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W. Y. Rockne et al.
hospital beds) [37]. While the number of burn centers has
increased slightly in the interim (currently 133 [38]), the burn
bed to hospital bed ratio remains largely unchanged [37].
Additionally, there is an increasing shortage of trained
burn surgeons across the country. At present, there are only
approximately 300 trained burn surgeons practicing at burn
centers across the country [38], and burn care is no longer a
part of the standard curriculum of surgical training in the
United States. This, combined with the decline in frequency of
major burns due to public safety and public health efforts/
interventions, have made it increasingly difficult to preserve
and pass on the collective expertise of existing burn experts
for the future [38]. These factors are essential to be aware of
during disaster planning, as the limited availability of
resources necessary for optimal burn care can quickly become
a critical bottleneck in the healthcare system response [38–
40], requiring careful planning and strategy to circumvent.
Given the relative scarcity of resources and infrequency of
BMCIs, it is both reasonable and prudent to consider and
plan for these events as worst-case scenarios in modern
health care systems [2]. While this strategy has been discussed
intermittently in the American burn community for decades
[41, 42], the various terrorist acts, military conflicts, and natural disasters that occurred with the commencement of the
twenty-first century sparked a new focus on disaster research
and improvement of disaster burn care systems [38]. In 2012,
a National Burn Surge Strategy Meeting was convened by the
Emergency Care Coordination Center (ECCC) of the Office
of the Assistant Secretary for Preparedness and Response
within the U.S.Department of Health and Human Services
(HHS). This meeting examined the foundations of a national
framework to address the complex issues in facilitating a
rapid, coordinated, and effective response to BMCIs, spurring
further collaboration for and research into BMCI response
[16]. Additionally, across the United States, both state and
regional research and disaster preparedness efforts are
advancing, adding to a growing repository of BMCI planning
resources [41, 42].
Chapter 18. Burn Disasters
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National, Federal, andMilitary Resources
fortheBMCI
The American Burn Association
In burn disaster response, both geography and lines of
political jurisdiction play a large part in ability to both plan
and enact an appropriate response. Therefore, close
communication and coordination between burn centers are
essential [2].
The ABA is a multidisciplinary organization which consists
of over 2000 members in the USA, Canada, Latin America,
Asia, and Europe. Members include physicians, nurses,
physical and occupational therapists, researchers, firefighters,
social workers, and hospitals with burn centers [43]. The
ABA’s stated mission is to improve quality care, burn
prevention, education, research, and service to its members.
Its website, https://ameriburn.org, includes a plethora of
resources both for members and for the public, including
burn center referral criteria, a regional map of burn centers,
support services for burn survivors, and disaster response
resources.
It is important not to confuse burn capacity with trauma
capacity; although most burn surgeons are also trained
trauma surgeons, the converse is not necessarily the case, just
as trauma centers are not the same as burn centers [16, 44]. So
what defines a burn center?
A facility earns the title of “designated burn center” when
it meets the requirements of government or other authorized
entities. This burn center designation is not determined by
the ABA [45]. However, the ABA provides an additional
system for burn center verification.
ABA burn center verification, intended to ensure that a
burn center is meeting the highest current standards of care
for the burn patient, is based upon an extensive list of criteria
and continuously evaluated by the ABA Verification Review
Committee. This comprehensive list includes specific requirements for important burn care aspects such as patient vol-
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W. Y. Rockne et al.
ume, nursing and therapy staff, prehospital burn care,
ambulatory care, prevention and outreach, research, emergency department care, quality improvement measures, and
disaster planning [45]. Ongoing compliance with these standards by ABA-verified burn centers is reverified via periodic
site visits.
There are currently 133 burn centers across the United
States staffed by approximately 300 burn surgeons and comprising approximately 2000 burn specialty beds. Of these 133
burn centers, 72 are ABA verified burn centers, and represent
approximately 75% of the national burn bed capacity [38].
The ABA additionally serves as a central point for
unification of burn resources and coordination of burn
response, especially in burn disasters on the national scale.
Current data estimates that the U.S. burn care community,
utilizing all burn centers across the country, could manage
approximately 2000 patients within approximately 120 h of
an inciting disaster event [14] if sufficient transportation
resources exist to redistribute patients from initial hospital
care sites to specialized burn centers [3, 46].
ABA regions do not line up with the ten designated
Federal Emergency Management Agency (FEMA) regions,
but rather lie along natural lines of referral and regional support [47]. There are currently five designated U.S. ABA
regions: Northeast Region, Southern Region, Eastern Great
Lakes Region, Midwest Region, and Western Region. While
all associated with the ABA, these regions choose their own
organizational structure, and the activities of each region vary
to suit the individual needs of their specific geographical
areas, burn providers, and patient populations [16, 47].
Additionally, each region has its own Regional Disaster Plan
available for reference on the ABA website.
Federal Resources
In an MCI or BMCI response, the primary responsibility for
disaster response lies with local and state agencies, as by
Chapter 18. Burn Disasters
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395
statue the U.S. government becomes involved in a disaster
only when local and state capabilities are overwhelmed. A
request for federal assistance is normally initiated by a state
governor and usually involves the Department of Health and
Human Services (DHHS), the Department of Homeland
Security (DHS), and may include the Department of Justice
(DOJ) [16].
Additionally, although federal resources are available in
the event of a large-scale BMCI, logistically these resources
cannot be relied upon to reach the incident scene prior to
72h after the inciting event [16]. Therefore, during the first
3days following an event, the disaster response will be essentially limited to local and regional resources. As it is inevitable that the burn resources of a single state (and even region)
will be quickly overwhelmed in a large-scale BMCI, additional coordination on the regional and national level is
essential in order to maximize burn bed surge capacity [16].
Emergency Support Function # 8 (ESF-8) provides the
mechanisms for coordinating federal assistance in civilian
disaster response [48]. The Secretary of Health and Human
Services (HHS) leads all such federal public health and medical response and assumes control of operational federal
assets (with the exclusion of members of the Armed Forces,
who remain under the authority and control of the Secretary
of Defense). The Secretary of HHS (through the Office of the
Assistant Secretary for Preparedness and Response, or
ASPR) coordinates national ESF-8 preparedness, response,
and recovery actions [48].
ASPR provides funding and technical assistance to state,
local, and territorial public health departments in order to
help prepare healthcare systems for disasters through the
Hospital Preparedness Program (HPP) Cooperative
Agreement [49]. ASPR also defines a set of “Healthcare
Preparedness Capabilities” based on common preparedness
methodologies from FEMA to assist healthcare systems
with preparedness and response. These capabilities are
designed to facilitate joint ESF-8 preparedness planning,
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W. Y. Rockne et al.
ultimately assuring safer, more resilient, and better-prepared
communities [49].
The Strategic National Stockpile (SNS), originally called
the National Pharmaceutical Stockpile, is part of the federal
medical response infrastructure that can be used to supplement medical response during public health emergencies.
This stockpile of medical supplies, medicines, and devices can
be used as a short-term, stopgap buffer during disaster
response [50]. States, territories, tribal nations, and the largest
metropolitan areas may request federal assistance from the
SNS in the event, their supplies are exhausted and commercial supplies are unavailable to meet disaster response needs
[50]. Regional emergency coordinators assigned to each of
the HHS regions throughout the country work directly with
public health authorities to determine needs and assist with
supply requests.
The Biomedical Advanced Research Development
Authority (BARDA) is an HHS office responsible for the
procurement and development of medical countermeasures
needed in response to public health emergencies, including
chemical, biological, radiological, and nuclear (CBRN) accidents, incidents, and attacks. BARDA, established in 2006
though the Pandemic and All-Hazards Preparedness Act
(PAHPA), reports to ASPR and acts as an official interface
between the U.S. federal government and the biomedical
industry. BARDA uses grants and other assistance to promote the advancement of biomedical research, innovation,
and product development. BARDA also procures and maintains supplies for the SNS [51].
Military Resources
The U.S. military involvement occurs only at the request of
another federal agency, and only when the pooled assets of
local, state, and federal governments are found to be insufficient. These requests are routed to the Department of
Defense (DOD), which then assigns response tasks to the
Chapter 18. Burn Disasters
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397
U.S.Northern Command (NORTHCOM). NORTHCOM, a
unified command based in Colorado, holds responsibility for
the defense of North America. However, the command may
also provide military support to civil authorities at the direction of the President of the United States or Secretary of
Defense. When activated for civilian assistance, any asset of
the military services may be requested and assigned to
NORTHCOM for response to a civilian disaster, including
mobile hospitals, staging facilities, and transportation
resources. Military assets deployed for civilian disasters are
required by federal law to be the last to be committed to a
response and the first to leave a response area when no longer required [16, 51].
The National Disaster Medical System (NDMS), a
collaboration between HHS, DHS, DOD, and the Department
of Veterans Affairs, acts to supplement local, state, tribal,
territorial, and military medical resources during disaster
response. It serves three major functions: onsite care, large
scale patient movement, and definitive medical care. Its
deployable onsite medical function consists of more than
7000 personnel organized into teams including International
Medical Surgical Response Teams, Disaster Mortuary
Operational Response Teams, and Disaster Medical
Assistance Teams. In addition, deployed NDMS medical
assets are designed to operate in dynamic/evolving
environments and are able to provide their own water, food,
and shelter to avoid further burdening communities impacted
by disaster [16].
Guidelines forBMCI Triage andResponse
The ABA’s Organization and Delivery of Burn Care
Committee (ODBC) develops and maintains plans to manage regional burn surge capabilities in the event of a mass
casualty or other disaster [52]. This includes a list of regularly
updated guidelines available to the public at https://ameri-
burn.org/quality- care/disaster- response/. A brief (and by no
398
W. Y. Rockne et al.
means comprehensive) overview of some highlights of the
currently linked guidelines available on the ABA’s website
for public use is included below.
Patient Care Priorities fortheFirst 24h inaBurn
Mass Casualty forNon-burn Physicians
Based upon Guidelines for Burn Care Under Austere
Conditions by Jeng etal [14], this succinct outline provides a
framework for establishing patient treatment priorities in the
first 24 h after a BMCI. This includes guidelines for triage,
initial decontamination and wound care, airway management,
and burn-specific resuscitation [14].
Actionable, Revised (v.3), andAmplified American
Burn Association Triage Tables forMass
Casualties: ACivilian Defense Guideline
This detailed work by Kearns etal. [38] is free to the public
to download in PDF form and provides evidence-based
tables that can be applied in a BMCI by those tasked with
triaging and caring for large numbers of patients with burn
injuries. Last revised in March of 2020, it was written by clinical burn experts and led by the ABA in order to provide clinicians evidence-based tools to maximize burn care capabilities
based on realistic assumptions in the event of a BMCI [38],
updating and merging findings from previous publications on
the subject [53, 54]. These triage tables were examined for
face validity during a functional exercise of the component of
the ASPR-funded Regional Disaster Health Response System
(RDHRS) pilot program in August 2019.
Additionally, this work integrates and defines newer
principles and terminology that arose from the publication of
Committee on Crisis Standards of Care (CoCSoC): A Toolkit
for Indicators and Triggers by Hanfling etal. (along with pre-
vious and subsequent research by Hick et al) [36, 46]. The
Chapter 18. Burn Disasters
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provided tables allow a tailored response dependent on number of burn patients, severity of burn injuries, and location/
availability of resources within burn regions. These include
conventional burn care (50–200 burn victims), contingency
burn care (100–500 burn victims), crisis burn care (500–2000
burn victims), and catastrophic burn care (>2000 burn victims) [38]. Of course, these tables are templates only and
require personalization for each disaster.
Conclusion
While the BMCI is not an everyday event, the complex needs
of an adequate burn disaster response necessitate careful
planning, coordination, and cooperation in order to minimize
loss of life and limb. Practicing medical professionals, especially those involved in emergency response, healthcare systems, and disaster preparedness, should maintain a working
knowledge of the available resources for burn disasters,
including local and regional support systems, national and
federal organizations, and military resources. Knowledge of
these critical resources and how to activate and implement
them can help reduce the significant morbidity and mortality
associated with these disastrous events.
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