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Dr. Randy D. Kearns

Crisis Standards of Care: A Toolkit for Indicators and Triggers

Committee Meeting

Dr. Randy D. KearnsDHA 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– 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, • 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 Burn Center, Co-Located with a Trauma Center

Verified Burn Center, No Trauma Center

Self Designated Burn 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 – 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: • 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])First Receiver(s) (local hospital[s])

State: Mutual Aid EMS, Intrastate regional response teams, burn and trauma centers

Regional: 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-• 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 @Risk

Kearns RD. Burn surge capacity in the south what is the capacity of burn centers within the

American Burn Association southern region to absorb significant numbers of burn injured

patients during a medical disaster? Medical University of South Carolina: ProQuest

Dissertations 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) NCJBC Data)

– Deterministic computation• Probabilistic values for bed availability

– Aggregate results• Compounding variable, number of hospitals

Von Neumann, Ulam, Metropolis

1940’s at Los Alamos

working on nuclear weapons

• Distribution Curve (normal)

– Data from NCJBC

• Coefficient of variation

– Average Daily Census/Standard Deviation

• X = Simulations (X1-X10)• 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

SimulationsSimulations ESFESF--88 Approach, Hospitals/State Burn Center ResourcesApproach, Hospitals/State Burn Center Resources

X1 – 54 patients

X2 – 130 patients

X3 – 38 patients

X4 – 215 patients

X5 – 243 patients

X6 – 500 patients

X7 – 1,000 patients

X8 – 2,500 patients

X9 – 5,000 patients

X10 – 10,000 patients

Y1 Home hospital – NC Jaycee Burn Center at UNC Hospitals

Y2 Intrastate resources – WFUBMC, Wake Forest Baptist Health

Y3 Virginia state resources – 4 Burn Centers

Y4 Georgia state resources – 2 Burn Centers

Y5 Tennessee state resources – 2 Burn Centers

Y6 Remainder of Southern Regional Burn Centers

• 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• 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 – 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)Deployment Time (X axis)

• In economic terms, you would say the American Healthcare Model is based on Static Equilibrium – Intersection point of supply/demand

Pro

ba

bility

99.99%

Day to Day CapacityPro

ba

bility

0.01%Severity

Greater >

< Lessor

Conventional Surge Capacity

Contingency Surge Capacity

Crisis Surge Capacity

• Goal–Take all steps necessary to avoid or end –Take all steps necessary to avoid or end

Crisis Surge Capacity as soon as possible

–Crisis Surge ends when…

• Staff

• Space

• Stuff

• Patients

– Ongoing CareDisaster

• Stuff

• Transport• Patients

– Discharged

– Transferred

– Expire

Surge Equilibrium: all competing influences are balanced

Pro

ba

bility

99.99%

Pro

ba

bility

0.01%Severity

Greater >

< Lessor

Goal: Return to

Day to Day Capacity

Kearns R, Holmes 4th J, Cairns B. Burn disaster preparedness and the southern

region 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 and

Principles of Burn Surge outside the Burn Center. Journal Burn Care Research

Accepted 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, Transportation

Kearns RD, Hubble, MW, Holmes 4th JH, Cairns BA. Disaster Planning: Transportation

Resources and Considerations for Managing a Burn Disaster. Journal Burn Care Research

Accepted 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, DHA

Randy_kearns@med.unc.edu

Bruce A. Cairns, MD

Distinguished Professor of Surgery and Immunology, Director North Carolina Jaycee Burn Center, University of North Carolina- School of Medicine

Bruce_cairns@med.unc.edu

James H Holmes 4th, MDJames H Holmes 4th, MD

Associate Professor of Surgery, Wake Forest University, Director Wake Forest Baptist Health Burn Center

jholmes@wakehealth.edu

Charles B. Cairns, MD

Professor and Chair, Department of Emergency Medicine, University of North Carolina –School of Medicine

Charles_cairns@med.unc.edu

• www.ncburndisaster.org

• www.southernburndisaster.org