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Planning for Health and Medical Response to Mass Casualty Incidents in New York City
Celia Quinn, MD, MPHCareer Epidemiology Field Officer, CDCAssigned to: Office of Emergency Preparedness and Response, New York City Department of Health and Mental Hygiene
Planning for Health and Medical Response to Mass Casualty Incidents in New York City
Celia Quinn, MD, MPH
New York City Department of Health and Mental Hygiene Office of Emergency Preparedness and Response
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Objectives
} At the end of this session, attendees will be able to:• Describe emerging practices and theories that can
be applied to improve community preparedness and community resilience at the local level• Describe the use of a mass casualty consultation
team to support coordinated inter-facility transfer of patients during a large-scale Mass Casualty Incident• List factors that influence physician decision-
making when prioritizing patients for inter-facility transfer during a large-scale Mass Casualty Incident
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Overview
}Background: NYC Mass Casualty Incident (MCI) response landscape
} Testing coordinated secondary transfer of patients with severe burn and/or traumatic injury during an exercise
} Implementing a new MCI notification protocol in NYC
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BackgroundBackground
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NYC at High Risk
} Over 8.5 million residents
} International icons and landmarks
} Planned events• United Nations General Assembly• New Year’s Eve
} Vulnerability to natural and man-made disasters, including intentional attacks
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New York City Healthcare Response Landscape
} The Fire Department, City of New York (FDNY) coordinates prehospital resources and runs the city’s 911 system
} New York City hospital resources:• 62 acute care hospitals• 19 trauma centers• 4 burn centers (~44 beds)
} Health and medical support function (ESF-8) coordinated by New York City Emergency Management (NYCEM)
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MCI Definition
} FDNY activates MCI protocols for any event with the potential to produce five or more patients
} MCIs are relatively common in NYC (multiple per day)• More than half of MCIs do not generate any patients• Only about 5% of patients related to MCIs are considered
“critical” on triage
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The NYC Burn MCI Protocol (2011)
} NYC’s plan for managing a large number of severe burn injuries
} Developed with city agencies, NY State Department of Health, and local hospitals
} Features coordinated secondary transport of patients with severe burn injuries to definitive care in burn centers
} Describes “Burn Disaster Receiving Hospitals” as those hospitals with sufficient capacity to manage up to 10 severe burn injury patients for up to 5 days
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Time to update the plan?
} September 2015: Pope Francis visit to NYC coincides with United Nations General Assembly
} November 2015: Paris terror attacks
} March 2016: Brussels airport attack
} June 2016: Orlando Pulse nightclub shooting
} July 2016: Nice truck attack (Bastille day)
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Rethinking MCI in NYC
} Plan for events that generate burn, trauma, and mixed injuries
} Consider special needs of pediatric patients
} Develop notification protocols that scale to the scope of the event
} Improve coordination between pre-hospital and hospital systems
} Use interagency structures to advance planning and implementation
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Healthcare Coalitions and the Health Department Role in MCI Planning
} The Brooklyn Coalition 2016 full scale exercise• Opportunity to test coordinated secondary transport• Included burn, trauma, and mixed injury patients
} NYC’s Health and Medical Executive Committee and implementation of a new framework for MCI notifications• Development of a “Fixed Allotment” MCI notification protocol• Integrating new citywide policies into hospital-level plans
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E-bombable Brooklyn 2016E-bombable Brooklyn 2016FACTORS INFLUENCING THE PRIORITIZATION FOR TRANSFER OF FACTORS INFLUENCING THE PRIORITIZATION FOR TRANSFER OF
INJURED PATIENTS TO A BURN OR TRAUMA CENTER INJURED PATIENTS TO A BURN OR TRAUMA CENTER FOLLOWING A MASS CASUALTY EVENTFOLLOWING A MASS CASUALTY EVENT
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Initial update of 2011 Burn MCI Protocol
} Started in fall 2015
} Included representatives from NYC Burn Centers, FDNY, and NYC Department of Health
} Expanded focus from burn only to include trauma and mixed injuries
} Proposed development of a “Mass Casualty Consultation Center” to support FDNY prioritization of patients for secondary transfer
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Mass Casualty Consultation Center (MCCC)
} Interdisciplinary team of 3 physicians• FDNY Emergency Medical Services physician in lead• Burn surgeon • Trauma surgeon
} Virtual• Convened by conference call
} Locally managed• Activated by FDNY• All volunteer physicians from NYC burn centers
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E-bombable Brooklyn Exercise
} Conducted by NYC’s Brooklyn Coalition (one of 5 borough-based healthcare coalitions in NYC) in March, 2016
} Tested ability to prioritize patients for secondary transfer 24 hours after an explosive event in Brooklyn
} Multi-hospital, interagency participants• 11 of 12 Brooklyn hospitals • 3 of 4 NYC burn centers• FDNY• Regional EMS Council• Greater NY Hospital Association• NYC Emergency Management• NYC Department of Health and Mental Hygiene• NYS Department of Health
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Methods: Transfer request during exercise
} Hospitals were each assigned up to 69 patient profiles
} Hospital staff :• Assessed current resources for management of the patient
profiles• Determined which profiles to prioritize for request to transfer
to a burn, trauma, or specialty center• Completed a worksheet summarizing patient details to share
with MCCC• Faxed completed worksheet to MCCC to “request transfer” of
patients
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Methods: Assessing reliability of MCCC decisions
} Two MCCC teams (“Team A” and “Team B”) simultaneously prioritized an identical set of patient profiles during the exercise
} Teams did not communicate with each other during the exercise, and used separate conference lines
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Methods: Post-exercise data collection
} Team A and Team B decisions on the disposition of each of 69 patient profiles were compared and discordant decisions were analyzed
} Qualitative: • Researchers interviewed EMS physician leaders of each team to
review each discordant decision; reasons for differing responses were classified into 4 categories
} Quantitative:• Researchers calculated burn or injury severity scores for each
patient profile• Agreement between teams was assessed based on patient profile
demographics and injury severity
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Results: Secondary transport decisions
Secondary Transport Decisions Made by MCCC Teams (A vs. B) for 69 Patient Profiles
Decisiona Team A No. (%)
Team BNo. (%)
Significance
Transfers 49 (71%) 36 (52%) 0.003b
Transfer to Burn Center 26 (38%) 16 (23%) 0.002b
Transfer to Trauma Center 23 (33%) 20 (29%) 0.405
No Transfer 20 (29%) 33 (48%) 0.003b
a Decision groups are mutually exclusiveb Significant at the 0.05 level using the McNemar test of groups
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Results: Inter-rater reliability
Percent Agreement and Inter-rater Reliability between MCCC Teams A and B for Secondary Transport
Destination Percent Agreement
Inter-rater reliability (Team A vs. B)a
Strengthb
Rate 95% CI
Overall 69.6 0.55 (0.40-0.71) Moderate
Burn 85.5 0.67 (0.49-0.85) Substantial
Trauma 81 0.56 (0.35-0.77) Moderate
No Transfer 72 0.44 (0.24-0.64) Moderatea Cohen’s Kappab Strength of agreement based on Landis and Koch guidelines
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Results: Agreement by injury severityLevel of Agreement Between MCCC Teams A and B by Injury Severity Scores
Injury Severity Agreement/Total Agreement Percent
Burn Injuries Total Body Surface Area (TBSA) 0
1/3 33.3%
TBSA 1-19 11/23 47.8%
TBSA 20-39 8/8 100.0%
TBSA ≥ 40 8/8 100.0%
Revised Baux Score < 45.5 (median) 10/21 47.6%
≥ 45.5 18/21 85.7%
Injury Severity Score <9 (median) 8/21 38.1%
≥ 9 (median) 30/33 90.9%
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Results: Reasons for disagreement
} Team leads were interviewed about reasons for disagreement for each of 21 discordant decisions• Insider knowledge of hospital capabilities (n = 6)• Different interpretation for role of trauma vs burn care (n = 2)• Different prioritization of a specific burn injury (n = 3)• More than one reason for disagreement (n = 4)• Could not identify a reason (n = 6)
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Conclusions
} MCCC successfully prioritized patients for secondary transfer using limited clinical information
} Transfer decisions were more consistent across MCCC teams for cases with more severe injury or burn
} Training for consultation teams should emphasize guidelines for transfer based on existing services and sending and receiving hospitals
} Local knowledge of hospital capabilities appeared to influence decision making about secondary transfer
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Looking Ahead
} Health department conducted a multi-hospital exercise testing secondary transfer processes for pediatric patients in 2017
} Efforts are underway to finalize protocols and update plan to reflect incorporation of trauma and pediatric patients
} Challenges include keeping burn and trauma surgeons engaged in planning, identifying availability of specialty services and available beds at the time of an event, and the need for ongoing training to maintain the secondary transport capability
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Implementing a New Implementing a New Framework for MCI Framework for MCI Notification in NYCNotification in NYC
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NYC’s Health and Medical Executive Committee
} Formed in December 2015} Meets monthly to advance joint health and medical planning
initiatives} Serves as a policy advisory group to the Health and Medical
Response Function (ESF-8) during emergency responses} Steering committee for the NYC Healthcare Coalition } Members include: NYC Department of Health, NYS Department of
Health, NYC Emergency Management, NYC Health + Hospitals, Fire Department of City of New York, Greater New York Hospital Association
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HMExec Role in Leading Change to Notification Protocol
} By Spring 2016, world events increased urgency of planning for MCI of all scales
} HMExec members worked together to implement a new protocol for MCI notification by August 1, 2016
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Previous Notification Method
} Fire Department declares MCI• Potential for 5 or more patients
} Fire Department notifies nearest hospital• Asks about current ED capacity• Inquiry often failed to provide actionable information
for EDs or FDNY
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New Framework: Fixed Allotment
} FDNY assesses the scale of the MCI and assigns a level• Level A: Minimal to moderate• Level B: Significant• Level C: Major• Level D: Catastrophic
} Hospitals are pre-assigned expected number of critical and non-critical patients to arrive by EMS for each MCI level
} Additional hospitals are notified depending on MCI level
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Fixed Allotment Based on Hospital Capacity
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Implementation
} HMExec agreement to pursue fixed allotment model
} Formation of hospital workgroup led by hospital association
} Determination of allotment levels
} Hospital meeting July 2016
} FDNY letter to hospital leadership July 2016
} Implementation August 2016
} Ongoing monitoring by workgroup and HMExec
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Supporting Implementation in NYC hospitals
} Health Department leveraged HPP funds to support integration of the new notification protocols into hospital plans
} Participating hospitals updated internal notification protocols and trained relevant staff
} Health Department collected information about hospital plans to identify best practices and common challenges
} GNYHA disseminated an update to members
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Methods: Collecting information about hospital implementation
} Hospital were asked to complete a survey focused on expected hospital actions during different MCI levels including:• MCI Level or conditions leading to activation of surge plans • Internal alert notifications• Surge preparation elsewhere in the hospital
} The survey did not specify hospital operational conditions at time of MCI notification.
} Survey responses were entered into a Microsoft Excel 2013 database } Free text responses were documented in the database and reviewed
for repeated themes.
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Results
Of 50 eligible NYC 911-receiving hospitals, 38 completed the survey} Hospital planned responses to FDNY MCI Level A and B
notifications varied from only alerting ED staff to activating the Hospital Incident Command Systems (HICS) to coordinate hospital response
} Level C and D FDNY notifications to hospitals universally triggered alerting ED staff and hospital leadership
} Activation of emergency operations or surge plans and Hospital Incident Command Systems were not universal when notified of a Level C or D MCI
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Hospital Response to Level C or D Notification
Level C or D Notifications Trauma Centers
Non-Trauma Center
Total
Immediately Activate Emergency Operations Plans and Hospital ICS
8 (73%) 16 (59%) 24 (63%)
Do Not Automatically Activate (Leadership assessment of situation)
3 (27%) 11 (41%) 14 (37%)
Totals 11 (100%) 27 (100%) 38 (100%)
Note: activation by trauma designation was not statistically significant p=0.69 by Fisher’s exact
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Themes Reported by Hospital Emergency Preparedness Coordinators
} Staff seemed to understand the new fixed allotment notification protocol
} Some expressed concern about the maximum numbers of critical and non-critical patients• In addition to patients brought by EMS, hospitals need to
anticipate patients brought by other means
} Actual patients brought by EMS could be far fewer or differ in clinical needs depending on injury types sustained
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Themes Reported by Hospital Emergency Preparedness Coordinators
} Hospitals need additional situational awareness surrounding incident to better prepare including:• Information of the type of event and injuries• Whether the incident is ongoing• Proximity of the event to the hospital
} Hospitals need to practice response to various MCI level notifications to ensure staff familiarity and readiness • Especially for infrequent, higher-level MCIs (Level B, Level C,
Level D)
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Conclusions
} Hospitals methods of integrating patient fixed allotment into hospital surge plans varied• Different responses to the same MCI Level notification
} Hospitals reported there is still a need for additional situational awareness to guide response activities• Details about the event• Injuries expected
} Systems that enhance coordination between public health, health care delivery system, and first responders can support innovations in mass casualty response
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Looking Ahead
} Pre-hospital to hospital notification workgroup continues to meet and recently released annual data summarizing experience to date with the fixed allotment model
} Health Department is supporting hospitals to test their Level C notification and ED activation plans using “mini drills”
