The café fire on New Year's Eve in Volendam, the Netherlands: description of events

Experience of the Coronavirus Disease (COVID-19) Patient Care in the Amsterdam Region: Optimization of Acute Care Organization

The coronavirus disease (COVID-19) pandemic causes a large number of patients to simultaneously be in need of specialized care. In the Netherlands, hospitals scaled up their intensive care unit and clinical admission capacity at an early stage of the pandemic. The importance of coordinating resources during a pandemic has already been emphasized in the literature. Therefore, in order to prevent hospitals from being overwhelmed by COVID-19 admissions, national and regional task forces were established for the purpose of coordinating patient transfers. This review describes the experience of Regionaal Overleg Acute Zorg (ROAZ) region Noord-Holland Flevoland, in coordinating patient transfers in the Amsterdam region. In total, 130 patient transfers were coordinated by our region, of which 73% patients were transferred to a hospital within the region. Over a 2-month period, similarities regarding days with increased patient transfers were seen between our region and the national task force. In parallel, an increased incidence in hospital admissions in the Netherlands was observed. During a pandemic, an early upscale (an increase in surge spaces) of hospital admission capacity is imperative. Furthermore, it is preferred to establish national and regional task forces, coordinated by physicians experienced and trained in handling crisis situations, adhering full transparency regarding hospital admission capacity.

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

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.

Are burn centers in German-speaking countries prepared to respond to a burn disaster? Survey-based study

Burn disasters present a challenge not only to burn centers but the entire healthcare system. Most burn centers worldwide are unprepared to deal with a burn disaster as it is an uncommon event. We investigated the status of burn center preparedness in German-speaking countries to respond to a burn disaster. Self-administered survey questionnaires were sent to the directors of burn centers; the questions of survey used before in a similar way in Belgium were translated into German language. Of the 46 questioned burn centers, 32 (78%) responded, including all of the German adult burn centers. A clear difference in the preparation status of the burn centers in the three countries was observed due to geopolitical factors such as decentralized healthcare systems. However, the healthcare system is generally well-prepared concerning command, transfer, and capacity to provide sustained supplies to handle a massive influx of patients. Nevertheless, there are some gaps in the areas of planning and preparation, funding for disaster activities, and regular training of staff for burn disasters. We call for a unified burn disaster plan and increased cooperation between burn centers and civil defense regarding communication and training. We strongly recommend the implementation of a special disaster fund and telemedicine in disaster management to circumvent shortages in burn staff.

Implication of Burn Disaster Planning and Management: Coverage and Accessibility of Burn Centers in Belgium

INTRODUCTION

Burn disasters represent a real challenge to burn centers worldwide. Several burn disasters with a considerable number of casualties happened in Belgium in the past. The positioning of burn centers is a significant issue to account for in a burn disaster preparedness and response. The objectives of this study are to identify the geographic coverage and accessibility of the burn centers in Belgium in the realm of a burn disaster scenario.

METHOD

Cross-sectional secondary analysis was performed using data from the Belgian Burn Association and Belgian Department of the Statistic. Data were analyzed using ArcGIS, a geographic information system tool to identify the coverage of burn centers within half an hour driving time, and access time of both populations in the districts and the disaster-prone areas to the individual burn centers.

RESULTS

Around 7.3 million (65%) people are covered by a half an hour driving time window from the burn centers. However, the accessibility to the individual burn centers is varied across different regions and provinces.

CONCLUSION

There is a slightly over-supply of burn centers in the mid part of the country, contrasted by an under-supply and poor accessibility for the population living near the borders, particularly in the south part of the country. This study would provide a benchmark for stakeholders in Belgium and other industrial countries to consider the coverage and accessibility of the burn centers as part of preparation and planning for burn disasters in the future.

Excess mortality reduction given a "reduce patient mortality at all costs" scenario for mass burn casualties

OBJECTIVE

The aim of this study was to estimate the effect on medical resource use and mortality of full financial support from the government for treatment costs after a mass burn casualty event in Taiwan.

METHODS

All patients with burn injuries from the event were included (n = 483). Each burn patient from this incident was matched to a separate burn patient identified from the National Health Insurance database. Medical care usage and mortality were compared between groups at 1-, 3-, 6-, 9-, and 12-month intervals.

RESULTS

Regarding outpatient expenditure, burn patients from the mass casualty event had significantly higher levels of medical expenditure compared with their control counterparts at all intervals and levels of medical institution. For inpatient expenditure, patients from the mass casualty event only had higher expenditure for the first month, and excess procedures used by these patients mainly consisted of nonvital procedures such as rehabilitation training. The mortality rate was only slightly lower for this group of burn patients compared with their control counterparts.

CONCLUSIONS

Full financial support by the government in terms of medical treatment may engender only marginal additional benefits in terms of mortality if burn treatment procedures are already well established in the country.

Response and legislative changes after the Kiss nightclub tragedy in Santa Maria/RS/Brazil: Learning from a large-scale burn disaster

PURPOSE

A major fire occurred on January 27, 2013, at 02:30 at Kiss nightclub in the city of Santa Maria, State of Rio Grande do Sul, in Southern Brazil. In this retrospective report, we aimed to describe the nightclub fire event, its immediate consequences, and evaluated its impact on legislation. Our objective was to disseminate the lessons we learned from this large-scale nightclub fire disaster.

METHODS

We conducted a literature review in PubMed and Lilacs database from 2013 to 2015 related to the nightclub Kiss, Santa Maria, fire, burns, and similar events worldwide over the past 15 years. We searched in the general press and online media information sites, and seeking legislation about this topic at the federal level in Brazil. We reported on the legislation changes that resulted from this nightclub fire.

RESULTS

Current federal legislation on fire prevention and the scope of public safety, including night clubs and discos, states is the duty of the state and everyone's responsibility, pursuant to Article 144 of the Federal Constitution of Brazil. Thus, the federal union, individual states and municipalities have the power to legislate on fire prevention, and especially to ensure the security of the population. A state law called "Law Kiss", was passed in 2014, establishing standards on safety, prevention and protection against fire in buildings and areas of fire risk in the state of Rio Grande do Sul. On a national level, a law of prevention and fire fighting in Brazil was also drafted after the Santa Maria disaster (Law project no. 4923, 2013). Currently, this bill is still awaiting sanction before it can take effect.

CONCLUSION

As we push for enactment of the national law of prevention and fire fighting in Brazil, we will continue emphasizing fire prevention, fire protection, fire fighting, means of escape and proper management. All similar events in this and other countries remind us that similar tragedies may occur anywhere, and that the analysis of facts, previous mistakes, during and after the incident are crucial to our understanding, and will help us lessen the chance of future occurrences.

Disaster planning: the basics of creating a burn mass casualty disaster plan for a burn center

In 2005, the American Burn Association published burn disaster guidelines. This work recognized that local and state assets are the most important resources in the initial 24- to 48-hour management of a burn disaster. Historical experiences suggest there is ample opportunity to improve local and state preparedness for a major burn disaster. This review will focus on the basics of developing a burn surge disaster plan for a mass casualty event. In the event of a disaster, burn centers must recognize their place in the context of local and state disaster plan activation. Planning for a burn center takes on three forms; institutional/intrafacility, interfacility/intrastate, and interstate/regional. Priorities for a burn disaster plan include: coordination, communication, triage, plan activation (trigger point), surge, and regional capacity. Capacity and capability of the plan should be modeled and exercised to determine limitations and identify breaking points. When there is more than one burn center in a given state or jurisdiction, close coordination and communication between the burn centers are essential for a successful response. Burn surge mass casualty planning at the facility and specialty planning levels, including a state burn surge disaster plan, must have interface points with governmental plans. Local, state, and federal governmental agencies have key roles and responsibilities in a burn mass casualty disaster. This work will include a framework and critical concepts any burn disaster planning effort should consider when developing future plans.

Disaster planning: the past, present, and future concepts and principles of managing a surge of burn injured patients for those involved in hospital facility planning and preparedness

The 9/11 attacks reframed the narrative regarding disaster medicine. Bypass strategies have been replaced with absorption strategies and are more specifically described as "surge capacity." In the succeeding years, a consensus has coalesced around stratifying the surge capacity into three distinct tiers: conventional, contingency, and crisis surge capacities. For the purpose of this work, these three distinct tiers were adapted specifically to burn surge for disaster planning activities at hospitals where burn centers are not located. A review was conducted involving published plans, other related academic works, and findings from actual disasters as well as modeling. The aim was to create burn-specific definitions for surge capacity for hospitals where a burn center is not located. The three-tier consensus description of surge capacity is delineated in their respective stratifications by what will hereinafter be referred to as the three "S's"; staff, space, and supplies (also referred to as supplies, pharmaceuticals, and equipment). This effort also included the creation of a checklist for nonburn center hospitals to assist in their development of a burn surge plan. Patients with serious burn injuries should always be moved to and managed at burn centers, but during a medical disaster with significant numbers of burn injured patients, there may be impediments to meeting this goal. It may be necessary for burn injured patients to remain for hours in an outlying hospital until being moved to a burn center. This work was aimed at aiding local and regional hospitals in developing an extemporizing measure until their burn injured patients can be moved to and managed at a burn center(s).

Epidemiology and trends in severe burns in the Netherlands

INTRODUCTION

The aim of this study was to characterize the epidemiology of severe burns in the Netherlands, including trends in burn centre admissions, non burn centre admissions and differences by age.

METHODS

Patients with burn-related primary admission in a Dutch centre from 1995 to 2011 were included. Nationwide prospectively collected data were used from three separate historical databases and the uniform Dutch Burn Repository R3 (2009 onwards). General hospital data were derived from the National Hospital Discharge Register. Age and gender-adjusted rates were calculated by direct standardization, using the 2005 population as the reference standard.

RESULTS

The annual number of admitted patients increased from 430 in 1995 to 747 in 2011, incidence rates increased from 2.72 to 4.66 per 100,000. Incidence rates were high in young children, aged 0-4 years and doubled from 10.26 to 22.96 per 100,000. Incidence rates in persons from 5 up to 59 increased as well, in older adults (60 years and older) admission rates were stable. Overall burn centre mortality rate was 4.1%, and significantly decreased over time. There was a trend towards admissions of less extensive burns, median total burned surface area (TBSA) decreased from 8% to 4%. Length of stay and length of stay per percent TBSA decreased over time as well.

CONCLUSIONS

Data on 9031 patients admitted in a 17-year period showed an increasing incidence rate of burn-related burn centre admissions, with a decreasing TBSA and decreasing in-burn centre mortality. These data are important for prevention and establishment of required burn care capacity.

Disasters; the 2010 Haitian earthquake and the evacuation of burn victims to US burn centers

Response to the 2010 Haitian earthquake included an array of diverse yet critical actions. This paper will briefly review the evacuation of a small group of patients with burns to burn centers in the southeastern United States (US). This particular evacuation brought together for the first time plans, groups, and organizations that had previously only exercised this process. The response to the Haitian earthquake was a glimpse at what the international community working together can do to help others, and relieve suffering following a catastrophic disaster. The international response was substantial. This paper will trace one evacuation, one day for one unique group of patients with burns to burn centers in the US and review the lessons learned from this process. The patient population with burns being evacuated from Haiti was very small compared to the overall operation. Nevertheless, the outcomes included a better understanding of how a larger event could challenge the limited resources for all involved. This paper includes aspects of the patient movement, the logistics needed, and briefly discusses reimbursement for the care provided.

Simulation-assisted burn disaster planning

The aim of the study was to evaluate the Swedish medical systems response to a mass casualty burn incident in a rural area with a focus on national coordination of burn care. Data were collected from two simulations of a mass casualty incident with burns in a rural area in the mid portion of Sweden close to the Norwegian border, based on a large inventory of emergency resources available in this area as well as regional hospitals, university hospitals and burn centres in Sweden and abroad. The simulation system Emergo Train System(®) (ETS) was used and risk for preventable death and complications were used as outcome measures: simulation I, 18.5% (n=13) preventable deaths and 15.5% (n=11) preventable complications; simulation II, 11.4% (n=8) preventable deaths and 11.4% (n=8) preventable complications. The last T1 patient was evacuated after 7h in simulation I, compared with 5h in simulation II. Better national coordination of burn care and more timely distribution based on the experience from the first simulation, and possibly a learning effect, led to a better patient outcome in simulation II. The experience using a system that combines both process and outcome indicators can create important results that may support disaster planning.

Design of a model to predict surge capacity bottlenecks for burn mass casualties at a large academic medical center

OBJECTIVES

To design and test a model to predict surge capacity bottlenecks at a large academic medical center in response to a mass-casualty incident (MCI) involving multiple burn victims.

METHODS

Using the simulation software ProModel, a model of patient flow and anticipated resource use, according to principles of disaster management, was developed based upon historical data from the University Hospital of the University of Michigan Health System. Model inputs included: (a) age and weight distribution for casualties, and distribution of size and depth of burns; (b) rate of arrival of casualties to the hospital, and triage to ward or critical care settings; (c) eligibility for early discharge of non-MCI inpatients at time of MCI; (d) baseline occupancy of intensive care unit (ICU), surgical step-down, and ward; (e) staff availability-number of physicians, nurses, and respiratory therapists, and the expected ratio of each group to patients; (f) floor and operating room resources-anticipating the need for mechanical ventilators, burn care and surgical resources, blood products, and intravenous fluids; (g) average hospital length of stay and mortality rate for patients with inhalation injury and different size burns; and (h) average number of times that different size burns undergo surgery. Key model outputs include time to bottleneck for each limiting resource and average waiting time to hospital bed availability.

RESULTS

Given base-case model assumptions (including 100 mass casualties with an inter-arrival rate to the hospital of one patient every three minutes), hospital utilization is constrained within the first 120 minutes to 21 casualties, due to the limited number of beds. The first bottleneck is attributable to exhausting critical care beds, followed by floor beds. Given this limitation in number of patients, the temporal order of the ensuing bottlenecks is as follows: Lactated Ringer's solution (4 h), silver sulfadiazine/Silvadene (6 h), albumin (48 h), thrombin topical (72 h), type AB packed red blood cells (76 h), silver dressing/Acticoat (100 h), bismuth tribromophenate/Xeroform (102 h), and gauze bandage rolls/Kerlix (168 h). The following items do not precipitate a bottleneck: ventilators, topical epinephrine, staplers, foams, antimicrobial non-adherent dressing/Telfa types A, B, or O blood. Nurse, respiratory therapist, and physician staffing does not induce bottlenecks.

CONCLUSIONS

This model, and similar models for non-burn-related MCIs, can serve as a real-time estimation and management tool for hospital capacity in the setting of MCIs, and can inform supply decision support for disaster management.

Posttraumatic stress symptoms after exposure to two fire disasters: comparative study

This study investigated traumatic stress symptoms in severely burned survivors of two fire disasters and two comparison groups of patients with "non-disaster" burn injuries, as well as risk factors associated with acute and chronic stress symptoms. Patients were admitted to one out of eight burn centers in The Netherlands or Belgium. The Impact of Event Scale (IES) was administered to 61 and 33 survivors respectively of two fire disasters and 54 and 57 patients with "non-disaster" burn etiologies at 2 weeks, 3, 6, 12 and 24 months after the event. We used latent growth modeling (LGM) analyses to investigate the stress trajectories and predictors in the two disaster and two comparison groups. The results showed that initial traumatic stress reactions in disaster survivors with severe burns are more intense and prolonged during several months relative to survivors of "non-disaster" burn injuries. Excluding the industrial fire group, all participants' symptoms on average decreased over the two year period. Burn severity, peritraumatic anxiety and dissociation predicted the long-term negative outcomes only in the industrial fire group. In conclusion, fire disaster survivors appear to experience higher levels of traumatic stress symptoms on the short term, but the long-term outcome appears dependent on factors different from the first response. Likely, the younger age, and several beneficial post-disaster factors such as psychosocial aftercare and social support, along with swift judicial procedures, contributed to the positive outcome in one disaster cohort.

The Volendam Fire: Lessons Learned from Disaster Research

Introduction:

After the Volendam fire, a multidisciplinary, integral evaluation, called the Medical Evaluation of the Disaster in Volendam (MERV), was established. This article is a discussion of disaster research methodology. It describes the organizational framework of this project and the methodological problems.

Methods:

A scientific steering group consisting of members from three hospitals prepared and guided the project. A research team wrote the final study protocol and performed the study. The project was funded by the Ministry of Health. The study protocol had a modular design in which each of the modules focused on one specific area or location. The main questions for each location were: (1) which treatment protocols were used; (2)what was the condition of the patient; and (3) was medical care provided according to existing protocols. After the fire, 241 victims were treated in hospitals; they all were included in the study. Most of the victims had burn injuries, and approximately one-third suffered from inhalation injury. All hospitals and ambulance services involved were visited in order to collect data, and interviewers obtained additional information. The government helped obtain permission for data-collection in three of the hospitals. Over 1,200 items of information about each patient and >200,000 total items were collected. During data processing, the data were re-organized, categorized, and presented in a uniform and consistent style. A cross-sectional site analysis and a longitudinal patient analysis were conducted. This was facilitated by the use of several sub-data-bases. The modular approach made it possible to obtain a complete overview of the medical care provided. The project team was guided by a multidisciplinary steering group and the research was performed by a research team. This enabled the research team to focus on the scientific aspects.

Conclusion:

The evaluation of the Volendam fire indicates that a project approach with a modular design is effective for the analysis of complex incidents. The use of several sub-databases makes it easy to combine findings and conduct cross-sectional and longitudinal analyses. The government played an important role in the funding and support of the project. To limit and structure data collection and analysis, a pilot study based on several predefined main questions should be conducted. The questions then can be specified further based on the availability of data.

Burn Disasters—An Audit of the Literature

All events that result in disasters are unique, and it is impossible to become fully prepared. However, through thorough planning and preparedness, it is possible to gain a better understanding of the typical injury patterns and problems that arise from a variety of hazards. Such events have the potential to claim many lives and overwhelm local medical resources. Burn disasters vary in scope of injury and procedures required, and are much more labor and resource intensive than non-burn disasters.

This review of the literature should help determine whether, despite each event having its own unique features, there still are common problems disaster responders face in the prehospital and hospital phases, what recommendations were made from these disasters, and whether these recommendations have been implemented into practice and the current disaster planning processes.

The objective of this review was to assess: (1) prehospital and hospital responses used during past burn disasters; (2) problems faced during those disaster responses; (3) recommendations made following those disasters; (4) whether these recommendations were integrated into practice; and (5) the key characteristics of burn disasters and how they differ from other disasters. This review is important to determine why, despite having disaster plans, things still go wrong.

Managing burn patients in a fire disaster: Experience from a burn unit in Bangladesh

Although burn disaster is not a frequent event, with urbanisation and industrialisation, burn disaster is becoming an emerging problem in Bangladesh. On 3 June 2010, a fire disaster killed 124 people in Neemtali, Dhaka, Bangladesh. This paper narrates the management of burn patients of this disaster in the burn unit of Dhaka Medical College Hospital. The burn unit managed 192 burn victims of the disaster. Forty-two victims were admitted and 150 of them received primary care at the emergency room and were sent back home. Ten patients among 42 in-patients died. The in-patient mortality was 23.8%. Burn unit in Dhaka Medical College Hospital is the only burn management centre in Bangladesh. Proper planning and coordinated effort by all sectors and persons concerned were the key elements in this successful management.

Mass casualty incidents with multiple burn victims: rationale for a Swiss burn plan

INTRODUCTION

Mass casualty incidents involving victims with severe burns pose difficult and unique problems for both rescue teams and hospitals. This paper presents an analysis of the published reports with the aim of proposing a rational model for burn rescue and hospital referral for Switzerland.

METHODS

Literature review including systematic searches of PubMed/Medline, reference textbooks and journals as well as landmark articles.

RESULTS

Since hospitals have limited surge capacities in the event of burn disasters, a special approach to both prehospital and hospital management of these victims is required. Specialized rescue and care can be adequately met and at all levels of needs by deploying mobile burn teams to the scene. These burn teams can bring needed skills and enhance the efficiency of the classical disaster response teams. Burn teams assist with both primary and secondary triage, contribute to initial patient management and offer advice to non-specialized designated hospitals that provide acute care for burn patients with Total Burn Surface Area (TBSA) <20-30%. The main components required for successful deployments of mobile burn teams include socio-economic feasibility, streamlined logistical implementation as well as partnership coordination with other agencies including subsidiary military resources.

CONCLUSIONS

Disaster preparedness plans involving burn specialists dispatched from a referral burn center can upgrade and significantly improve prehospital rescue outcome, initial resuscitation care and help prevent an overload to hospital surge capacities in case of multiple burn victims. This is the rationale behind the ongoing development and implementation of the Swiss burn plan.

Posttraumatic stress disorder (PTSD) in children after paediatric intensive care treatment compared to children who survived a major fire disaster

BACKGROUND

The goals were to determine the presence of posttraumatic stress disorder (PTSD) in children after paediatric intensive care treatment, to identify risk factors for PTSD, and to compare this data with data from a major fire disaster in the Netherlands.

METHODS

Children completed the Dutch Children's Responses to Trauma Inventory at three and nine months after discharge from the paediatric intensive care unit (PICU). Comparison data were available from 355 children survivors who completed the same questionnaire 10 months after a major fire disaster.

RESULTS

Thirty-six children aged eight to 17 years completed questionnaires at three month follow-up, nine month follow-up, or both. More than one third (34.5%) of the children had subclinical PTSD, while 13.8% were likely to meet criteria for PTSD. Maternal PTSD was the strongest predictor for child PTSD. There were no significant differences in (subclinical) PTSD symptoms either over time or compared to symptoms of survivors from the fire disaster.

CONCLUSION

This study shows that a considerable number of children have persistent PTSD after PICU treatment. Prevention of PTSD is important to minimize the profound adverse effects that PTSD can have on children's well-being and future development.

A cohort study of the long-term impact of a fire disaster on the physical and mental health of adolescents

The literature on adult trauma survivors demonstrates that those exposed to traumatic stress have a poorer physical health status than nonexposed individuals. Studies on physical health effects in adolescent trauma survivors, in contrast, are scarce. In the current study, it was hypothesized that adolescents who have been involved in a mass burn incident (N = 124) will demonstrate more physical and mental health problems than an unaffected cohort from the same community (N = 1,487). Health data were extracted from electronic medical records, covering 1-year prefire and 4-years postfire. When compared to the prefire baseline, survivors showed significantly larger increases in mental, respiratory, and musculoskeletal problems than community controls during the first year after the fire, but not during the later years.

Prevention of Staphylococcus aureus burn wound colonization by nasal mupirocin

BACKGROUND

There are two important routes for the transmission of Staphylococcus aureus to the burn wound. In the endogenous route, patients naturally carrying S. aureus colonize their own wounds, whereas in the exogenous route burn wounds are cross-infected from other sources. In this study we evaluated the effect of blocking the endogenous route on S. aureus burn wound colonization by mupirocin application in the nose of patients at the time of admission.

METHODS

From September 2000 to January 2002 all patients with burns admitted to a single dedicated Burn Centre received nasal mupirocin upon admission. This period was compared to two control periods (C1: July 1999 to July 2000 and C2: January 2002 to January 2003) for S. aureus burn wound colonization. The colonization risk was analysed, adjusting for confounding, with Cox proportional hazard regression.

RESULTS

A total of 98 patients did not have S. aureus burn wound colonization at the time of admission and were, thus, considered at risk for S. aureus acquisition during their stay. As compared to C1, the relative risk of acquiring S. aureus in their wound was 0.48 (95% CI: 0.24-0.97) in the mupirocin period and 0.55 (95% CI: 0.28-1.1) during the C2 period. S. aureus nasal/pharyngeal colonization was a significant independent risk factor for wound colonization (RR: 2.3; 95% CI: 1.2-4.2).

CONCLUSION

Nasal mupirocin may contribute to risk reduction of S. aureus wound colonization in patients with burns.

Physical and mental health problems in parents of adolescents with burns--a controlled, longitudinal study

OBJECTIVE

Caregiving has been described in the literature as a risk factor for ill health in the carer. This controlled, prospective study examines the course of physical and mental health problems in parents of adolescent survivors of a mass burn incident.

METHODS

Health information was extracted from electronic medical records. Continuous data were available for 1 year before and 4 years after the fire. Cohorts comprised 273 parents of survivors with burns, 199 parents of survivors without burns, and 1756 controls. Post-fire increases in health problems were compared by means of logistic regression.

RESULTS

Parents of burn victims were more likely to present mental health problems during the first 2 years after the incident, when compared to the baseline. Moreover, they were more likely to present cardiovascular health problems in every year following the disaster, compared to the baseline. Increases observed in mental and cardiovascular health problems were significantly larger in parents of burn victims compared to controls. Risk factors for presenting mental health problems were female gender of the parent and a large burn size in the child. Lower socioeconomic status and female gender of the parent predicted cardiovascular health problems.

CONCLUSION

Evidence gained in longitudinal studies informs on which health problems are most likely to develop in parental caregivers. In the interest of both parent and child, a family-oriented approach is proposed.

Mass chemical burn casualty: Emergency management of 118 patients with alkali burn during a Matsa typhoon attack in Shanghai, China in 2005

BACKGROUND

This article reports a chemical burn incident that occurred on August 7th, 2005, when a Matsa typhoon hit Shanghai, China. This is the largest chemical burn incident reported in the literature for 20 years in China, involving 118 alkali burn patients who were rescued by the Burn Department of Shanghai Changhai Hospital independently.

METHODS

The scene of the incident was investigated, and the clinical, emergency and hospitalized data of the patients were summarized.

RESULTS

The main injurious chemical was a water solution of sodium hydroxide and ammonium chloride. The 118 victims were mostly young men with 5%TBSA deep thickness burn of both lower extremities, including 31 patients who had additional light coughing. Of 58 patients who were finally hospitalized, 42 patients received surgical treatment. Most of these patients recovered within 1 month. There were no deaths.

DISCUSSION

Retrospective analysis of the therapeutic data of the incident demonstrates that pre-designed disaster planning for emergency management of mass burn patients, an effective command group, accurate assessment of pathological conditions, and correct allocation of different casualties are key elements in successful management in a mass casualty even involving burn patients. In addition, it is essential for specialized personnel to take part in emergency treatment of chemical burns.

Design of a randomized controlled trial on the effects of counseling of mental health problems by occupational physicians on return to work: the CO-OP-study

Background

Mental health problems often lead to prolonged sick leave. In primary care, the usual approach towards these patients was the advice to take rest and not return to work before all complaints had disappeared. When complaints persist, these patients are often referred to psychologists from primary and specialized secondary care. As an alternative, ways have been sought to activate the Dutch occupational physician (OP) in primary care. Early 2000, the Dutch Association of Occupational Physicians (NVAB) published a guideline concerning the management by OPs of employees with mental health problems. The guideline received positive reactions from employees, employers and Dutch OPs. This manuscript describes the design of a study, which aims to assess the effects of the guideline, compared with usual care.

Methods/Design

In a randomized controlled trial (RCT), subjects in the intervention group were treated according to the guideline. The control group received usual care, with minimal involvement of the OP and easy access to a psychologist. Subjects were recruited from two Dutch police departments. The primary outcomes of the study are return to work and treatment satisfaction by the employee, employer, and OP. A secondary outcome is cost-effectiveness of the intervention, compared with usual care. Furthermore, prognostic measures are taken into account as potential confounders. A process evaluation will be done by means of performance indicators, based on the guideline.

Discussion

In this pragmatic trial, effectiveness instead of efficacy is studied. We will evaluate what is possible in real clinical practice, rather than under ideal circumstances. Many requirements for a high quality trial are being met. Results of this study will contribute to treatment options in occupational health practice for employees on sick leave due to mental health problems. Additionally, they may contribute to new and better-suited guidelines and stepped care. Results will become available during 2007.

Trial registration

Current Controlled Trials ISRCTN34887348

Prospective cohort study into post-disaster benzodiazepine use demonstrated only short-term increase

OBJECTIVES

Benzodiazepines are typically prescribed for anxiety and insomnia, two complaints often reported after disasters. Benzodiazepines can cause mental or physical dependence, especially when taken for a long time. This study aims at evaluating benzodiazepine use in a disaster-stricken community with the help of computer-based records.

STUDY DESIGN AND SETTING

This prospective cohort study covers a period of 4 years. For every patient, predisaster baseline data are available. Multilevel regression is applied to study differences in benzodiazepine use in 496 patients whose children were involved in the Volendam café fire on January 1, 2001 compared with 1,709 community controls, and 4,530 patients from an unaffected cohort.

RESULTS

In community controls and patients from the unaffected cohort, benzodiazepine use remained stable in the course of the years. In the first year postfire, parents of disaster victims were 1.58 times more likely to use benzodiazepines than community controls (95% confidence interval 1.13-2.23). With regard to long-term use, differences between community controls and parents were statistically nonsignificant.

CONCLUSIONS

In the studied community, benzodiazepines were predominantly prescribed as a short-term intervention. Clinical guidelines that advocate a conservative prescription policy were well adhered to.

Disaster preparedness: experience from a smoke inhalation mass casualty incident

OBJECTIVE

We describe a modified triage system used in managing a smoke inhalation mass casualty incident that we recently encountered at our community hospital.

MATERIALS AND METHODS

The patients were triaged as priority 1, 2 or 3 on the basis of their symptoms, signs and circumstances at scene. In addition, the use of fibre-optic examinations of the upper airway, chest radiography and carboxyhaemoglobin levels with arterial blood gas analyses were used to aid in disposal plans.

RESULTS

Of the 22 patients evacuated, 15 were triaged as priority 2 and the remaining seven as priority 3. None of the patients was identified as priority 1. All the priority 2 patients underwent further investigations. Those with mild upper airway oedema (four patients) or raised carboxyhaemoglobin levels (two patients) were admitted. Only one patient had both. Another patient who was a known asthmatic developed bronchospasm and was admitted as well. All six were admitted to the general ward with subsequent good recovery and were discharged within 3 days. The remaining nine priority 2 and seven priority 3 patients were discharged from the emergency department.

CONCLUSIONS

These modified triage criteria, with selective use of fibre-optic examinations, chest radiography and arterial blood gas analyses with carboxyhaemoglobin levels, are useful in smoke inhalation mass casualty incidents without dermal burns. Systemic injury and poisoning by toxic fumes often coexist with airway burns and should not be overlooked. Lastly, disaster planning and frequent drills at both local and national levels will optimize the response to future mass casualty incidents.

Analysis of the pre-incident education and subsequent performance of emergency medical responders to the Volendam caf?? fire

OBJECTIVE

At this moment, in the Netherlands, rescue workers are not given any specific standardized training in disaster response or disaster management. After the café fire in Volendam, the Netherlands, on New Year's Eve 2000, around 200 rescue workers were deployed on-site. The aim of this study is to investigate the rescue workers' experiences with regard to their level of preparation for the emergency response.

METHODS

In 2002, 30 members of the medical and paramedical personnel were requested to participate in a structured interview, focused on education, task perception, triage and registration.

RESULTS

Twenty-seven participated. Twenty-two rescue workers received previous training in emergency medicine. During the alarm phase, 11 rescue workers had a clear perception of their tasks. Twenty-four were involved in triage and injury assessment. Three rescue workers used a protocol for triage and 15 for injury assessment. Twenty-five rescue workers gave on-scene treatment and 15 used a protocol. Eight registered their findings.

CONCLUSIONS

Preparation for the emergency response lacked standardized procedures. The use of triage protocols was extremely poor, as was documentation of actions. Slightly more than half of the personnel followed treatment protocols. It is advisable that all rescue workers become familiar with the basic uniform principles and protocols regarding disaster management. A dedicated and standardized national disaster management course is needed for all rescue workers.