Case Study: New Orleans and Minneapolis, a Tale of Two Cities Carl H. Schultz, MD Professor of Emergency Medicine Director, Disaster Medical Services
Overview Need for Scientific Inquiry Measuring effectiveness Mass casualty triage Credentialing of volunteers Leadership education and training
Triage No clear evidence that triage is useful, but assume is axiomatic Science supporting civilian mass casualty triage is in its infancy Reliable/reproducible Applicable to entire population Evidence based Performance characteristics OUTCOME
Triage Reliable/reproducible START Triage Different people triaging the same victims place them in the same triage classification interrater reliability Tested in simulations and in individual patients and found to produce consistent results across professions. Not tested in actual disasters
Triage Applicable to entire population START Triage applies to adults but not small children Use of respiratory parameters Normal < 30 Mental status Normal: follows commands JumpSTART modifies START to accommodate needs of children Normal respiratory rate 15-40 Mental status measure by AVPU
Triage Evidence based START: ability to follow commands Motor component of GCS correlates well with risk of death, and is as good as RTS and full GCS in predicting outcome GMR of 6 = can follow commands. Predicted good outcome. Score of 1-51 5 predicted worse outcome. Respiratory rate.not so good
Triage Performance characteristics Issues of tool performance vs provider performance In evaluating accuracy of a triage tool, study must differentiate between validity of tool and if providers applied it correctly Testing under real conditions, not simulations or surrogate situations Does disaster triage correctly identify victims (are reds really red?)
Triage START Triage: April 23, 2002 collision between two trains 162 victims triaged by START Outcome criteria used to calculate triage accuracy Red criteria: 100% sensitive, 85% specific Yellow criteria: 57% sensitive, 12% specific Green criteria: 48% sensitive, 84% specific Would a gestalt system be better? Minneapolis Israel
Credentialing of Volunteers Emergency System for Advanced Registration of Volunteer Health Professionals (ESAR-VHP) Designed to meet needs of hospitals State-based standardized system Advanced registration of volunteers provides verifiable, up-to-date information about volunteer identity and credentials Permits sharing of personnel across state lines, addresses liability and worker s comp
Credentialing of Volunteers Issues with ESAR-VHP Its expensive $10 million expended thru 2005 2006-2007 2007 cost estimates for California alone = $850K. Costs for subsequent years = $335K? Millions for the entire country and for how long
Credentialing of Volunteers Issues with ESAR-VHP State-based Level of provider expertise can vary state by state Makes resource typing difficult Type 1 versus Type 2-42 Inherent delays in activating, mobilizing, and delivering personnel Take years to implement fully
Credentialing of Volunteers Issues with ESAR-VHP Each state must: Design and maintain system Register volunteers Recruit and sustain participation Collect credentialing information Support system use A whole new bureaucracy? Don t t we already do this?
Credentialing of Volunteers Are there other alternatives? Implement a hospital-based credentialing system Create database of all practitioners in good standing from current hospital staff Information already exists at each hospital. It just has to be combined in a single database Controlled by county and shared with all hospitals Can be shared by counties during a disaster Now each practitioner is credentialed all hospitals Rapid, cheaper, more efficient
Leadership Education & Training Who s s in charge? What do they know? Lessons learned? Not science Emerging approach Masters degrees in public health, urban planning, and disaster management Bachelor of science degrees Certificate programs
Leadership Education & Training Standardized curriculum? Comprehensive emergency management (Philadelphia Univ.) Public health (George Washington Univ.) Emergency/disaster management (SUNY Stony Brook) EMS (MCP Hahnemann University) Public policy (UC Irvine) Terrorism (Georgetown Univ.) Disaster medicine (European Masters in DM) Threat /response management (Univ. of Chicago)
Leadership Education & Training Outcome measurements? Performance during disasters - metrics difficult but Reduction in preventable errors Reduction in repetitive nature of lessons learned. Reduction in deaths/injuries Reduction in costs In the meantime, requiring formal training for positions in management would be nice
THANK YOU! QUESTIONS? Carl Schultz, MD schultzc@uci.edu
References 1. Schultz CH, Stratton SJ: Improving Hospital Surge Capacity: A New Concept for Emergency Credentialing of Volunteers. Ann Emerg Med 2007;49:602-609. 609. 2. Schultz CH, Koenig KL: State of Research in High- consequence Hospital Surge Capacity. Acad Emerg Med 2006;13(11):1153-1156. 1156. 3. Hick JL, Hanfling D, Burstein JL, et al. Health care facility and community strategies for patient care surge capacity. Ann Emerg Med.. 2004;44:253-261. 261. 4. Hick JL, O Laughlin O DT. Concept of operations for triage of mechanical ventilation in an epidemic. Acad Emerg Med. 2006; 13:223 9.
References 5. Garner A, Lee A, Harrison K, Schultz CH: Comparative Analysis of Multiple-Casualty Incident Triage Algorithms. Ann Emerg Med 2001;38:541-548. 548. 6. Cone DC, Koenig KL: Mass casualty triage in the chemical, biological, radiological, or nuclear environment. Eur J Emerg Med 2005;12:287-302. 7. Risavi BL, Salen PN, Heller MB, Arcona S. A two-hour intervention using START improves prehospital triage of mass casualty incidents. Prehosp Emerg Care 2001; 5:197 199. 8. Kahn C, Schultz CH, Miller K, Anderson, C: Does START Triage Work? An Outcomes-Level Assessment of Use at a Mass Casualty Event. Acad Emerg Med 2007;14, Suppl 1:S12-S13 S13