Crisis Standards of Care: A Toolkit for Indicators and Triggers Committee Meeting Dr. Randy D. Kearns DHA MSA CEM Program Director, Burn Surge Disaster Program Department of Surgery Administrator, EMSPIC Department of Emergency Medicine January 15, 2013
• US Department of Health and Human Services – Office of the Assistant Secretary for Preparedness and Response – Through the Hospital Preparedness Program• US Department of Homeland Security – Federal Emergency Management Agency – Fire Prevention and Public Education• Foundation and Other Organizations – North Carolina Jaycee Burn Center Foundation – The Duke Endowment
• Burn – is a time sensitive injury/illness• Small – but manageable patient population• Data quality – small, easier troubleshoot, better to understand gaps and anomalies• Scalability – lessons learned have applicability in other specialties• Limited Supply of Critical Facilities
Verified BurnCenter, Co-Located with aTrauma CenterVerified BurnCenter, NoTrauma CenterSelf DesignatedBurn Center
• Type III Burn Disaster: – Isolated burn disaster such as the Station Night Club Fire – Burn Care System Impact• Type II Burn Disaster: – Multiple aspect disaster, such as an explosion with significant numbers of traumatic as well as burn injured patients such as the 05 London or 04 Madrid Bombings – Healthcare System Impact• Type I Burn Disaster: – Catastrophic/wide spread event, multi-state such as 9/11 attacks or Earthquakes such as Northridge or Loma Prieta – Infrastructure Impact
Disaster plans should reflect an extension of daily activities.Planning from the burn center perspective should reflect (minimally) three levels;• Local: – Intrafacility (your hospital/system)• State: – Interfacility/instrastate (burn and trauma centers) (state ESF-8)• Regional: – Interstate (burn and trauma centers) NDMS or EMAC through state ESF-8
Planning from the governmental perspective should reflect:Local: First Responder (EMS system) First Receiver(s) (local hospital[s])State: Mutual Aid EMS, Intrastate regional response teams, burn and trauma centersRegional: Interstate Burn Centers, Regional or Federal Response Teams through EMAC or NDMS
Immediate: best you can with what you have and know who to call for what you need (also referred to as a No-notice Event)6-120 hrs: leaning forward with response teams, transport agencies, and push packs of equipment (staff, space, stuff)>72-120 hrs: high census but normal operation
• Entry - Activation – “Back of a Napkin” • Data and Assumptions • Involves SME’s and Lunch• Activity within the Plan – Modeling – Test: Exercise Table Top, Functional and Full Scale – Use it• Plan Fatigue/Failure – Plan vs. Framework
• The Value of Modeling: – Test multiple hypotheses – Inject variability – Increased frequency of exercise• Three Types of Simulation – Discrete Event – Continuous• Plan Fatigue/Failure – Plan vs. Framework
• Descriptive analysis – Self designated and self reported bed capacity – Burn Center Surge capacity (50% above stated capacity) – Trauma Center static capacity (temporary)• Monte Carlo Simulation (North Carolina Jaycee Burn Center 2009- 10 to determine a distribution curve) – Reported Staffed Capacity – Avg. Daily Census = Bed Availability – Randomly perform 10,000 iterations using @RiskKearns RD. Burn surge capacity in the south what is the capacity of burn centers within theAmerican Burn Association southern region to absorb significant numbers of burn injuredpatients during a medical disaster? Medical University of South Carolina: ProQuestDissertations and Theses; 2011.
• Computational algorithms – Rely on repeated random sampling to yield results • Census and Admissions – Define possible inputs • Frequency distribution (Normal Distribution, determined by the NCJBC Data) – Deterministic computation • Probabilistic values for bed availability – Aggregate results • Compounding variable, number of hospitalsVon Neumann, Ulam, Metropolis1940’s at Los Alamosworking on nuclear weapons
• Distribution Curve (normal) – Data from NCJBC• Coefficient of variation – Average Daily Census/Standard Deviation• X = Simulations (X1-X10) – X1-X5 Real events, assumes all burn injured need burn beds – X6-X10 Theoretical Patient Inputs• Y = Hospitals/States/Balance of the Region – Hospitals (Intrastate) Y1, Y2 – States (Interstate) Y3, Y4, Y5 – Balance of the Region Y6
• Determine number of beds needed (expressed as X) input parameter• Test with historical data• Compare X to available beds at UNC Hospitals (expressed as Y1) – X < Y1 then stop, if X > Y1 then add in WFUBMC Y2 – If (Y1+Y2) > X then stop, if X > (Y1+Y2) then proceed Simulations ESF-8 Approach, Hospitals/State Burn Center Resources ESF-X1 – 54 patients Y1 Home hospital – NC Jaycee Burn Center at UNC HospitalsX2 – 130 patientsX3 – 38 patients Y2 Intrastate resources – WFUBMC, Wake Forest Baptist HealthX4 – 215 patients Y3 Virginia state resources – 4 Burn CentersX5 – 243 patientsX6 – 500 patients Y4 Georgia state resources – 2 Burn CentersX7 – 1,000 patients Y5 Tennessee state resources – 2 Burn CentersX8 – 2,500 patientsX9 – 5,000 patients Y6 Remainder of Southern Regional Burn CentersX10 – 10,000 patients
• Confirmed Trigger points for planning tools• Activation points for transportation assets/resources• Better understanding of capacities and capabilities• 6:5:6 Trigger to activate Plan• 20-60 patients = Intrastate Plan Failure• 425-450 patients = Interstate Plan Failure (Regional)
Surge Capacity (and Capability) includes the – Staff – Space – Stuff (Supplies, Pharmaceuticals & Equipment)required to meet the needs of the patients. The most important contributing factor outside of S3 is medical transportation resources.
• Probability is inversely proportional to Capacity Demand (Y axis)• Severity is a product of Capacity Demand + Deployment Time (X axis)• In economic terms, you would say the American Healthcare Model is based on Static Equilibrium – Intersection point of supply/demand
99.99% Day to Day Capacity Probability Probability Conventional Surge Capacity Contingency Surge Capacity Crisis Surge Capacity0.01% Greater > < Lessor Severity
• Goal –Take all steps necessary to avoid or end Crisis Surge Capacity as soon as possible –Crisis Surge ends when…
• Staff • Patients• Space Disaster – Ongoing Care• Stuff • Patients• Transport – Discharged – Transferred – ExpireSurge Equilibrium: all competing influences are balanced
99.99% Probability Probability Goal: Return to Day to Day Capacity0.01% Greater > < Lessor Severity
Kearns R, Holmes 4th J, Cairns B. Burn disaster preparedness and the southernregion of the United States. South Med J. Jan 2013;106(1):69-73.
Kearns RD, Holmes 4th JH, Alson RL, Cairns BA. Disaster Planning: The Concepts andPrinciples of Burn Surge outside the Burn Center. Journal Burn Care ResearchAccepted for publication JBCR: 2013.
Modeling helps us predict: Trigger points Sufficient Resources to the scene to care for and move patients to appropriate destinations Upstream notification Receiving hospitals Mutual aid ground/air ambulances Capacity, Capability, TransportationKearns RD, Hubble, MW, Holmes 4th JH, Cairns BA. Disaster Planning: TransportationResources and Considerations for Managing a Burn Disaster. Journal Burn Care ResearchAccepted for publication JBCR: 2013.
• Plans – Relationships – Local, State, Regional• Who to call and what can you bring? – Staff, Space, Stuff – Transport resources• Plans – Scalability, Trigger Points, Activity, Failure• All disasters are local, so are all solutions• Education = Comfort
Randy D. Kearns, DHARandy_kearns@med.unc.eduBruce A. Cairns, MDDistinguished Professor of Surgery and Immunology, Director North Carolina JayceeBurn Center, University of North Carolina- School of MedicineBruce_cairns@med.unc.eduJames H Holmes 4th, MDAssociate Professor of Surgery, Wake Forest University, Director Wake Forest BaptistHealth Burn Centerjholmes@wakehealth.eduCharles B. Cairns, MDProfessor and Chair, Department of Emergency Medicine, University of North Carolina –School of MedicineCharles_cairns@med.unc.edu• www.ncburndisaster.org• www.southernburndisaster.org