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

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

• Carl H. Schultz, MD
• Professor of Emergency Medicine
• Director, Disaster Medical Services
• UC Irvine School of Medicine

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Overview

• Need for Scientific Inquiry
• Measuring effectiveness
• Mass casualty triage
• Credentialing of volunteers
• Leadership education and training

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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

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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

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Triage

• Applicable to entire population
• START Triage applies to adults but not small
  children
• Use of respiratory parameters
• Normal lt 30
• Mental status
• Normal follows commands
• JumpSTART modifies START to accommodate needs
  of children
• Normal respiratory rate 15 - 40
• Mental status measure by AVPU

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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 1-5 predicted worse outcome.
• Respiratory rate.not so good

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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?)

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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

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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 workers comp

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Credentialing of Volunteers

• Issues with ESAR-VHP
• Its expensive
• 10 million expended thru 2005
• 2006-2007 cost estimates forCalifornia alone
  850K. Costsfor subsequent years 335K
• ? Millions for the entire countryand for how
  long

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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 2-4
• Inherent delays in activating, mobilizing, and
  delivering personnel
• Take years to implement fully

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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?
• Dont we already do this?

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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

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Leadership Education Training

• Whos 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

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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)

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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

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THANK YOU!

• QUESTIONS?
• Carl Schultz, MD
• schultzc_at_uci.edu

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References

1. Schultz CH, Stratton SJ Improving Hospital
   Surge Capacity A New Concept for Emergency
   Credentialing of Volunteers. Ann Emerg Med
   200749602-609.
2. Schultz CH, Koenig KL State of Research in
   High-consequence Hospital Surge Capacity. Acad
   Emerg Med 200613(11)1153-1156.
3. Hick JL, Hanfling D, Burstein JL, et al. Health
   care facility and community strategies for
   patient care surge capacity. Ann Emerg Med.
   200444253-261.
4. Hick JL, OLaughlin DT. Concept of operations for
   triage of mechanical ventilation in an epidemic.
   Acad Emerg Med. 2006 132239.

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References

• Garner A, Lee A, Harrison K, Schultz CH
  Comparative Analysis of Multiple-Casualty
  Incident Triage Algorithms. Ann Emerg Med
  200138541-548.
• Cone DC, Koenig KL Mass casualty triage in the
  chemical, biological, radiological, or nuclear
  environment. Eur J Emerg Med 200512287-302.
• 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 5197199.
• 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
  200714, Suppl 1S12-S13