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

1. 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

2. Overview • Need for Scientific Inquiry • Measuring effectiveness • Mass casualty triage • Credentialing of volunteers • Leadership education and training UC Irvine School of Medicine Department of Emergency Medicine

3. 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 UC Irvine School of Medicine Department of Emergency Medicine

4. 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 UC Irvine School of Medicine Department of Emergency Medicine

5. 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 UC Irvine School of Medicine Department of Emergency Medicine

6. 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 UC Irvine School of Medicine Department of Emergency Medicine

7. 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?) UC Irvine School of Medicine Department of Emergency Medicine

8. 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 UC Irvine School of Medicine Department of Emergency Medicine

9. 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 UC Irvine School of Medicine Department of Emergency Medicine

10. 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 UC Irvine School of Medicine Department of Emergency Medicine

11. 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 UC Irvine School of Medicine Department of Emergency Medicine

12. 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 we already do this? UC Irvine School of Medicine Department of Emergency Medicine

13. 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 UC Irvine School of Medicine Department of Emergency Medicine

14. Leadership Education & Training • Who’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 UC Irvine School of Medicine Department of Emergency Medicine

15. 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) UC Irvine School of Medicine Department of Emergency Medicine

16. 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 UC Irvine School of Medicine Department of Emergency Medicine

18. THANK YOU! QUESTIONS? Carl Schultz, MD schultzc@uci.edu UC Irvine School of Medicine Department of Emergency Medicine

19. References • Schultz CH, Stratton SJ: Improving Hospital Surge Capacity: A New Concept for Emergency Credentialing of Volunteers. Ann Emerg Med 2007;49:602-609. • Schultz CH, Koenig KL: State of Research in High-consequence Hospital Surge Capacity. Acad Emerg Med 2006;13(11):1153-1156. • 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. • Hick JL, O’Laughlin DT. Concept of operations for triage of mechanical ventilation in an epidemic. Acad Emerg Med. 2006; 13:223–9. UC Irvine School of Medicine Department of Emergency Medicine

20. References • Garner A, Lee A, Harrison K, Schultz CH: Comparative Analysis of Multiple-Casualty Incident Triage Algorithms. Ann Emerg Med 2001;38:541-548. • Cone DC, Koenig KL: Mass casualty triage in the chemical, biological, radiological, or nuclear environment. Eur J Emerg Med 2005;12:287-302. • 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; 5:197–199. • 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 UC Irvine School of Medicine Department of Emergency Medicine