Case Study: New Orleans and Minneapolis, a Tale of Two Cities - PowerPoint PPT Presentation

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

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Public health (George Washington Univ.) Emergency/disaster management (SUNY Stony Brook) ... Garner A, Lee A, Harrison K, Schultz CH: Comparative Analysis of Multiple ... – PowerPoint PPT presentation

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Title: 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

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

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

5
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

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

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?)

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

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 workers comp

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

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

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?
  • Dont we already do this?

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

14
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

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)

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

17
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18
THANK YOU!
  • QUESTIONS?
  • Carl Schultz, MD
  • schultzc_at_uci.edu

19
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.

20
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
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