North Carolina Burn Disaster Program Carolina Hospital Burn Surge Plan Template Developed by: UNC School of Medicine North Carolina Jaycee Burn Center North Carolina Office of EMS NC Burn Disaster Program April 2012 Version 2.0
Table of Contents OVERVIEW... 3 PURPOSE... 3 SITUATION... 3 DEFINITIONS... 4 PLAN INITIATION... 5 PLANNING ASSUMPTIONS... 5 CONCEPT OF OPERATIONS... 6 Command and Management... 6 Creating Conventional and Contingency Surge Capacity... 7 Triage:... 7 Decontamination:... 8 Holding Areas:... 8 Treatment Areas:... 8 PERSONNEL... 9 Staffing:... 9 Staff/Family Needs:... 9 SUPPLIES, PHARMACEUTICALS AND EQUIPMENT... 10 IMPORTANT CONSIDERATIONS... 10 Communication:... 10 Behavioral Health Needs:... 10 Media Communication:... 10 Documentation:... 11 CREATING CRISIS SURGE CAPACITY... 11 BURN SURGE ANNEX RESPONSE PROCESS... 12 APPENDIX A... 13 APPENDIX B... 26 APPENDIX C... 31
OVERVIEW This tool is to be used to assist in the planning and response to a burn casualty event. Even though the incidence of a burn mass causality event is low the demand and stress on a hospital warrants the need to develop a specific annex to handle such an event. This annex will work as an adjunct to the Carolina Hospital Medical Surge Plan. It is the intent of this plan to effectively integrate the existing medical surge plan with the extraordinary staff and resource demands that will accompany a Burn Medical Disaster. This annex is compliant with the National Incident Management System and depends on strong relationships, and effective networking efforts between all partners using a multiagency coordination approach. PURPOSE Planning for a surge of bun injured patients poses a unique emergency to the hospital. The intense visual presentation of the injuries, the inordinate amount of resource/supply usage, and the increased demand on staff this is an inherent problem that could quickly overwhelm the hospital if it is not properly planned for. The purpose of this annex is to assist Carolina Hospital in planning for and responding to a mass casualty incident involving a significant number of burn victims. This plan exists to be used as an adjunct the Carolina Hospital Medical Surge Plan and addresses the complexities and resource demands required during a significant burn event. This adjunct defines what constitutes a multi causality burn event as well as the different levels of surge capacity with burn specific definitions. This annex in combination with the hospital s medical surge plan will provide the facility guidance for: A uniform assessment of current capability to care for burn patients Assessment of burn surge capabilities Uniform system of triage for burn patients Categorization of hospital supplies Address staff and training readiness for the facility SITUATION A mass casualty incident involving fire, explosions, or chemical release is the most common event that would require the use of the Burn Surge Plan Annex. The cause could be a man made or natural event. The influx of patients from these events usually takes place with little preparation or warning and will place an inordinate amount of stress on the medical facilities closest to the incident..
DEFINITIONS Burn Medical Disaster In North Carolina a Burn Medical Disaster is defined by having 6 or more burn injured patients with more than 5 percent 2 nd or 3 rd degree burn. Mass Burn Casualty Disaster Any catastrophic event in which the number of burn victims exceeds the capacity of the local burn center to provide optimal burn care. Capacity includes availability of: burn beds, burn surgeons, burn nurses, other support staff, operating rooms, equipment, supplies, and related resources. Surge Capacity Surge capacity is the capacity to handle up to 50% more than the normal number of burn patients when there is a disaster. Normal capacity will be different for each burn center, may be seasonal, and will vary from week to week or possibly even day to day. Primary Triage Primary triage is triage which occurs at the disaster scene or at the emergency room of the first receiving hospital. Primary triage should be handled according to local and state mass casualty disaster plans. Under the federal bioterrorism legislation and the implementation actions of the Health Resources and Services Agency (HRSA) of HHS, state disaster plans must incorporate burn centers into such plans. Secondary Triage Secondary triage is the transfer of burn patients from one burn center to another burn center upon reaching surge capacity. Secondary triage policy should be put in place at every burn center, with formal written transfer agreements in place. Crisis Standard of Care This is a standard of care used when the medical needs outstrip the available resources, and the focus changes from appropriate individual care to care that is most appropriate for the group Conventional Surge Capacity The spaces, staff and supplies used are consistent with daily practices within the institution. These spaces and practices are used during an MCI that triggers activation of the facility EOP. Conventional Surge Capacity for a Burn Disaster Relies on the spaces, staff and supplies within a given ED providing care during an MCI, triggers facility EOP, and may require staff to manage some burn injured patients up to 6 hrs with existing staff and existing SPE. Standard of Care is maintained. Contingency Surge Capacity The spaces, staff, and supplies used are not consistent with dailypractices but maintain or have minimal impact on usual patient care practices. These spaces or practices may be used temporarily during a major mass casualty incident or on a more sustained basis during a disaster (when the demands of the incident exceed community resources).
Contingency Surge Capacity for a Burn Disaster Relies on the spaces, both within the ED and designated areas within the facility. It relies on staff who are appropriately credentialed but do not routinely manage patients with injuries of this nature and relies on SPE that may be marginally sufficient from on hand stock or available through a rapid deployment from a SMAT II for a period of 6 24 hrs. Standard of care is maintained but could be only marginally sufficient. Crisis Surge Capacity Adaptive spaces, staff and supplies are not consistent with usual standards of care but provide sufficiency of care in the setting of a catastrophic disaster (i.e. Provide the best possible care to patients given the circumstances and resources available.) Crisis Surge Capacity for a Burn Disaster Relies on adaptive spaces such as rapidly deployed tents in the parking area, or adjacent buildings, relies on staff, mutual aid personnel and volunteers who may or may not be routinely credentialed to manage patients with injuries of this nature, relies on SPE from on hand stock, rapidly deployed stock from a SMAT II or other state/federal resources, and still may not initially meet the needs for a period of 24 120 hours. (Depending on the event, it could extend beyond 120 hours). Some care during this period will be provided outside the typical Standard of Care. PLAN INITIATION The Carolina Hospital Medical Surge Plan and the Burn Surge Annex, is to be initiated once the hospital s capability to handle an influx of burn injured patients has been exceeded. PLANNING ASSUMPTIONS This annex addresses the specific incidence of a burn mass casualty event. It is presumed that general areas such as security, alternate care sites, hospital command and coordination, and other ancillary and support services are outlined in the medical surge plan. Under normal circumstances surge occurs when we have achieved maximum census for either Inpatient or Emergency Department Services. Burn Surge, due to the complexity and resource demand of the patients, can occur a a much lower patient number where maximum census has not occurred.
A Burn Surge Event that exceeds the capability of Carolina Hospital to care for the influx of patients will require the activation of the Medical Surge Plan, declaration of an internal disaster, and elements if not all of the Emergency Operations Plan. The medical center is not directly affected by the burn event or by another emergency event and is physically capable of handling patients. Adequate staffing is available as need is determined The hospital s emergency operations center will be activated if the burn surge annex or the medical surge plan is implemented. CONCEPT OF OPERATIONS The concept of operations of the Burn Surge Annex consists of those elements in addition to the Carolina Hospital Medical Surge Plan or that are unique to the burn surge event. This annex is not meant to replace the medical surge plan, it is meant to augment its performance during a burn medical disaster. Command and Management This annex will identify triggers and decision making processes for a Burn Surge Event including the activation of the Hospital Surge Plan, the Hospital BSP or Annex, and as necessary the Hospital EOP. Initial assessment of the event type, scope and magnitude, estimated influx of patients, real or potential impact on the hospital, and special response needs. The Hospital Emergency Manager will activate the Hospital EOP and the Medical Surge Plan as needed for the event. The Hospital Emergency Manager will handle all out of facility local government and state contacts as he or she deems necessary. The Hospital EOP will identify these local government and state contacts. Activate Internal notification/communications and staff call back protocols (call trees, contact information, etc.). Ensure a higher priority is given to those staff members that have advanced burn education. Establish ongoing communications with local Burn Center Hospital to report hospital status, critical issues and resource requests. The local Burn Center, known as the primary burn center, will activate the NC Burn Coordination Center as needed per the North Carolina Burn Surge Plan. The North Carolina Burn Coordination Center will coordinate transport destinations for burn patients.
Activation of resource management system including inventory, tracking, prioritizing, procuring and allocating of resources. Burn Supplies should be requested through the Hospital Emergency Manager Several of the SMAT IIs maintain a cache of burn supplies for rapid deployment. Creating Conventional and Contingency Surge Capacity Immediate Response: Assume when a burn medical disaster event is in the patient catchment area of Carolina Hospital that we will be receiving burn patients that will require triage, treatment, and transfer to a burn care facility. Also assume that in the situation where the burn center is overwhelmed Carolina Hospital will be responsible for burn care for up to 24 hours in conventional and contingency burn surge events and possibly up to 72 hours in a crisis (catastrophic) burn surge event. Triage: Activate and operate additional/alternate triage area(s) during a burn surge event. The activation of the Triage system should be outlined in the hospital surge plan. When possible in the Burn Medical Disaster burn patients need to be triaged to inpatient care treatment areas due to the inherent complexities of the burn injury. Recognize however that this may not be an option in a catastrophic event. Burn Patient Triage plan should follow the hospital triage guidelines for burn patients as outlined by the North Carolina Burn Disaster Program Field Operations Guide (See Appendix A) Assumption: Medical Triage area activation and operations are outlined in the hospital s surge plan. The activation triggers for establishing alternate/additional triage areas are defined in the Carolina Hospital Medical Surge Plan. The number of burn patients required to meet the threshold of a surge event will depend on the patient s criticality and is normally much less than the number that is used to activate the hospital s surge plan. A small number of critical burn
patients can quickly exceed capability due to the complexity of care and supply and personnel demand. Decontamination: Plan to activate and perform decontamination, as necessary and outlined by the Carolina Hospital Medical Surge Plan and/or Carolina Hospital Emergency Operations Plan (EOP) for patient decontamination during a surge event. Holding Areas: Activation of in patient / in facility holding areas for burn patients in a Burn Medical Disaster is outlined and identified in the Carolina Hospital Medical Surge Plan. These areas will be used for those burn patients awaiting further triage, further decontamination, treatment, admission, or transfer. Treatment Areas: Activation of in patient / in facility surge treatment areas for patients of a Burn Medical Disaster are outlined and identified in the Carolina Hospital Medical Surge Plan. Security Facility / Treatment Area / Alternative Site Access during a Burn Medical Disaster Event is outlined in the Carolina Hospital Medical Surge Plan and the Carolina Hospital Emergency Operations Plan. Direct Patient Care Areas If the need arises where the Burn Medical Disaster Event exceeds the capabilities of Carolina Hospital s primary and alternate care areas then the Hospital Emergency Manager will communicate and coordinate the activation (through local and state emergency management) of local community, regional, state, and or federal assets to expand patient care areas. Examples of these resources would be the SMAT II and the National Mobile Disaster Hospital (MDH). Transport The Hospital Emergency Manager (HEM)will communicate and coordinate with the transportation of patients to be transferred. The HEM should ensure that appropriate measures are taken so that local EMS transport resources are not overused. The HEM will coordinated with local and state Emergency Management to activate alternative transport means as needed (e.g. SMRS, AST, Medical Buses)
PERSONNEL Staffing: Staffing needs and staff type during a Medical Surge Event are identified in the Carolina Hospital Medical Surge Plan. During a Burn Medical Disaster staff priority to care for burn patients will also include those staff members with advance burn care training. Additional staff will be requested as requested through the Hospital Emergency Manager (HEM). Burn Specific JIT Training will be delivered to staff resources that are not or minimally trained in appropriate burn care. Staff with Advanced Burn Training may be asked to function as a team leader, during high patient demand, to those staff members that do not have burn specific training. Staff/Family Needs: In the event there is sufficient lead time for an event ask staff members to prepare for an extended period of augmented schedules. This would include assisting staff to make a family disaster plan. Ensure internal or external arrangements to care for staff members and potentially staff dependents. This could include board and lodging and any other special needs that the staff might have. This is done to encourage staff to be at work during a period of augmented work hours. This should extend to pet care as possible. The Hospital Emergency Manager can assist with this task as requested. Secondary to the high stress load that is inherent to Burn Medical Disasters, Mental Health Professionals (Counselors) will be available on site to assist staff members by monitoring for stress induced and physical health concerns.
SUPPLIES, PHARMACEUTICALS AND EQUIPMENT The Carolina Hospital Medical Surge Plan addresses SPE for patients and staff during a surge event. Because of the uniqueness and high resource demand caused by a Burn Medical Disaster, a burn cache equipment list is maintained in Appendix C. If the in house burn equipment cache is not sufficient for the Burn Medical Disaster than a request should be placed to the Hospital Emergency Manager to request Burn Cache, as available, from your regional SMAT II. IMPORTANT CONSIDERATIONS Communication: Primary Communications contact with the local burn center or the NC Burn Coordination Center when stood up in a Burn Medical Disaster will be handled via land line phone systems. In the event that this primary communications means is lost then the Hospital Emergency Manager (HEM) will be responsible for identifying a secondary means of outside facility communication. This could be in the form of mobile phones, radio equipment, or internet based computer transmissions to name a few. Behavioral Health Needs: A burn surge event can take a devastating toll on staff who are not accustomed to those types of injuries. The patient and family needs will also differ from a normal surge event due to the magnitude, unsightliness and devastation of the injuries. Mental Health Professionals will be made available from hospital staff or through the employee assistance program during and after the crisis. On staff Mental Health Professionals (through the hospital s current social services structure) will be made available to family members during their stay at Carolina Hospital and referrals will be made upon family request upon discharge. Media Communication: Media communications will be handled through existing pathways as delineated by the Emergency Operations Plan.
Documentation: Documentation and tracking of patients will be through their the pre existing medical surge triage process. Minimal burn specific data will however need to be gathered, especially for those patients being transferred to a burn center. Burn specific information will include Burn Type, Body Surface Area Burned, Urinary Output, and other specific information. CREATING CRISIS SURGE CAPACITY The Burn Surge Annex does not directly identify or address the alternate care facilities and resources that may be need in a Crisis Event however it is common for such facilities to be set up in tents in parking lots, etc. Burn injured patients are however extremely difficult to manage in these types of environments and every effort should be made however to keep burn care areas out of these alternate care sites. Registered out of facility staff with burn care knowledge may also be available per request through the Hospital Emergency Manager. He should request personnel though the hospital emergency manager who should in turn request such assets through the local or state emergency management. The most expeditious way to request these volunteers is through ESAR VHP at the federal level or ServNC on the North Carolina level.
Burn Surge Annex Response Process Trigger: Indication of a potential surge of Burn Injuries. This could be the declaration of a Burn Medical Disaster (BMD) either externally by EMS or internally by hospital staff. Initial Assessment: Identify or estimate as best possible the event type, scope, magnitude and estimated influx of patients. What is the real or potential impact on the hospital? Are there any special needs requests? Activation: Activate the Medical Surge Plan and the Burn Surge Annex. Hospital Emergency Management (HEM) should be notified by plan at this point and the Emergency Operations Plan should be activated as needed by HEM. Notification: Internal notification and communications and staff call back systems. Highest staff call back should be given to those staff members with advanced burn education. Establish: Establish ongoing communications with the local burn center hospital to report hospital status, `any critical issues and resource needs. Resources Activate the resource management system including inventory, tracking, prioritizing, procuring and allocating resources. Burn supplies should be requested through hospital emergency management.
Carolina Hospital Burn Surge Annex Appendix A NC Burn Disaster Program Field Operations Guide
Carolina Hospital Burn Surge Annex Appendix B NC Burn Disaster Program NC Hospital Burn Surge Plan Checklist
Carolina Hospital Burn Surge Annex Appendix C NC Burn Disaster Program Burn Transfer Form