used to augment staff and provide expert assistance “virtually” when the necessary technology is available to support the effort.
Effective strategies that are commonly used to expand staffing resources during a crisis surge is the planned incorporation of disaster medical responders from other communities via preexisting memoranda of understanding or capability expansion through the JIT training and use of nontraditional personnel. Availability of these resources varies widely between jurisdictions, and often includes state or regional teams in addition to federal disaster resources. The federal disaster teams are incorporated into the National Disaster Medical System (NDMS) within the US Department of Health and Human Services. This multifaceted approach facilitates the coordinated surge response, including both specialized equipment and personnel directly into the affected area and provides integrated transportation resources allowing patient movement away from the disaster site.
Historically, the BMCI has also been widely discussed as a burn disaster. For the purpose of using a common language, 3 general BMCI scenarios were identified, relying on National Incident Management System standards, to aid disaster planners with a common language (detailed in Box 1 ). The 3 scenarios established 3 broad groups that escalate in complexity: one that impacts the burn care system, one that impacts the broader health care system, and one that reflects an impact on critical infrastructure.
