1. Developing Hospital & Regional Burn Disaster Plans David J. Barillo, MD, FACS Chair, ABA Region IV Commander, BST-2 © 2005 burndisaster.com

2. DISCLAIMER This presentation contains draft material which may or may not appear in the final edition of the Region IV disaster plan

3. © Copyright 2005 The material in this presentation exclusive of government documents is copyrighted Permission is granted for unrestricted use as long as the source is credited © 2005 burndisaster.com

4. Overview ABA Regionalization Developing the Region IV plan Burn Center disaster plans © 2005 burndisaster.com

5. Overview ABA Regionalization © 2005 burndisaster.com

9. Overview ABA Regionalization Developing the Region IV plan © 2005 burndisaster.com

10. Region IV Region 3 Region 4 Region 5 Region 6 © 2005 burndisaster.com

11. Goal: How can we best help each other when a disaster occurs within Region IV and one or more burn centers are overwhelmed? © 2005 burndisaster.com

12. Criteria Simple Scalable Flexible Written for and driven by the end user Applicable to national emergencies © 2005 burndisaster.com

13. Components Each burn center needs a disaster plan A regional mutual – aid system Pre-planning (who is ‘next-up’ for overflow admissions ? ) Regional communications hub © 2005 burndisaster.com

14. Driven by the End User BC Director decides if and when to activate plan BC Director decides how far to activate plan BC Director decides when disaster is over © 2005 burndisaster.com

15. Region IV Communications Center (R4CC) A location outside of the disaster area when one or more experienced burn surgeons can make phone calls and transfer arrangements on your behalf Has lists of critical phone numbers, BC capabilities and transport assets within the region Has copies of the pre-plans of who goes where Has a list of transport distances © 2005 burndisaster.com

17. Region IV Communications Center Ideally co-located at an EMS Dispatch center, county or state EOC or similar facility with existing commo capability and staff Tentative choice: Birmingham AL TCC TCC already keeps track of bed and asset availability within regional trauma system Availability of 2 Burn Centers, Regional Trauma Center, at least 4 experienced burn surgeons A back-up Center also needs to be designated © 2005 burndisaster.com

18. Stages OPEN FULL DIVERT OFFLOAD RETURN © 2005 burndisaster.com

19. OPEN The burn center is open and available for referrals, either local or distant ACTION: R4CC has the center listed as open, status updated as needed over internet © 2005 burndisaster.com

20. FULL There is no disaster but the burn center is full, there are no other ICU beds open and there is no one transferrable out of the burn center © 2005 burndisaster.com

21. FULL ACTION: BC Director notifies next closest burn center(s) of full status. Region IV Comm Center (R4CC) notified to mark unit as ‘full’ Decision to accept or transfer new patients made by BC Director on case-by-case basis. Overflow to next closest burn center(s) © 2005 burndisaster.com

22. DIVERT There is a Mass Casualty Incident (MASCAL) in progress The burn center can presently handle all patients No further patients from the incident are expected © 2005 burndisaster.com

23. DIVERT ACTION: BC Director notifies R4CC R4CC notifies next-closest burn centers that they will get subsequent local admissions. R4CC provides heads-up notification to other Region IV burn centers and to BST-2 and NDMS The affected burn center automatically closes to all new admissions for predetermined period (5-7 days) at which time BC Director reassesses status © 2005 burndisaster.com

24. OFFLOAD There is a mass casualty incident in progress The burn center is overloaded and not able to handle all patients OR Additional patients from the incident are expected OR The situation is ongoing,unstable or unpredictable © 2005 burndisaster.com

25. OFFLOAD ACTION: BC Director notifies R4CC that offloading will be needed R4CC notifies all regional burn centers, NDMS, BST-2 and ABA Central Office R4CC checks on availability of beds/transport R4CC awaits further input from BC Director © 2005 burndisaster.com

26. OFFLOAD BC Director notifies R4CC of number/condition of patients requiring transfer Local BC handles situation for first 24 hours R4CC schedules transport and acceptance of burn patients at regional burn centers At 24-48 hours, transport teams start arriving to offload patients If needed, NDMS Burn Specialty Teams arrive within several days to work in 2 week shifts until situation resolved Pre-empt the Hospital CEO response to CNN trucks in the parking lot © 2005 burndisaster.com

27. OFFLOAD THE BC DIRECTOR Decides if and when to declare ‘offload’ Can decide which patients stay and which patients go (or can delegate this to R4CC) Can decide where and how to send patients or can leave this to R4CC Can decide to ask for or to refuse NDMS help The process is driven by the end-user! © 2005 burndisaster.com

28. RETURN The disaster is over or under control The BC is again accepting new patients Plans are made to start transferring offloaded patients back to the BC closest to home (if you and the patient want to!!) © 2005 burndisaster.com

29. RETURN ACTION: BC Director notifies R4CC of ‘return’ status R4CC marks the BC as ‘available’ BC Director can contact accepting burn centers and make individual decisions regarding transfer of patients back BC Director can decide to leave patients where they are © 2005 burndisaster.com

30. The Big Controversy Do you transport patients away from the disaster to other burn centers OR Do you transport burn care professionals into the disaster area ? © 2005 burndisaster.com

31. Region IV Plan answer: IT DEPENDS ! Flexibility Within this plan we can do either, both, or neither as the situation dictates Decision made by by the end-user © 2005 burndisaster.com

32. Implementation Present to May : Regional Disaster Committee develops guide to writing the hospital disaster plan BC directors inventory resources and existing disaster plans ABA meeting : one additional day working on plan May – November: Burn Centers write disaster plans Disaster Committee drafts regional plan November: Meet as a group to revise/approve regional plan © 2005 burndisaster.com

33. Overview ABA Regionalization Developing the Region IV plan Burn Center disaster plans © 2005 burndisaster.com

35. Disaster Plan One size will not fit all Develop a guide to writing YOUR OWN disaster plan © 2005 burndisaster.com

38. Under development: A Region IV guide to writing your own burn center disaster plan © 2005 burndisaster.com

39. Planning Team Need to consider everyone that you would interface with in a disaster: Regional burn centers State OEM / EMS Regional EMS Nursing OT/ PT/ RT Emergency Dept Trauma Service Pediatric, Medical and Surgical Services Pharmacy Local Government Hospital Administration Who has a disaster plan with the words ‘burn center’ in it ? © 2005 burndisaster.com

40. Planning Team Keep the working group small so that work can actually get done Keep others in the loop as the plan is developed SELECT A LEADER ! © 2005 burndisaster.com

41. Find a Common Language Anyone on the team not trained in ICS / NIMS should complete on-line courses before any planning is started Review the National Response Plan © 2005 burndisaster.com

42. Review / Coordinate Existing Plans The worst plan is no plan. The next worse is two plans Start with EMS / ED/ Trauma Service / Hospital / OEM © 2005 burndisaster.com

43. Hazards Identification What are the dangers in town ? –Chemical plants –Railways –Ports –Farming / grain storage / anhydrous ammonia –Meth labs –Nursing homes –Colleges –Airports What are the regional hazards? Terrorists © 2005 burndisaster.com

44. Hazards Identification What is the unit history? What has happened in the past that sent many patients to the BC? What were your biggest incidents ? What regional disasters have occurred in the past ? What is the MASCAL experience of other burn centers? © 2005 burndisaster.com

45. Assess Response Capabilities Burn Center/Hospital/local ER capacity Bed capacity Building capacity Nurses Operating rooms Intubation supplies IV fluids Bronchoscopes and technicians to run/clean them Drugs Other supplies © 2005 burndisaster.com

46. Assess Response Capabilities Regional / National –EMS / Fire –Other hospitals –Other burn centers –Transport capabilities –State Assets (NG) –Federal assets (DMAT/ military) © 2005 burndisaster.com

47. Now can we write the plan? Not quite Decide on definitions, terms, roles, and responsibilities © 2005 burndisaster.com

48. 6 Blind Men Describing Elephant

49. A burn MASCAL can result in: Chemical exposure where injury needs to be ruled out Just burn injury Just inhalation injury Burn injury with inhalation injury Multiple trauma with minimal burn injury ( + / - inhalation) Multiple trauma with massive burn injury ( + / - inhalation) Is ER, burn, trauma or pulmonary in charge? © 2005 burndisaster.com

50. Keep in mind: Surgeons may not be available for triage or management Initial care, intubation and resuscitation may be done in other ICUs by other intensivists including medical intensivists The nurses that help will not be burn nurses and maybe not even surgical nurses. They cannot be relied upon to keep the residents out of trouble A surgical intern may be the most qualified person managing a critical patient for the first 24 hours Plan for the lowest common denominator © 2005 burndisaster.com

51. Communications Patients are going to be stuffed into unfamiliar floors or units which may or may not have convenient phones Outside telephones will overload or might even be intentionally shut off Cellphones will overload or towers may be lost The trunked radio system probably won’t work Digital radio systems are 100% or 0% Plan for alternatives! © 2005 burndisaster.com

52. Communications Wireless carriers have priority access systems Analog VHF simplex FM portable radios Amateur radio clubs (www.arrl.org) SATCOM

53. write the plan Review and revise the plan Keep reviewing and revising until everyone can sign off on it –Administration –ER –Trauma –Medicine/Surgery/Peds –All ICU directors © 2005 burndisaster.com

54. Test the Plan Run a MASCAL drill and see how the plan works Revise the plan Set up a mechanism for annual review Run a drill at least once a year © 2005 burndisaster.com

55. SUMMARY All things work best in a system The worst plan is no plan. The next worse is two plans Plan locally, think regionally Everyone signs off on the plan PRACTICE THE PLAN ! Revise the plan at least annually © 2005 burndisaster.com

56. Resources Prevention: www.burnandfireprevention.org Region IV disaster planning: www.burndisaster.com Journal of Burn Care and Rehabilitation March April 05 American Burn Association www.ameriburn.orgwww.ameriburn.org Department of Homeland Security: www.dhs.gov FEMA: www.fema.govwww.fema.gov National Disaster Medical System : http://ndms.dhhs.govhttp://ndms.dhhs.gov Burn Specialty Team 2: www.bst2.orgwww.bst2.org © 2005 burndisaster.com