Background: In this study, we review a recent mass-casualty event at our institution to assess patient flow and resource consumption as well as the impact of this event on non-trauma services.

Aim:

Methods: We evaluated patient flow by determining time for transfer from ED to diagnostic studies, ICU, floor, OR and IR. Mobilization and integration of additional clinical and non-clinical staff was reviewed. ED non-trauma patient flow and OR patient flow were similarly studied. Outcomes were compared with chi-square analysis and case matched outcomes.

Results: On Wednesday October 2, 2013, a church tour bus carrying 18 passengers crossed a median and collided with an oncoming tractor-trailer and an SUV. Twelve patients were transported to our center, a level one trauma center. The average age was 69.7 years old and the average ISS was 24.3. ED LOS was 3.4 hours (range 0.6-9 hours). The average time to diagnostic studies (CT scan) for all patients was 72.7 min (range 18 to 212 minutes), however, the average time for trauma alert patients was 34.6 minutes (range 18-63). Average time to transfer to ICU was 2.7 hours (range 45-322 minutes). Transfer times from arrival to IR were 35 minutes and 105 minutes for two patients. No patients required emergency operations. Additional personnel that were mobilized included trauma surgeons, residents, nursing administrators, clerks, and housekeeping. Neither OR volume nor ED wait times were significantly different from baseline.

Conclusions: Review of our recent mass casualty event demonstrates that by mobilizing key internal personnel resources, a mature trauma center can effectively manage a casualty surge without delaying other non-trauma services. Mass casualty preparation should include plans for utilization of clinical and support staff who can be shifted from other assignments in order to avoid a hospital wide impact as a result of a mass casualty event.

MCI: Mass Casualty Event; IRb: Internal Review Board; Ems: Emergency Medical Service; Ed: Emergency Department; ICU: Intensive Care Unit; Or: Operating Room; Los: Length of Stay; Ct: Computed Tomography; IR: Interventional Radiology

By definition, a mass casualty incident (MCI) is an event in which the number of victims is enough to overwhelm healthcare resources. These events have multiple consequences including disruption of patient flow resulting in delays of care, as well as loss of revenue for hospitals. The ability of a hospital to effectively manage a surge of mass casualty patients has the potential to affect patient outcomes, and one of the goals of mass casualty preparedness is to improve this ability [1,2]. However, the best way to manage a facility’s scarce resources is not yet clear [3]. To better understand the effectiveness of resource management at our institution, we reviewed our most recent MCI to assess patient flow and resource consumption as well as the impact of this event on non-trauma services.

Many H, Corder J, Rasnake N, Mc Nutt K, Enderson B, et al. (2017) Internal Staff Surge during Mass Casualty Event Preserves Other Hospital Resources. Arch Emerg Med Crit Care 2(1): 1022.

Mass casualty event, Resource utilization, ass casualty preparedness, Surge capacity

As part of performance improvement and with IRB approval, we studied a recent MCI at our institution. Twelve elderly patients were brought to our level one trauma center following a tour bus crash after EMS scene triage based on START methodology. We evaluated patient flow by measuring time from arrival to the emergency department (ED) to arrival at diagnostic studies, the intensive care unit (ICU), floor, operating room (OR) or interventional radiology (IR). Mobilization and integration of additional clinical and non-clinical staff was reviewed. ED nontrauma patient flow and OR patient flow were similarly studied. Patient demographics and outcomes were recorded from the NTRACS database. Outcomes were compared with chi-square analysis and case matched outcomes.

On Wednesday October 2, 2013 at approximately 2:00PM EDT, a church tour bus carrying 18 passengers crossed a median and collided with an oncoming tractor-trailer and a sport utility vehicle. Eight people died at the scene. A total of 14 victims of the accident required medical evaluation and all of these patients were eventually transferred to our facility. Mobilization of emergency medical services (EMS) included both air (4 helicopters) and ground services. Following field triage using START methodology patients were transferred to our facility, a level one trauma center located 30 miles away. Patients arrived in correct triage order with the first three patients arriving by air approximately one hour after the accident. In addition to these three patients, four more patients arrived by ground who met criteria for trauma team activation. This initial surge of seven critically injured patients arrived within a time window of 30 minutes. In total, 11 patients were transported by EMS directly to our center all of which arrived within a time window of 77 minutes. Those patients (four totals) that did not require trauma team activation criteria were triaged to general ED rooms or to hallway beds where they were evaluated by ED or surgical personnel who were not part of the assigned trauma team. One patient was initially transferred from the scene to an outlying hospital. This patient was subsequently transferred to our facility by ground arriving three hours after the time of the accident. Two patients arrived several hours later by private vehicle and were evaluated and discharged by ED personnel.

Our hospital’s Emergency Incident Command System was implemented. Additional personnel resources for patient care were derived from three additional trauma surgeons (in addition to the surgeon on call). Two of these trauma surgeons were already in-house and one arrived from home. A surgical critical care fellow as well as three additional chief surgical residents and three mid-level surgical residents all of who were located inhouse were mobilized to assist. ED physicians on duty covered patients who arrived who did not meet trauma team activation. This did not require anymore than normal coverage. Four nurses were mobilized from administration to help coordinate patient flow, and of these, 3 had ED experience. Three clerks were shifted to handle non-clinical trauma victim duties. Housekeeping prioritized ICU bed cleaning for 2 hours from on duty personnel.

The average patient age was 69.7 (range 62.7 -74.5) years old and the average ISS was 24.3. Patients who met criteria for trauma team activation (8 of 14) were generally resuscitated by ATLS guidelines. Extended FAST (eFAST) exams were performed on all patients and chest radiographs were performed selectively based on patient presentation and eFAST findings. Procedures performed in the trauma bay included one needle decompression for tension pneumothorax, 4 chest tube placements, and 2 intubations (Table 1). ED length of stay (LOS) was 3.4 hours (range 0.6-9 hours). The average time to diagnostic studies (CT scan) for all patients was 72.7 min (range 18 to 212 minutes), however, the average time for trauma alert patients was 34.6 minutes (range 18-63). Average time to transfer to ICU was 2.7 hours (range 45-322 minutes). Two patients required procedures by interventional radiology. One of these patients required splenic embolization, and the other hypogastric artery embolization due to pelvic hemorrhage. Transfer times from arrival to IR were 35 minutes and 105 minutes for these two patients. During the time interval, ED patient flow was maintained (238 patients/day, 5 patients/day left without being seen, not different than quarterly data) and OR volume was 67 cases (not significantly different from daily case volume preceding three months). Three patients were admitted to floor beds and 2 were discharged home. All patients survived, mean LOS was 13.6 days, and 9 patients (75%) were discharged to SNF/Rehab. Survival was improved from case matched controls (p<0.05), but LOS was significantly longer (p<0.05).

Table 1: Summary of Patients Admitted.

Trauma centers must provide 24-hour per day coverage to meet the needs of critically injured patients. Mass casualty events can overwhelm this system which not only affects those involved in the mass casualty event, but also affects delivery of care to uninvolved inpatients and outpatients. In addition, health care systems can lose significant revenue because of the impact a mass casualty event can make on scheduled services [4]. In contrast a multiple casualty event is one in which resources are strained but are not overwhelmed, and therefore a facility is able carry out its usual services [5]. The ability of a facility to adapt to a surge of casualties can determine the difference between a mass casualty event and a multiple casualty event. Strategic use of in-hospital resources not only facilitates effective management of a mass casualty event, but can also convert it into a multi-casualty scenario that allows for normal functioning of the hospital facility. Recent consensus guidelines have stressed the importance of mass casualty preparation which includes the mobilization of personnel and resources [6], however, the best method for utilizing in-hospital scarce resources is uncertain. Currently, there is not sufficient data to support one methodology over another [3]. It is likely that there is no single best method, and each healthcare system must be able to adapt to a variety of mass casualty scenarios.

In this study we reviewed a recent MCI at our institution to assess resource consumption and patient flow to allow us to better understand how to effectively use our hospital’s resources. This knowledge is added to twice yearly disaster drills (one full scale community exercise and one table top) to improve delivery of care during mass casualty events. After receiving multiple critically-injured casualties within a short time frame, personnel resources were mobilized which allowed our facility to maintain normal patient flow in the emergency room and OR without delaying care for our mass casualty patients. Key facility resources utilized in our MCI were CT imaging and ICU beds. Due to the blunt mechanism of our patients’ injuries, all required CT imaging. Eight of 12 required admission to the ICU which created potential for bottlenecking. Other authors who have reviewed in-hospital resource utilization have also found CT and ICU bed availability to be an important source of impediment to patient flow [7]. Internal review and feedback from involved personnel suggests that nursing administrators were instrumental in coordinating efficient patient flow from the ED to radiology. Nursing administrators also facilitated the prompt availability of ICU beds by prioritizing transfers out of the unit. Housekeeping mobilized additional staff to help prioritize the cleaning of ICU rooms so that casualty patients could be transferred more expediently from the ED. Additional attending trauma surgeons and surgical residents allowed for more timely evaluation and decision making. The ability to mobilize additional trauma surgeons was felt to be an important component to the success of our MCI which is in line with others’ observation [8]. Our hospital emergency incident command system was implemented and on internal review was thought to have functioned well.

This particular MCI was characterized by the elderly population involved (average 69.7 years) and this patient demographic presents some unique challenges to trauma care. Elderly patients have a high mortality relative to the degree of trauma they sustain which can lead to under triage [9,10]. Standard physiologic variables used for triage are not always reliable for determining severity of injury in this population [11]. Aggressive and timely evaluation of elderly patients after multisystem trauma is required to minimize morbidity and mortality; however, time and resource constraints during an MCI can make attaining this goal difficult. Lastly, it should also be recognized that frailty, and not necessarily age alone, is a marker of severe injury [12]. Therefore, chronologic age alone may not correctly identify patients at risk for higher severity of injury.

Applicability of our findings to other facilities has some limitations. This particular incident was limited to elderly blunt trauma patients who did not require emergent operative interventions. This allowed the operating room to continue to function at full capacity. Secondly, due to the location of the incident, transport times were long which allowed for better preparation and personnel mobilization ahead of the patient surge.

In summary, review of our recent mass casualty event demonstrates that by mobilizing key internal personnel resources, a mature trauma center can effectively manage a casualty surge without delaying other non-trauma services. Mass casualty preparation should include plans for utilization of clinical and support staff who can be shifted from other assignments in order to avoid a hospital wide impact as a result of a mass casualty event.

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12. Oskutis MQ, Lauerman MH, Kufera JA, Shanmuganathan K, Burch C, Kerns T, et al. J Trauma Acute Care Surg. 2016; 81: 156-161