Ohio Statewide Burn Surge Tabletop Exercise

After-Action Report/Improvement Plan

Exercise Date: May 14, 2014

Report Date: June 9, 2014

The After-Action Report/Improvement Plan (AAR/IP) was developed from the evaluation of activities which took place during a explosion/mass casualty event resulting in a surge of burn patients to the hospitals across Ohio. This document contains compiled notes, evaluation points and feedback from participants, evaluators, and exercise staff.

Rev. April 2013

HSEEP-IP01

After-Action Report/ Ohio Statewide Burn Surge

Improvement Plan (AAR/IP) Tabletop Exercise

Exercise Overview

Exercise Name / Ohio Statewide Burn Surge Tabletop Exercise
Exercise Dates / May 14, 2014, 10am – 3pm
Scope / This exercise is a tabletop exercise, planned for five hours at the Bridgewater Conference Center in Powell, OH. Exercise play is limited to Regional Medical Coordination Centers, Regional Burn Coordinating Center, Regional Burn Surge Facilities, and State Coordinating Center within Ohio.
Mission Area(s) / Response
Core Capabilities / Healthcare System Preparedness
Information Sharing
Medical Surge
Objectives / 1.  Healthcare System Preparedness: Determine the number of patients each facility can care for based on census in dedicated and non-dedicated burn beds.
2.  Information Sharing: Evaluate the ability to coordinate information sharing and identify needs within the region and with the state coordinating center.
3.  Medical Surge: Determine the trigger points and process to activate the state burn surge plan vs. activation for a region.
4.  Information Sharing: Determine the appropriate mechanism of information sharing during a burn surge event within existing systems and resources.
Threat or Hazard / Explosion/ Mass Casualty
Scenario / It is a warm spring day in May. Hundreds of people are out enjoying the weather during their lunch break by visiting the Food Truck Food Court in Fountain Square in downtown Anytown, OH. The “Flaming Taco” truck is a popular option with people lining up to order. Suddenly a large explosion occurs emitting a large fireball from the Flaming Taco Truck, pushing patrons back and starting a fire in the truck. 911 has been called and first responders are on their way. It is initial estimated that more than 50 people are injured in the explosion including severe burns on at least 10 people who were inside and closest to the truck when the explosion occurred.
Sponsor / Federal funds through the U.S. Department of Health and Human Services, Assistant Secretary for Preparedness and Response Hospital Preparedness Program were used in the development of this exercise. Funds were distributed by the Ohio Department of Health to the Research and Educational Foundation of the Ohio Hospital Association.
Participating Organizations / A total of 36 participants/players participated in this exercise including representatives from hospitals, public health, and healthcare regional coordination centers. There were also four facilitator/evaluators and one facilitator.
Point of Contact / Carol Jacobson, RN
Director, Public Health Programs
Ohio Hospital Association
155 E. Broad Street, Suite 301
Columbus, OH 43215
614-221-7614

Ginny Schwartzer
Vice President/Owner
All Clear Emergency Management Group
3434 Edwards Mill Road, Suite 112-162
Raleigh, NC 27612
336-802-1800

Exercise Overview 1 Ohio Hospital Association

For Official Use Only

Homeland Security Exercise and Evaluation Program (HSEEP)

After-Action Report/ Ohio Statewide Burn Surge

Improvement Plan (AAR/IP) Tabletop Exercise

Analysis of Core Capabilities

The following sections provide an overview of the performance related to each exercise objective and associated core capability, highlighting strengths and areas for improvement. The discussion is broken out by table number to reflect the small group discussions that occurred during the exercise.

Table 1 - Discussion and Analysis

The strengths and areas for improvement for each module are described in the sections below.

Module 1: Initial Notification

Strength 1.1.1: Hospitals represented at this table were knowledgeable of the capabilities of the region and hospitals within the region.

Analysis: The Columbus area hospitals reported they would contact the Ohio State University Burn Center serving as the Regional Burn Coordinating Center (RBCC). The Akron area hospitals would contact Akron, or Allegheny Health was their backup if they needed to go out of state. Mansfield reported they had no burn bed capacity, but were geographically located in a manner they could access Columbus, Akron and Cleveland area burn centers. Depending on the area where the patients would be referred would depend on who they would contact to work with and coordinate transfer of their patients.

There are four verified burn centers in the Columbus, Cleveland and Akron areas. Generally speaking, Ohio State University Medical Center and Dorland Health CR Boekman Burn Center in Akron were identified within the group as primary points of contact depending on where the event took place and while the Columbus area seemed to have a better working knowledge of the planning that has taken place in Ohio, all discussed working with their area burn centers. Each of these burn centers also accepted their critical role for identifying what they could and could not manage during a burn disaster.

When asked what they would do if the event exceeded their regional capability, the general thought was the burn centers of Columbus, Akron and Cleveland would rely on each other. They also were aware of resources in Cincinnati, Pittsburgh, and Detroit with some discussion regarding the operational (albeit not verified) burn center in the Toledo area.

Area for Improvement 1.1.1: Not all hospitals are familiar with state burn surge plan and the roles contained within the plan.

Analysis: During plan activation discussion, many participants seemed unaware of or unfamiliar with the various roles within the state burn surge plan. While the role of the Regional Medical Coordination Center (RMCC) seemed to be assumed by the existing burn centers, there was limited awareness/understanding of the RBCC’s role in the context of the planning process.

Area for Improvement 1.1.2: Regional burn plans do not exist for all regions.

Analysis: The Central Ohio Region was the only region with a regional burn surge plan. There seemed to be lack of a well-defined plan for Regional Coordinator to Regional Coordinator interaction across adjoining regions. It was assumed that ESF 8 would play a pivotal role, but this should be a focus for future planning and exercise activity.

Module 2: Response: Patient Reception

Strength 1.2.1: Hospital representatives were knowledgeable of Hospital Incident Command System (HICS) and emergency management practices.

Analysis: Representatives for each of the hospitals represented, specifically their emergency managers, seemed to have a good grasp of HICS, general emergency management operations and command roles. Each seemed to be engaged and eager to get problems solved, and work together to that end. General disaster preparedness for those represented appeared to be excellent.

Strength 1.2.2: Each facility was familiar with existing internal resources and availability and the process for requesting additional assistance if necessary.

Analysis: Each facility identified their availability to stand up their resources, call in additional assistance for triage and initial care, and was well aware of which burn center they would refer their patients to and coordinate with (OSU and Akron) and other burn centers in the State if needed. While the processes they discussed were not entirely consistent with the plan, in general they would follow much of what they do whenever they have a burn injured patient. State and regional roles were discussed in the context of the need for potential state or regional resources.

Strength 1.2.3: Hospitals were comfortable with existing plans to triage burn patients upon arrival at the hospital.

Analysis: Depending on the initial receiving facility, triage could include an emergency department physician, nurse or surgeon. Regardless, each felt they had a functional MCI plan and could operate with a surge of burn specific patients (while acknowledging the difficulty with this complex patient). It was generally agreed that there may be a tendency to over triage these patients due to the nature and appearance of the injury.

Area for Improvement 1.2.1: Burn event trigger points are not defined specifically which may result in event information not being shared with all appropriate parties across the region.

Analysis: While SurgeNet would be available, it is not specific to a burn event so unless additional information was relayed the facilities providing bed counts may not be aware of the event specifics.

Area for Improvement 1.2.2: A lack of uniform pre-hospital patient distribution protocol for EMS agencies across Ohio exists.

Analysis: The group discussed the likelihood of the closest hospital to the scene receiving most patients from EMS rather than an organized distribution from the scene matching the right patient with the right facility in the initial transport. Cuyahoga Emergency Communications System (CECOMS) has the ability to gather the bed status information, but there does not appear to be an established method to provide this information to the field and most felt the query may not be completed by the time ambulances were ready to leave the scene for destination hospital(s). While it was felt a bed count could quickly be conducted, there was less certainty that it could drive distribution at the time EMS was initially determining destinations at the scene.

Recommendation: EMS providers were not invited to participate in this exercise. In order to fully test the patient placement and coordination process, EMS providers should be involved in future planning and exercise events.

Area for Improvement 1.2.3: Inconsistency exists in burn surge supplies and supply caches throughout the regions.

Analysis: Regional resources (burn surge supplies) were not uniformly available in all regions including limited pediatric burn resources. The Ohio Health Department (ODH) and Columbus area could discuss burn cache resources available, but there was no awareness outside of this area. The burn centers and trauma centers reported having existing relationships with vendors who could provide additional supplies. ODH discussed supply caches that are available both in state and through federal resources such as VMI and Push Packs. There was limited knowledge of federal resources, but all knew if they needed access, they would work with their state/regional coordinators.

Module 3: Ongoing Response: Patient Distribution (up to 72 Hours)

Area for Improvement 1.3.1: Additional burn care training is needed for staff at non-burn centers.

Analysis: While the burn centers have access to additional staffing for managing a surge of patients, regional hospitals and trauma centers (not co-located with a burn center) would rely on their general staff for triage of these patients. The burn centers were looked to for outreach education and provided it as they could, but access to specific burn care training/education was limited. Additional burn care education is available through trauma programs (Advanced Trauma Life Support, Trauma Nurse Core Course, Basic Trauma Life Support, Prehospital Trauma Life Support, etc.) and Advanced Burn Life Support. The issue of training to prevent over triage was discussed.

Area for Improvement 1.3.2: Patient placement and referral patterns may be challenged during a disaster that exceeds burn and trauma center capacities.

Analysis: While the RMCC role was not completely clear to all of the participants, the traditional referral patterns would include burn patients with destinations in Columbus (OSU and Nationwide) Akron and Cleveland with other known and occasionally/rarely used burn centers in Pittsburgh and Cincinnati. The existing system can manage the day to day burn activities but during a disaster, seemed to be less certain what would happen if the numbers exceeded burn and trauma center capacities. It was noted however, state/regional coordination would be consulted/notified to help with the decision process.

Conclusion

Written by Randy Kearns – Table 1 Facilitator

It is my opinion that for small events, representatives for the regions or hospitals present in our work group could manage with little to no difficulty. As the event becomes increasingly more complex and includes many more patients, I also believe the experience and intellectual resources are present to manage the event, but may have weaknesses due to a lack of preexisting structure, recent training/education or previous experience.

The greater Columbus area has many healthcare resources commensurate with the population served. While Akron and Mansfield have fewer resources, they have good relationships with healthcare systems in Cleveland and Columbus who can assist with managing a surge of burn injured patients.

ODH and the Ohio Hospital Association (OHA) should be commended on their focus for improving preparedness activities and awareness for this difficult scenario. The probability for a burn surge disaster is low, but the consequence of the disaster will call to bear far more resources on a per patient basis than most any other disaster scenario. Furthermore, there are multiple high risk scenarios that include a burn disaster as an aspect of the overall scenario. The data supports that a disaster will lead to extended stays for ALL PATIENTS (not just those in the disaster as resources are diverted). Burns are particularly difficult to manage due to frequency, complexity, and even some of the less serious burns are distracting in appearance and odor leading to over triage and disproportional assignment of resources.

I was impressed with the knowledge/skills/abilities of the healthcare emergency management personnel and feel they could clearly manage institutional events. It was also clear that while some had a better interaction/existing relationship with ODH and OHA representatives than others, each of the hospitals represented knew how to reach their regional contacts and seemed comfortable reaching out to them if needed.

The gaps and opportunities to improve here are similar to many other parts of the US to include clinician/provider burn specific education, review (in one region) and creation (in another) of a regional plan to include small but targeted equipment caches to underpin burn surge preparedness. Involvement with EMS and small community hospitals (always the first responder and often the first receiver) of these disasters must improve to maximize the effectiveness for this planning and preparedness activity.

Under ideal circumstances with extensive training and supplies, this remains a difficult scenario. Activities such as this will improve the potential outcomes following a burn disaster. While some communities in other states have chosen “hope” (I hope this doesn’t happen!) over “preparedness,” as previously stated, the stakeholders should be applauded for their efforts to manage a surge of burn injured patients and encouraged to continue to improve preparedness through education and planning activities.