Case Study: New Orleans and Minneapolis, a Tale of Two Cities

Case Study: New Orleans and Case Study: New Orleans and Minneapolis, a Tale of Two Minneapolis, a Tale of Two

CitiesCities

Carl H. Schultz, MDCarl H. Schultz, MDProfessor of Emergency MedicineProfessor of Emergency MedicineDirector, Disaster Medical ServicesDirector, Disaster Medical Services

UC Irvine School of MedicineUC Irvine School of Medicine


Department of Emergency MedicineDepartment of Emergency Medicine

OverviewOverview

Need for Scientific InquiryNeed for Scientific Inquiry

Measuring effectivenessMeasuring effectiveness

– Mass casualty triageMass casualty triage

– Credentialing of volunteersCredentialing of volunteers

– Leadership education and trainingLeadership education and training

UC Irvine School of MedicineUC Irvine School of MedicineDepartment of Emergency MedicineDepartment of Emergency Medicine

TriageTriage

No clear evidence that triage is useful, No clear evidence that triage is useful, but assume is axiomaticbut assume is axiomaticScience supporting civilian mass Science supporting civilian mass casualty triage is in its infancycasualty triage is in its infancy– Reliable/reproducibleReliable/reproducible– Applicable to entire populationApplicable to entire population– Evidence basedEvidence based– Performance characteristicsPerformance characteristics

OUTCOMEOUTCOME



TriageTriage

Reliable/reproducibleReliable/reproducible– START TriageSTART Triage

Different people triaging the same victims Different people triaging the same victims place them in the same triage classification place them in the same triage classification – interrater reliability – interrater reliability

Tested in simulations and in individual Tested in simulations and in individual patients and found to produce consistent patients and found to produce consistent results across professions.results across professions.

Not tested in actual disastersNot tested in actual disasters


TriageTriageApplicable to entire populationApplicable to entire population

– START Triage – applies to adults but not START Triage – applies to adults but not small childrensmall children

Use of respiratory parameters Use of respiratory parameters – Normal < 30Normal < 30Mental statusMental status– Normal: follows commandsNormal: follows commands

– JumpSTART – modifies START to JumpSTART – modifies START to accommodate needs of childrenaccommodate needs of children

Normal respiratory rate 15 - 40Normal respiratory rate 15 - 40Mental status measure by AVPU Mental status measure by AVPU


TriageTriage

Evidence basedEvidence based– START: ability to follow commandsSTART: ability to follow commands

Motor component of GCS correlates well Motor component of GCS correlates well with risk of death, and is as good as RTS with risk of death, and is as good as RTS and full GCS in predicting outcomeand full GCS in predicting outcome

GMR of 6 = can follow commands. GMR of 6 = can follow commands. Predicted good outcome. Predicted good outcome.

Score of 1-5 predicted worse outcomeScore of 1-5 predicted worse outcome..

– Respiratory rate….not so goodRespiratory rate….not so good


TriageTriage

Performance characteristicsPerformance characteristics– Issues of tool performance vs provider Issues of tool performance vs provider

performanceperformanceIn evaluating accuracy of a triage tool, In evaluating accuracy of a triage tool, study must differentiate between validity of study must differentiate between validity of tool and if providers applied it correctlytool and if providers applied it correctly

– Testing under real conditions, not simulations Testing under real conditions, not simulations or surrogate situationsor surrogate situations

– Does disaster triage correctly identify victims Does disaster triage correctly identify victims (are reds really red?)(are reds really red?)



TriageTriage

START Triage: April 23, 2002 – START Triage: April 23, 2002 – collision between two trainscollision between two trains– 162 victims triaged by START162 victims triaged by START– Outcome criteria used to calculate triage accuracyOutcome criteria used to calculate triage accuracy– Red criteria: 100% sensitive, 85% specificRed criteria: 100% sensitive, 85% specific– Yellow criteria: 57% sensitive, 12% specificYellow criteria: 57% sensitive, 12% specific– Green criteria: 48% sensitive, 84% specificGreen criteria: 48% sensitive, 84% specific

Would a “gestalt” system be better?Would a “gestalt” system be better?– MinneapolisMinneapolis– IsraelIsrael



Credentialing of VolunteersCredentialing of Volunteers

Emergency System for Advanced Registration of Emergency System for Advanced Registration of Volunteer Health Professionals (ESAR-VHP)Volunteer Health Professionals (ESAR-VHP)– Designed to meet needs of hospitalsDesigned to meet needs of hospitals– State-based standardized systemState-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




Issues with ESAR-VHPIssues with ESAR-VHP– Its expensiveIts expensive

$10 million expended thru 2005$10 million expended thru 2005

2006-2007 cost estimates for2006-2007 cost estimates forCalifornia alone = $850K. CostsCalifornia alone = $850K. Costsfor subsequent years = $335Kfor subsequent years = $335K

? Millions for the entire country? Millions for the entire countryand for how long and for how long




Issues with ESAR-VHPIssues with ESAR-VHP– State-basedState-based

Level of provider expertise can vary Level of provider expertise can vary state by statestate by state

–Makes resource typing difficultMakes resource typing difficult–Type 1 versus Type 2-4Type 1 versus Type 2-4

Inherent delays in activating, mobilizing, Inherent delays in activating, mobilizing, and delivering personneland delivering personnel

– Take years to implement fullyTake years to implement fully




Issues with ESAR-VHPIssues with ESAR-VHP– Each state must:Each state must:

– Design and maintain systemDesign and maintain system– Register volunteersRegister volunteers– Recruit and sustain participationRecruit and sustain participation– Collect credentialing informationCollect credentialing information– Support system useSupport system use

A whole new bureaucracy?A whole new bureaucracy?– Don’t we already do this?Don’t we already do this?




Implement a hospital-based credentialing system Implement a hospital-based credentialing system

Create database of all practitioners in good standing Create database of all practitioners in good standing from current hospital stafffrom current hospital staff

Information already exists at each hospital. It just Information already exists at each hospital. It just has to be combined in a single databasehas to be combined in a single database

Controlled by county and shared with all hospitalsControlled by county and shared with all hospitals

Can be shared by counties during a disasterCan be shared by counties during a disaster

Now each practitioner is credentialed all hospitalsNow each practitioner is credentialed all hospitals

Rapid, cheaper, more efficientRapid, cheaper, more efficient

Are there other alternatives?



Leadership Education & TrainingLeadership Education & Training

Who’s in charge?Who’s in charge?What do they know?What do they know?Lessons learned?Lessons learned?– Not scienceNot science

Emerging approachEmerging approach– Masters degrees in public health, urban Masters degrees in public health, urban

planning, and disaster managementplanning, and disaster management– Bachelor of science degreesBachelor of science degrees– Certificate programsCertificate programs




Standardized curriculum?Standardized curriculum?– Comprehensive emergency management Comprehensive emergency management

(Philadelphia Univ.)(Philadelphia Univ.)– Public health (George Washington Univ.)Public health (George Washington Univ.)– Emergency/disaster management (SUNY Stony Emergency/disaster management (SUNY Stony

Brook)Brook)– EMS (MCP Hahnemann University)EMS (MCP Hahnemann University)– Public policy (UC Irvine)Public policy (UC Irvine)– Terrorism (Georgetown Univ.)Terrorism (Georgetown Univ.)– Disaster medicine (European Masters in DM)Disaster medicine (European Masters in DM)– Threat /response management (Univ. of Chicago)Threat /response management (Univ. of Chicago)




Outcome measurements?Outcome measurements?– Performance during disasters - metrics Performance during disasters - metrics

difficult but…difficult but…

Reduction in preventable errorsReduction in preventable errors

Reduction in repetitive nature of “lessons Reduction in repetitive nature of “lessons learned”.learned”.

Reduction in deaths/injuriesReduction in deaths/injuries

Reduction in costsReduction in costs

– In the meantime, requiring formal training for In the meantime, requiring formal training for positions in management would be nicepositions in management would be nice



THANK YOU!THANK YOU!

QUESTIONS?QUESTIONS?

Carl Schultz, MDCarl Schultz, MD

[email protected]@uci.edu



ReferencesReferences

1.1. Schultz CH, Stratton SJ: Improving Hospital Surge Capacity: Schultz CH, Stratton SJ: Improving Hospital Surge Capacity: A New Concept for Emergency Credentialing of Volunteers. A New Concept for Emergency Credentialing of Volunteers. Ann Emerg Med 2007;49:602-609.Ann Emerg Med 2007;49:602-609.

2.2. Schultz CH, Koenig KL: State of Research in High-Schultz CH, Koenig KL: State of Research in High-consequence Hospital Surge Capacity. Acad Emerg Med consequence Hospital Surge Capacity. Acad Emerg Med 2006;13(11):1153-1156. 2006;13(11):1153-1156.

3.3. Hick JL, Hanfling D, Burstein JL, et al. Health care facility and Hick JL, Hanfling D, Burstein JL, et al. Health care facility and community strategies for patient care surge capacity. community strategies for patient care surge capacity. Ann Ann Emerg MedEmerg Med. 2004;44:253-261.. 2004;44:253-261.

4.4. Hick JL, O’Laughlin DT. Concept of operations for triage of Hick JL, O’Laughlin DT. Concept of operations for triage of mechanical ventilation in an epidemic. Acad Emerg Med. mechanical ventilation in an epidemic. Acad Emerg Med. 2006; 13:223–9.2006; 13:223–9.


ReferencesReferences5.5. Garner A, Lee A, Harrison K, Schultz CH: Comparative Garner A, Lee A, Harrison K, Schultz CH: Comparative

Analysis of Multiple-Casualty Incident Triage Algorithms. Analysis of Multiple-Casualty Incident Triage Algorithms. Ann Emerg Med 2001;38:541-548. Ann Emerg Med 2001;38:541-548.

6.6. Cone DC, Koenig KL: Mass casualty triage in the chemical, Cone DC, Koenig KL: Mass casualty triage in the chemical, biological, radiological, or nuclear environment. Eur J Emerg biological, radiological, or nuclear environment. Eur J Emerg Med 2005;12:287-302.Med 2005;12:287-302.

7.7. Risavi BL, Salen PN, Heller MB, Arcona S. A two-hour Risavi BL, Salen PN, Heller MB, Arcona S. A two-hour intervention using START improves prehospital triage of intervention using START improves prehospital triage of mass casualty incidents. Prehosp Emerg Care 2001; 5:197–mass casualty incidents. Prehosp Emerg Care 2001; 5:197–199.199.

8.8. Kahn C, Schultz CH, Miller K, Anderson, C: Does START Kahn C, Schultz CH, Miller K, Anderson, C: Does START Triage Work? An Outcomes-Level Assessment of Use at a Triage Work? An Outcomes-Level Assessment of Use at a Mass Casualty Event. Acad Emerg Med 2007;14, Suppl Mass Casualty Event. Acad Emerg Med 2007;14, Suppl 1:S12-S13 1:S12-S13

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Case Study: New Orleans and Minneapolis, a Tale of Two Cities