Planning for major burns incidents in the UK using an accelerated Delphi technique

doi:10.1016/S0305-4179(02)00108-0

Burns

Volume 28, Issue 5, August 2002, Pages 405-412

https://doi.org/10.1016/S0305-4179(02)00108-0 Get rights and content

Abstract

Background: Major incidents require careful planning if they are to be managed well. Although a generic plan to deal with all major incidents is essential, a number of “special incidents” deserve special consideration because of their potential to impact on specialist services. This paper examines the problems of managing a major incident involving large numbers of burns casualties.

Method: A three-round Delphi study was conducted using a multidisciplinary panel of experts from prehospital care, emergency medicine, burns surgery, intensive care and emergency planning.

Results: A series of consensus statements on the management of burns incidents are presented. An accompanying paper describes the practical implementation of this guidance.

Conclusion: Specific consideration should be given to the problems of managing a major incident involving burns casualties.

Introduction

Major incident planning should follow an “all hazards approach” [1], [2] that must be designed to deal with all types of major incident.¹ Certain types of incident require additional arrangements, if optimal patient care is to be achieved [2]. Incidents resulting in chemical [3], burns [4], or radiation [5], casualties require additional arrangements, primarily because the resources to deal with these types of patients are scarce and often located in regional centres. An incident resulting in only a few such casualties may result in the incident becoming decompensated [6].

In the UK, for example of an average three to four major incidents occur each year [7]. Table 1 lists examples of incidents resulting in large numbers of burns casualties. Even these brief descriptions show the potential impact of a burns incidents.

Planning and preparation is essential if the best possible care is to be delivered to any individual patient [1]. This is even more important when there is a large number of casualties with complex and varying problems, such as in major incidents. Treatment of burns casualties can involve a wide variety of specialists, from burns surgeons and intensive care specialists to bacteriologists and psychiatrists. This complexity of care required in a burns major incident and the co-ordination of responding services and specialities calls for careful preparation.

In some respects, major incidents involving burns are unique in that there is usually so little spare capacity in the system that any incident will result in the incident becoming decompensated [4], with services unable to deliver standard levels of care to the majority of patients.

We conducted a three-part Delphi [8] study with the aim of identifying areas of concern in planning for major incidents involving burns.

Section snippets

Methods

A three-round Delphi was conducted over a 6-week period in the summer of 2000 using a panel of 30 experts from specialities involved in the management of burns in major incidents. Specialists were recruited from the Ambulance Service, Immediate (prehospital) Care, Emergency Medicine, Plastic Surgery, Burns Nursing, Intensive Care Medicine, Intensive Care Nursing, the Department of Health (emergency planning) and Regional Emergency Planning Officers. The Delphi technique is summarised in Box 1.

Selection of the expert panel

Two of the authors selected the panel. Expertise was defined using two criteria: firstly, known interest/experience in emergency planning; secondly, expertise in the management of major and minor burns; thirdly, experience in the implementation and practical application of emergency planning guidance [8]. Forty individuals were approached of whom 30 agreed to participate. Specialists included in the Delphi group are shown at the end of this paper.

Results

We present our results as a series of consensus statements. These are summaries of the main points of consensus from Rounds 2 and 3 of the Delphi study.

Result tables are set out as for all phases of major incident response [1], that is preparation (Box 3), prehospital response (Box 4), hospital response (Box 5), burns units response (Box 6) and post-incident care and follow-up (Box 7). For the purposes of publication some statements using terms relevant to UK practice have been changed to

Discussion

Major incidents are unpredictable events where research is difficult and clinical experimentation impossible. Classically, major incident planning is based on case reports, of which there are few, and expert opinions. Unfortunately, single author opinions are highly susceptible to bias and we believe a multidisciplinary approach is necessary in major incident planning. However, committees and expert working groups are also susceptible to bias through confounding by interpersonal relationships

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European Burns Association guidelines for the management of burn mass casualty incidents within a European response plan
2023, Burns
Citation Excerpt :
Using a dedicated smart device-based application such as e-Burn or other similar tools may be advisable to reduce error and TBSA assessment time [40–43]. The need for secondary triage and subsequent patient transfers is put forward by most existing BMCI preparedness plans [21,44–47]. Their implementation is addressed in recommendations R 1.6 and R 1.7.
A European response plan to burn mass casualty incidents has been jointly developed by the European Commission and the European Burn Association. Upon request for assistance by an affected country, the plan outlines a mechanism for coordinated international assistance, aiming to alleviate the burden of care in the affected country and to offer adequate specialized care to all patients who can benefit from it. To that aim, Burn Assessment Teams are deployed to assess and triage patients. Their transportation priority recommendations are used to distribute outnumbering burn casualties to foreign burn centers. Following an appropriate medical evacuation, these casualties receive specialized care in those facilities.
The European Burns Association’s disaster committee developed medical-organizational guidelines to support this European plan. The experts identified fields of interest, defined questions to be addressed, performed relevant literature searches, and added their expertise in burn disaster preparedness and response. Due to the lack of high-level evidence in the available literature, recommendations and specially designed implementation tools were provided from expert opinion. The European Burns Association officially endorsed the draft recommendations in 2019, and the final full text was approved by the EBA executive committee in 2022.
The resulting 46 recommendations address four fields. Field 1 underlines the need for national preparedness plans and the necessary core items within such plans, including coordination and integration with an international response. Field 2 describes Burn Assessment Teams' roles, composition, training requirements, and reporting goals. Field 3 addresses the goals of specialized in-hospital triage, appropriate severity criteria, and their effects on priorities and triage. Finally, field 4 covers medical evacuations, including their timing and organization, the composition of evacuation teams and their assets, preparation, and the principles of en route care.
Are burn centers in German-speaking countries prepared to respond to a burn disaster? Survey-based study
2020, Burns
Citation Excerpt :
The responses were obtained in most cases from the deputy managers of the centers (n = 14, 43%) followed by the directors (n = 11, 34%); the remaining responses were from specialist physicians employed at the targeted burn centers (n = 7, 23%). Based on the previous literature [17], and to ease the readability of the results the survey was divided into four major sections (I) Preparation and plan, (II) Command, triage, and transfer, (III) Capacity, capability, and treatment strategies, and (IV) Training. All the centers provided feedback regarding the presence or absence of a special burn disaster plan.
Burn disasters present a challenge not only to burn centers but the entire healthcare system. Most burn centers worldwide are unprepared to deal with a burn disaster as it is an uncommon event. We investigated the status of burn center preparedness in German-speaking countries to respond to a burn disaster. Self-administered survey questionnaires were sent to the directors of burn centers; the questions of survey used before in a similar way in Belgium were translated into German language. Of the 46 questioned burn centers, 32 (78%) responded, including all of the German adult burn centers. A clear difference in the preparation status of the burn centers in the three countries was observed due to geopolitical factors such as decentralized healthcare systems. However, the healthcare system is generally well-prepared concerning command, transfer, and capacity to provide sustained supplies to handle a massive influx of patients. Nevertheless, there are some gaps in the areas of planning and preparation, funding for disaster activities, and regular training of staff for burn disasters. We call for a unified burn disaster plan and increased cooperation between burn centers and civil defense regarding communication and training. We strongly recommend the implementation of a special disaster fund and telemedicine in disaster management to circumvent shortages in burn staff.
Factors associated with ED length of stay during a mass casualty incident
2016, American Journal of Emergency Medicine
Citation Excerpt :
Although ED waiting time and length of stay (LOS) are used as indicators of ED overcrowding [6–8], no study examines the use of these indicators during a hospital MCI response. Previous studies have focused on ED load, preparedness of the hospital response, and management during a hospital MCI response [9–12]. To monitor the quality of care during a hospital MCI response, analysis of time effectiveness using an ED patient flow model is important.
The aim of this study was to examine the factors associated with emergency department (ED) length of stay (LOS) using the patient registry data from a medical burns center during a burn injury mass casualty incident (MCI) after a dust explosion in New Taipei City, Taiwan.
This was a retrospective cohort study conducted at an urban, tertiary care teaching hospital during an MCI event that occurred on June 27, 2015. A celebratory party was held at the Formosa Fun Water Park in New Taipei City, Taiwan. At 20:32, the was an explosion caused by an overheated spotlight accidentally igniting colored cornstarch powder that had been sprayed on the stage. Factors associated with ED LOS were compared.
In total, 48 burn injury patients were enrolled for study analysis. The median total body surface area of second- to third-degree burns was 35.0% (interquartile range [IQR], 15.8%-55.0%). The median ED LOS was 121.5 minutes (IQR, 38.3-209.8 minutes). The output time interval accounted for the longest interval with a median time of 56.0 minutes (IQR, 15.3-117.3 minutes). In multivariate analysis of the variables, triage level (level III; hazard ratio, 0.06; 95% confidence interval, 0.01-0.52) and output time (hazard ratio, 0.97; 95% confidence interval, 0.96-0.98) were significant influential factors.
The triage level and output time intervals were significantly associated with ED LOS in a burn-related MCI. Time effectiveness analyses, using a patient flow model, might serve as an important indicator during a hospital MCI response.
30 Years of burn disasters within the UK: Guidance for UK emergency preparedness
2012, Burns
To review casualty profiles of major UK burn disasters over the last 30 years in order to provide guidance to aid burn and emergency service planning and provision so as to improve emergency preparedness for future national disasters.
A review of published literature was undertaken for disasters within the UK that had occurred between 1980 and 2009. Those producing 10 or more casualties with at least one sustaining cutaneous burns injuries were included. Frequency and extent of burns were recorded and analysed.
In total 37 disasters were included in this study, their frequency of occurrence falling over the 30 years reviewed. Burns tended to make up a small proportion of all casualties and were often relatively small in size with only 3 disasters having more than 5 patients with >10% burns.
This paper can help guide appropriate staffing and bed capacity planning for regional burns units and provide realistic figures to guide scenarios for national emergency training exercises. Due to the infrequent nature of major disasters, Critical Care, Trauma Care and Burn Care Networks will all need to be closely integrated and their implementation rehearsed so as to ensure optimal response to a major national disaster.
Mass casualty incidents with multiple burn victims: Rationale for a Swiss burn plan
2010, Burns
Citation Excerpt :
A thorough review of these events, including whether they took place in a civilian or military setting, is beyond the scope of this article [see [2–4]]. However, the lessons learned emphasize the many similarities among these situations and also show that some issues are shared among all major disasters (Table 3) [2,3,6]. Many burn disasters have occurred in civilian settings with numerous victims deceasing at the scene or within hours after the incident.
Mass casualty incidents involving victims with severe burns pose difficult and unique problems for both rescue teams and hospitals. This paper presents an analysis of the published reports with the aim of proposing a rational model for burn rescue and hospital referral for Switzerland.
Literature review including systematic searches of PubMed/Medline, reference textbooks and journals as well as landmark articles.
Since hospitals have limited surge capacities in the event of burn disasters, a special approach to both prehospital and hospital management of these victims is required. Specialized rescue and care can be adequately met and at all levels of needs by deploying mobile burn teams to the scene. These burn teams can bring needed skills and enhance the efficiency of the classical disaster response teams. Burn teams assist with both primary and secondary triage, contribute to initial patient management and offer advice to non-specialized designated hospitals that provide acute care for burn patients with Total Burn Surface Area (TBSA) <20–30%. The main components required for successful deployments of mobile burn teams include socio-economic feasibility, streamlined logistical implementation as well as partnership coordination with other agencies including subsidiary military resources.
Disaster preparedness plans involving burn specialists dispatched from a referral burn center can upgrade and significantly improve prehospital rescue outcome, initial resuscitation care and help prevent an overload to hospital surge capacities in case of multiple burn victims. This is the rationale behind the ongoing development and implementation of the Swiss burn plan.
How to choose? Using the delphi method to develop consensus triggers and indicators for disaster response
2017, Disaster Medicine and Public Health Preparedness

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Planning for major burns incidents in the UK using an accelerated Delphi technique

Abstract

Introduction

Section snippets

Methods

Selection of the expert panel

Results

Discussion

Disas. Med.

Injury: Br. J. Accid. Surg.

Injury

Technol. Forecast Soc. Change

Am. J. Surg.

J. Emerg. Med.

Burns

Burns

The capability of accident and Emergency Departments to safely decontaminate victims of chemical incidents

J. Acc. Emerg. Med.