Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Assessment of the Capacity and Capability of Burn Centers to Respond to Burn Disasters in Belgium: A Mixed-Method Study

Assessment of the Capacity and Capability of Burn Centers to Respond to Burn Disasters in... ORIGINAL ARTICLE Assessment of the Capacity and Capability of Burn Centers to Respond to Burn Disasters in Belgium: A Mixed-Method Study ,† Mustafa Al-Shamsi, MD, MPH,* Maria Moitinho de Almeida, MD, MPH,* ‡,||,$ ¶ Linda Nyanchoka, MPH, Debarati Guha-Sapir, PhD,* and Serge Jennes, MD Burn disaster is defined as a massive influx of patients that exceeds a burn center’s capacity and capability. This study investigates the capacity and capability of burn centers to respond to burn disasters in the Belgian ground. Quantitative survey and qualitative semistructured interview questionnaires were administered directly to key informants of burn centers. The data collected from both methods were compared to get a more in-depth overview of the issue. Quantitative data were converted into a narrative to enrich the qualitative data and included in the thematic analysis. Finally, data from both methods were analyzed and organized into five themes. The Belgian Association of Burn Injury (BABI) has a specific prehospital plan for burn disaster management. Once the BABI Plan is activated, all burn centers respond as one entity. Burn Team (B-Team) is a professional team that is formed in case of urgent need and it is deployed to a scene or to nonburn specialized hospitals to help in disaster relief. The challenges for burn disasters response occur particularly in the area of triage, transfer, communication, funding, and training. We conclude that there is a variation in the capacity and capability of burn centers. Overall, the system of burn disaster management is advanced and it is comparable to other high-income countries. Nevertheless, further improvement in the areas of preparation, triage, communication, and finally training would make disaster response more resilient in the future. Therefore, there is still space for further improvement of the management of burn disasters in Belgium. Burn disaster, also known as Burn Mass Casualty Incident This results in a poor reaction from officials on funding and (BMCI), is defined as a condition in which the number of in- maintaining the activities that relate to burn disaster prepara- flux patients exceeds the coping capacity and capability of a tion and management. As a result, this leads to multiple gaps burn center. The capacity of a burn center can be defined as in planning which might not be discovered until a disaster the availability of space and supplies, while capability means the becomes reality. presence of sufficient and prepared staff to handle a sudden and Belgium is known to have nuclear power plants and sev- 2,3 massive influx of burned patients. BMCI may result from a eral petrochemical factories which makes it liable to the risk of 6,7 variety of accidents including man-made such as explosions, burn disasters. Among several burn disasters that happened 8–10 chemical, nuclear, biological attacks as well as natural disasters worldwide, Belgium was not immune. In the last 30 years, such as earthquake, volcanic eruption, and wildfire. major disasters affected the country including the attack Globally, there is insufficient awareness to BMCI since on the auditorium of the Catholic University of Louvain in it is not common and it does not happen on a daily basis. Brussels, Switel hotel fire in Antwerp, Cockerill factory dis- aster in Liège, Ghislenghien gas pipeline explosion in Hainaut, and finally the 2016 terrorist attacks in Brussels. The objective From the *Centre for Research on the Epidemiology of Disasters (CRED), of this study is to assess the capacity and capability of burn Institute of Health and Society, Université catholique de Louvain, Brussels, centers in Belgium and to explore challenges and possibilities Unit for Research in Emergency and Disaster, University of Oviedo, Belgium; that may arise in the event of a burn disaster. Université Paris Descartes, Sorbonne Paris Cité, Faculté Oviedo, Spain; || INSERM, UMR1153, Epidemiology and de Médecine, Paris, France; Statistics Sorbonne Paris Cité Research Center (CRESS), Team METHODS, University of Liverpool, Institute of Translational Medicine, Paris, France; Burn Wound Centers of Loverval and Brussels (IMTR METHODS Liverpool, UK; Loverval, Centre des brûlés) Charleroi, Belgium Conflict of interest statement. The authors declare that they do not have any Research Design conflict of interest regarding this submission. This is a cross-sectional descriptive study using mixed methods Address correspondence to Mustafa Al-Shamsi, MD, MPH, Centre for Research on the Epidemiology of Disasters (CRED), School of Public Health, Université (concurrent design approach). The concurrent implementa- catholique de Louvain, Clos Chapelle-aux-Champs, Bte B1.30.15, 1200 tion allows the use of both the quantitative and qualitative Brussels, Belgium. Email: mustafatalibb@yahoo.com 11,12 data equally. In this study, both a quantitative survey and © The Author(s) 2019. Published by Oxford University Press on behalf of the qualitative semistructured questionnaire were used. American Burn Association. This is an Open Access article distributed To our knowledge, there is no predesigned checklist for under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits assessing hospital preparedness to disasters in Belgium. non-commercial re-use, distribution, and reproduction in any medium, pro- Therefore, the quantitative survey was developed based on vided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com an extensive review of literature relevant to the preparation and management of burn disasters in other countries. We doi:10.1093/jbcr/irz105 869 Journal of Burn Care & Research 870 Al-Shamsi et al November/December 2019 identified 60 questions related to burn disaster preparedness first author (Al-Shamsi) traveled to all centers to interview the and management. Thereafter, the questionnaire was discussed participants between May and June 2018. The data collection by the research team, which includes burn specialists. This included both the quantitative survey, which lasted around process resulted in the selection of 32 final questions. The 30 minutes, and qualitative interviews on the same day. The questions were framed according to eight domains adopted entire process lasted between 60 and 90 minutes and the in- 13,14 from previous studies on burn disasters planning. The re- terview was conducted in the English language. During the sponse was dichotomized into 1 for yes and 0 for no and un- interviews, notes were taken and the entire interviews were known answers (Figure 1 and Supplementary Annex 1). recorded and transcribed verbatim. Qualitative interviews with key informants provide an in-depth understanding of the process of disaster preparedness Data Analysis in the healthcare context. It also provides insight into the atti- We compared the data collected from the quantitative survey tude, practice, and perception of healthcare workers regarding with the qualitative interviews to get a more in-depth over- disaster management and response. The semistructured in- view of the preparedness and management of burn centers terview was designed based on the Consolidated Criteria for in the event of burn disasters. Typically, data from mixed- Reporting Qualitative Research. An interview guide was method studies are presented into a separated section or may prepared based on the relevant domains of preparation and be transformed from one type to another to converge the management of burn disasters. Probes were provided to results. allow the interviewees to expand on the topic covered. The Data transformation is a method by which both quanti- interview was structured into five themes (Supplementary tative and qualitative data can be integrated during analysis. Annex 2). For example, qualitative data could be numerically coded and included in the quantitative analysis or the reverse. In our Data Collection study, quantitative responses were coded and entered into a All six Belgian burn centers (Antwerp, Brussels; Charleroi; Microsoft Excel 2013 spreadsheet and analyzed descriptively. Ghent, Leuven, and Liege) were targeted. Initially, we Quantitative data were then transformed into a narrative and requested an appointment with the head of burn centers. included in the qualitative thematic analysis. When they could not participate (mostly due to schedule The result of the qualitative interviews transcribed ver- constraints), we inter viewed the deputy or associate physicians. batim and organized according to the predefined themes. The In total, five centers participated in the study and nine people transcripts were sent to all interviewees so that they review completed the interview, including three principal physicians and confirm them. Finally, the data from both methods were in three burn centers. In the fourth center, both the deputy analyzed and organized into five predefined themes: 1) prepa- physicians and the emergency physician were interviewed. For ration & plan; 2) command & communication, 3) transfer & the last burn center, the author interviewed the deputy phy- triage; 4) capacity, capability, treatment; and 5) training. sician as well as hospital disaster manager, chief and deputy nurses of the burn unit. Table 1 shows the details of the Ethical Consideration participants. Firstly, the interviewees were contacted by email. A  short The participation of both the survey and the interview was explanation of the protocol of the study was provided. The voluntary and the researcher explained the protocol of the Further reduction Firstly 60 questions The �inal questions Reduced to 44 after to 32 items retrieved based on consists of 32 items a discussion with following a extensive literature distributed on 8 the research team discussion with an review domains expert Figure 1. The iterative process of designing the quantitative survey. Table 1. Demographic information of the interviewees Interviewee Position Profession Burn Center Identity Gender Deputy physician Plastic surgeon 1 Female Head physician Emergency & disaster medicine 1 Male Head physician Anesthesia and intensive care medicine 2 Female Head physician Anesthesia and intensive care medicine 3 Male Deputy physician Plastic surgeon 4 Male Head nurse Burn and intensive care nursing 4 Female Deputy nurse Burn and intensive care nursing 4 Male Manager Disaster management 4 Male Head physician Anesthesia and intensive care medicine 5 Male Journal of Burn Care & Research Volume 40, Number 6 Al-Shamsi et al 871 study for every interviewee. Written consent was obtained All burn centers faced and responded to a burn disaster from each of the interviewees. The interviewees informed at some point. Several challenges were identified by the about their right of withdrawal at any point during the inter- respondents, such as difficulty in coordination and standardi- view. No financial incentive was offered to the interviewees. zation of protocol for all centers. The BABI Plan is not a com- The researcher ensured that all information obtained would plete solution to disaster response and every hospital needs to be kept confidential by anonymizing both the interviewees’ have its own protocol to respond to burn disasters in addition identity and the data obtained from the centers. to BABI Plan. Lack of funding of disaster-related activities represents a real challenge for maintaining and updating the plan. A  high daily bed occupancy rate is another challenge RESULTS that could create a bottleneck in case of a massive influx of patients. Receiving more than three severely burned patients is We identified six operating burn centers in Belgium with a ca- considered a big challenge for many centers. The major burn pacity varying from 6 to 26 beds, giving overall 75 operating center in Belgium is well-equipped to receive a considerable beds all over the country. We obtained data from five out of number of burned patients, but not burn with comorbidities the six burn centers (response rate of 80%). Out of the five since other trauma specialties have not emerged in the same centers that participated in the study, nine people completed facility. Finally, deployment of emergency medicine physicians the quantitative survey and participated in the qualitative with little burn-care experience could influence the accurate interviews. Information about each theme was obtained from estimation of TBSA burnt. Table 2 presents a summary on the interviewees and organized according to the interview preparation and plan section. guide of the questionnaire. There might be some challenges for this center; for example, better coordination and standardization of protocol. Even Preparation & Plan though there is BABI plan, it is not a complete solution for major disasters according to my opinion………principal The Belgian Association Burn of Injury Plan (BABI Plan) is physician of the burn center 2 a special plan for burn disasters in Belgium; it is led by the Militar y body. The Central Station (also known as the National Center of Regulation and coordination of Burn Beds or BABI Command & Communication Central) is set up within the department of intervention in the One burn center has the capability to send a mobile medical Military Hospital and it operates on a daily basis 7/24. The team to the field. It is essentially a specialized team called Burn Central Station is responsible for maintaining the coordina- Team (B-Team). The B-Team is dispatched either to the scene tion and the regulation of prehospital response in case of a of a disaster or to nonburn hospitals where patients are being massive disaster. It is headed by a coordinator who is special- initially stabilized. The B-Team consists of a highly compe- ized in emergency relief and management. The coordinator tent surgeon, anesthetist, and/or intensivist as well as a nurse, manages the triggering and implementation of the BABI Plan all specialized in burn care. The major role of the B-Team and is assisted by an expert burn specialist. is to triage patients at nonspecialized burn hospitals, often The decision to activate the BABI Plan depends on the head in the first 12 to 24 hours following a major burn calamity. of the dispatching center. EMS units who arrive at a scene call the Moreover, it is responsible for following up and evaluating emergency center 112 and declare the disaster situation based patients in the vicinity of a burn disaster. Table 3 summarizes on their primary evaluation. The emergency center then calls the the major roles of the B-Team. The remaining centers have a Central Station to activate the BABI Plan. The plan could also low capability in terms of burn specialists. Therefore, they de- be activated by Federal Health Inspector of each province; the pend on emergency physicians who have some experience in nearest burn centers; and even burn centers in the neighboring dealing with burn patients at the scene of a disaster. countries in case there is a national crisis. As soon as the plan is activated, the Central or BABI Station contacts the president B-Team; however, is able to do such a procedure, but it so of the BABI and all burn centers’ heads by telephone to gather complicated because the number of burn experts in Belgium information on each burn center’s capacity and capability, which is so low and a disaster is not the best situation to send burn ideally should be provided within an hour. Figure 2 presents the experts outside the burn units, unless the center is over- simplified process of activation of the BABI Plan. staffed which is not the case in so many burn centers except, All centers but one have a contingency plan that could be may be, the military hospital………principal emergency activated in case of delay in activation of BABI Plan or transfer and disaster medicine physician in burn center 1 of burn patients to other centers. The contingency plan is often part of the hospital’s internal disaster plan. It consists Regarding communication, the Central Station is considered of moving stable inpatients to other wards and expanding the the only focal point for communication between all centers. burn beds, as well as the request for extra staff from other Apart from this, all centers depend on personal contact be- wards. However, this plan is only effective for small-scale burn tween faculty members, even with burn centers in neigh- disasters. On the other hand, none of the burn centers have a boring countries. However, apart from the liaison office of special plan for pediatric burn disasters. However, since most the Central Station, there are no special channels through of the burn centers are part of a large university hospital, the which burn centers could directly communicate with each respondents stated that it is possible to care for pediatric burn other. There is also limited communication with fire units at inside pediatric Intensive Care Units (ICU). the scene, which is currently informally undertaken through Journal of Burn Care & Research 872 Al-Shamsi et al November/December 2019 BABI PLAN Burn Centers in Every center conducts its capacity & Contact all burn centers in Belgium Belgium capability to the Central Staon The Central Staon/ BABI Central Burn Centers The Central Staon collects Burn disaster is beyond the capacity (the Center of Coordinaon of Burn informaon on capacity & in the of the local burn centers! capability of each burn center Beds) neighboring countries Acvaon of BABI plan in case of a burn disaster beyond the naonal capacity & capability Disaster! The Central Staon gives the final Following the acvaon of decision to the contacted body the plan by these bodies A Burn Center Emergency medical Director of Medical Federal Health Inspector services (EMS) Service at the scene of in the affected province a disaster (DSM) Calling Centers (100, 112) Disaster! Figure 2. Activation of the Belgian Association of Burn Injury (BABI) plan. Table 2. Summary of the respondents’ answers on prepara- personal contact also. Nonetheless, all emergency services tion and plan section in Belgium have a secured communication network called Digital Tetra Tracking Network (ASTRID), with fixed radio Items Yes No/Unknown transmitters installed in every EMS hospital. Respondents see Burn disaster plan 5 (100%) 0 this network as an alternative in the event of a disaster should Fund for plan activities 0 5 (100%) personal contact fail. Contingency plan 4 (80%) 1 (20%) Predefined agreement with 1 (20%) 4 (80%) Triage & Transfer nonburn specialized hospital Triage is often done by emergency physicians based on prior Pediatric burn disaster plan 0 5 (100%) experience and personal decision without predefined policy Daily information on burn bed 4 (80%) 1 (20%) and/or triage decision table that could be considered as a ref- status erence in the event of a disaster. Journal of Burn Care & Research Volume 40, Number 6 Al-Shamsi et al 873 Transfer of patients to nonspecialized burn hospitals is The transfer is done exclusively by EMS through a cen- also possible should burn centers be overwhelmed. However, tral dispatch office in each province. A Medical Director at a this depends on personal contacts and is done according scene acts as an Incident Commander. Typically, the Medical to the emerging disaster situation with no prior agree- Director has experience in dealing with burn casualty situa- ment or predefined policy. In fact, wild evacuation to close tion and could assess the disaster situation. In case of a burn nonspecialized hospitals was an observed reality during many disaster, communication is established between the BABI Belgian disasters (eg, Antwerpen 1995, Ghislenghien 2004, Central Station and Incident Commander at the scene of a and Brussels terrorist attacks 2016)  despite short delays for disaster. Basically, all centers wait for a signal from the Central deploying a forward medical post that can do the triage of Station to transfer or receive patients. If the local burn centers’ the casualties. capacity and capability are sufficient, patients are transferred to the Belgian hospitals. However, if the number of patients is beyond the capacity and capability of the Belgian burn centers, Table 3. Organization of the Burn Team a transfer to neighboring countries is decided (Figure 3). The B-Team Incident Commander liaises with BABI Central Station then a decision is pursued whether there is a capacity or Where to go not. In case there is a capacity, patients are distributed to • Nonspecialized burn centers the Belgian hospitals; however, if the Incident Commander • Disaster scene and BABI office see that the number of patients is beyond What to do the capacity and capability of the burn centers. A transfer • Primary triage to neighboring countries is decided………Principal phys- • Secondary triage ician of the burn center 5 • Follow-up and evaluation • Consult & advice All centers have the capacity and authorization to transport • Transport patients outside Belgium through air transfer. This is often How to help done in coordination with the Belgian Military after activation • Estimation of burn bed surge capacity of the BABI Plan. The transfer is often started from the mili- • Close coordination with Incident Commanders tary or the civilian sanitary rotary-wings platforms in Belgium (Brugges and Bra-sur-Lienne) or in the neighboring countries Fire and Civil defense a Burn Disaster? Alarm Center at a scene Incident Commander/ Medical Director takes Nearest hospital EMS dispatch team to the inial decision and emergency assess the situaon contact the BABI department primirly center Belgian burn centers BABI coordinaon could deal with the center has the final disaster? decision No Yes Coordinaon with Start the transfer and higher authority to coordinaon on a transfer to the naonal level neighboring countries Figure 3. Communication and transfer hierarchy in the event of a disaster. Journal of Burn Care & Research 874 Al-Shamsi et al November/December 2019 Respondents stated that all burn centers have enough medical Table 4. Summary of the respondents’ answers on triage & supplies and equipment such as ventilators; however, the exact transfer section capacity could not be determined. The usual procedure to Items Yes No/Unknown maintain adequate supply during the mass casualty situation is to contact central pharmacies of the corresponding hos- Triage held according to prede- 0 5 (100%) pital and request the medications and equipment. Generally fined policy speaking, the maximum capacity in all burn centers is the ad- Presence of triage decision table 0 5 (100%) mission of three to five severely burned victims. Trace and track system 1 (20%) 4 (80%) Regarding treatment strategies, three centers express the Capacity to request air transport 5 (100%) 0 possibility of using alternative dressing in case of disaster aus- Capacity to transfer patients out- 5 (100%) 0 tere conditions, including the long-term antimicrobial dressing side the country ® ® (such as Aquacel Ag and Flammacerium ). However, this is Capacity to send a mobile medical 1 (20%) 4 (80%) not a standard protocol in all Belgian hospitals. Telemedicine team technology has a well-known role in disaster management ; however, none of the centers has this capacity until now. Table 5 presents a summary of capacity and capability. (France, Luxembourg, and Germany). Nevertheless, trace and tracking system where patients could be followed does not Training exist in the Belgian healthcare system, but one center used Participants expressed that, since Belgium is a safe country, an internal system that could follow up patients admitted in less attention is paid from the authorities on funding disaster- the hospital providing that they were transferred within same related activities. Two centers have the ability to hold disaster hospitals’ group. Table 4 presents a summary on triage and drills on an annual basis. However, both hospital management transfer. and health workers are less motivated to participate in disaster drilling and exercises. In addition to this, the cost of this kind Capability, Capacity, and Treatment Strategies of exercise is covered neither by the health department nor There is the possibility to call for the assistance of professional by the individual hospitals; another reason that makes them staff in case of a massive influx of patients. This varies across less appealing for healthcare workers. Only one center had different centers and it is easier and more feasible in burn performed disaster drilling in the past. Nevertheless, it was centers nested in large university hospitals. Since burn man- part of a hospital internal disaster plan and it was not about agement involves complex dressings that require experienced burn disaster in particular. All respondents felt that there nurses, the recruited staff members should work under the su- should be more training and disaster drilling in the area of pervision of experienced nursing staff. However, there is still burn and massive casualty incidence. no official predefined policy and protocol to request for extra In Belgium, training such as Advanced Burn Life staff from other hospitals, since health insurance does not Support ABLS is not mandatory. Our staff are not usu- cover staff operating outside their facilities. Nonnursing staff ally enrolled in such training since we are not the one who members could provide a valuable contribution in case the is going to a scene………(Principle Physician of the burn conventional staff is over whelmed. Most burn centers have the center 3) possibility to recruit occupational and respiratory therapists as a part of the enforcement team to do burn-related procedures. Furthermore, in all burn centers, there is a special EMS team DISCUSSION that could be made available to accompany intubated patients if a transfer is needed. To our knowledge, this is the first English written paper that Measures to increase capacity could include expanding discusses burn disaster management in Belgium. In our study, the conventional burn beds and operation theaters to handle we only interviewed people responsible for running, but not more patients. This is the main strategy to deal with a mas- the implementation of the disaster plan. Therefore, this re- sive influx of patients. Nevertheless, such expansion should be search focuses mainly on a strategic rather than an operational accompanied by increasing the experienced staff, which may level. Our findings reveal that there is a special predesigned not be immediately possible. As part of assistance, three centers plan for burn disaster in Belgium. This plan (BABI Plan) have a specially designed burn cart that could be deployed to regulates the response between different Belgian burn centers a scene or to a nonspecialized center where patients are being at the prehospital setting and it represents the backbone for initially stabilized. burn centers not only in Belgium, but also in the neighboring We can increase the free beds. For example, we have in- countries in the event of a massive casualty. It was executed patients waiting for medication and rehabilitation. We successfully in disasters before such as in Ghislenghien dis- could ask the rehabilitation unit to take patients quicker aster and 2016 Brussels’ attacks. Moreover, in 2001, in the or we send patients in a normal unit while waiting for the aftermath of the café fire in Volendam in the Netherlands, transfer to the other burn centers in Belgium. So patients Belgian burn centers admitted 20 severely burned casualties with minor injuries will be transferred to non-burn wards and in 2015, the Brussels Burn Center admitted eight while those with major burn kept in burn center……… casualties from the collective nightclub fire in Bucharest. deputy physician of the burn center 4 The concept of BABI Plan is similar to burn disaster plans Journal of Burn Care & Research Volume 40, Number 6 Al-Shamsi et al 875 Table 5. Summary of the respondents’ answers on the capacity & capability section Items Yes No/Unknown Burn cart ready for deployment 3 (60%) 2 (40%) Requesting equipment and supply from other hospitals 0 5 (100%) Capacity to expand ICU bed 4 (80%) 1 (20%) Capacity to expand the conventional beds 5 (100%) 0 Capacity to expand operation theater 3 (60%) 2 (40%) Capability to request extra burn surgeon 5 (100%) 0 Capability to request extra staff from the same hospitals 3 (60%) 2 (40%) Capability to recruit nonnursing staff 4 (80%) 1 (20%) Capability to request staff from outside hospitals 0 5 (100%) Presence of dedicated team that could accompany burned patients 4 (80%) 1 (20%) ICU, Intensive Care Unit. in other high-income countries, such as the American Burn victims requires extra staff not often directly involved in burn 21 22 Association plan, Australian Burn Plan, United Kingdom care and intervention. Those would provide a valuable con- 23 33 National Major Incident Plan for Burn Injuries, the Dutch tribution; for example, physiotherapists and psychologists. 24 24 National Mass Disaster Plan, Swiss burn plan, and the Fortunately, this is possible in most of the centers. Sweden National Burn Disaster Management Plan. Burn disasters are not common, this leads to a relative The BABI-Plan provides a framework to coordinate re- apathy to follow up and update plan and contact details. As sponse in the decentralized Belgian healthcare systems. It is a result, multiple gaps in burn disaster planning might not led by the military body which is responsible for coordination be discovered until disaster becomes reality. Despite the between different centers. This is considered a strong point above advantageous points of the BABI Plan, there are some toward burn disaster response and management due to the challenges and limitations for the response to burn disasters fact that governments usually invest well in the military sector. in Belgium. The military is often well-equipped and has both the capacity Firstly, lack of coordination between burn and nonburn and capability to respond to large-scale disasters. Hence, in hospitals. A burn disaster may happen at any time. It will be case of a disaster, the Belgian burn centers are supposed to challenging to transport all victims to definitive burn centers respond as one entity in contrast to disaster systems in other immediately, especially in case of mass casualty disasters. 21,27 countries. Therefore, it is imperative to have prepared facilities to re- The B-Team is a special team that can act as an Incident suscitate patients even in a small country with good trans- Commander and directly involved in the coordination of re- portation network. This is done by identifying enough sponse to mass casualty events. It could be deployed to aug- resource and experience in advance as well as coordination ment burn team in specialized hospitals as well as to give with nonspecialized hospitals. consultation to not-specialized one. Additionally, it optimizes Secondly, lack of specific pediatric burn disaster plan. A pe- the use of burn surge capacity and resources, and organize diatric burn disaster is likely to occur such as burn in school the transfer and triage procedures. This has been proven to or kindergarten; therefore, the pediatric plan is an essential 22 35 improve the outcome of burn disasters’ response in general. part of any disaster planning. This is because this group of 4,28 The concept of B-Team also exists in other countries. It patients is negatively affected when the resources become is clear that the deployment of such a team to hospitals is an scarce. Full pediatric plan means not only unified treat- effective solution in austere conditions since it can be easily ment guidelines, but also special protocol, communication 9 30,37 assembled within days or even hours. channels, and equipment. Coordination of the transfer is organized by the Central Thirdly, lack of funding for BABI Plan activities. Funding Station and the medical director on the site of the disaster is an indispensable part of any disaster plan. In the United to guarantee the rational distribution of patients according States, for example, both the burn disaster plan and burn team to local capacity and capability. An advantage is that Belgium have a special fund that could be activated in case of disaster. is a small country with a good road network, making rapid Unfortunately, BABI Plan lacks specific fund and once the movement between different centers possible. Furthermore, plan is activated, it totally depends on the hospitals’ initiative in large-scale disasters, the military becomes the main body with no clear roadmap of funds. This issue could be mitigated responsible for the transfer, particularly outside Belgium. This by including BABI Plan fund in the national disaster fund, is another advantage since the military means is often more for example, the special fund that already allocated to face the capable than the civilian one. danger of epidemics or natural disasters. This at least would Requesting extra staff from the same facility is possible in ensure the maintenance of the BABI Plan and B-Team during some centers. It is known that staff shortage would be a bot- a massive disaster. tleneck in case of massive casualty, providing enough space Fourthly, many decisive steps depend solely on personal is available. Therefore, having a clear contingency plan that contact. Although Central Station is responsible for coordi- defines staff duties is crucial at both national and local level. nation in the event of a disaster, the presence of predefined Moreover, a large catastrophic incident with a large number of communication channels between burn centers, and between Journal of Burn Care & Research 876 Al-Shamsi et al November/December 2019 burn centers and directors at a disaster scene is vital. Those CONCLUSION bodies play a vital role in the distribution of patients to the There is a specific plan for burn disasters in Belgium. This plan available resources, in particular, in the first hours of a dis- mainly coordinates the prehospital setting in the event of mas- aster. Additionally, normal means of communication are sive disasters such as the deployment of a highly specialized usually disrupted during disastrous situations, which makes 40,41 team to optimize the distribution of patients according to the them unreliable. available resources. Moreover, the plan functions to coordi- Finally, there is no national tracking and tracing system of nate cooperation between different centers and ensures the burn patients, which is regarded as one of the greatest challenges smooth transfer of patients. Generally speaking, the capacity in disaster setting that might affect the response in term of 42,43 to respond to burn disasters varies across different centers in triage and transportation. A  system following patients term of staff, space, and supply. This is, nevertheless, mitigated from the point of registration until discharge would optimize by the BABI Plan which ensures a balanced response between disaster response in a resource-limited environment. This different burn centers based on their capacities and capabilities. system has been developed effectively in the Netherlands. However, our study identified some challenges in disaster However, it is still under development in Belgium. management and response in Belgium. These include lack of special pediatric burn disaster plan, defined triage protocol, Strength and Limitation of the Study funding to the burn disaster plan activities, and deficient This is the first study aiming to describe current preparation national track and tracing system. Moreover, specific training to the massive casualty burn incidences in Belgium. The study and drills on burn disaster seem to be a real challenge because used a combined quantitative and qualitative methodology, such training makes the healthcare professional more oriented an effective approach in health research. All interviews and resilient should they encountered by massive casualty were held directly by the lead researcher with key informants burn situation. from the burn centers. Nevertheless, there are some limita- Overall, planning and preparation for burn disasters have de- tions to this study. Firstly, not all burn centers participated in veloped in Belgium. It is not a coincidence that Belgian burn the study, we could not get an appointment from the sixth centers have previously responded to burn disasters successfully. burn center despite frequent contact, but the response rate However, we identified some areas that need improvement in was 80%. Therefore, we believe that this does not adversely order to achieve an efficient response. These include but are affect our findings. Secondly, there might be a social desir- not limited to communication, triage, transfer policy and agree- ability bias. A  typical issue in the interview-based research ment, and finally the funding and training which needs to be where inter viewee tries to manipulate the conversation based further sought by stakeholders in Belgium. Therefore, we rec- on their wishes. This issue was mitigated by informing the ommend frequent revision of the plan and more coordination participants that their identities and burn centers would be between the directors of burn centers and stakeholders in order anonymized. Thirdly, although the interview was initially to identify the possibilities and challenges and, thus, ensure a directed toward the heads of burn centers, the researcher better response in the future. This includes, in particular, more could not inter view all of them. Additionally, in some center, effort to fundraise the disaster plan with its associated activities we had the opportunity to interview people more directly as well as training programs that ensure the readiness of the staff involved in disaster response such as the emergency physi- to handle massive casualty situation. Furthermore, we recom- cian officer and hospital disaster manager. This might also mend that further steps are taken to establish formal commu- create an unbalanced response between different centers. nication channels between burn and nonburn centers. Last but Fourthly, some of the questions were difficult to address ex- not least we believe that this study would provide a benchmark actly since interviewees are not directly involved in; for ex- for policymakers to further improve the preparation and re- ample, the items of equipment and supply. Furthermore, the sponse to burn disasters not only in Belgium, but also in other questionnaire was not validated before for Belgium, but it countries in Europe. The fact that there are few studies have was constructed based on an extensive literature review so been done on burn disaster planning in Europe justifies the some of these questions may be hypothetical for Belgium uniqueness of methodological approach in this study. Except since each country has its own possibilities and challenge to for narratives, mixed methods of research have not been used respond to certain calamities. Nevertheless, the question- in this context, but they represent a useful and efficient way to naire was validated by a Belgian burn expert. Additionally, assess flaws and strengths of disaster plans. the interview was held in the English language, but neither the researcher nor the interviewees are native of English. Therefore, the language may have affected the interpretation SUPPLEMENTARY DATA of some questions. Nevertheless, the results were sent after Supplementary data is available at Journal of Burn Care & the interview to all participants to ensure the best possible Research online. response. Finally, this study targeted key informants from the burn centers, in other words, it is based on a strategic level perception, and not operational. To have a detailed view on ACKNOWLEDGEMENTS operational issues related with burn disaster management, we recommend further studies to complement this one; This study was part of thesis submitted to fulfill a degree of for example, a study that includes views and experiences of Public Health in Disaster. The research team would like to ac- frontline responders. knowledge all the participants who made this study possible. Journal of Burn Care & Research Volume 40, Number 6 Al-Shamsi et al 877 24. Welling  L, van  Harten  SM, Patka  P, et  al. The café fire on New Year’s REFERENCES Eve in Volendam, the Netherlands: description of events. Burns 1. Committee on Trauma, American College of Surgeons. Advanced trauma 2005;31:548–54. life support program for physicians. Chicago, IL: American College of 25. Nilsson H, Jonson CO, Vikström T, et al. Simulation-assisted burn dis- Surgeons; 1997. aster planning. Burns 2013;39:1122–30. 2. Kearns RD, Cairns BA, Cairns CB. Surge capacity and capability. A review 26. Leahy NE, Yurt RW, Lazar EJ, et al. Burn disaster response planning in of the history and where the science is today regarding surge capacity New York City: updated recommendations for best practices. J Burn Care during a mass casualty disaster. Front Public Health 2014;2:29. Res 2012;33:587–94. 3. Kearns RD, Marcozzi DE, Barry N, Rubinson L, Hultman CS, Rich PB. 27. Yurt RW, Lazar EJ, Leahy NE, et al. Burn disaster response planning: an Disaster preparedness and response for the burn mass casualty incident in urban region’s approach. J Burn Care Res 2008;29:158–65. the twenty-first century. Clin Plast Surg 2017;44:441–9. 28. Kearns RD, Holmes J IV, Cairns B. Southeastern burn surge capabilities 4. Mackie DP. Editorial: mass burn casualties: a rational approach to plan- during the 2009 presidential inauguration. J Burn Care Res 2010;31:1. ning. Burns 2002;28:403–4. 29. Pirson J, Degrave E. Aeromedical transfer to Belgium of severely burned 5. Atiyeh  B. Brazilian kiss nightclub disaster. Ann Burns Fire Disasters patients during the initial days following the Volendam fire. Mil Med 2013;26:3. 2003;168:360–3. 6. Mortelmans LJ, Van Boxstael S, De Cauwer HG, et al. Preparedness of 30. Kearns RD, Hubble MW, Holmes JH IV, Cairns BA. Disaster planning: Belgian civil hospitals for chemical, biological, radiation, and nuclear transportation resources and considerations for managing a burn disaster. incidents: are we there yet? Eur J Emerg Med 2014;21:296–300. J Burn Care Res 2014;35:e21–32. 7. Versporten  AP, De  Soir  E, Zech  E, et  al. A longitudinal study on the 31. Abir M, Davis MM, Sankar P, Wong AC, Wang SC. Design of a model to Ghislenghien disaster in Belgium: strengths and weaknesses of the study predict surge capacity bottlenecks for burn mass casualties at a large aca- design and influence on response rate. Arch Public Health 2009;67:116. demic medical center. Prehosp Disaster Med 2013;28:23–32. 8. Saffle JR. The 1942 fire at Boston’s cocoanut grove nightclub. Am J Surg 32. Hick  JL, Barbera  JA, Kelen  GD. Refining surge capacity: conventional, 1993;166:581–91. contingency, and crisis capacity. Disaster Med Public Health Prep 9. Cassuto  J, Tarnow  P. The discotheque fire in Gothenburg 1998. 2009;3(2 Suppl):S59–67. A tragedy among teenagers. Burns 2003;29:405–16. 33. Jenkins JL, McCarthy ML, Sauer LM, et al. Mass-casualty triage: time for 10. Buerk  CA, Batdorf  JW, Cammack  KV, Ravenholt  O. The MGM an evidence-based approach. Prehosp Disaster Med 2008;23:3–8. Grand Hotel fire: lessons learned from a major disaster. Arch Surg 34. Leslie CL, Cushman M, McDonald GS, et al. Management of multiple 1982;117:641–4. burn casualties in a high volume ED without a verified burn unit. Am J 11. Leech  N, Onwuegbuzie  A. A typology of mixed methods research Emerg Med 2001;19:469–73. designs. Qual Quant 2008;43:265–75. 35. Ryan CM, Antoon A, Fagan SP, et al. Considerations for preparedness for 12. Creswell  JW, Plano Clark  VL. Understanding mixed methods research. a pediatric burn disaster. J Burn Care Res 2011;32:e165–6. 2006. accessed 13 July 2018; available from http://www.sagepub.com/ 36. Jeng J, Gibran N, Peck M. Burn care in disaster and other austere settings. upm-data/10981_Chapter_1.pdf Surg Clin North Am 2014;94:893–907. 13. Carley SD, Mackway-Jones K, Donnan S. Delphi study into planning for 37. Centers for Bioterrorism Preparedness Planning (CBPP) Pediatric Task care of children in major incidents. Arch Dis Child 1999;80:406–9. Force & New York City Department of Health and Mental Hygiene 14. Randic  L, Carley  S, Mackway-Jones  K, Dunn  K. Planning for major Pediatric Disaster Advisory Group. Pediatric disaster toolkit: hospital burns incidents in the UK using an accelerated Delphi technique. Burns guidelines for pediatrics during disasters. 3rd ed. 2008. accessed 25 July 2002;28:405–12. 2018; available from http://www.nyc.gov/html/doh/downloads/pdf/ 15. Mathew D, Hubloue I. The readiness of primary healthcare facilities in bhpp/hepp-peds-childrenindisasters-010709.pdf Qatar to deal with potential mass casualty incidents during the Fifa World 38. Jordan MH, Mozingo DW, Gibran NS, Barillo DJ, Purdue GF. Plenary Cup 2022. Arch Med 2018;10:5. session II: American Burn Association disaster readiness plan. J Burn Care 16. Pope C, Mays N. Reaching the parts other methods cannot reach: an in- Rehabil 2005;26:183–91. troduction to qualitative methods in health and health services research. 39. Cancio LC, Pruitt BA Jr. Management of mass casualty burn disasters. Int BMJ 1995;311:42–5. J Disaster Med 2004;2:114–29. 17. Tong  A, Sainsbury  P, Craig  J. Consolidated criteria for reporting qual- 40. Yurt RW, Bessey PQ, Bauer GJ, et al. A regional burn center’s response to itative research (COREQ): a 32-item checklist for interviews and focus a disaster: September 11, 2001, and the days beyond. J Burn Care Rehabil groups. Int J Qual Health Care 2007;19:349–57. 2005;26:117–24. 18. Welling  L, Boers  M, Mackie  DP, et  al. A consensus process on man- 41. Augustine JJ. What’s in your all-hazards plan? In Boston they were pre- agement of major burns accidents: lessons learned from the café fire in pared. Are you? EMS World 2013;42:18, 20, 23. Volendam, The Netherlands. J Health Organ Manag 2006;20:243–52. 42. Marres GM, Taal L, Bemelman M, Bouman J, Leenen LP. Online Victim 19. Baskerville  NB, Hogg  W, Lemelin  J. Process evaluation of a tailored Tracking and Tracing System (ViTTS) for major incident casualties. multifaceted approach to changing family physician practice patterns Prehosp Disaster Med 2013;28:445–53. improving preventive care. J Fam Pract 2001;50:W242–9. 43. Koning  SW, Ellerbroek  PM, Leenen  LP. Indoor fire in a nursing 20. Piza F, Steinman M, Baldisserotto S, Morbeck RA, Silva E. Is there a role home: evaluation of the medical response to a mass casualty inci- for telemedicine in disaster medicine? Crit Care 2014;18:646. dent based on a standardized protocol. Eur J Trauma Emerg Surg 21. Kearns  RD, Cairns  BA, Hickerson  WL, Holmes  JH IV. ABA Southern 2015;41:167–78. Region Burn disaster plan: the process of creating and experience with the 44. Bouman  JH, Schouwerwou  RJ, Van  der  Eijk  KJ, van  Leusden  AJ, ABA southern region burn disaster plan. J Burn Care Res 2014;35:e43–8. Savelkoul  TJ. Computerization of patient tracking and tracing during 22. Potin M, Sénéchaud C, Carsin H, et al. Mass casualty incidents with mul- mass casualty incidents. Eur J Emerg Med 2000;7:211–6. tiple burn victims: rationale for a Swiss burn plan. Burns 2010;36:741–50. 45. Creswell  JW, Fetters  MD, Ivankova  NV. Designing a mixed methods 23. National Burn Care Group. National major incident plan for burn injury. study in primary care. Ann Fam Med 2004;2:7–12. 2006, 34 pp. accessed 20 July 2018; available from http://www.nbcg. 46. De  Oliveira  AP. The medical response to burn disasters in Europe: a nhs.uk/burns-major-incident-plan scoping review. Am J Disaster Med 2018:13:169–179. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Burn Care & Research: Official Publication of the American Burn Association Pubmed Central

Assessment of the Capacity and Capability of Burn Centers to Respond to Burn Disasters in Belgium: A Mixed-Method Study

Al-Shamsi, Mustafa; Moitinho de Almeida, Maria; Nyanchoka, Linda; Guha-Sapir, Debarati; Jennes, Serge
Journal of Burn Care & Research: Official Publication of the American Burn Association , Volume 40 (6) – Jun 17, 2019
Download PDF
9 pages

Loading next page...
 
/lp/pubmed-central/assessment-of-the-capacity-and-capability-of-burn-centers-to-respond-373cWr79QJ

References (94)

Publisher
Pubmed Central
Copyright
© The Author(s) 2019. Published by Oxford University Press on behalf of the American Burn Association.
ISSN
1559-047X
eISSN
1559-0488
DOI
10.1093/jbcr/irz105
Publisher site
See Article on Publisher Site

Abstract

ORIGINAL ARTICLE Assessment of the Capacity and Capability of Burn Centers to Respond to Burn Disasters in Belgium: A Mixed-Method Study ,† Mustafa Al-Shamsi, MD, MPH,* Maria Moitinho de Almeida, MD, MPH,* ‡,||,$ ¶ Linda Nyanchoka, MPH, Debarati Guha-Sapir, PhD,* and Serge Jennes, MD Burn disaster is defined as a massive influx of patients that exceeds a burn center’s capacity and capability. This study investigates the capacity and capability of burn centers to respond to burn disasters in the Belgian ground. Quantitative survey and qualitative semistructured interview questionnaires were administered directly to key informants of burn centers. The data collected from both methods were compared to get a more in-depth overview of the issue. Quantitative data were converted into a narrative to enrich the qualitative data and included in the thematic analysis. Finally, data from both methods were analyzed and organized into five themes. The Belgian Association of Burn Injury (BABI) has a specific prehospital plan for burn disaster management. Once the BABI Plan is activated, all burn centers respond as one entity. Burn Team (B-Team) is a professional team that is formed in case of urgent need and it is deployed to a scene or to nonburn specialized hospitals to help in disaster relief. The challenges for burn disasters response occur particularly in the area of triage, transfer, communication, funding, and training. We conclude that there is a variation in the capacity and capability of burn centers. Overall, the system of burn disaster management is advanced and it is comparable to other high-income countries. Nevertheless, further improvement in the areas of preparation, triage, communication, and finally training would make disaster response more resilient in the future. Therefore, there is still space for further improvement of the management of burn disasters in Belgium. Burn disaster, also known as Burn Mass Casualty Incident This results in a poor reaction from officials on funding and (BMCI), is defined as a condition in which the number of in- maintaining the activities that relate to burn disaster prepara- flux patients exceeds the coping capacity and capability of a tion and management. As a result, this leads to multiple gaps burn center. The capacity of a burn center can be defined as in planning which might not be discovered until a disaster the availability of space and supplies, while capability means the becomes reality. presence of sufficient and prepared staff to handle a sudden and Belgium is known to have nuclear power plants and sev- 2,3 massive influx of burned patients. BMCI may result from a eral petrochemical factories which makes it liable to the risk of 6,7 variety of accidents including man-made such as explosions, burn disasters. Among several burn disasters that happened 8–10 chemical, nuclear, biological attacks as well as natural disasters worldwide, Belgium was not immune. In the last 30 years, such as earthquake, volcanic eruption, and wildfire. major disasters affected the country including the attack Globally, there is insufficient awareness to BMCI since on the auditorium of the Catholic University of Louvain in it is not common and it does not happen on a daily basis. Brussels, Switel hotel fire in Antwerp, Cockerill factory dis- aster in Liège, Ghislenghien gas pipeline explosion in Hainaut, and finally the 2016 terrorist attacks in Brussels. The objective From the *Centre for Research on the Epidemiology of Disasters (CRED), of this study is to assess the capacity and capability of burn Institute of Health and Society, Université catholique de Louvain, Brussels, centers in Belgium and to explore challenges and possibilities Unit for Research in Emergency and Disaster, University of Oviedo, Belgium; that may arise in the event of a burn disaster. Université Paris Descartes, Sorbonne Paris Cité, Faculté Oviedo, Spain; || INSERM, UMR1153, Epidemiology and de Médecine, Paris, France; Statistics Sorbonne Paris Cité Research Center (CRESS), Team METHODS, University of Liverpool, Institute of Translational Medicine, Paris, France; Burn Wound Centers of Loverval and Brussels (IMTR METHODS Liverpool, UK; Loverval, Centre des brûlés) Charleroi, Belgium Conflict of interest statement. The authors declare that they do not have any Research Design conflict of interest regarding this submission. This is a cross-sectional descriptive study using mixed methods Address correspondence to Mustafa Al-Shamsi, MD, MPH, Centre for Research on the Epidemiology of Disasters (CRED), School of Public Health, Université (concurrent design approach). The concurrent implementa- catholique de Louvain, Clos Chapelle-aux-Champs, Bte B1.30.15, 1200 tion allows the use of both the quantitative and qualitative Brussels, Belgium. Email: mustafatalibb@yahoo.com 11,12 data equally. In this study, both a quantitative survey and © The Author(s) 2019. Published by Oxford University Press on behalf of the qualitative semistructured questionnaire were used. American Burn Association. This is an Open Access article distributed To our knowledge, there is no predesigned checklist for under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits assessing hospital preparedness to disasters in Belgium. non-commercial re-use, distribution, and reproduction in any medium, pro- Therefore, the quantitative survey was developed based on vided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com an extensive review of literature relevant to the preparation and management of burn disasters in other countries. We doi:10.1093/jbcr/irz105 869 Journal of Burn Care & Research 870 Al-Shamsi et al November/December 2019 identified 60 questions related to burn disaster preparedness first author (Al-Shamsi) traveled to all centers to interview the and management. Thereafter, the questionnaire was discussed participants between May and June 2018. The data collection by the research team, which includes burn specialists. This included both the quantitative survey, which lasted around process resulted in the selection of 32 final questions. The 30 minutes, and qualitative interviews on the same day. The questions were framed according to eight domains adopted entire process lasted between 60 and 90 minutes and the in- 13,14 from previous studies on burn disasters planning. The re- terview was conducted in the English language. During the sponse was dichotomized into 1 for yes and 0 for no and un- interviews, notes were taken and the entire interviews were known answers (Figure 1 and Supplementary Annex 1). recorded and transcribed verbatim. Qualitative interviews with key informants provide an in-depth understanding of the process of disaster preparedness Data Analysis in the healthcare context. It also provides insight into the atti- We compared the data collected from the quantitative survey tude, practice, and perception of healthcare workers regarding with the qualitative interviews to get a more in-depth over- disaster management and response. The semistructured in- view of the preparedness and management of burn centers terview was designed based on the Consolidated Criteria for in the event of burn disasters. Typically, data from mixed- Reporting Qualitative Research. An interview guide was method studies are presented into a separated section or may prepared based on the relevant domains of preparation and be transformed from one type to another to converge the management of burn disasters. Probes were provided to results. allow the interviewees to expand on the topic covered. The Data transformation is a method by which both quanti- interview was structured into five themes (Supplementary tative and qualitative data can be integrated during analysis. Annex 2). For example, qualitative data could be numerically coded and included in the quantitative analysis or the reverse. In our Data Collection study, quantitative responses were coded and entered into a All six Belgian burn centers (Antwerp, Brussels; Charleroi; Microsoft Excel 2013 spreadsheet and analyzed descriptively. Ghent, Leuven, and Liege) were targeted. Initially, we Quantitative data were then transformed into a narrative and requested an appointment with the head of burn centers. included in the qualitative thematic analysis. When they could not participate (mostly due to schedule The result of the qualitative interviews transcribed ver- constraints), we inter viewed the deputy or associate physicians. batim and organized according to the predefined themes. The In total, five centers participated in the study and nine people transcripts were sent to all interviewees so that they review completed the interview, including three principal physicians and confirm them. Finally, the data from both methods were in three burn centers. In the fourth center, both the deputy analyzed and organized into five predefined themes: 1) prepa- physicians and the emergency physician were interviewed. For ration & plan; 2) command & communication, 3) transfer & the last burn center, the author interviewed the deputy phy- triage; 4) capacity, capability, treatment; and 5) training. sician as well as hospital disaster manager, chief and deputy nurses of the burn unit. Table 1 shows the details of the Ethical Consideration participants. Firstly, the interviewees were contacted by email. A  short The participation of both the survey and the interview was explanation of the protocol of the study was provided. The voluntary and the researcher explained the protocol of the Further reduction Firstly 60 questions The �inal questions Reduced to 44 after to 32 items retrieved based on consists of 32 items a discussion with following a extensive literature distributed on 8 the research team discussion with an review domains expert Figure 1. The iterative process of designing the quantitative survey. Table 1. Demographic information of the interviewees Interviewee Position Profession Burn Center Identity Gender Deputy physician Plastic surgeon 1 Female Head physician Emergency & disaster medicine 1 Male Head physician Anesthesia and intensive care medicine 2 Female Head physician Anesthesia and intensive care medicine 3 Male Deputy physician Plastic surgeon 4 Male Head nurse Burn and intensive care nursing 4 Female Deputy nurse Burn and intensive care nursing 4 Male Manager Disaster management 4 Male Head physician Anesthesia and intensive care medicine 5 Male Journal of Burn Care & Research Volume 40, Number 6 Al-Shamsi et al 871 study for every interviewee. Written consent was obtained All burn centers faced and responded to a burn disaster from each of the interviewees. The interviewees informed at some point. Several challenges were identified by the about their right of withdrawal at any point during the inter- respondents, such as difficulty in coordination and standardi- view. No financial incentive was offered to the interviewees. zation of protocol for all centers. The BABI Plan is not a com- The researcher ensured that all information obtained would plete solution to disaster response and every hospital needs to be kept confidential by anonymizing both the interviewees’ have its own protocol to respond to burn disasters in addition identity and the data obtained from the centers. to BABI Plan. Lack of funding of disaster-related activities represents a real challenge for maintaining and updating the plan. A  high daily bed occupancy rate is another challenge RESULTS that could create a bottleneck in case of a massive influx of patients. Receiving more than three severely burned patients is We identified six operating burn centers in Belgium with a ca- considered a big challenge for many centers. The major burn pacity varying from 6 to 26 beds, giving overall 75 operating center in Belgium is well-equipped to receive a considerable beds all over the country. We obtained data from five out of number of burned patients, but not burn with comorbidities the six burn centers (response rate of 80%). Out of the five since other trauma specialties have not emerged in the same centers that participated in the study, nine people completed facility. Finally, deployment of emergency medicine physicians the quantitative survey and participated in the qualitative with little burn-care experience could influence the accurate interviews. Information about each theme was obtained from estimation of TBSA burnt. Table 2 presents a summary on the interviewees and organized according to the interview preparation and plan section. guide of the questionnaire. There might be some challenges for this center; for example, better coordination and standardization of protocol. Even Preparation & Plan though there is BABI plan, it is not a complete solution for major disasters according to my opinion………principal The Belgian Association Burn of Injury Plan (BABI Plan) is physician of the burn center 2 a special plan for burn disasters in Belgium; it is led by the Militar y body. The Central Station (also known as the National Center of Regulation and coordination of Burn Beds or BABI Command & Communication Central) is set up within the department of intervention in the One burn center has the capability to send a mobile medical Military Hospital and it operates on a daily basis 7/24. The team to the field. It is essentially a specialized team called Burn Central Station is responsible for maintaining the coordina- Team (B-Team). The B-Team is dispatched either to the scene tion and the regulation of prehospital response in case of a of a disaster or to nonburn hospitals where patients are being massive disaster. It is headed by a coordinator who is special- initially stabilized. The B-Team consists of a highly compe- ized in emergency relief and management. The coordinator tent surgeon, anesthetist, and/or intensivist as well as a nurse, manages the triggering and implementation of the BABI Plan all specialized in burn care. The major role of the B-Team and is assisted by an expert burn specialist. is to triage patients at nonspecialized burn hospitals, often The decision to activate the BABI Plan depends on the head in the first 12 to 24 hours following a major burn calamity. of the dispatching center. EMS units who arrive at a scene call the Moreover, it is responsible for following up and evaluating emergency center 112 and declare the disaster situation based patients in the vicinity of a burn disaster. Table 3 summarizes on their primary evaluation. The emergency center then calls the the major roles of the B-Team. The remaining centers have a Central Station to activate the BABI Plan. The plan could also low capability in terms of burn specialists. Therefore, they de- be activated by Federal Health Inspector of each province; the pend on emergency physicians who have some experience in nearest burn centers; and even burn centers in the neighboring dealing with burn patients at the scene of a disaster. countries in case there is a national crisis. As soon as the plan is activated, the Central or BABI Station contacts the president B-Team; however, is able to do such a procedure, but it so of the BABI and all burn centers’ heads by telephone to gather complicated because the number of burn experts in Belgium information on each burn center’s capacity and capability, which is so low and a disaster is not the best situation to send burn ideally should be provided within an hour. Figure 2 presents the experts outside the burn units, unless the center is over- simplified process of activation of the BABI Plan. staffed which is not the case in so many burn centers except, All centers but one have a contingency plan that could be may be, the military hospital………principal emergency activated in case of delay in activation of BABI Plan or transfer and disaster medicine physician in burn center 1 of burn patients to other centers. The contingency plan is often part of the hospital’s internal disaster plan. It consists Regarding communication, the Central Station is considered of moving stable inpatients to other wards and expanding the the only focal point for communication between all centers. burn beds, as well as the request for extra staff from other Apart from this, all centers depend on personal contact be- wards. However, this plan is only effective for small-scale burn tween faculty members, even with burn centers in neigh- disasters. On the other hand, none of the burn centers have a boring countries. However, apart from the liaison office of special plan for pediatric burn disasters. However, since most the Central Station, there are no special channels through of the burn centers are part of a large university hospital, the which burn centers could directly communicate with each respondents stated that it is possible to care for pediatric burn other. There is also limited communication with fire units at inside pediatric Intensive Care Units (ICU). the scene, which is currently informally undertaken through Journal of Burn Care & Research 872 Al-Shamsi et al November/December 2019 BABI PLAN Burn Centers in Every center conducts its capacity & Contact all burn centers in Belgium Belgium capability to the Central Staon The Central Staon/ BABI Central Burn Centers The Central Staon collects Burn disaster is beyond the capacity (the Center of Coordinaon of Burn informaon on capacity & in the of the local burn centers! capability of each burn center Beds) neighboring countries Acvaon of BABI plan in case of a burn disaster beyond the naonal capacity & capability Disaster! The Central Staon gives the final Following the acvaon of decision to the contacted body the plan by these bodies A Burn Center Emergency medical Director of Medical Federal Health Inspector services (EMS) Service at the scene of in the affected province a disaster (DSM) Calling Centers (100, 112) Disaster! Figure 2. Activation of the Belgian Association of Burn Injury (BABI) plan. Table 2. Summary of the respondents’ answers on prepara- personal contact also. Nonetheless, all emergency services tion and plan section in Belgium have a secured communication network called Digital Tetra Tracking Network (ASTRID), with fixed radio Items Yes No/Unknown transmitters installed in every EMS hospital. Respondents see Burn disaster plan 5 (100%) 0 this network as an alternative in the event of a disaster should Fund for plan activities 0 5 (100%) personal contact fail. Contingency plan 4 (80%) 1 (20%) Predefined agreement with 1 (20%) 4 (80%) Triage & Transfer nonburn specialized hospital Triage is often done by emergency physicians based on prior Pediatric burn disaster plan 0 5 (100%) experience and personal decision without predefined policy Daily information on burn bed 4 (80%) 1 (20%) and/or triage decision table that could be considered as a ref- status erence in the event of a disaster. Journal of Burn Care & Research Volume 40, Number 6 Al-Shamsi et al 873 Transfer of patients to nonspecialized burn hospitals is The transfer is done exclusively by EMS through a cen- also possible should burn centers be overwhelmed. However, tral dispatch office in each province. A Medical Director at a this depends on personal contacts and is done according scene acts as an Incident Commander. Typically, the Medical to the emerging disaster situation with no prior agree- Director has experience in dealing with burn casualty situa- ment or predefined policy. In fact, wild evacuation to close tion and could assess the disaster situation. In case of a burn nonspecialized hospitals was an observed reality during many disaster, communication is established between the BABI Belgian disasters (eg, Antwerpen 1995, Ghislenghien 2004, Central Station and Incident Commander at the scene of a and Brussels terrorist attacks 2016)  despite short delays for disaster. Basically, all centers wait for a signal from the Central deploying a forward medical post that can do the triage of Station to transfer or receive patients. If the local burn centers’ the casualties. capacity and capability are sufficient, patients are transferred to the Belgian hospitals. However, if the number of patients is beyond the capacity and capability of the Belgian burn centers, Table 3. Organization of the Burn Team a transfer to neighboring countries is decided (Figure 3). The B-Team Incident Commander liaises with BABI Central Station then a decision is pursued whether there is a capacity or Where to go not. In case there is a capacity, patients are distributed to • Nonspecialized burn centers the Belgian hospitals; however, if the Incident Commander • Disaster scene and BABI office see that the number of patients is beyond What to do the capacity and capability of the burn centers. A transfer • Primary triage to neighboring countries is decided………Principal phys- • Secondary triage ician of the burn center 5 • Follow-up and evaluation • Consult & advice All centers have the capacity and authorization to transport • Transport patients outside Belgium through air transfer. This is often How to help done in coordination with the Belgian Military after activation • Estimation of burn bed surge capacity of the BABI Plan. The transfer is often started from the mili- • Close coordination with Incident Commanders tary or the civilian sanitary rotary-wings platforms in Belgium (Brugges and Bra-sur-Lienne) or in the neighboring countries Fire and Civil defense a Burn Disaster? Alarm Center at a scene Incident Commander/ Medical Director takes Nearest hospital EMS dispatch team to the inial decision and emergency assess the situaon contact the BABI department primirly center Belgian burn centers BABI coordinaon could deal with the center has the final disaster? decision No Yes Coordinaon with Start the transfer and higher authority to coordinaon on a transfer to the naonal level neighboring countries Figure 3. Communication and transfer hierarchy in the event of a disaster. Journal of Burn Care & Research 874 Al-Shamsi et al November/December 2019 Respondents stated that all burn centers have enough medical Table 4. Summary of the respondents’ answers on triage & supplies and equipment such as ventilators; however, the exact transfer section capacity could not be determined. The usual procedure to Items Yes No/Unknown maintain adequate supply during the mass casualty situation is to contact central pharmacies of the corresponding hos- Triage held according to prede- 0 5 (100%) pital and request the medications and equipment. Generally fined policy speaking, the maximum capacity in all burn centers is the ad- Presence of triage decision table 0 5 (100%) mission of three to five severely burned victims. Trace and track system 1 (20%) 4 (80%) Regarding treatment strategies, three centers express the Capacity to request air transport 5 (100%) 0 possibility of using alternative dressing in case of disaster aus- Capacity to transfer patients out- 5 (100%) 0 tere conditions, including the long-term antimicrobial dressing side the country ® ® (such as Aquacel Ag and Flammacerium ). However, this is Capacity to send a mobile medical 1 (20%) 4 (80%) not a standard protocol in all Belgian hospitals. Telemedicine team technology has a well-known role in disaster management ; however, none of the centers has this capacity until now. Table 5 presents a summary of capacity and capability. (France, Luxembourg, and Germany). Nevertheless, trace and tracking system where patients could be followed does not Training exist in the Belgian healthcare system, but one center used Participants expressed that, since Belgium is a safe country, an internal system that could follow up patients admitted in less attention is paid from the authorities on funding disaster- the hospital providing that they were transferred within same related activities. Two centers have the ability to hold disaster hospitals’ group. Table 4 presents a summary on triage and drills on an annual basis. However, both hospital management transfer. and health workers are less motivated to participate in disaster drilling and exercises. In addition to this, the cost of this kind Capability, Capacity, and Treatment Strategies of exercise is covered neither by the health department nor There is the possibility to call for the assistance of professional by the individual hospitals; another reason that makes them staff in case of a massive influx of patients. This varies across less appealing for healthcare workers. Only one center had different centers and it is easier and more feasible in burn performed disaster drilling in the past. Nevertheless, it was centers nested in large university hospitals. Since burn man- part of a hospital internal disaster plan and it was not about agement involves complex dressings that require experienced burn disaster in particular. All respondents felt that there nurses, the recruited staff members should work under the su- should be more training and disaster drilling in the area of pervision of experienced nursing staff. However, there is still burn and massive casualty incidence. no official predefined policy and protocol to request for extra In Belgium, training such as Advanced Burn Life staff from other hospitals, since health insurance does not Support ABLS is not mandatory. Our staff are not usu- cover staff operating outside their facilities. Nonnursing staff ally enrolled in such training since we are not the one who members could provide a valuable contribution in case the is going to a scene………(Principle Physician of the burn conventional staff is over whelmed. Most burn centers have the center 3) possibility to recruit occupational and respiratory therapists as a part of the enforcement team to do burn-related procedures. Furthermore, in all burn centers, there is a special EMS team DISCUSSION that could be made available to accompany intubated patients if a transfer is needed. To our knowledge, this is the first English written paper that Measures to increase capacity could include expanding discusses burn disaster management in Belgium. In our study, the conventional burn beds and operation theaters to handle we only interviewed people responsible for running, but not more patients. This is the main strategy to deal with a mas- the implementation of the disaster plan. Therefore, this re- sive influx of patients. Nevertheless, such expansion should be search focuses mainly on a strategic rather than an operational accompanied by increasing the experienced staff, which may level. Our findings reveal that there is a special predesigned not be immediately possible. As part of assistance, three centers plan for burn disaster in Belgium. This plan (BABI Plan) have a specially designed burn cart that could be deployed to regulates the response between different Belgian burn centers a scene or to a nonspecialized center where patients are being at the prehospital setting and it represents the backbone for initially stabilized. burn centers not only in Belgium, but also in the neighboring We can increase the free beds. For example, we have in- countries in the event of a massive casualty. It was executed patients waiting for medication and rehabilitation. We successfully in disasters before such as in Ghislenghien dis- could ask the rehabilitation unit to take patients quicker aster and 2016 Brussels’ attacks. Moreover, in 2001, in the or we send patients in a normal unit while waiting for the aftermath of the café fire in Volendam in the Netherlands, transfer to the other burn centers in Belgium. So patients Belgian burn centers admitted 20 severely burned casualties with minor injuries will be transferred to non-burn wards and in 2015, the Brussels Burn Center admitted eight while those with major burn kept in burn center……… casualties from the collective nightclub fire in Bucharest. deputy physician of the burn center 4 The concept of BABI Plan is similar to burn disaster plans Journal of Burn Care & Research Volume 40, Number 6 Al-Shamsi et al 875 Table 5. Summary of the respondents’ answers on the capacity & capability section Items Yes No/Unknown Burn cart ready for deployment 3 (60%) 2 (40%) Requesting equipment and supply from other hospitals 0 5 (100%) Capacity to expand ICU bed 4 (80%) 1 (20%) Capacity to expand the conventional beds 5 (100%) 0 Capacity to expand operation theater 3 (60%) 2 (40%) Capability to request extra burn surgeon 5 (100%) 0 Capability to request extra staff from the same hospitals 3 (60%) 2 (40%) Capability to recruit nonnursing staff 4 (80%) 1 (20%) Capability to request staff from outside hospitals 0 5 (100%) Presence of dedicated team that could accompany burned patients 4 (80%) 1 (20%) ICU, Intensive Care Unit. in other high-income countries, such as the American Burn victims requires extra staff not often directly involved in burn 21 22 Association plan, Australian Burn Plan, United Kingdom care and intervention. Those would provide a valuable con- 23 33 National Major Incident Plan for Burn Injuries, the Dutch tribution; for example, physiotherapists and psychologists. 24 24 National Mass Disaster Plan, Swiss burn plan, and the Fortunately, this is possible in most of the centers. Sweden National Burn Disaster Management Plan. Burn disasters are not common, this leads to a relative The BABI-Plan provides a framework to coordinate re- apathy to follow up and update plan and contact details. As sponse in the decentralized Belgian healthcare systems. It is a result, multiple gaps in burn disaster planning might not led by the military body which is responsible for coordination be discovered until disaster becomes reality. Despite the between different centers. This is considered a strong point above advantageous points of the BABI Plan, there are some toward burn disaster response and management due to the challenges and limitations for the response to burn disasters fact that governments usually invest well in the military sector. in Belgium. The military is often well-equipped and has both the capacity Firstly, lack of coordination between burn and nonburn and capability to respond to large-scale disasters. Hence, in hospitals. A burn disaster may happen at any time. It will be case of a disaster, the Belgian burn centers are supposed to challenging to transport all victims to definitive burn centers respond as one entity in contrast to disaster systems in other immediately, especially in case of mass casualty disasters. 21,27 countries. Therefore, it is imperative to have prepared facilities to re- The B-Team is a special team that can act as an Incident suscitate patients even in a small country with good trans- Commander and directly involved in the coordination of re- portation network. This is done by identifying enough sponse to mass casualty events. It could be deployed to aug- resource and experience in advance as well as coordination ment burn team in specialized hospitals as well as to give with nonspecialized hospitals. consultation to not-specialized one. Additionally, it optimizes Secondly, lack of specific pediatric burn disaster plan. A pe- the use of burn surge capacity and resources, and organize diatric burn disaster is likely to occur such as burn in school the transfer and triage procedures. This has been proven to or kindergarten; therefore, the pediatric plan is an essential 22 35 improve the outcome of burn disasters’ response in general. part of any disaster planning. This is because this group of 4,28 The concept of B-Team also exists in other countries. It patients is negatively affected when the resources become is clear that the deployment of such a team to hospitals is an scarce. Full pediatric plan means not only unified treat- effective solution in austere conditions since it can be easily ment guidelines, but also special protocol, communication 9 30,37 assembled within days or even hours. channels, and equipment. Coordination of the transfer is organized by the Central Thirdly, lack of funding for BABI Plan activities. Funding Station and the medical director on the site of the disaster is an indispensable part of any disaster plan. In the United to guarantee the rational distribution of patients according States, for example, both the burn disaster plan and burn team to local capacity and capability. An advantage is that Belgium have a special fund that could be activated in case of disaster. is a small country with a good road network, making rapid Unfortunately, BABI Plan lacks specific fund and once the movement between different centers possible. Furthermore, plan is activated, it totally depends on the hospitals’ initiative in large-scale disasters, the military becomes the main body with no clear roadmap of funds. This issue could be mitigated responsible for the transfer, particularly outside Belgium. This by including BABI Plan fund in the national disaster fund, is another advantage since the military means is often more for example, the special fund that already allocated to face the capable than the civilian one. danger of epidemics or natural disasters. This at least would Requesting extra staff from the same facility is possible in ensure the maintenance of the BABI Plan and B-Team during some centers. It is known that staff shortage would be a bot- a massive disaster. tleneck in case of massive casualty, providing enough space Fourthly, many decisive steps depend solely on personal is available. Therefore, having a clear contingency plan that contact. Although Central Station is responsible for coordi- defines staff duties is crucial at both national and local level. nation in the event of a disaster, the presence of predefined Moreover, a large catastrophic incident with a large number of communication channels between burn centers, and between Journal of Burn Care & Research 876 Al-Shamsi et al November/December 2019 burn centers and directors at a disaster scene is vital. Those CONCLUSION bodies play a vital role in the distribution of patients to the There is a specific plan for burn disasters in Belgium. This plan available resources, in particular, in the first hours of a dis- mainly coordinates the prehospital setting in the event of mas- aster. Additionally, normal means of communication are sive disasters such as the deployment of a highly specialized usually disrupted during disastrous situations, which makes 40,41 team to optimize the distribution of patients according to the them unreliable. available resources. Moreover, the plan functions to coordi- Finally, there is no national tracking and tracing system of nate cooperation between different centers and ensures the burn patients, which is regarded as one of the greatest challenges smooth transfer of patients. Generally speaking, the capacity in disaster setting that might affect the response in term of 42,43 to respond to burn disasters varies across different centers in triage and transportation. A  system following patients term of staff, space, and supply. This is, nevertheless, mitigated from the point of registration until discharge would optimize by the BABI Plan which ensures a balanced response between disaster response in a resource-limited environment. This different burn centers based on their capacities and capabilities. system has been developed effectively in the Netherlands. However, our study identified some challenges in disaster However, it is still under development in Belgium. management and response in Belgium. These include lack of special pediatric burn disaster plan, defined triage protocol, Strength and Limitation of the Study funding to the burn disaster plan activities, and deficient This is the first study aiming to describe current preparation national track and tracing system. Moreover, specific training to the massive casualty burn incidences in Belgium. The study and drills on burn disaster seem to be a real challenge because used a combined quantitative and qualitative methodology, such training makes the healthcare professional more oriented an effective approach in health research. All interviews and resilient should they encountered by massive casualty were held directly by the lead researcher with key informants burn situation. from the burn centers. Nevertheless, there are some limita- Overall, planning and preparation for burn disasters have de- tions to this study. Firstly, not all burn centers participated in veloped in Belgium. It is not a coincidence that Belgian burn the study, we could not get an appointment from the sixth centers have previously responded to burn disasters successfully. burn center despite frequent contact, but the response rate However, we identified some areas that need improvement in was 80%. Therefore, we believe that this does not adversely order to achieve an efficient response. These include but are affect our findings. Secondly, there might be a social desir- not limited to communication, triage, transfer policy and agree- ability bias. A  typical issue in the interview-based research ment, and finally the funding and training which needs to be where inter viewee tries to manipulate the conversation based further sought by stakeholders in Belgium. Therefore, we rec- on their wishes. This issue was mitigated by informing the ommend frequent revision of the plan and more coordination participants that their identities and burn centers would be between the directors of burn centers and stakeholders in order anonymized. Thirdly, although the interview was initially to identify the possibilities and challenges and, thus, ensure a directed toward the heads of burn centers, the researcher better response in the future. This includes, in particular, more could not inter view all of them. Additionally, in some center, effort to fundraise the disaster plan with its associated activities we had the opportunity to interview people more directly as well as training programs that ensure the readiness of the staff involved in disaster response such as the emergency physi- to handle massive casualty situation. Furthermore, we recom- cian officer and hospital disaster manager. This might also mend that further steps are taken to establish formal commu- create an unbalanced response between different centers. nication channels between burn and nonburn centers. Last but Fourthly, some of the questions were difficult to address ex- not least we believe that this study would provide a benchmark actly since interviewees are not directly involved in; for ex- for policymakers to further improve the preparation and re- ample, the items of equipment and supply. Furthermore, the sponse to burn disasters not only in Belgium, but also in other questionnaire was not validated before for Belgium, but it countries in Europe. The fact that there are few studies have was constructed based on an extensive literature review so been done on burn disaster planning in Europe justifies the some of these questions may be hypothetical for Belgium uniqueness of methodological approach in this study. Except since each country has its own possibilities and challenge to for narratives, mixed methods of research have not been used respond to certain calamities. Nevertheless, the question- in this context, but they represent a useful and efficient way to naire was validated by a Belgian burn expert. Additionally, assess flaws and strengths of disaster plans. the interview was held in the English language, but neither the researcher nor the interviewees are native of English. Therefore, the language may have affected the interpretation SUPPLEMENTARY DATA of some questions. Nevertheless, the results were sent after Supplementary data is available at Journal of Burn Care & the interview to all participants to ensure the best possible Research online. response. Finally, this study targeted key informants from the burn centers, in other words, it is based on a strategic level perception, and not operational. To have a detailed view on ACKNOWLEDGEMENTS operational issues related with burn disaster management, we recommend further studies to complement this one; This study was part of thesis submitted to fulfill a degree of for example, a study that includes views and experiences of Public Health in Disaster. The research team would like to ac- frontline responders. knowledge all the participants who made this study possible. Journal of Burn Care & Research Volume 40, Number 6 Al-Shamsi et al 877 24. Welling  L, van  Harten  SM, Patka  P, et  al. The café fire on New Year’s REFERENCES Eve in Volendam, the Netherlands: description of events. Burns 1. Committee on Trauma, American College of Surgeons. Advanced trauma 2005;31:548–54. life support program for physicians. Chicago, IL: American College of 25. Nilsson H, Jonson CO, Vikström T, et al. Simulation-assisted burn dis- Surgeons; 1997. aster planning. Burns 2013;39:1122–30. 2. Kearns RD, Cairns BA, Cairns CB. Surge capacity and capability. A review 26. Leahy NE, Yurt RW, Lazar EJ, et al. Burn disaster response planning in of the history and where the science is today regarding surge capacity New York City: updated recommendations for best practices. J Burn Care during a mass casualty disaster. Front Public Health 2014;2:29. Res 2012;33:587–94. 3. Kearns RD, Marcozzi DE, Barry N, Rubinson L, Hultman CS, Rich PB. 27. Yurt RW, Lazar EJ, Leahy NE, et al. Burn disaster response planning: an Disaster preparedness and response for the burn mass casualty incident in urban region’s approach. J Burn Care Res 2008;29:158–65. the twenty-first century. Clin Plast Surg 2017;44:441–9. 28. Kearns RD, Holmes J IV, Cairns B. Southeastern burn surge capabilities 4. Mackie DP. Editorial: mass burn casualties: a rational approach to plan- during the 2009 presidential inauguration. J Burn Care Res 2010;31:1. ning. Burns 2002;28:403–4. 29. Pirson J, Degrave E. Aeromedical transfer to Belgium of severely burned 5. Atiyeh  B. Brazilian kiss nightclub disaster. Ann Burns Fire Disasters patients during the initial days following the Volendam fire. Mil Med 2013;26:3. 2003;168:360–3. 6. Mortelmans LJ, Van Boxstael S, De Cauwer HG, et al. Preparedness of 30. Kearns RD, Hubble MW, Holmes JH IV, Cairns BA. Disaster planning: Belgian civil hospitals for chemical, biological, radiation, and nuclear transportation resources and considerations for managing a burn disaster. incidents: are we there yet? Eur J Emerg Med 2014;21:296–300. J Burn Care Res 2014;35:e21–32. 7. Versporten  AP, De  Soir  E, Zech  E, et  al. A longitudinal study on the 31. Abir M, Davis MM, Sankar P, Wong AC, Wang SC. Design of a model to Ghislenghien disaster in Belgium: strengths and weaknesses of the study predict surge capacity bottlenecks for burn mass casualties at a large aca- design and influence on response rate. Arch Public Health 2009;67:116. demic medical center. Prehosp Disaster Med 2013;28:23–32. 8. Saffle JR. The 1942 fire at Boston’s cocoanut grove nightclub. Am J Surg 32. Hick  JL, Barbera  JA, Kelen  GD. Refining surge capacity: conventional, 1993;166:581–91. contingency, and crisis capacity. Disaster Med Public Health Prep 9. Cassuto  J, Tarnow  P. The discotheque fire in Gothenburg 1998. 2009;3(2 Suppl):S59–67. A tragedy among teenagers. Burns 2003;29:405–16. 33. Jenkins JL, McCarthy ML, Sauer LM, et al. Mass-casualty triage: time for 10. Buerk  CA, Batdorf  JW, Cammack  KV, Ravenholt  O. The MGM an evidence-based approach. Prehosp Disaster Med 2008;23:3–8. Grand Hotel fire: lessons learned from a major disaster. Arch Surg 34. Leslie CL, Cushman M, McDonald GS, et al. Management of multiple 1982;117:641–4. burn casualties in a high volume ED without a verified burn unit. Am J 11. Leech  N, Onwuegbuzie  A. A typology of mixed methods research Emerg Med 2001;19:469–73. designs. Qual Quant 2008;43:265–75. 35. Ryan CM, Antoon A, Fagan SP, et al. Considerations for preparedness for 12. Creswell  JW, Plano Clark  VL. Understanding mixed methods research. a pediatric burn disaster. J Burn Care Res 2011;32:e165–6. 2006. accessed 13 July 2018; available from http://www.sagepub.com/ 36. Jeng J, Gibran N, Peck M. Burn care in disaster and other austere settings. upm-data/10981_Chapter_1.pdf Surg Clin North Am 2014;94:893–907. 13. Carley SD, Mackway-Jones K, Donnan S. Delphi study into planning for 37. Centers for Bioterrorism Preparedness Planning (CBPP) Pediatric Task care of children in major incidents. Arch Dis Child 1999;80:406–9. Force & New York City Department of Health and Mental Hygiene 14. Randic  L, Carley  S, Mackway-Jones  K, Dunn  K. Planning for major Pediatric Disaster Advisory Group. Pediatric disaster toolkit: hospital burns incidents in the UK using an accelerated Delphi technique. Burns guidelines for pediatrics during disasters. 3rd ed. 2008. accessed 25 July 2002;28:405–12. 2018; available from http://www.nyc.gov/html/doh/downloads/pdf/ 15. Mathew D, Hubloue I. The readiness of primary healthcare facilities in bhpp/hepp-peds-childrenindisasters-010709.pdf Qatar to deal with potential mass casualty incidents during the Fifa World 38. Jordan MH, Mozingo DW, Gibran NS, Barillo DJ, Purdue GF. Plenary Cup 2022. Arch Med 2018;10:5. session II: American Burn Association disaster readiness plan. J Burn Care 16. Pope C, Mays N. Reaching the parts other methods cannot reach: an in- Rehabil 2005;26:183–91. troduction to qualitative methods in health and health services research. 39. Cancio LC, Pruitt BA Jr. Management of mass casualty burn disasters. Int BMJ 1995;311:42–5. J Disaster Med 2004;2:114–29. 17. Tong  A, Sainsbury  P, Craig  J. Consolidated criteria for reporting qual- 40. Yurt RW, Bessey PQ, Bauer GJ, et al. A regional burn center’s response to itative research (COREQ): a 32-item checklist for interviews and focus a disaster: September 11, 2001, and the days beyond. J Burn Care Rehabil groups. Int J Qual Health Care 2007;19:349–57. 2005;26:117–24. 18. Welling  L, Boers  M, Mackie  DP, et  al. A consensus process on man- 41. Augustine JJ. What’s in your all-hazards plan? In Boston they were pre- agement of major burns accidents: lessons learned from the café fire in pared. Are you? EMS World 2013;42:18, 20, 23. Volendam, The Netherlands. J Health Organ Manag 2006;20:243–52. 42. Marres GM, Taal L, Bemelman M, Bouman J, Leenen LP. Online Victim 19. Baskerville  NB, Hogg  W, Lemelin  J. Process evaluation of a tailored Tracking and Tracing System (ViTTS) for major incident casualties. multifaceted approach to changing family physician practice patterns Prehosp Disaster Med 2013;28:445–53. improving preventive care. J Fam Pract 2001;50:W242–9. 43. Koning  SW, Ellerbroek  PM, Leenen  LP. Indoor fire in a nursing 20. Piza F, Steinman M, Baldisserotto S, Morbeck RA, Silva E. Is there a role home: evaluation of the medical response to a mass casualty inci- for telemedicine in disaster medicine? Crit Care 2014;18:646. dent based on a standardized protocol. Eur J Trauma Emerg Surg 21. Kearns  RD, Cairns  BA, Hickerson  WL, Holmes  JH IV. ABA Southern 2015;41:167–78. Region Burn disaster plan: the process of creating and experience with the 44. Bouman  JH, Schouwerwou  RJ, Van  der  Eijk  KJ, van  Leusden  AJ, ABA southern region burn disaster plan. J Burn Care Res 2014;35:e43–8. Savelkoul  TJ. Computerization of patient tracking and tracing during 22. Potin M, Sénéchaud C, Carsin H, et al. Mass casualty incidents with mul- mass casualty incidents. Eur J Emerg Med 2000;7:211–6. tiple burn victims: rationale for a Swiss burn plan. Burns 2010;36:741–50. 45. Creswell  JW, Fetters  MD, Ivankova  NV. Designing a mixed methods 23. National Burn Care Group. National major incident plan for burn injury. study in primary care. Ann Fam Med 2004;2:7–12. 2006, 34 pp. accessed 20 July 2018; available from http://www.nbcg. 46. De  Oliveira  AP. The medical response to burn disasters in Europe: a nhs.uk/burns-major-incident-plan scoping review. Am J Disaster Med 2018:13:169–179.

Journal

Journal of Burn Care & Research: Official Publication of the American Burn Association – Pubmed Central

Published: Jun 17, 2019

There are no references for this article.