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4_07_4.ppt
4_07_4.ppt
4_07_4.ppt
4_07_4.ppt
4_07_4.ppt
4_07_4.ppt
4_07_4.ppt
4_07_4.ppt
4_07_4.ppt
4_07_4.ppt
4_07_4.ppt
4_07_4.ppt
4_07_4.ppt
4_07_4.ppt
4_07_4.ppt
4_07_4.ppt
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4_07_4.ppt

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  • 1. Case Study: New Orleans andCase Study: New Orleans and Minneapolis, a Tale of TwoMinneapolis, a Tale of Two CitiesCities Carl H. Schultz, MDCarl H. Schultz, MD Professor of Emergency MedicineProfessor of Emergency Medicine Director, Disaster Medical ServicesDirector, Disaster Medical Services UC Irvine School of MedicineUC Irvine School of Medicine
  • 2. UC Irvine School of Medicine Department of Emergency Medicine OverviewOverview Need for Scientific InquiryNeed for Scientific Inquiry Measuring effectivenessMeasuring effectiveness – Mass casualty triageMass casualty triage – Credentialing of volunteersCredentialing of volunteers – Leadership education and trainingLeadership education and training
  • 3. UC Irvine School of Medicine Department of Emergency Medicine TriageTriage No clear evidence that triage is useful,No clear evidence that triage is useful, but assume is axiomaticbut assume is axiomatic Science supporting civilian massScience supporting civilian mass casualty triage is in its infancycasualty triage is in its infancy – Reliable/reproducibleReliable/reproducible – Applicable to entire populationApplicable to entire population – Evidence basedEvidence based – Performance characteristicsPerformance characteristics OUTCOMEOUTCOME
  • 4. UC Irvine School of Medicine Department of Emergency Medicine TriageTriage Reliable/reproducibleReliable/reproducible – START TriageSTART Triage Different people triaging the same victimsDifferent people triaging the same victims place them in the same triage classificationplace them in the same triage classification – interrater reliability– interrater reliability Tested in simulations and in individualTested in simulations and in individual patients and found to produce consistentpatients and found to produce consistent results across professions.results across professions. Not tested in actual disastersNot tested in actual disasters
  • 5. UC Irvine School of Medicine Department of Emergency Medicine TriageTriage Applicable to entire populationApplicable to entire population – START Triage – applies to adults but notSTART Triage – applies to adults but not small childrensmall children Use of respiratory parametersUse of respiratory parameters – Normal < 30Normal < 30 Mental statusMental status – Normal: follows commandsNormal: follows commands – JumpSTART – modifies START toJumpSTART – modifies START to accommodate needs of childrenaccommodate needs of children Normal respiratory rate 15 - 40Normal respiratory rate 15 - 40 Mental status measure by AVPUMental status measure by AVPU
  • 6. UC Irvine School of Medicine Department of Emergency Medicine TriageTriage Evidence basedEvidence based – START: ability to follow commandsSTART: ability to follow commands Motor component of GCS correlates wellMotor component of GCS correlates well with risk of death, and is as good as RTSwith risk of death, and is as good as RTS and full GCS in predicting outcomeand full GCS in predicting outcome GMR of 6 = can follow commands.GMR of 6 = can follow commands. Predicted good outcome.Predicted good outcome. Score of 1-5 predicted worse outcomeScore of 1-5 predicted worse outcome.. – Respiratory rate….not so goodRespiratory rate….not so good
  • 7. UC Irvine School of Medicine Department of Emergency Medicine TriageTriage Performance characteristicsPerformance characteristics – Issues of tool performance vs providerIssues of tool performance vs provider performanceperformance In evaluating accuracy of a triage tool,In evaluating accuracy of a triage tool, study must differentiate between validity ofstudy must differentiate between validity of tool and if providers applied it correctlytool and if providers applied it correctly – Testing under real conditions, not simulationsTesting under real conditions, not simulations or surrogate situationsor surrogate situations – Does disaster triage correctly identify victimsDoes disaster triage correctly identify victims (are reds really red?)(are reds really red?)
  • 8. UC Irvine School of Medicine Department of Emergency Medicine TriageTriage START Triage: April 23, 2002 –START Triage: April 23, 2002 – collision between two trainscollision between two trains – 162 victims triaged by START162 victims triaged by START – Outcome criteria used to calculate triage accuracyOutcome criteria used to calculate triage accuracy – Red criteria: 100% sensitive, 85% specificRed criteria: 100% sensitive, 85% specific – Yellow criteria: 57% sensitive, 12% specificYellow criteria: 57% sensitive, 12% specific – Green criteria: 48% sensitive, 84% specificGreen criteria: 48% sensitive, 84% specific Would a “gestalt” system be better?Would a “gestalt” system be better? – MinneapolisMinneapolis – IsraelIsrael
  • 9. UC Irvine School of Medicine Department of Emergency Medicine Credentialing of VolunteersCredentialing of Volunteers Emergency System for Advanced Registration ofEmergency System for Advanced Registration of Volunteer Health Professionals (ESAR-VHP)Volunteer Health Professionals (ESAR-VHP) – Designed to meet needs of hospitalsDesigned to meet needs of hospitals – State-based standardized systemState-based standardized system Advanced registration of volunteers provides verifiable, up-to-date information about volunteer identity and credentials – Permits sharing of personnel across state lines, addresses liability and worker’s comp
  • 10. UC Irvine School of Medicine Department of Emergency Medicine Credentialing of VolunteersCredentialing of Volunteers Issues with ESAR-VHPIssues with ESAR-VHP – Its expensiveIts expensive $10 million expended thru 2005$10 million expended thru 2005 2006-2007 cost estimates for2006-2007 cost estimates for California alone = $850K. CostsCalifornia alone = $850K. Costs for subsequent years = $335Kfor subsequent years = $335K ? Millions for the entire country? Millions for the entire country and for how longand for how long
  • 11. UC Irvine School of Medicine Department of Emergency Medicine Credentialing of VolunteersCredentialing of Volunteers Issues with ESAR-VHPIssues with ESAR-VHP – State-basedState-based Level of provider expertise can varyLevel of provider expertise can vary state by statestate by state –Makes resource typing difficultMakes resource typing difficult –Type 1 versus Type 2-4Type 1 versus Type 2-4 Inherent delays in activating, mobilizing,Inherent delays in activating, mobilizing, and delivering personneland delivering personnel – Take years to implement fullyTake years to implement fully
  • 12. UC Irvine School of Medicine Department of Emergency Medicine Credentialing of VolunteersCredentialing of Volunteers Issues with ESAR-VHPIssues with ESAR-VHP – Each state must:Each state must: – Design and maintain systemDesign and maintain system – Register volunteersRegister volunteers – Recruit and sustain participationRecruit and sustain participation – Collect credentialing informationCollect credentialing information – Support system useSupport system use A whole new bureaucracy?A whole new bureaucracy? – Don’t we already do this?Don’t we already do this?
  • 13. UC Irvine School of Medicine Department of Emergency Medicine Credentialing of VolunteersCredentialing of Volunteers Implement a hospital-based credentialing systemImplement a hospital-based credentialing system Create database of all practitioners in good standingCreate database of all practitioners in good standing from current hospital stafffrom current hospital staff Information already exists at each hospital. It justInformation already exists at each hospital. It just has to be combined in a single databasehas to be combined in a single database Controlled by county and shared with all hospitalsControlled by county and shared with all hospitals Can be shared by counties during a disasterCan be shared by counties during a disaster Now each practitioner is credentialed all hospitalsNow each practitioner is credentialed all hospitals Rapid, cheaper, more efficientRapid, cheaper, more efficient Are there other alternatives?
  • 14. UC Irvine School of Medicine Department of Emergency Medicine Leadership Education & TrainingLeadership Education & Training Who’s in charge?Who’s in charge? What do they know?What do they know? Lessons learned?Lessons learned? – Not scienceNot science Emerging approachEmerging approach – Masters degrees in public health, urbanMasters degrees in public health, urban planning, and disaster managementplanning, and disaster management – Bachelor of science degreesBachelor of science degrees – Certificate programsCertificate programs
  • 15. UC Irvine School of Medicine Department of Emergency Medicine Leadership Education & TrainingLeadership Education & Training Standardized curriculum?Standardized curriculum? – Comprehensive emergency managementComprehensive emergency management (Philadelphia Univ.)(Philadelphia Univ.) – Public health (George Washington Univ.)Public health (George Washington Univ.) – Emergency/disaster management (SUNY StonyEmergency/disaster management (SUNY Stony Brook)Brook) – EMS (MCP Hahnemann University)EMS (MCP Hahnemann University) – Public policy (UC Irvine)Public policy (UC Irvine) – Terrorism (Georgetown Univ.)Terrorism (Georgetown Univ.) – Disaster medicine (European Masters in DM)Disaster medicine (European Masters in DM) – Threat /response management (Univ. of Chicago)Threat /response management (Univ. of Chicago)
  • 16. UC Irvine School of Medicine Department of Emergency Medicine Leadership Education & TrainingLeadership Education & Training Outcome measurements?Outcome measurements? – Performance during disasters - metricsPerformance during disasters - metrics difficult but…difficult but… Reduction in preventable errorsReduction in preventable errors Reduction in repetitive nature of “lessonsReduction in repetitive nature of “lessons learned”.learned”. Reduction in deaths/injuriesReduction in deaths/injuries Reduction in costsReduction in costs – In the meantime, requiring formal training forIn the meantime, requiring formal training for positions in management would be nicepositions in management would be nice
  • 17. UC Irvine School of Medicine Department of Emergency Medicine THANK YOU!THANK YOU! QUESTIONS?QUESTIONS? Carl Schultz, MDCarl Schultz, MD schultzc@uci.eduschultzc@uci.edu
  • 18. UC Irvine School of Medicine Department of Emergency Medicine ReferencesReferences 1.1. Schultz CH, Stratton SJ: Improving Hospital Surge Capacity:Schultz CH, Stratton SJ: Improving Hospital Surge Capacity: A New Concept for Emergency Credentialing of Volunteers.A New Concept for Emergency Credentialing of Volunteers. Ann Emerg Med 2007;49:602-609.Ann Emerg Med 2007;49:602-609. 2.2. Schultz CH, Koenig KL: State of Research in High-Schultz CH, Koenig KL: State of Research in High- consequence Hospital Surge Capacity. Acad Emerg Medconsequence Hospital Surge Capacity. Acad Emerg Med 2006;13(11):1153-1156.2006;13(11):1153-1156. 3.3. Hick JL, Hanfling D, Burstein JL, et al. Health care facility andHick JL, Hanfling D, Burstein JL, et al. Health care facility and community strategies for patient care surge capacity.community strategies for patient care surge capacity. AnnAnn Emerg MedEmerg Med. 2004;44:253-261.. 2004;44:253-261. 4.4. Hick JL, O’Laughlin DT. Concept of operations for triage ofHick JL, O’Laughlin DT. Concept of operations for triage of mechanical ventilation in an epidemic. Acad Emerg Med.mechanical ventilation in an epidemic. Acad Emerg Med. 2006; 13:223–9.2006; 13:223–9.
  • 19. UC Irvine School of Medicine Department of Emergency Medicine ReferencesReferences 5.5. Garner A, Lee A, Harrison K, Schultz CH: ComparativeGarner A, Lee A, Harrison K, Schultz CH: Comparative Analysis of Multiple-Casualty Incident Triage Algorithms.Analysis of Multiple-Casualty Incident Triage Algorithms. Ann Emerg Med 2001;38:541-548.Ann Emerg Med 2001;38:541-548. 6.6. Cone DC, Koenig KL: Mass casualty triage in the chemical,Cone DC, Koenig KL: Mass casualty triage in the chemical, biological, radiological, or nuclear environment. Eur J Emergbiological, radiological, or nuclear environment. Eur J Emerg Med 2005;12:287-302.Med 2005;12:287-302. 7.7. Risavi BL, Salen PN, Heller MB, Arcona S. A two-hourRisavi BL, Salen PN, Heller MB, Arcona S. A two-hour intervention using START improves prehospital triage ofintervention using START improves prehospital triage of mass casualty incidents. Prehosp Emerg Care 2001; 5:197–mass casualty incidents. Prehosp Emerg Care 2001; 5:197– 199.199. 8.8. Kahn C, Schultz CH, Miller K, Anderson, C: Does STARTKahn C, Schultz CH, Miller K, Anderson, C: Does START Triage Work? An Outcomes-Level Assessment of Use at aTriage Work? An Outcomes-Level Assessment of Use at a Mass Casualty Event. Acad Emerg Med 2007;14, SupplMass Casualty Event. Acad Emerg Med 2007;14, Suppl 1:S12-S131:S12-S13

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