Simulation-assisted burn disaster planning.

Simulation exercise

Performance indicators:Assess and evaluate content of alarm Declaration of major incident for regional health care within own region Decision on level of alert for staff Establish contact with burn centre within own region (local level) Establish contact with burn centre in other region Establish contact with affected region Deliver preliminary referrals for burns Decide on inventory; ensure the base information for a more definitive distribution of burnsFormulate general guidelines for national burn response and coordinationCreate basis for first bulletin (internal + external)Assess whether national coordination of ambulance transport resources (EMS + HEMS) needs to be establishedEnsure that there is adequate information for decision on referrals (deliver definitive key for distribution of burns and notify all burn centres) Identify the need for cooperation with other national authorities and international networks based on the burn assessment Create base information for depiction of the national situation

A draft of a national burn response plan was developed in a consensus meeting process between the two national burn centres (Linkoping and Uppsala) and the regional disaster preparedness organizations of the two county councils (Ostergotland and Uppsala). The plan was based on national laws and regulations for disaster medicine preparedness for peacetime and the regional command and control system for major incidents. One important part of the plan was a designated national point of contact with a mandate to coordinate all burn care and directly convey expert support or patient distribution support to the affected county council concerning burns.Two simulations were conducted.

The core of the Emergo Train System1 (ETS) consists of a patient database with specific casualties and typical in-hospital patients that, together with specific staff and other types of resources involved in  emergency/disaster management, can be used to translate local prerequisites into the system. All ETS victims belong to a specific standardized injury category and each victim has a defined medical need within a certain period. The time taken for each measure is calculated according to a defined standard. If a patient’s specific need (e.g. airway intervention, pleural drainage, surgery or intensive care unit (ICU) assessment) is not met within the stipulated period, the patient risks an unfavourable outcome. This risk is expressed by the system as a risk for preventable death or a risk for preventable complications. Thus, at the end of a simulation exercise, it is possible to calculate and summarize patient outcome and relate the result to the treatment given and to other decisions made. The different injury categories have been developed in a consensus process with national experts within the fields of traumatology and disaster medicine and in accordance with evidence-based best practice of trauma care. The specific burn categories have been developed in consensus and collaboration with national burn experts in Australia and Sweden

The differences in the results between the two simulations were small but detectable and the reproducibility of the simulation was satisfactory. Further experimental simulations are needed with defined interventions to ascertain outcome and examine whether preventable deaths and complications can be reduced. Measurable performance indicators through the ETS, as used in the present study, are obtainable and can depict a more effective management response. The experience from the present simulations using a simulation system that combines both process and outcome indicators can create important results that may serve to support disaster planning. Future studies are needed to further explore how national coordination of air transportation can be optimized for a mass casualty incident in Sweden.

The result is that timely and accurate response from the regional medical command together with timely response from a national coordination function most likely had a positive impact on patient outcome in simulation II. In addition, the results indicate that a more precise distribution of casualties over short distances to regional hospitals and long distance with HEMS to university hospitals and burn centres can be an advantage. Thus, by timely and specific referrals, the on-scene time was also reduced. Second simulation has better outcome due to three reasons. First, despite the long transport distances, the early mobilization of resources from both the Swedish and Norwegian side of the border made it possible to start transportation to the nearest regional hospitals by ambulances after 45 min. Second, the early mobilization of ambulance helicopters from Norway with both anesthesia physicians and nurses was a factor that probably contributed to these results due to the possibility of performing life-saving airway interventions after 1 h. Third, measurable performance indicators used in simulation II were found by the participants to be applicable and probably stimulated the participants to perform more timely and effective management in simulation IIHowever, despite correct triage at the scene, four patients with blunt head trauma causing expanding intracranial hematoma were identified in the system as risk for preventable death in both simulations. These cases were prioritized as immediate  but did not receive airway intervention within the stipulated period of 1 h. To address this issue, it is important to note that it was the burn perspective that governed much of the simulation and burns were to some extent prioritized for long-distance helicopter transport to the burn centres. Furthermore, the present disaster scenario occurred in a rural area where the early medical needs exceeded the response capabilities. Under such circumstances, without aggressive treatment, severe head injuries can have a poor prognosis. Nevertheless, these patients were never triaged as expectants  and could perhaps have survived in the simulation if they had received a higher priority leading to early transportation by helicopter to a university hospital for neurosurgeryThe result of this study shows that a large part of the Swedish health care system would be involved in this type of event, which might have displacement effects on regular health care in the long term. Furthermore, lessons learned from other burn disasters are that the national specialized intensive care resources can quickly become saturated for a long period. Therefore, the need for additional use of burn beds in Europe would probably arise in the longer term. National planning in case of such needs is called for.In these two simulations, we found that, in rural areas of Sweden, the major challenge in coping with a mass casualty incident with many burn cases is due to the long distances to specialized trauma and burn care units. A significant limitation in these settings is the possibility of achieving rapid patient evacuation based on the accessibility of transport resources (e.g. ambulances and helicopters). During these simulations, the extent of air transportation and coordination of helicopters were shown to be a bottleneck and were identified as significant risk factors for an unfavourable outcome. The absence of predefined organization and coordination routines concerning air transport in a mass casualty event must be addressed further at the national level. Unfortunately, it was not possible to fully test this function during these simulations.The rapid establishment of cooperation between the two county councils where the two national burn centres are located was of importance for the timely response seen in the simulations. This national coordinating function for burn care was established early and in accordance with the proposed national burn response plan. Furthermore, it was operational at an early stage and provided support to the regional management group by developing strategies for the distribution of burns.

To evaluate the Swedish medical systems response to a mass casualty burn incident in a rural area with a focus on national coordination of burn care