* There is a limited capacity in burn centers each day, and although that capacity accommodates the traditional ebb and flow of patients, during a disaster the system becomes overwhelmed quickly.
* The terrorist attacks of September 11, 2001 pushed healthcare professionals to redesign systems and reconsider assumptions with respect to medical disaster planning and preparedness, including exploring and adopting initial treatment and distribution of burn patients based on need and availability of beds.
* This article recaps surge capacity as currently defined and the key considerations when developing, implementing, and improving a medical disaster plan based on the authors’ experience in the world of burn care.
An Agency for Healthcare Research and Quality of the US Department of Health and Human Services report made clear the need for allocation guidelines in a mass casualty. The need was based on significant limitations, identified in the report as scarce resources, specifically “ventilators, burn beds, or surgical suites.”1
According to the American Burn Association (ABA), there are 1895 burn beds in the United States2 serving a population of 308,745,538 residents,3 which equates to 1 burn bed for every 176,024 US residents. The ABA data are derived from a self-reporting system updated semiannually; however, the reports do not differentiate burn beds from those hospital beds that serve principally as “dual use,” meaning that the beds may be distributed among multiple medical/surgical services as needed. Furthermore, the numbers reported are typically known as “static” bed counts, based on the licensed capacity, which is typically a larger number than staffed beds. Although state burn bed definitions vary, the most common definition and most comprehensive approach of defining a burn unit is found in the ABA and American College of Surgeons’ Committee on Trauma “Resources for Optimal Care of the Injured Patient.”4
According to the American Hospital Association,5 there are 5795 hospitals with 944,277 staffed beds. With 123 self-identified burn centers reporting 1895 beds collectively, this yields a ratio of approximately 1 burn center for every 47 hospitals or 1 burn bed for every 498 beds. In addition, these 123 burn centers typically operate near capacity. Therefore, the ability to manage a surge of burn-injured patients in most communities remains limited and relies on traditional burn bed capacity.
The September 11, 2001 attacks and ensuing tragedies had the potential to overwhelm the medical disaster capacities of much of the American healthcare system. Catastrophic events in general serve as a steadfast reminder of the importance of preparedness. As with previous catastrophes, these terrorist attacks were the impetus for improved surge capacity planning and medical disaster preparedness.
Key Aspects of a Burn Disaster
The ability to manage a burn disaster will depend on three key aspects: is this an isolated disaster with mostly flame-induced injury, did this disaster involve multiple casualties with blunt force injuries, such as an explosion, or is this part of a widespread disaster involving multiple casualties with various injuries, such as an earthquake?
Burn care ideally is provided in an ABA-verified (or at least ABA-dedicated) burn center. Burn centers are identified as locations where an array of services and clinical expertise coordinate the management of burn patients. The services include acute care and long-term surgical interventions, critical care, and rehabilitation in one of the most comprehensive and complex medical environments. Burn centers typically are located in large major medical centers where related expertise, diagnostics, and ancillary care are available. Probably the most important colocated service for burn patients is a trauma center because approximately 5% of patients with major burns also have a concomitant nonburn injury.6
Comprehensive medical disaster planning and preparedness include reasonable efforts to transport the right patient to the right destination. The planning process should address alternatives when the patient cannot be transported to the best destination (eg, a burn center) because of distance, duration of transport, or resource limitations and can include the development of buffers in the system to absorb and temporarily manage seriously injured patients. One critical element of disaster preparedness includes improving care and capacity at local and regional levels, which minimizes the impact of the wait for access to limited resources. This aspect, which is vital to comprehensive planning, especially for burn patients who cannot immediately be moved to a burn center, is successful in military medicine and also has applicability in civilian medicine.
The business principles of the US healthcare system are similar to the business principles found throughout a market-based economy. These principles include the supply of services (stated generally in health care as staffed beds) and the demand for those services. Supply is influenced or deterred by the ability to pay for the services provided. Although there are many altruistic examples of healthcare provision in the US system, the disaster response strategies used by socialized medical systems have limited domestic application; for example, the solutions that were used following the café fire in Volendam, the Netherlands to ensure that burn patients had their needs met by the best available resources could not be used domestically. In this disaster, the burn center was closed and did not admit patients, forcing those with burn injuries to surge into regional hospitals.7 The burn center worked with those hospitals to ensure the patients with the most significant yet survivable injuries were assigned beds and transferred to the burn center. In the US model, hospitals compete for patients and efforts to manage the patient flow can vary and be circumvented if some hospitals choose to use different triage considerations, such as the patient’s payer source.
ABA Southern Region
The ABA Southern Region comprises the states of Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia. In 2005, the Southern Region developed the framework for a plan should a disaster occur that required the application of interstate resources.8 Several states have addressed burn disasters in the post–September 11 environment9 Barillo and Goode10 noted that many of the fires and subsequent burn disasters with significant loss of life occurred before the institution of the building codes that are in force across much of the United States, but there have been other such disasters since their institution here and abroad, for example, Rhode Island,11 the Netherlands,7 and Sweden.12 Any of these scenarios could play out in the Southern Region.
All disasters are local, and a burn disaster is not different. The first line of response includes emergency medical services (EMS) and extends to community or regional hospitals, the first receivers. In a burn disaster, it is critical that these organizations have a system in place to manage the initial inflow of patients and that they are comfortable with the initial care and treatment of burn-injured patients. Comfort begins with training of and education for the providers who will be involved in the initial care of burn-injured patients.13
Although beyond the control of responders, the geographic site of the disaster plays a key role in how the disaster unfolds. In resource-rich communities, it is less likely that local EMS systems and local hospitals would be overwhelmed with injured patients for extended periods. In such situations, patients are more quickly assessed, initial care is begun, and patients are transported to first-receiver hospitals.
The initial buffer in any disaster is the first receiver hospital(s), and the surge of patients is managed in what has been loosely defined as surge capacity. Multiple state burn disaster plans recognize the role of first-receiver hospitals and trauma centers not colocated with burn centers as sites to manage burn-injured patients on a temporary basis. This role is discussed in the New York,14 Los Angeles,15 and North Carolina plans.16
In the years following the September 11 attacks, the ABA put forward a quantified definition for surge capacity that included the ability to absorb 50% above the self-reported capacity of a burn center17; however, Hick et al18 proposed a more specific definition that stratified surge capacity into three categories: conventional, contingency, and crisis surge capacities. Hick and colleagues differentiated surge capacity based on the use of three metrics: staff, supplies (stuff), and space. How does the disaster affect your staff and do you have sufficient staff on hand? Do you have the supplies, pharmaceuticals and equipment you need, and where are you providing this care in your facility (space)?
Even in a disaster in the American South, it is reasonable to believe that all burn-injured patients can be examined in a burn center by a burn surgeon within 6, and no more than 24, hours after the disaster, provided it is a singular burn disaster event that did not dramatically disrupt the transportation infrastructure. Holmes et al6 noted that many burn patients who meet the criteria for transfer to a burn center19 are never treated there. Although it is reassuring that at least a significant portion of clinicians are comfortable with managing burn-injured patients, even in a disaster, burn-injured patients should be examined by a burn surgeon at a burn center within 24 hours following the disaster.
Several state plans have defined durations for managing the surge of burn patients held at trauma centers for up to 120 hours.15,16,20 A truly catastrophic event would have to occur to create such a crisis that necessitated patients remaining outside a burn center for 120 hours. Nevertheless, the occurrence of the September 11 attacks and Hurricane Katrina in a span of <5 years is a reminder that even the most unlikely catastrophic events can occur.
The framework for national burn disaster planning strategies was published in 2005 by the ABA.17 Repeating a number of themes recognized through the years, the ABA document represents a consensus opinion of the national leadership in the burn community and includes the important role burn centers play in disaster planning, response, and operations, as well as why treatment of burn patients should occur in burn centers, even during a disaster. The paper also examines the general interface/interactions between burn centers and other healthcare partners, from community hospitals and trauma centers to state and federal officials.
Related Military Experiences
The wars in Iraq and Afghanistan were the driving creative force of a system to measure on a regular basis the national availability for civilian burn beds.21 As the care of injured military personnel evolved during these conflicts, so did the sophistication of the military response to burn-injured patients. From the battlefield to forward care units with rapid evacuation and airlift back to the United States for ongoing burn care, the military response was a series of lessons learned that also have civilian applications. This military experience has been that well-planned equipment packs should accompany clinicians during the transport of injured service members,22 and the long-range transport system that is used to evacuate injured military personnel23 has civilian applications. Furthermore, the military experience produced reasonable outcomes early on24 and improved in the years that followed.25 By using military strategies of transporting patients to higher echelons of care, the efficiency and effectiveness in managing civilian casualties can be improved, even when the numbers of them are substantial.
Current State of Preparedness
Substantial improvements in preparedness activities and disaster planning have been made since 2002. The Southern Burn Plan was activated in mid-January 2009, and those daily bed counts provided greater accuracy in the burn surge capabilities and limitations. As millions gathered in Washington, DC, for the inauguration ceremonies for President Obama, the frank reality was that even with lead time and transportation assets, only approximately 325 burn beds in the region could be cleared and prepared.
The Southern Burn Plan also was activated during the intake of patients following the 2010 earthquake in Haiti. Haitian health care was abysmal at the time of the earthquake, and following the disaster it was almost nonexistent until international response teams arrived. US disaster response is typically a domestic operation, and there is a limited infrastructure to deploy a large civilian response to an international disaster. Although significant military response and relief were provided, the most critically injured repatriated Americans or foreign nationals received treatment in the United States and were initially transported to southern Florida. Within the first 2 weeks, much of the capacity in Florida was saturated, and the Southern Burn Plan was activated so that additional burn-injured patients could be treated. Two landing sites were selected. The first segment of the flight landed in Orlando, Florida, which had burn bed availability, and the second segment was transported to North Carolina, where patients were sent to two burn centers and were transported from the airport by ambulances.
Although states such as North Carolina and Florida have functional and exercised burn surge disaster plans, the 2004 Bioterrorism Hospital Preparedness Program requires each state to have in place a basic plan as a condition of the grant administered by the Health Regulation Services Administration (today administered by the Office of the Assistant Secretary for Preparedness and Response). The agency responsible for this activity varies by state, but in general, it can be found at the Division/Office of Public Health or Emergency Medical Services. Based on the National Response Framework,26 these are the state representatives for Emergency Support Function 8, Health and Medical (ESF-8).27 In 2008, representatives from these state agencies in the US South formed the Unified Planning Coalition to coordinate interstate ESF-8 activities.
Key Planning Concepts
Key planning concepts for any disaster plan include both an entry point and a break point: At what point do we declare a disaster and activate our plan and at what point have we “broken” the general capabilities of the plan? Each planning effort must recognize both points. No plan is infinitely scalable, and with burn care, these numbers are generally smaller and more finite than those in other disciplines.
Useful tools are available to aid with decision making when there are 5000 burn-injured patients and a system with a capacity to absorb fewer than 500. One such work28 relies on the ABA’s National Burn Registry20 and includes a rather simplistic chart that is based on retrospective analysis of the National Burn Repository. This focuses on patient outcomes based on age and total body surface area (TBSA) of burn injury. This work introduced a graphic representation of probable outcomes.
The general premise for all burn disaster plans includes an activation point, the associated activities during the disaster, and when the plan begins to break down. This break point includes what Hick et al18 described as crisis surge capacity and involves patients being managed according to altered standards of care. Although due diligence should be taken to limit the number of patients examined and the duration needed to operate in crisis surge capacity, it must be an option in certain catastrophic circumstances for a short period of time until resources can be located and transportation arranged to move patients to those available resources.
The Three Components of a Healthcare-Based Plan
All plans must comprise three components: institutional, interfacility, and interstate. Just as all disasters are local, all planning begins at the local (institutional) level: What can you manage and what is your breaking point? At what point are patients transported directly to another facility? At what point do you transfer several of your patients to other hospitals, and what transportation assets do you rely upon? At what point does your patient volume exceed your available burn resources, and where do you go when you need to move patients to another state? Has your state ESF-8 contact been notified? Are you working with burn centers in neighboring states to transfer some of your burn-injured patients? Are you working through ESF-8 to coordinate transportation of these patients? Ideally, all of these questions will have formulated answers assigned via testing your burn disaster plan well ahead of any real catastrophic event.
The terrorist attacks of September 11, 2001 changed the way we discuss and prepare for disasters. In the years after the attacks, a significant investment of time and resources has been made to improve the preparedness of first responders and first receivers. Hurricane Katrina in 2005 also served as a stark reminder that catastrophes can quickly overwhelm planning and preparedness efforts. It is imperative to have an entry (activation) point in disaster plans, that plans have scalability that maximizes local and regional resources, and that it be understood that at some point, all plans fail. When the plan fails, what is done and for what length of time?
Although significant strides have been made to identify resources, open lines of communication, identify weaknesses, and break down barriers, much remains to be done. These ongoing efforts include local plan development for each state, inclusion of the trauma community, and the engagement of everyone involved in the initial care of burn-injured patients. A recent survey29 found that fewer than 50% of clinicians who work in either a hospital or as part of EMS felt either “comfortable” or “very comfortable” with their knowledge, skills, and abilities to manage one burn-injured patient with a ≥20% TBSA. Developing a burn surge disaster plan for dozens of patients in the face of this statistic is daunting. If a majority of the clinicians do not feel comfortable managing their first burn-injured patient, then it is unlikely that proper care will be provided to the remaining patients. The silent but omnipresent threat in the disaster plan lies with interstate cooperation. Depending on the nature of the burn disaster, several of the likely scenarios include significant numbers of burn-injured patients without a known payer source. The average charge in 2010 for a single 50% to 59% TBSA burn-injured patient according to the National Burn Repository20 was $603,000. What hospital will open bed space for essentially 10 patients representing $6.03 million in charges, potentially displacing typical and local burn-injured patients and having no known source of reimbursement?
Real-world experiences during the past 15 years and lessons learned through exercises and modeling have led to vastly improved burn disaster preparedness. As the body of knowledge has grown, more opportunities have been identified for further investigation and development.
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. Published April 2005. Accessed September 10, 2012.
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