1. Crisis Standards of Care: A Toolkit for Indicators and Triggers
Committee Meeting
Dr. Randy D. Kearns
DHA MSA CEM
Program Director, Burn Surge Disaster Program
Department of Surgery
Administrator, EMSPIC
Department of Emergency Medicine
January 15, 2013

2. • US Department of Health and Human
Services
– Office of the Assistant Secretary for
Preparedness and Response
– 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

3. • Burn – is a time sensitive injury/illness
• Small – but manageable patient population
• Data quality – small, easier troubleshoot,
better to understand gaps and anomalies
• Scalability – lessons learned have applicability
in other specialties
• Limited Supply of Critical Facilities

4. Verified Burn
Center, Co-
Located with a
Trauma Center
Verified Burn
Center, No
Trauma Center
Self Designated
Burn Center

5. • 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
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

6. Disaster plans should reflect an extension of daily
activities.
Planning from the burn center perspective should
reflect (minimally) three levels;
• 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

7. Planning from the governmental perspective should
reflect:
Local: First Responder (EMS system)
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

8. 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

9. • 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

10. • 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

11. • 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-
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.

12. • 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)
– 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

13. • Distribution Curve (normal)
– Data from NCJBC
• Coefficient of variation
– Average Daily Census/Standard Deviation
• 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

14. • 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
Simulations ESF-8 Approach, Hospitals/State Burn Center Resources
ESF-
X1 – 54 patients Y1 Home hospital – NC Jaycee Burn Center at UNC Hospitals
X2 – 130 patients
X3 – 38 patients Y2 Intrastate resources – WFUBMC, Wake Forest Baptist Health
X4 – 215 patients Y3 Virginia state resources – 4 Burn Centers
X5 – 243 patients
X6 – 500 patients Y4 Georgia state resources – 2 Burn Centers
X7 – 1,000 patients Y5 Tennessee state resources – 2 Burn Centers
X8 – 2,500 patients
X9 – 5,000 patients Y6 Remainder of Southern Regional Burn Centers
X10 – 10,000 patients

15. • 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
• 20-60 patients = Intrastate Plan Failure
• 425-450 patients = Interstate Plan Failure (Regional)

16. Surge Capacity (and Capability) includes the
– Staff
– 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.

17. • Probability is inversely proportional to
Capacity Demand (Y axis)
• Severity is a product of Capacity Demand +
Deployment Time (X axis)
• In economic terms, you would say the
American Healthcare Model is based on
Static Equilibrium
– Intersection point of supply/demand

18. 99.99%
Day to Day Capacity
Probability
Probability
Conventional Surge Capacity
Contingency Surge Capacity
Crisis Surge Capacity
0.01% Greater >
< Lessor Severity

19. • Goal
–Take all steps necessary to avoid or end
Crisis Surge Capacity as soon as possible
–Crisis Surge ends when…

20. • Staff • Patients
• Space Disaster – Ongoing Care
• Stuff
• Patients
• Transport – Discharged
– Transferred
– Expire
Surge Equilibrium: all competing influences are balanced

21. 99.99%
Probability
Probability
Goal: Return to
Day to Day Capacity
0.01% Greater >
< Lessor Severity

22. 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.

23. 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.

24. 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.

25. • 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

26. 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, 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