HEALTH CARE

Multidisciplinary team response to a mass burn casualty event: outcomes and implications

Heather J Cleland, David Proud, Anneliese Spinks and Jason Wasiak

n 7 February 2009, devastating ABSTRACT bushfires in the state of caused one of Australia’s worst-ever Objectives: To describe the characteristics of patients with burn injury admitted to a O major trauma hospital in Melbourne following the of 7 February disasters. There were 173 people killed and more than 400 injured in the “Black Satur- 2009, and to provide a detailed analysis of the hospital’s response to the crisis. day” fires.1 Thousands of dwellings and Design, setting and participants: A retrospective chart review of ambulance and other infrastructure were destroyed. As a hospital records of patients admitted to the Victorian Adult Burns Service (VABS) at The Alfred Hospital (The Alfred) following the bushfires. resultThe of theMedical fires, Journal 19 patients of Australia with burnISSN: Main outcome measures: Patient characteristics and outcomes: age, sex, total and full injuries0025-729X were admitted 6 June to2011 The 194 Alfred 11 589-593 Hospi- tal (The©The Alfred), Medical a major Journal trauma of Australia hospital 2011 in thickness body surface area burnt, type and site of burn, hospital and intensive care unit Melbournewww.mja.com.au that houses the Victorian Adult length of stay (LOS) and receipt of standard burn care practices. Estimated glomerular BurnsHealth Service care (VABS). VABS is the state’s filtration rate, theatre time and LOS data for the bushfire cohort compared with only adult burns service, treating 250–300 corresponding data for historical cohorts from VABS and from a similar institution in acute burn-injured inpatients each year. New Zealand. Severe burn injury is an uncommon event Results: Nineteen patients were admitted to VABS over the first 48 hours after the in Western societies, and it is well recognised bushfires. Of these, nine patients were subsequently admitted to The Alfred’s intensive that burn health care resources are soon care unit. Most patients (74%) were men with a mean age of 52.7 years (SD, 12.4 years). overwhelmed by relatively small numbers of Seventeen patients (89%) underwent at least one surgical procedure, which resulted in patients with significant burn injuries in a 4355 minutes of theatre time for the bushfire cohort in the first week. Hospital LOS was mass casualty setting.2 Victoria’s mass casu- similar for the bushfire and New Zealand cohorts. Compared with the VABS historical alty burns plan defines a mass burns casualty cohort, there was a higher incidence of abnormal renal function among the bushfire as an event causing burns injuries that exceed cohort patients. or are likely to exceed the ability of the burns Conclusions: Although relatively few patients with severe burns were admitted to VABS, unit to manage them (five or more severe significant increases in resource allocation were required to manage them in terms of burn injuries is the figure used as a guide).3 additional theatre time, consumables and staffing. The experience of VABS may aid Reports of bushfires in Canberra4 and San planning for future mass burns casualty events. Diego5 have focused on pre-hospital plan- ning and emergency department manage- MJA 2011; 194: 589–593 ment rather than the overall experience of a multidisciplinary unit. In recent Australian 2009 bushfires. We collected data from %TBSA12 from the National Burn Centre at history, the most similar event was the Ash Ambulance Victoria records, and from The Middlemore Hospital, Manukau, New Zea- Wednesday bushfires of 1983 in which 75 Alfred’s VABS data registry and operating land,13 which serves a similar population people died;6 however, the medical litera- theatre and intensive care unit (ICU) data- base to that of VABS.14 The Alfred’s finance ture on these fires relates to psychological bases. This provided information on department provided data on costs, and indi- trauma.7,8 Mass casualty events that have patients’ age, sex, percentage of total body vidual units and departments provided infor- been studied in terms of burn centre surface area burned (%TBSA), percentage of mation on additional resource allocation. responses include the terrorist attacks in full thickness body surface area burned 9 New York, NY and Washington, DC in (%FTSA), type and site of burn, hospital Data analysis 2001,10 and Bali in 2002.11 and ICU length of stay (LOS), and standard All data were managed and analysed using Our study describes the characteristics of burn care practices, including fluid resusci- Microsoft Excel (Microsoft Corporation, admitted patients, analyses the hospital tation therapies, number of surgical proce- Redmond, Wash, USA) and OpenEpi (Open response, and highlights the resource dures and overall operating theatre time. Source Epidemiologic Statistics for Public requirements for an adequate response to For each case patient, a series of historical Health, version 2.3.1; http://www. this incident. The circumstances of the inju- control patients were selected to compare openepi.com). Continuous data are pre- ries placed a number of these people at high renal function (measured by estimated sented as mean (SD) for symmetrical data, risk of infective and other complications. glomerular filtration rate [eGFR]) and LOS and as median (interquartile range [IQR]) or post-burn injury. The control patients were odds ratio (OR) (95% CI) for asymmetrical identified from the VABS database over a 12- METHODS data. month period (April 2008 to April 2009). Data collection Each control was matched for age (±10 years), A retrospective chart review was performed sex, ICU admission and %TBSA burns. Ethics on all patients who were admitted to VABS For broader comparison, we obtained Our study was approved by The Alfred’s with burn injuries sustained in the February additional historical data on inpatient LOS/ human research ethics committee.

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1 Time intervals for stages of care for patients with burn injury admitted to the 2 Characteristics and injuries of Victorian Adult Burns Service (VABS) following the February 2009 bushfires patients admitted to the Victorian Adult Burns Service following the No. of Mean Range February 2009 bushfires Time interval patients (hours) SD (hours) Receipt of documented first aid 8 (42%) 2.17 2.80 0–8 Characteristic/injury No. of patients Time to documented ambulance arrival 14 (74%) 2.16 2.02 0.33–8 Sex Time from injury to VABS 19 (100%) 6.62 4.92 1.13–20 Male 14 (73.7%) Female 5 (26.3%) RESULTS patients (32%) required the use of cadaver Age (years) skin due to contaminated wound sites. Total <35 1 (5.3%) Transport from scene to VABS operating theatre time and operating time by 36–49 6 (31.6%) Nineteen patients injured in the Black Satur- %TBSA are shown in Box 3. There was an 50–64 8 (42.1%) day bushfires were admitted to VABS. Each average requirement of 16.5 minutes of patient’s trauma triage flow sheet and history operating time and 26.1 minutes of total 65 4 (21.1%) detailing pre-hospital first aid interventions theatre time per %TBSA. All primary surgery TBSA and treatments by Ambulance Victoria were was completed by Day 33 (Box 4). After the < 10% 5 (26.3%) analysed (Box 1). first week, there was a rapid decrease in 10%–19% 7 (36.8%) theatre-time requirements (Box 5). Histori- 20% 7 (36.8%) Admission to VABS cal data from Middlemore Hospital shows a FTSA The characteristics of patients admitted to comparable theatre-time requirement of <10% 12 (63.2%) VABS are shown in Box 2. Patients were 22.8 minutes/%TBSA burn for patients with mostly men, with a mean age of 52.7 years burns > 10% TBSA, with operating time 10%–19% 2 (10.5%) (SD, 12.4 years; range, 31–77 years). Nine greatest in the first week and roughly halv- 20% 5 (26.3%) 12 of the 19 patients were admitted to the ICU ing in each subsequent week. Burn location with burns ranging up to 50% TBSA Hands 15 (78.9%) Complications (mean = 18.4%; SD, 14.5%). The %FTSA Upper limbs 14 (73.7%) ranged up to 35% (mean = 11.0%; SD, Complications are summarised in Box 6. Many Feet 7 (36.8%) 12.6%). All patients received intravenous patients had a common history of wound fluid resuscitation in the first 24 hours of contamination through contact with water in Lower limbs 12 (63.2%) injury (mean = 7.26 mL/kg/%TBSA; SD, 3.5 dams and cattle troughs, or with dirt and ash Head/neck 10 (52.6%) mL/kg/%TBSA; range, 3.62–16.25 mL/kg/ after injury. Given delays in transfer and diffi- Trunk 6 (31.5%) %TBSA). Data on urine output are not pre- culty ensuring adequate clinical wound sur- TBSA = total body surface area burned. sented, as urine output was not recorded for veillance, we considered infection risk to be FTSA = full thickness body surface area burned. ◆ all patients. Injuries were predominantly elevated. Thus wound cultures and specimens caused by radiant heat, with most patients were obtained at every dressing change and suffering burns to their hands, upper and theatre visit, with all positive cultures treated Eleven of the 17 surviving patients were lower limbs, and head and neck region (Box with antibiotics. Repeated bronchoscopies discharged to a hospital-in-the-home pro- 2). Other injuries included four inhalational were performed in patients with evidence of gram. The LOS in this program ranged from injuries (21.1%), two corneal abrasions inhalation of dust and smoke. 7 to 29 days (mean = 17 days; SD, 6.3 days). (10.5%), one foreign body injury (5.3%), Three patients were discharged to another and a likely episode of severe hypoxia. Hospital and recovery outcomes hospital or rehabilitation facility, and three were discharged home. Of the 19 patients admitted to VABS, two The extra resource allocations required in Surgical response died in hospital: one presented with multi- various departments are shown in Box 7. Seventeen patients (89%) underwent at least system organ failure and did not recover; the one surgical procedure (mean = 2.6; SD, second died of respiratory failure due to Additional costs for hospital medical officers 2.04; range, 0–8), with a mean total operat- fungal airway infection superimposed on and consultants were estimated at ing time of 350.1 minutes (SD, severe inhalation injury. A$64 000, and extra operating theatre costs 292.9 minutes). Thirteen patients (68%) Duration of hospital LOS ranged from 0 (staffing and consumables) for the month of underwent a surgical procedure in the first to 46 days (median = 22 days; IQR, 11.75– February were estimated to be A$61 500. 24 hours after injury, of which two occurred 29.5 days). Nine patients were admitted to Inpatient LOS/%TBSA was similar for at other hospitals. Six patients required at the ICU, with LOS ranging from 2 to 24 both the VABS bushfire and the Middlemore least one emergency escharotomy, and eight days (median = 13.5 days; IQR, 6.25–16.5 Hospital cohorts (1.0 days and 1.1 days, patients required transfusion of packed red days). Nine patients required mechanical respectively). blood cells during their admission (mean = ventilation (mean hours ventilated = 222.1; Median hospital LOS was greater for the 17.5 units; SD, 13.1 units; range, 1– SD, 118.9). Time to wound healing in days VABS bushfire cohort than for the VABS 42 units). Synthetic skin substitutes were was reported in 13 patients (mean = 39.7 historical cohort (21 days [IQR, 12–27 days] used in nine patients (47.3%) and six days; SD, 13.6 days). v 13 days [IQR, 4–28.5 days]). The VABS

590 MJA • Volume 194 Number 11 • 6 June 2011 HEALTH CARE bushfire cohort had a higher inci- estimated that for the state of 3 Theatre usage time following the Victorian dence of acute renal impairment , five adult patients bushfires, by percentage of total burn surface area (defined by abnormal eGFR levels) with massive burns would con- (%TBSA), February–March 2009 compared with those of the VABS sume all normal burns unit historical cohort (68% v 55%; OR, 1200 Theatre time resources for at least 3 months, 1.75 [95% CI, 0.55–5.59]). 1000 after requiring a minimum of 5 Operating time 800 hours each of surgery per week for 17 600 the first 3 weeks. A patient with DISCUSSION > 50% TBSA burns has insufficient 400 Burns > 20% TBSA are considered donor sites to provide early defini- 200 “severe” in the setting of a mass tive wound closure, and is prone casualty incident, and seven Theatre usage (minutes) 0 to a multitude of complications, 0–9 patients admitted to VABS as a 10–19 20–29 30–39 40–49 50–59 making for a highly idiosyncratic result of the bushfires had what is clinical course. Add to this the fact % TBSA defined as a severe burn injury. To that these are relatively uncom- put this in context, an average of mon injuries (most Australian 35 patients a year in the state of 4 Daily theatre usage following the Victorian burns units would admit around three to four such patients a year, Victoria received burns of bushfires, February–March 2009 > 20% TBSA in the years 2000– some of whom might be treated 15 1200 palliatively), and it becomes very 2006. Theatre time difficult to produce meaningful The requirement for ICU beds Operating time when treating burn patients is fre- 1000 average data. The presence of peo- quently the limiting factor in the ple with burns > 50% TBSA in a acute response to mass casualty 800 mass casualty cohort increases incidents,16 as patients with airway both acute and longer-term resource requirements exponen- injury or extensive burns necessi- 600 tating large doses of opiates for tially, as well as greatly extending the length of time of increased analgesia require intubation and 400 demands, and would significantly ventilation. The acute creation of Theatre usage (minutes) complicate decision making with 10 additional ICU ventilator beds 200 respect to resource allocation. The at The Alfred has been docu- recently established Australia and mented elsewhere.1 0 New Zealand Bi-National Burns Disaster plans focus on the 8 10 12 14 16 18 20 22 24 26 28 2 4 6 8 10 12 Registry will provide comprehen- triage and distribution of casualties Feb 2009 Mar 2009 sive data on these uncommon to hospitals. While it has been injuries and aid in predicting increasingly recognised in recent resource requirements. years that burns patients require 5 Total weekly theatre usage following the Victorian The ability to provide early total large amounts of resources — bushfires, February–March 2009 burn wound excision is crucial in human, infrastructural and con- 5000 Theatre time minimising complications in sumable — what this actually 4500 burns patients18 — especially in means in terms of capacity is diffi- 4000 Operating time those with severe burns cult to quantify. The delayed 3500 (> 20% TBSA) who are at risk of demands on such resources are 3000 2500 developing systemic compli- 19 increasingly difficult to measure as 2000 cations — which consume extra time from the incident elapses, yet 1500 resources over increasing time burns patients have notoriously 1000 periods in an already pressured Theatre usage (minutes) prolonged and complex hospital 500 environment. A hospital respond- 0 stays, and require lengthy rehabili- Week 1 Week 2 Week 3 Week 4 ing to a mass burn casualty event tation and secondary surgery. must, as a priority, ensure that In terms of calculating what the Week 1 = 8–14 Feb 2009. Week 2 = 15–21 Feb 2009. theatres and surgeons are acutely ◆ theatre requirements of a particu- Week 3 = 22–28 Feb 2009. Week 4 = 1–7 Mar 2009. available to enable early excision lar burn patient are likely to be, for of severe burns. This strategy will the group with burns between 10% and provide appropriate care for the cohort of minimise ongoing demands for resources 50% TBSA, 21 minutes of theatre time per patients with 10%–50% TBSA burns. Thea- and ensure best outcomes for patients. If %TBSA burn for the whole inpatient stay tre demands are maximal in the first week excision is delayed, complications increase, would seem to provide a reasonable esti- and decrease rapidly thereafter, at least halv- hospital stays drag out, and the drain on mate, based on experiences at Middlemore ing in each subsequent week. resources limits the institution’s ability to Hospital and VABS. This estimate can be However, attempts to predict the require- return to business as usual quickly. used in the event of a mass burn casualty ments of patients with massive burns are far In the aftermath of the 2009 bushfires, event to determine the ability of a hospital to more problematic and uncertain. It has been VABS was able to continue to admit and

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lost family members, homes, livestock and COMPETING INTERESTS 6 Post-burn injury complications in their livelihoods. They had significant loss patients admitted to the Victorian None identified. and grief issues. In addition to the provision Adult Burns Service of medical treatment, The Alfred dealt with AUTHOR DETAILS Complication No. of patients media issues, provided psychological sup- port, and responded to the social needs of Heather J Cleland, MB BS, FRACS, Director1 Infective these patients and their families as part of David Proud, MB BS, Surgical Trainee1 2,3 Blood stream infection 2 (10.5%) the statewide response to this unpre- Anneliese Spinks, PhD, Research Fellow Jason Wasiak, MPH, Research Fellow1 External auricular abscess 1 (5.3%) cedented catastrophe. There were relatively few patients with 1 Victorian Adult Burns Service, The Alfred Urine 1 (5.3%) Hospital, Melbourne, VIC. severe burns admitted as a result of the Chest infection 2 CSIRO Ecosystem Sciences, Brisbane, QLD. bushfires when compared with the number 3 organisms 2 (10.5%) 3 School of Medicine, Griffith University, of lives lost. This may reflect the extreme Meadowbrook, QLD. 2 organisms 2 (10.5%) conditions created by the experi- Correspondence: [email protected] 1 organism 1 (5.3%) enced on 7 February 2009 and that most Positive wound culture 4 (21.1%) people trapped by the fires perished. None- donor site theless, significant increases in resource allo- REFERENCES Non-infective cation were required to manage the 1 Cameron PA, Mitra B, Fitzgerald M, et al. Black survivors with burn injuries. Analysis of this Saturday: the immediate impact of the Febru- Perioperative respiratory 1 (5.3%) resource allocation can assist in planning for ary 2009 , Australia. Med J arrest Aust 2009; 191: 11-16. future mass burn casualty incidents. Missed subcutaneous 1 (5.3%) 2 Cassuto J, Tarnow P. The discotheque fire in Gothenburg 1998. A tragedy among teenag- foreign body ers. Burns 2003; 29: 405-416. Non-healing wound 2 (10.5%) ACKNOWLEDGEMENTS 3 Victorian Government Emergency Manage- requiring split skin graft We thank Richard Wong She, Department of Plastic, ment Branch. Victorian mass casualty burns Reconstructive and Burn Surgery, Middlemore Hos- plan. Melbourne: Department of Human Serv- Failed grafting requiring 1 (5.3%) pital, Auckland, New Zealand, for providing us with ices, 2006. http://www.dhs.vic.gov.au/__data/ regrafting additional patient data. In addition, many staff assets/pdf_file/0005/69791/burns_subplan_ Retained staples requiring 2 (10.5%) members in many departments throughout The 2006.pdf (accessed Jan 2011). anaesthetic for removal Alfred, as well as volunteers, contributed an extraor- 4 Richardson DB, Kumar S. Emergency response dinary amount of unpaid time and effort to ensure to the Canberra bushfires. Med J Aust 2004; that the Burns Service and the rest of the hospital 181: 40-42. continued to function smoothly and provide a high 5 Vilke GM, Smith AM, Stepanski BM, et al. treat all patients who met the criteria for standard of care to all patients and their families. Impact of the San Diego county on transfer to a specialist burns unit according to the Australia and New Zealand Burn Association guidelines. However, in a true 7 Extra staff* allocated to the Victorian Adult Burns Service in the aftermath of mass casualty situation, patients with burns the February 2009 bushfires < 20% TBSA may well require admission to a non-specialist facility in order to allow the Department Level Extra staff Comments specialist burns referral centre to continue Acute Pain Service Pain nurse 1 Immediate acute doubling to manage more severe and complicated Pain consultant 1 of workload burns injuries. The amount of fluid resuscitation in the Infectious Diseases Registrar 0.25 Plus 100 hours of overtime for laboratory staff VABS bushfire cohort is comparable to Consultant 0.25 results previously obtained at the same insti- Junior Medical Staff Resident 1 20 tution. The mean amount of fluid received Nursing Clinical nurse specialist 2 An extra 296 nursing hours exceeded that calculated by the Parkland (ward) allocated over 6 weeks formula and reflects the recent trend Nutrition Nutritionist 0.35 Initial tripling of workload towards “fluid creep” in burns resuscita- Occupational therapy Occupational therapist 1 tion.21 However, many of the patients were dehydrated on presentation through a com- Allied health assistant 0.5 bination of burns injury, high ambient tem- Physiotherapy Physiotherapist 1 peratures (> 46°C) and delayed presentation Allied health assistant 0.5 to hospital. The increased rate of renal Psychiatry Psychiatry nurse 1 Provided staff support impairment compared with the matched Psychiatry registrar 1 service in addition to patient cohort may reflect this. The infectious com- care plications in patients with histories of expo- Psychiatry consultant 0.5 sure to contaminated water are in keeping Social work Social worker 1 Provided patient, family and with recent literature.22 Social worker (after 0.5 staff support and assistance It is important to recognise that victims of hours service) a mass casualty event have needs beyond * Full-time equivalent. ◆ medical treatment. Many of our patients had

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emergency medical services. Prehosp Disaster 11 Palmer D, Stephens D, Fisher DA, Spain B, et 17 Greenwood JE, Mackie IP. Factors for consider- Med 2006; 21: 353-358. al. The Bali bombing: the Royal Darwin Hospi- ation in developing a plan to cope with mass 6 Australian Government Bureau of Meteorology. tal response. Med J Aust 2003; 179: 358-361. burn casualties. ANZ J Surg 2009; 79: 581-583. Climate education. Ash Wednesday, Feb 1983. 12 Phua YS, Miller JD, Wong She RB. Total care 18 Mosier MJ, Gibran NS. Surgical excision of the http://www.bom.gov.au/lam/climate/level- requirements of burn patients: implications for burn wound. Clin Plast Surg 2009; 36: 617-25. 19 Chrysopoulo MT. Acute renal dysfunction in three/c20thc/fire5.htm (accessed Jan 2011). a disaster management plan. J Burn Care Res severely burned adults. J Trauma 1999; 46: 141- 7 McFarlane AC, Raphael B. Ash Wednesday: the 2010; 31: 935-941. 144. effects of a fire. Aust N Z J Psychiatry 1984; 18: 13 HealthPoint. Auckland Regional Burn Service/ National Burn Service. http://www.health- 20 Mitra B, Fitzgerald M, Cameron P, Cleland H. 341-351. point.co.nz/default,28348.sm?location=3727 Fluid resuscitation in major burns. ANZ J Surg 8 Valent P. The Ash Wednesday bushfires in Vic- (accessed Jan 2011). 2006; 76: 35-38. toria. Med J Aust 1984; 141: 291-300. 21 Tricklebank S. Modern trends in fluid therapy 14 The World Bank. Data. New Zealand. http:// for burns. Burns 2009; 35: 757-767. 9 Yurt RW, Bessey PQ, Bauer GJ, et al. A regional data.worldbank.org/country/new-zealand 22 Ribeiro NF, Heath CH, Kierath J, et al. Burn burn center’s response to a disaster: Septem- (accessed Jan 2011). wounds infected by contaminated water: case ber 11, 2001, and the days beyond. J Burn Care 15 Wasiak J, Spinks A, Ashby K, et al. The epide- reports, review of the literature and recommen- Rehabil 2005; 26: 117-124. miology of burn injuries in an Australian setting, dations for treatment. Burns 2010; 36: 9-22. 10 Jordan MH, Hollowed KA, Turner DG, et al. The 2000–2006. Burns 2009; 35: 1124-1132. Pentagon attack of September 11, 2001: a burn 16 Barillo DJ, Wolf S. Planning for burn disasters: Provenance: Not commissioned; externally peer center’s experience. J Burn Care Rehabil 2005; lessons learned from one hundred years of reviewed. 26: 109-116. history. J Burn Care Res 2006; 27: 622-634. (Received 21 Sep 2010, accepted 17 Feb 2011) ❏

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