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 Victoria 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 Black Saturday bushfires 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. MJA • Volume 194 Number 11 • 6 June 2011 589 HEALTH CARE 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).