"After The Fire"; The Legacy of College Dormitory Fire Twenty Years Later.

In January of 2000 the team at The Burn Center at Saint Barnabas was confronted with what is to date, the single largest burn mass casualty incident since its doors opened in 1977. Looking back through history at other catastrophes shows that, even in the wake of these "landmark events", the lessons learned remain, so that perhaps all was not in vain. 2, 6, 7, 8, 9, 11, 13, 19 While this fire took place more than twenty years ago, its legacy is still being felt today. The following discussion examines some of the key lessons learned, and underscores the fact that positive change does come from tragedy.

Determining Immediate Burn Bed Availability to Support Regional Disaster Response.

Determining burn bed availability from the start of a disaster is critical to emergency response efforts, yet continues to be one of the most elusive aspects for planners to anticipate. Healthcare providers agree that, over time, burn centers (BCs) can and will move patients, activate staff, and bring in supplies to meet surge needs. The real challenge lies in identifying how many beds will be immediately available to handle any initial surge of patients. A consortium of 27 BCs in the northeast participates in a telephone bed census program. Although only accurate at the time of each call, clinical staff is asked to report the number of open ICU and/or step-down beds. Retrospective review of 86 Burn Bed Census (BBC) reports was conducted over an 8-year period. Data were statistically analyzed for total, absolute minimum, mean, SD and linear trend analysis. The mean for immediately available beds from January 2009 through December 2016 is 72; with monthly averages ranging from 62 (7%) average available beds in January to 78 (9%) average available beds in November. Monthly SDs range from 6 in July to 17 in November. One goal for disaster planners is to approximate a number of immediately available beds without overwhelming any one BC with too many patients. Utilizing this model enables planners and clinicians throughout the northeast to predict potential burn bed availability and make more reliable decisions about when and where to initially send patients.

District of Columbia Emergency Healthcare Coalition Burn Mass Casualty Plan: Development to Exercise Date.

The District of Columbia Emergency Healthcare Coalition (DC EHC) brought together a Burn Task Force to tackle the issue of mass burn care in a metropolitan area in light of limited local burn center resources. This article outlines the development of the mass burn care plan. Using a tiered treatment approach, mass burn victims would be transported first to burn centers within the area, followed by nonburn center trauma centers, and finally to nonburn and nontrauma center acute care facilities. Once activated the Burn Task Force would triage and coordinate transfer of mass burn patients within the District for further care at burn centers using a strong link with the Eastern Regional Burn Disaster Consortium. This plan was exercised in the spring of 2014 to test all of the components. To strengthen mass burn care, this plan, put in place for the District of Columbia, has been expanded to include the National Capital Region as well.

What's in a Name? Recent Key Projects of the Committee on Organization and Delivery of Burn Care.

The Committee for the Organization and Delivery of Burn Care (ODBC) was charged by President Palmieri and the American Burn Association (ABA) Board of Directors with presenting a plenary session at the 45th Meeting of the ABA in Palm Springs, CA, in 2013. The objective of the plenary session was to inform the membership about the wide range of the activities performed by the ODBC committee. The hope was that this session would encourage active involvement within the ABA as a means to improve the delivery of future burn care. Selected current activities were summarized by key leaders of each project and highlighted in the plenary session. The history of the committee, current projects in disaster management, regionalization, best practice guidelines, federal partnerships, product development, new technologies, electronic medical records, and manpower issues in the burn workforce were summarized. The ODBC committee is a keystone committee of the ABA. It is tasked by the ABA leadership with addressing and leading progress in many areas that constitute current challenges in the delivery of burn care.

Developing and implementing a plan for large-scale burn disaster response in New Jersey.

For the first time in modern history burn centers must face the reality of having to potentially care for a staggering number of injured patients. Factors such as staffing, patient acuity and bed availability compel medical professionals to regularly examine various aspects of their respective healthcare delivery systems, especially with regards to how these systems should function for mass casualty response. The majority of burn care in New Jersey is provided by one designated burn treatment facility. A planning group was formed to identify additional hospital support systems capable of providing short-term patient care during a disaster. Focus was on three key areas: identifying actual versus potential nonburn center resources, ascertaining the number and level of burn expertise at these facilities, and assessing the capacities of any available resources and personnel. Retrospective review of discharge data highlighted which of the more than seventy New Jersey hospitals besides The Burn Center were treating and releasing burn injures. In a disaster The Burn Center designates these hospitals as Tier Facilities to serve as additional resources until patients may be transferred to other recognized regional and national burn centers. Triage is conducted in accordance with the American Burn Association Benefit-to-Ratio Triage grid, matching patient acuity with each hospital's tier designation. A secondary triage, conducted 24 hours after the initial incident, identifies which patients require transport for more specialized burn care. Twenty-seven burn centers from Maine through Maryland and the District of Columbia, who have joined together as a Consortium, agree to support one another for optimal patient distribution and management in accordance with accepted national standards of care. State Medical Coordination Centers equipped to coordinate and track transport of large numbers of injured personnel are able to facilitate this collaborative, multiagency response throughout the northeast region. Burn centers share many issues common to emergency preparedness. Paramount among them is an ability to provide quality burn care for the greatest number of patients at a time when staff and resources will be severely limited. It is incumbent upon burn centers to explore opportunities extending beyond individual state and regional resources in order for centers to continually maintain this standard of care, particularly in a disaster.

Disaster planning: the basics of creating a burn mass casualty disaster plan for a burn center.

In 2005, the American Burn Association published burn disaster guidelines. This work recognized that local and state assets are the most important resources in the initial 24- to 48-hour management of a burn disaster. Historical experiences suggest there is ample opportunity to improve local and state preparedness for a major burn disaster. This review will focus on the basics of developing a burn surge disaster plan for a mass casualty event. In the event of a disaster, burn centers must recognize their place in the context of local and state disaster plan activation. Planning for a burn center takes on three forms; institutional/intrafacility, interfacility/intrastate, and interstate/regional. Priorities for a burn disaster plan include: coordination, communication, triage, plan activation (trigger point), surge, and regional capacity. Capacity and capability of the plan should be modeled and exercised to determine limitations and identify breaking points. When there is more than one burn center in a given state or jurisdiction, close coordination and communication between the burn centers are essential for a successful response. Burn surge mass casualty planning at the facility and specialty planning levels, including a state burn surge disaster plan, must have interface points with governmental plans. Local, state, and federal governmental agencies have key roles and responsibilities in a burn mass casualty disaster. This work will include a framework and critical concepts any burn disaster planning effort should consider when developing future plans.

Burn disaster response planning in New York City: updated recommendations for best practices.

Since its inception in 2006, the New York City (NYC) Task Force for Patients with Burns has continued to develop a city-wide and regional response plan that addressed the triage, treatment, transportation of 50/million (400) adult and pediatric victims for 3 to 5 days after a large-scale burn disaster within NYC until such time that a burn center bed and transportation could be secured. The following presents updated recommendations on these planning efforts. Previously published literature, project deliverables, and meeting documents for the period of 2009-2010 were reviewed. A numerical simulation was designed to evaluate the triage algorithm developed for this plan. A new, secondary triage scoring algorithm, based on co-morbidities and predicted outcomes, was created to prioritize multiple patients within a given acuity and predicted survivability cohort. Recommendations for a centralized patient and resource tracking database, plan operations, activation thresholds, mass triage, communications, data flow, staffing, resource utilization, provider indemnification, and stakeholder roles and responsibilities were specified. Educational modules for prehospital providers and nonburn center nurses and physicians who would provide interim care to burn injured disaster victims were created and pilot tested. These updated best practice recommendations provide a strong foundation for further planning efforts, and as of February 2011, serve as the frame work for the NYC Burn Surge Response Plan that has been incorporated into the New York State Burn Plan.

'Just send them all to a burn centre': managing burn resources in a mass casualty incident.

Burn experts estimate that 20-30 per cent of injuries from mass casualty events result in serious burns, many requiring specialised care only available at burn centres. Yet, in the USA there are less then 1,850 burn beds available to provide such a level and quality of care. To address this concern, burn centres are beginning to put into practice new mass casualty triage and transport guidelines that must coordinate with local, regional and federal response plans, while still adhering to an accepted standard of care. This presentation describes how one US burn centre developed and implemented a Homeland Security Exercise and Evaluation Program (HSEEP) designed mass casualty incident (MCI) exercise focused on coordinating 'the right patient to the right facility at the right time', based upon acuity and bed availability. Discussion will enable planners to identify methodologies adaptable for incorporation into catastrophic emergency management operations within their regions.

Practice guidelines for deep venous thrombosis prophylaxis in burns.

Measures to prevent deep venous thrombosis (DVT), including low-dose subcutaneous heparin, low molecular weight heparin, or sequential compression devices, may be considered in high-risk patients, specifically those with a previous history of thromboembolic disease, and in patients with significant burns of the lower extremities. The purpose of this guideline is to review the principles of prophylaxis for DVT in burn patients and to present a reasonable approach for the treatment of patients during burn resuscitation. This guideline is designed to aid those physicians who are responsible for the triage and initial management of burn patients. DVT in the burn patient is a more common event than previously reported, with incidence ranging from 1% to 23% in the few available series. The suspected risk of bleeding using low-dose heparin has deterred most burn surgeons from using heparin routinely in all burn patients. Much remains unknown, however, regarding the real risks and benefits of this complication and its treatment. A Medline search of all English language citations from 1966 through 2006 was undertaken using the key words "deep vein thrombosis" and "deep venous thrombosis" with "burns." This produced 18 references. The addition of the key words "pulmonary embolism" with "burns" produced a total of 82 references, of which 7 were felt to be relevant to this topic based on evidentiary classification of the data. There are no prospective, randomized, controlled studies evaluating the effectiveness of any prophylactic preventive measures against DVT in burn patients. The apparently low incidence of this condition in burn patients would appear to preclude its evaluation in a single-center study, and no multicenter studies have been conducted.