Beyond surge: Coping with mass burn casualty in the closest hospital to the Formosa Fun Coast Dust Explosion

Abstract

Purpose:
To provide an insight into the challenges faced by the closest hospital to the Formosa Fun Coast Dust Explosion (FFCDE) disaster scene, and to examine how the hospital staff adapted to cope with the mass burn casualty (MBC) in their overcrowded emergency department (ED) after the disaster.

Material and methods:
The critical incident technique was used for the investigation. Data was gathered through in-depth individual interviews with 15 key participants in this event. The interview data was combined with the medical records of the FFCDE patients and admission logs to build a detailed timeline of ED workload. Process tracing analysis was used to evaluate how the ED and other units adapted to deal with actual and potential bottlenecks created by the patient surge.

Results:
Fifty-eight burn patients were treated and registered in approximately six hours while the ED managed 43 non-FFCDE patients. Forty-four patients with average total body surface area burn 51.3% were admitted. Twenty burn patients were intubated. The overwhelming demand created shortages primarily of clinicians, ED space, stretchers, ICU beds, and critical medical materials for burn care. Adaptive activities for the initial resuscitation are identified and synthesized into three typical adaptation patterns. These adaptations were never previously adopted in ED normal practices for daily surge nor in periodical exercises. The analysis revealed adaptation stemmed from the dynamic re-planning and coordination across roles and units and the anticipation of bottlenecks ahead.

Conclusion:
In the hospital closest to the FFCDE disaster scene, it caused an overwhelming demand in an already crowded, beyond-nominal-capacity ED. This study describes how the hospital mobilized and reconfigured response capacity to cope with overload, uncertainty, and time pressure. These findings support improving disaster planning and preparedness for all healthcare entities through organizational support for adaptation and routine practice coping with unexpected scenarios.

Full text

Beyond
surge:
Coping
with
mass
burn
casualty
in
the
closest
hospital
to
the
Formosa
Fun
Coast
Dust
Explosion
Sheuwen
Chuang
a,b
,
Kuo-Song
Chang
c
,
David
D.
Woods
e
,
Hsiao-Chun
Chen
b
,
Morgan
E.
Reynolds
e
,
Ding-Kuo
Chien
c,d,
*
a
Graduate
Institute
of
Data
Science,
Taipei
Medical
University,
Taipei,
Taiwan
b
Health
Policy
and
Care
Research
Center,
Taipei
Medical
University,
Taipei,
Taiwan
c
Department
of
Emergency
Medicine,
MacKay
Memorial
Hospital,
Taipei,
Taiwan
d
School
of
Medicine,
Mackay
Medical
College,
Taipei,
Taiwan
e
Department
of
Integrated
Systems
Engineering,
The
Ohio
State
University,
OH,
USA
a
b
s
t
r
a
c
t
Purpose:
To
provide
an
insight
into
the
challenges
faced
by
the
closest
hospital
to
the
Formosa
Fun
Coast
Dust
Explosion
(FFCDE)
disaster
scene,
and
to
examine
how
the
hospital
staff
adapted
to
cope
with
the
mass
burn
casualty
(MBC)
in
their
overcrowded
emergency
department
(ED)
after
the
disaster.
Material
and
methods:
The
critical
incident
technique
was
used
for
the
investigation.
Data
was
gathered
through
in-depth
individual
interviews
with
15
key
participants
in
this
event.
The
interview
data
was
combined
with
the
medical
records
of
the
FFCDE
patients
and
admission
logs
to
build
a
detailed
timeline
of
ED
workload.
Process
tracing
analysis
was
used
to
evaluate
how
the
ED
and
other
units
adapted
to
deal
with
actual
and
potential
bottlenecks
created
by
the
patient
surge.
Results:
Fifty-eight
burn
patients
were
treated
and
registered
in
approximately
six
hours
while
the
ED
managed
43
non-FFCDE
patients.
Forty-four
patients
with
average
total
body
surface
area
burn
51.3%
were
admitted.
Twenty
burn
patients
were
intubated.
The
overwhelming
demand
created
shortages
primarily
of
clinicians,
ED
space,
stretchers,
ICU
beds,
and
critical
medical
materials
for
burn
care.
Adaptive
activities
for
the
initial
resuscitation
are
identified
and
synthesized
into
three
typical
adaptation
patterns.
These
adaptations
were
never
previously
adopted
in
ED
normal
practices
for
daily
surge
nor
in
periodical
exercises.
The
analysis
revealed
adaptation
stemmed
from
the
dynamic
re-
planning
and
coordination
across
roles
and
units
and
the
anticipation
of
bottlenecks
ahead.
Conclusion:
In
the
hospital
closest
to
the
FFCDE
disaster
scene,
it
caused
an
overwhelming
demand
in
an
already
crowded,
beyond-nominal-capacity
ED.
This
study
describes
how
the
hospital
mobilized
and
reconfigured
response
capacity
to
cope
with
overload,
uncertainty,
and
time
pressure.
These
findings
support
improving
disaster
planning
and
preparedness
for
all
healthcare
entities
through
organizational
support
for
adaptation
and
routine
practice
coping
with
unexpected
scenarios.
©
2018
Elsevier
Ltd
and
ISBI.
All
rights
reserved.
a
r
t
i
c
l
e
i
n
f
o
Article
history:
Accepted
10
December
2018
Available
online
xxx
Keywords:
Mass
burn
casualty
Formosa
Fun
Coast
Dust
Explosion
Emergency
management
continuum
Disaster
planning
Cognitive
systems
engineering
Surge
capacity
*
Corresponding
author
at:
92,
Section
2,
Chungshan
North
Road,
Taipei
10449,
Taiwan.
E-mail
address:
mmhter2017@gmail.com
(D.-K.
Chien).
https://doi.org/10.1016/j.burns.2018.12.003
0305-4179/©
2018
Elsevier
Ltd
and
ISBI.
All
rights
reserved.
b
u
r
n
s
x
x
x
(
2
0
1
8
)
x
x
x
–
x
x
x
JBUR
5722
No.
of
Pages
10
Please
cite
this
article
in
press
as:
S.
Chuang,
et
al.,
Beyond
surge:
Coping
with
mass
burn
casualty
in
the
closest
hospital
to
the
Formosa
Fun
Coast
Dust
Explosion,
Burns
(2018),
https://doi.org/10.1016/j.burns.2018.12.003
Available
online
at
www.sciencedirect.com
ScienceDirect
jo
u
rn
al
h
o
mep
age:
w
ww
.elsevier
.co
m
/loc
ate/b
u
rn
s

1.
Introduction
Mass
burn
casualty
incidents
are
considered
one
of
the
most
difficult
events
for
hospitals
to
manage.
Burn
patients
require
specialized
treatment,
large
quantities
of
resources,
rapid
response,
and
vigilant
monitoring
because
burns
threaten
to
deteriorate
quickly
[1,2].
Additionally,
if
a
hospital
happens
to
be
located
in
proximity
to
a
disaster
scene,
lack
of
trauma
designation
or
burn
care
experience
will
not
shield
it
from
a
sudden
influx
of
patients
in
ambulances
or
private
cars
[3].
Although
there
are
guidelines,
standards,
procedures,
and
general
reports
to
prepare
for
mass
burn
casualty
events,
these
are
distillations
that
do
not
capture
the
real
difficulties
in
early
stages
of
disaster
management.
Description
and
analysis
of
hospitals’
prompt
and
effective
responses
to
incidents
that
exceed
practiced
capacity
can
better
prepare
staff
to
offer
patients
the
appropriate,
timely
care
after
disasters
[4,5].
The
Formosa
Fun
Coast
Dust
Explosion
(FFCDE)
in
New
Taipei
City
(NTC),
Taiwan
injured
499
people
at
approximately
20:30
on
Saturday,
June
27,
2015.
It
was
the
largest
man-made
mass
casualty
incident
in
Taiwan’s
history.
Victims,
average
age
of
23,
wore
flammable
swimwear
resulting
in
large
total
body
surface
area
burns
(TBSA,
average
44%;
281
people
with
TBSA
>40%,
41
people
>80%)
and
inhalation
injuries.
Nearly
300
emergency
vehicles
were
dispatched.
Within
six
hours,
499
victims
were
delivered
to
34
hospitals
[6].
The
FFCDE
disaster
has
led
to
several
studies
that
document
different
aspects
of
the
medical
response.
Some
of
these
provide
a
general
account
of
the
system
response
to
the
mass
burn
casualty
incident
(MBCI)
[7–9],
while
others
focus
on
the
clinical
details
and
the
appropriate
treatment
for
those
burned
[10,11].
However,
no
other
studies
have
com-
bined
cognitive
engineering
and
healthcare
to
provide
a
comprehensive
insight
into
the
hospitals’
prompt
and
effec-
tive
responses.
This
insight
is
essential
to
improve
hospital
disaster
planning
for
specialized
care,
including
burns,
when
the
number
of
patients
exceeds
the
nominal,
practiced,
and
predicted
surge
capacities
of
local
hospitals.
During
the
last
decade,
most
healthcare
systems
have
had
enough
surge
capacity
to
respond
effectively
to
conventional
multiple
casualty
incidents
(e.g.
a
bus
accident);
however,
less
progress
has
been
made
in
preparedness
for
catastrophic
disasters
(e.g.
massive
explosion,
nuclear
detonation).
Thus,
this
study
examines
how
the
closest
hospital
to
the
disaster
site
treated
victims
of
the
FFCDE
and
analyzes
how
it
adapted
to
challenges
associated
with
an
influx
of
severe
specialty
patients.
The
authors
aim
to
help
hospitals
develop
more
realistic
and
comprehensive
plans
for
mass
burn
casualty
events
in
disaster
planning.
2.
Materials
and
methods
Retrospective
research
interviews
were
conducted
in
MacKay
Memorial
Hospital
Tamsui
Branch
(MMHTB)
in
New
Taipei
City.
The
hospital
is
a
medical
center
(level
1
trauma
care
hospital)
and
part
of
a
five-hospital
network.
It
is
located
12.5km
from
the
disaster
site
and
has
1093
total
beds
including
28
medical
ICU
beds,
14
surgical
ICU
beds,
11
neurological
ICU
beds,
and
5
pediatric
ICU
beds;
however,
it
lacks
a
specialized
burn
unit.
The
ED
is
divided
into
six
major
treatment
rooms:
acute
areas
(trauma
room,
acute
medical
treatment
room,
and
observation
room
1–2)
and
non-acute
areas
(pediatric
room
and
observation
3).
The
ED’s
surge
capacity
is
55
beds
including
28
conventional
beds
and
27
contingency
stretchers.
The
trauma
room
can
treat
a
maximum
of
four
acute
patients
simultaneously.
The
ED
has
approximately
5000
visits
per
month.
The
average
number
of
visits
per
shift
is
75
daytime
(08:00–16:00),
65
night
(16:00–24:00),
and
30
late
night
(0:00–
08:00).
The
night
shift
is
generally
comprised
of
4
physicians,
2
nurse
practitioners,
10
nurses,
and
14
other
staff.
Preceding
the
incident,
the
hospital
had
periodically
practiced
mass
casualty
scenarios
with
an
influx
of
12–
15
patients
of
varying
severity,
including
heart
attacks
and
car
accidents.
It
also
practiced
receiving
2
patients
from
radiation
incidents.
The
hospital
had
neither
planned
nor
practiced
for
a
mass
burn
casualty
incident,
let
alone
one
that
would
exceed
their
practiced
surge
(contingency)
capacity
with
uncertainty
about
the
number
and
severity
of
patients
that
would
continue
to
arrive.
The
hospital’s
response
was
studied
using
the
critical
incident
technique
[12,13].
Hospital
records
were
reviewed
prior
to
the
interviews.
ED
admission
logs
were
reviewed
to
classify
FFCDE
and
non-FFCDE
patients
arriving
between
arrival
of
the
first
burn
patient
and
the
discharge
of
the
last
burn
patient.
For
all
patients,
the
ED
arrival
time,
ED
departure
time
(transfer
to
ICU/wards,
to
other
hospitals,
or
discharge),
and
triage
level
were
recorded.
For
FFCDE
patients
the
age,
gender,
and
%TBSA
burned
were
also
recorded.
Finally,
the
ED
video
record
was
checked
to
validate
the
accurate
arrival
time
of
some
critical
burn
patients.
These
data
were
used
to
develop
a
graphic
timeline,
later
used
by
interviewers
to
trigger
event
recall
and
capture
interviewees’
roles,
experiences,
and
perspectives
on
the
challenges
and
adaptations
for
use
during
the
interviews.
To
calculate
burn
patient
arrival
times,
time
zero
was
defined
as
the
time
the
ED
received
the
first
victim.
Open-ended
interview
questions
were
developed
from
a
literature
review
that
included
treatment
of
burn
patients
in
the
context
of
the
MBCI
and
interviews
with
two
experts
on
managing
mass
casualty
incidents.
The
questions
were
designed
to
probe
for
challenges
faced
during
the
incident,
how
and
when
challenges
were
recognized,
actions
taken
to
cope
with
challenges,
and
general
perceptions
of
the
ED
environment
during
the
incident.
Interviews
with
15
key
participants,
beginning
with
the
ED
director,
were
conducted
by
the
lead
researcher
and
a
research
assistant
between
May
2017
and
November
2017.
Five
physicians,
eight
nurses,
and
two
medical
material
management
staff
were
interviewed.
Each
interview
lasted
two
to
three
hours.
Conflicts
and
ambiguities
between
interviewee
accounts
of
the
event
were
clarified
through
later
calls,
emails,
or
in-person
discussions.
Then,
interviews
were
transcribed
into
time-binned
spreadsheets
(Excel)
along
with
patient
data.
The
transcrip-
tions
were
organized
for
process
tracing
analysis,
performance
in
critical
incidents
[14,15].
The
process
trace
highlighted
how
the
patient
surge
played
out
over
time,
how
it
challenged
the
ED,
and
how
the
ED
and
other
hospital
units
adapted
to
avoid
deterioration
of
patient
care.
Figs.
1–3
chart
the
process
in
terms
of
load
on
the
ED,
actual
and
potential
bottlenecks,
and
2b
u
r
n
s
x
x
x
(
2
0
1
8
)
x
x
x
–
x
x
x
JBUR
5722
No.
of
Pages
10
Please
cite
this
article
in
press
as:
S.
Chuang,
et
al.,
Beyond
surge:
Coping
with
mass
burn
casualty
in
the
closest
hospital
to
the
Formosa
Fun
Coast
Dust
Explosion,
Burns
(2018),
https://doi.org/10.1016/j.burns.2018.12.003

Fig.
2
–
Three
stages
before
the
ED
resumed
to
normal
operation.
Fig.
1
–
Patients
inflow
and
outflow
to
the
emergency
department
(ED)
in
detail
timeline.
b
u
r
n
s
x
x
x
(
2
0
1
8
)
x
x
x
–
x
x
x
3
JBUR
5722
No.
of
Pages
10
Please
cite
this
article
in
press
as:
S.
Chuang,
et
al.,
Beyond
surge:
Coping
with
mass
burn
casualty
in
the
closest
hospital
to
the
Formosa
Fun
Coast
Dust
Explosion,
Burns
(2018),
https://doi.org/10.1016/j.burns.2018.12.003

adaptive
responses.
The
study
was
approved
by
the
Institu-
tional
Review
Board
of
Taipei
Medical
University.
3.
Results
3.1.
Patient
characteristics
Overall,
60
burn
patients
were
counted,
which
includes
58
that
arrived
in
the
ED
the
night
of
June
27,
2015
for
treatment,
and
2
patients
who
arrived
the
next
morning.
This
excludes
any
patients
who
were
treated
but
missing
in
registration.
Only
forty-four
of
the
admitted
burn
patients
are
included
for
the
analysis
in
Table
1
due
to
incomplete
discharged
patient
data.
The
average
age
of
burn
patients
was
22.6,
and
injuries
ranged
from
TBSA
1%
to
90%;
the
average
was
51.3%.
An
additional
12
non-FFCDE
patients
arrived
for
treatment
during
the
event
and
43
patients
were
already
present
in
the
ED
prior
to
the
incident
(Table
2).
43.3%
of
the
60
patients
were
sent
by
ambulance
and
56.6%
were
sent
by
friends/family
or
arrived
on
their
own
accord.
Twenty-five
percent
of
the
patients
arrived
with
30min,
and
50%
arrived
within
60min
of
time
zero.
3.2.
Sequence
of
events
The
following
is
a
detailed
timeline
of
events,
starting
with
first
knowledge
of
the
FFCDE
disaster
and
ending
with
the
discharge
or
transfer
of
all
FFCDE
patients
from
the
ED.
Fig.
1
displays
different
types
of
ED
patient
flows
for
this
time
period.
In
addition
to
the
patients
described
previously,
300
cumulative
personnel
gradually
arrived
to
assist
in
treatment,
but
it
is
unknown
how
many
were
treating
patients
at
any
one
time.
Fig.
3
–
Shortage
of
three
critical
medical
supplies
and
corresponding
hospital’s
responses.
Table
1
–
Burn
patients
characteristics.
Characteristics
No.
(%)
Mean
(SD)
Age
(17–36)
22.6
(3.5)
220
13
(29.5)
<age230
30
(68.2)
>30
1
(2.3)
Gender
Female
28
(63.6)
Male
16
(36.4)
Severity
(TBSA
1–90%)
51.3
(22.8)
5%
1
(2.3)
5%<TBSA 20%
6
(13.6)
20%<TBSA 40%
5
(11.4)
40%<TBSA 60%
18
(40.9)
>60%
14
(31.8)
Total
44
a
TBSA:
Total
Body
Surface
Area.
a
Excluding
the
discharged
patients
who
had
incomplete
data.
4b
u
r
n
s
x
x
x
(
2
0
1
8
)
x
x
x
–
x
x
x
JBUR
5722
No.
of
Pages
10
Please
cite
this
article
in
press
as:
S.
Chuang,
et
al.,
Beyond
surge:
Coping
with
mass
burn
casualty
in
the
closest
hospital
to
the
Formosa
Fun
Coast
Dust
Explosion,
Burns
(2018),
https://doi.org/10.1016/j.burns.2018.12.003

The
ED’s
earliest
awareness
a
patient
surge
was
around
20:50
when
the
NTC
Dispatch
Center
called
asking
how
many
beds
they
could
provide
for
burn
patients.
At
approximately
20:55,
a
call
was
made
to
the
ED
Director,
who
was
not
currently
inthe
ED,
anditwas
askedifthe
masscasualtyalarm (333
signal)
should
be
activated.
The
ED
Director
postponed
the
333
signal,
requested
the
ED
be
ready
for
its
activation,
and
asked
for
the
clearance
of
both
trauma
and
acute
medical
treatment
rooms,
as
the
standard
operating
procedure
stated.
To
accomplish
this
the
ED
nurses
were
divided
between
existing
patients
and
incoming
FFCDE
patients
(Table
3,
A1).
Existing
patients
were
moved
into
observation
rooms
1–3,
depending
on
acuity
to
open
acute
beds
for
the
initial
surge
of
burn
patients.
Stretchers
were
prepared
on
standby
(Table
3,
B1).
The
first
FFCDE
patient
arrived
at
21:07,
immediately
followed
by
six
severe
burn
patients
with
TBSA
80–90%
and
two
of
them
required
intubation.
After
the
first
burn
patient
was
intubated,
the
on-duty
ED
physician
activated
the
333
signal
to
recruit
on-hospital
staff
(Table
3,
A2).
This
led
to
clinicians
moving
to
the
ED
from
within
the
hospital
(Table
3,
A3).
To
cope
with
the
influx
of
high
acuity
burn
patients,
the
on-duty
ED
physicians
moved
all
43
existing
patients
from
observation
rooms
1–2
into
room
3
(Table
3,
B2).
After
the
333
signal
was
activated,
the
central
supplies
unit
of
the
hospital
provided
supplies
to
the
ED
on
standby.
However,
the
standby
supplies
were
for
surgical
wounds–most
commonly
needed
after
mass
casualty
events–not
large
amounts
of
specific
medical
materials
needed
to
treat
burns.
Therefore,
the
patient
demand
overwhelmed
the
supply
quickly.
Due
to
the
potentially
limited
supply
of
burn
dressing
material
in
the
ED
pharmacy
and
lack
of
ED
space
and
time
for
treating
a
continuous
stream
of
patients,
it
was
decided
that
the
burn
patients
would
be
administered
the
ointment
(Silver
sulfadiazine)
after
moving
up
to
the
wards.
Only
about
ten
patients
were
treated
with
the
burn
ointment
(Table
3,
C1).
Registration
protocol
also
changed
after
the
333
signal
was
activated.
Standard
protocol
was
to
complete
patient
identification
prior
to
treatment
unless
the
patient
was
too
acute
to
answer
questions
during
triage;
acute
patients
would
be
identified
after
treatment.
In
mass
casualty
incidents,
patient
identification
was
simplified
to
using
the
mass
casualty
numbers
which
were
assigned
according
to
arrival;
for
example,
the
first
patient
to
arrive
was
assigned
number
333–001.
This
made
registration
more
efficient
in
getting
all
patients
treated;
however,
it
was
more
difficult
to
report
to
anxious
families
on
the
status
and
location
of
their
loved
one.
Because
patients
who
had
been
intubated
were
unable
to
identify
themselves
verbally
and
the
registration
protocol
changed
after
several
patients
had
been
registered
with
a
standard
registration
number
instead
of
a
mass
casualty
registration
number,
some
registrations
were
missed
and
others
duplicated.
After
17
burn
patients
arrived
the
ED
had
surpassed
practiced
surge
capacity
(55
patients)
and
the
shortage
of
ED
clinicians
became
apparent
a
call
for
off-hospital
physicians
was
initiated
(Table
3,
A4).
In
anticipation
of
critical
need,
the
Tamsui
ED
Director
called
the
both
ICU
directors
of
the
Taipei
and
Tamsui
Branches
to
prepare
beds
and
centrally
control
the
supply
and
demand
of
ICU
beds
(Table
3,
B3).
The
ED
pharmacy
exhausted
the
saline,
but
quickly
the
pharmacy
warehouse
door
was
opened
under
the
supervision
of
on-duty
head
nurse
and
an
inventory
staff
(Table
3,
C2).
The
ED
also
exhausted
the
intubation
tubes
after
only
seven
patients
were
intubated
and
additional
tubes
had
to
be
borrowed
from
ICU
(Table
3,
C3).
Finally,
the
ED
exhausted
the
wound
dressing
gauze
and
the
central
supplies
unit
helped
to
restock
(Table
3,
C4).
Shortly
after,
a
call
for
off-hospital
nurses
was
initiated
by
on-duty
head
nurse
and
a
nursing
supervisor
(Table
3,
A4).
Simultaneously,
the
hospital
called
the
Emergency
Operation
Center
(EOC)
to
request
that
the
emergency
services
stop
sending
FFCDE
patients
because
the
ED
was
reaching
satura-
tion
of
space
and
clinicians,
but
burn
patients
continued
to
arrive
(Table
3,
B4).
At
21:50,
a
mass
of
ED
clinical
personnel
arrived
to
assist
(Table
3,
A5).
There
was
insufficient
space
in
the
ED
for
simple
treat-
ments
due
to
overcrowding
of
clinicians,
administration
staff,
patients,
families,
and
reporters.
Spontaneously,
it
was
decided
simple
treatments
for
low
acuity
patients
(e.g.
flushing
patient’s
wound
area
and
covering
with
wet
gauze)
would
be
conducted
at
the
triage
area
before
moving
the
patients
inside
the
main
ED.
In
addition,
the
meeting
room,
storage
room,
staff
lounge,
and
shower
room
would
be
opened
up
to
allow
low-acuity
patients
to
flush
their
own
burns
to
reduce
wound
temperature
and
pain
(Table
3,
B5).
Facing
the
gridlock
of
ED
space,
at
21:50
the
ED
Director
of
Taipei
MacKay
arrived
and
proceeded
to
reorganize
the
space.
First,
entry
into
the
main
ED
was
regulated,
reporters
and
spectators
were
removed
from
the
ED
and
not
allowed
to
reenter,
chairs
in
the
waiting
area
were
removed,
and
a
few
patients
who
were
not
victims
of
FFCDE
but
were
waiting
for
clinical
services
were
asked
to
leave.
Second,
the
main
ED
was
divided
into
two
zones–patient
zone
and
non-patient
zone–
separated
by
a
guarded
door.
Third,
the
scattered
beds
were
reconfigured
into
lines,
each
patient
was
only
permitted
one
bedside
family
member,
and
nurses
were
assigned
to
specific
patients.
Fourth,
to
make
patients
easier
to
find
for
clinicians
Table
2
–
Non-FFCDE
patients.
Triage
level
Count
Remark
Existing
ED
patients
before
21:07
1
4
29
non-FFCDE
patients
were
dis-
charged
within
5h2
9
3
29
4
1
5
0
Total
43
New
arrivals
between
21:07
and
03:15
(last
burn
patient
discharged)
1
0
3
pediatric
patients,
1
gynecologic
patient,
7
internal
medicine
pa-
tients,
1
alcohol
addiction
patient.
2
3
3
9
4
0
5
0
4
discharged
Total
12
FFCDE:
Formosa
Fun
Coast
Dust
Explosion.
b
u
r
n
s
x
x
x
(
2
0
1
8
)
x
x
x
–
x
x
x
5
JBUR
5722
No.
of
Pages
10
Please
cite
this
article
in
press
as:
S.
Chuang,
et
al.,
Beyond
surge:
Coping
with
mass
burn
casualty
in
the
closest
hospital
to
the
Formosa
Fun
Coast
Dust
Explosion,
Burns
(2018),
https://doi.org/10.1016/j.burns.2018.12.003

Table
3
–
Summary
of
adaptations.
Code
Time
Key
adaptation
Workload
saturation
&
clinician
shortage
A1
20:55
The
ED
nurses
were
divided
between
existing
patients
and
incoming
FFCDE
patients
to
assist
in
clearing
the
trauma
and
acute
medical
rooms.
A2
21:10
After
the
first
burn
patient
was
intubated,
the
on-duty
ED
physician
activated
the
333
signal
to
recruit
on-hospital
staff.
Also,
patient
identification
was
simplified
to
using
the
mass
casualty
numbers
which
were
assigned
according
to
arrival,
making
registration
more
efficient
in
getting
all
patients
treatment.
A3
21:15
Clinicians
began
moving
to
the
ED
from
within
the
hospital.
A4
21:30
After
17
burn
patients
had
arrived
the
ED
had
surpassed
practiced
surge
capacity
(55
patients)
and
the
shortage
of
ED
clinicians
became
apparent;
a
call
for
off-hospital
physicians
was
initiated.
A5
21:40
A
call
for
off-hospital
nurses
was
initiated
by
on-duty
head
nurse
and
a
nursing
supervisor.
A6
21:50
A
mass
of
ED
clinical
personnel
arrived
to
assist
in
treatment.
A7
22:00
Contingency
stretchers
in
the
ED
and
ambulances
for
transfer
were
exhausted
so
ED
nurses
put
patients
with
injured
limbs
in
wheelchairs,
the
ED
Head
Nurse
borrowed
stretchers
from
119
ambulances
and
other
units
of
the
hospital,
and
the
Manager
of
General
Affairs
gathered
ten
ambulances
through
formal
and
informal
channels.
A8
22:30
ED
senior
attending
doctor
escorted
the
transferred
patients
to
other
hospitals,
usually
this
was
done
by
residents
and
nurses
ED
space
approaching
gridlock
and
shortage
of
ICU
beds
B1
20:55
Existing
patients
were
moved
into
observation
rooms
1–3,
depending
on
acuity
to
open
beds
for
the
initial
surge
of
burn
patients.
Stretchers
were
prepared
on
standby.
B2
21:15
To
cope
with
the
influx
of
high
acuity
burn
patients,
the
on-duty
ED
physician
moved
all
43
existing
patients
from
observation
rooms
1–2
into
room
3.
B3
21:30
In
anticipation
of
critical
need,
the
Tamsui
ED
Director
called
the
both
ICU
directors
of
the
Taipei
and
Tamsui
Branches
to
prepare
beds
and
centrally
control
the
supply
and
demand
of
ICU
beds.
B4
21:35
The
hospital
called
the
Emergency
Operation
Center
(EOC)
to
request
that
the
emergency
services
stop
sending
FFCDE
patients
because
the
ED
was
reaching
saturation
of
space
and
clinicians,
but
burn
patients
continued
to
arrive.
B5
21:50
Simple
treatments
for
low
acuity
patients
(e.g.
flushing
patient’s
wound
area
and
covering
with
wet
gauze)
would
be
conducted
at
the
triage
area
before
moving
the
patients
inside
the
main
ED.
In
addition,
the
meeting
room,
storage
room,
staff
lounge,
and
shower
room
would
be
opened
up
to
allow
low
acuity
patients
to
flush
their
own
burns
to
reduce
wound
temperature
and
pain.
B6
21:50
The
actions
of
the
ED
Director
and
Head
Nurse
(e.g.
regulating
door,
reorganizing
beds,
removing
bystanders,
etc.)
significantly
reduced
crowding
and
confusion
in
the
treatment
area.
B7
22:10
The
Vice-Superintendent
activated
emergency
transfer
protocol
in
the
ICU
and
general
wards
to
start
transferring
existing
patients
out
of
these
wards
to
accommodate
FFCDE
patients.
Subsequently,
ten
ICU
beds
in-hospital
and
an
additional
10
ICU
beds
in
the
Taipei
branch
were
subsequently
opened
to
the
burn
patients.
B8
22:30
The
first
of
ten
intubated
patients
was
transferred
to
the
ICU
of
Taipei
branch
containing
a
burn
unit.
B9
23:50
The
first
of
ten
additional
intubated
patients
was
transferred
to
an
in-hospital
ICU.
B10
23:30
The
first
of
twenty-three
other
FFCDE
patients
was
transferred
to
general
wards.
B11
00:30
The
first
of
four
FFCDE
patients
was
transferred
to
another
hospitals.
Exhaustion
of
critical
medical
supplies,
stretchers,
and
ambulances
C1
21:20
Due
to
the
limited
supply
of
burn
dressing
material
in
the
ED
pharmacy
and
lack
of
ED
space
and
time
for
treating
the
continuous
stream
of
patients
entering
the
ED,
it
was
decided
that
the
burn
ointment
will
be
administered
to
patients
after
transfer
to
the
wards.
Only
ten
patients
were
treated
with
the
burn
ointment.
C2
21:35
The
ED
pharmacy
exhausted
the
saline,
but
quickly
the
pharmacy
warehouse
door
was
opened
under
the
supervision
of
on-duty
Head
Nurse
and
an
inventory
keeper.
C3
22:19
The
ED
also
exhausted
the
intubation
tubes
after
only
seven
patients
were
intubated,
and
additional
tubes
had
to
be
borrowed
from
ICU.
C4
22:30
The
ED
exhausted
the
wound
dressing
gauze
and
the
central
supplies
unit
helped
to
restock.
C5
23:30
A
young
attending
physician,
anticipating
the
exhaustion
of
burn
ointment
in
the
wards
after
the
transfer
of
patients,
took
the
initiative
to
call
a
supplier
and
requested
an
urgent
delivery
of
burn
treatment
ointment.
C6
02:30
The
supplier
delivered
burn
ointment
for
the
ICU
and
general
wards.
6b
u
r
n
s
x
x
x
(
2
0
1
8
)
x
x
x
–
x
x
x
JBUR
5722
No.
of
Pages
10
Please
cite
this
article
in
press
as:
S.
Chuang,
et
al.,
Beyond
surge:
Coping
with
mass
burn
casualty
in
the
closest
hospital
to
the
Formosa
Fun
Coast
Dust
Explosion,
Burns
(2018),
https://doi.org/10.1016/j.burns.2018.12.003

and
families
and
to
mitigate
registration
numbering
issues,
the
ED
Head
Nurse
reassigned
medical
record
numbers
for
all
burn
patients
and
attached
a
piece
of
A4
white
paper
with
patient
name
and
number
to
the
drip
stand
of
each
bed.
These
actions
significantly
reduced
crowding
and
confusion
in
the
treatment
area
(Table
3,
B6).
Next,
the
Vice-Superintendent
activated
emergency
trans-
fer
protocol
in
the
ICU
and
general
wards
to
start
transferring
existing
patients
out
of
these
wards
to
accommodate
FFCDE
patients.
Ten
ICU
beds
in-hospital
and
an
additional
10
ICU
beds
in
the
Taipei
branch
were
subsequently
opened
to
the
burn
patients
(Table
3,
B7).
Contingency
stretchers
in
the
ED
were
exhausted
by
22:00
so
ED
nurses
put
patients
with
injured
limbs
in
wheelchairs
until
a
stretcher
was
available.
Because
burn
treatment
was
more
convenient
in
stretchers
than
wheel-
chairs,
the
ED
Head
Nurse
borrowed
stretchers
from
119
am-
bulances
and
other
units
of
the
hospital
until
transfer
of
patients
out
of
ED
created
available
stretchers.
In
the
meantime,
the
ED
faced
shortage
of
ambulances
so
the
ED
Head
Nurse
contacted
a
General
Affairs
staff
who
gathered
ten
ambulances
through
formal
and
informal
channels.
The
ED
started
the
transfer
of
burn
patients
to
ICU
around
22:30.
Generally,
intubated
patients
were
sent
to
ICU
and
others
were
sent
to
general
wards.
Therefore,
knowledge
and
expertise
needed
to
be
transferred
to
treat
burn
patients
in
inexperienced
general
wards.
The
first
of
ten
intubated
patients
was
transferred
to
the
ICUs
within
the
hospital
(Table
3,
B8).
An
hour
later,
a
young
attending
physician,
anticipating
the
exhaustion
of
burn
ointment
in
the
wards
after
the
transfer
of
patients,
took
the
initiative
to
call
a
supplier
and
requested
an
urgent
delivery
of
burn
treatment
ointment
and
other
medical
materials
(Table
3,
C5).
Then,
the
first
of
twenty-three
other
FFCDE
patients
was
transferred
to
the
general
wards
(Table
3,
B9),
the
first
of
ten
intubated
patients
was
transferred
to
the
ICUs
of
Taipei
MacKay,
containing
a
burn
unit
(Table
3,
B10),
and
the
first
of
four
FFCDE
patients
was
transferred
to
another
hospitals
(Table
3,
B11).
The
ED
resumed
to
the
conventional
care
around
02:00
June
28th.
At
02:30,
the
supplier
delivered
burn
ointment
for
the
ICU
and
general
wards
(Table
3,
C6).
The
last
of
14
minor
burn
patients
were
discharged
at
03:10.
After
the
burn
patients
were
admitted
in
ICUs
and
general
wards,
plastic
surgeon
teams
re-evaluated
and
treated
the
patients
with
necessary
sterile
dressings.
The
director
of
burn
care
center
of
the
Taipei
Branch
arrived
June
28th
at
approximately
08:00.
He
initiated
two
evaluation
teams
led
by
the
director
and
a
senior
plastic
surgeon
to
check
patients’
infusion
volume,
urine
output,
and
gas
data
for
intubated
patients.
Provision
of
adequate
fluid
resuscitation,
escharot-
omy,
early
wound
debridement,
or
temporary
wound
coverage
were
followed
until
the
applications
of
multiple
advanced
therapeutic
modalities.
To
prevent
infection
for
the
burn
patients,
the
neurologic
ICU
with
11
beds
was
reconfigured
as
a
burn
ICU
within
two
days
and
a
general
ward
was
reconfigured
as
a
burn
care
ward
within
three
days
of
the
FFCDE.
Eleven
patients
were
transferred
to
other
hospitals
within
nine
days,
seven
patients
were
referred
to
the
burn
care
ward
of
the
Taipei
Branch
in
September,
and
seventeen
patients
were
eventually
discharged
including
the
last
patient
on
November
13,
2015.
3.3.
Challenges
over
time
Based
on
the
ED
daily
surge
capacity
(55
beds),
three
stages
have
been
identified
before
the
ED
resumed
normal
operation:
(1)
initial
surge,
(2)
super
overload,
and
(3)
patient
transfer
out
of
the
ED.
These
stages
are
shown
in
Fig.
2
and
represent
a
different
set
of
challenges
and
adaptations.
The
challenges
the
hospital
personnel
faced
in
each
stage
are
described
below.
I.
Initial
surge
(20:50–21:25)
1.
ED
had
already
exceeded
nominal
capacity
(28
patients)
before
the
patient
influx
2.
ED
nearly
exceeded
practiced
daily
surge
capacity
(55
pa-
tients)
of
stretchers/beds,
space,
medical
materials,
and
clinicians
3.
Four
of
first
twelve
burn
patients
required
intubation
4.
Exhaustion
of
physical
space
in
designated
critical
care
rooms
and
overcrowding
of
other
ED
spaces
5.
High
uncertainty
about
how
many
patients
would
continue
to
arrive
6.
Risk
of
exhaustion
of
necessary
materials
7.
Patients
needed
ICU
level
care
but
no
ICU
beds
were
immediately
available
and
ICU
transfer
ability
was
uncertain
II.
Super
overload
(21:25–00:35)
1.
Acute
shortage
of
clinician
staff
to
support
intubation
and
patient
care
2.
Exhaustion
of
available
treatment
spaces,
including
contingency
spaces
to
hold
stretchers
and
aisles
to
move
through
ED
3.
Shortage
of
supplies
(i.e.
endotracheal
tube,
Ambu,
normal
saline,
and
large-size
gauze)
4.
Exhaustion
of
stretchers
5.
Continued
uncertainty
about
how
many
more
patients
would
arrive
6.
Patient
identification
for
anxious
family
members
is
hindered
by
multiple
factors
including
number
and
pace
of
arriving
patients,
intubation
interference
with
commu-
nication,
and
scattered
layout
of
patients
7.
ED
overcrowded
with
patients,
healthcare
staff,
volun-
teers,
media
reporters,
and
spectators
8.
Exhaustion
of
conventional
ICU
beds
9.
Shortage
of
available
ambulances
for
transfer
of
patients
to
other
hospitals
10.
Anticipated
risks
to
quality
of
care
with
the
overwhelming
demand
for
burn
dressings
III.
Patient
transfer
out
of
the
ED
(00:35–02:00)
1.
Deciding
which
patients
to
transfer
and
where
they
should
go
2.
Continued
shortage
of
ambulances
to
transfer
patients
out
of
the
hospital
3.
Shortage
of
clinicians
to
accompany
patients
in
need
of
transfer
b
u
r
n
s
x
x
x
(
2
0
1
8
)
x
x
x
–
x
x
x
7
JBUR
5722
No.
of
Pages
10
Please
cite
this
article
in
press
as:
S.
Chuang,
et
al.,
Beyond
surge:
Coping
with
mass
burn
casualty
in
the
closest
hospital
to
the
Formosa
Fun
Coast
Dust
Explosion,
Burns
(2018),
https://doi.org/10.1016/j.burns.2018.12.003

4.
Sparse
and
delayed
patient
identification
in
order
to
provide
adequate,
legally
requested
information
for
transferring
patients
to
receiving
hospitals
5.
How
to
follow
up
patients
transferred
within-hospital
and
between-hospital
3.4.
Key
adaptations
The
overload
manifested
into
three
axial
challenges:
(a)
workload
saturation
and
shortage
of
clinicians,
(b)
ED
space
approaching
gridlock
and
shortage
of
ICU
beds,
and
(c)
shortage
of
critical
medical
materials,
stretchers,
and
ambu-
lances
for
burn
care.
A
variety
of
adaptations
emerged
to
cope
with
challenges,
including
regularly-trained
protocols
and
novel
initiatives
to
extend
capacity
for
care.
Adaptations
associated
with
each
of
the
three
axial
challenges
are
summarized
in
Table
3.
Each
adaptation
has
an
associated
code
(e.g.
A1).
A
and
B
codes
can
be
referenced
in
Fig.
2
timeline
which
shows
multiple
types
of
patients
flows
over
time.
C
codes
can
be
referenced
in
Fig.
3
which
shows
the
shortage
of
three
critical
medical
supplies
and
hospital’s
response.
4.
Discussion
The
study
provides
insight
into
how
the
adaptive
responses
played
out
through
a
detailed
timeline.
These
responses
led
to
expanded
scales
of
operation,
dramatic
new
capabilities,
extensive
and
hidden
interdependencies,
and
new
vulner-
abilities
in
each
identified
patient
surge
stage.
The
ED
is
crowded
daily
and
already
runs
beyond
nominal
capacity
(28
patients).
According
to
the
Back
et.al.
study,
EDs
that
are
overcrowded
normally
reconfigure
(mobilize
and
deploy)
resources
to
maintain
the
ability
to
deliver
patient
care,
without
compromising
safety,
by
modifying
“normal”
pro-
cesses
to
extend
operation
capabilities
every
day.
Most
of
the
time,
internal
escalation
actions
are
performed
with
the
ED’s
existing
resources
and
occasionally
external
resources
that
are
not
currently
available
within
the
department
and
have
to
be
garnered
elsewhere
[11].
The
definition
of
surge
capacity
made
by
the
American
College
of
Emergency
Physicians
had
been
revised
in
2017
from
the
concept
of
daily
surge
to
a
broad
definition
which
describes
conventional
(daily),
contingency,
and
crisis
surge
capacities
as,
“Surge
capacity
is
a
measurable
representation
of
ability
to
manage
a
sudden
influx
of
patients.
It
is
dependent
on
a
well-
functioning
incident
management
system
and
the
variables
of
space,
supplies,
staff
and
any
special
considerations
(contam-
inated
or
contagious
patients,
for
example)”
[16].
However,
health
care
administrations
have
been
in
the
realm
of
daily
surge.
Internal
operations
in
health
care
facilities
manage
daily
surge
on
a
routine
basis.
Periodic
drills
or
exercises
to
train
health
care
staff
are
designed
with
the
concept
of
daily
or
contingency
surge
and
with
very
little
preparation
for
disaster
surge
[17,18].
Mass
burn
casualty
disasters
that
create
an
influx
of
severely
injured
patients
are
likely
to
overrun
ED
capacity.
This
can
happen
if
the
number
of
patients
exceeds
what
surge
planning
anticipates
(i.e.
59
beds
in
an
ED’s
daily
surge
capacity).
If
the
ED
is
already
working
at
daily
surge
capacity
there
may
be
no
other
resources
readily
available
to
cope
with
the
mass
casualty.
Moreover,
if
the
hospital
is
located
near
the
disaster
scene,
mass
burn
patients
may
arrive
promptly,
giving
the
hospital
less
time
to
acquire
additional
resources
neces-
sary
for
treatment.
The
resources
needed
to
mobilize
were
not
only
from
the
ED
but
from
the
entire
hospital
and
external
agencies.
The
intensified
pressures
and
the
scale
of
demand
were
far
greater
than
they
would
have
reasonably
thought
of
and
planned
for
regularly
[3,19].
Therefore,
it
required
a
massive
ad
hoc
effort
to
generate
adequate
resources.
To
respond
to
this
MBCI,
the
hospital
staff
initiated
standard
protocols
based
on
the
daily
or
contingency
surge
which
included
use
of
a
mass
casualty
numbering
system,
development
of
a
nurse
queue
to
receive
assignment
in
the
triage
area,
early
relocation
of
ED
acute
area
for
victims,
cooperation
with
logistic
support
units
to
fulfill
demand,
and
implementation
of
incident
command
center.
However,
these
responses
were
only
some
of
the
notable
adaptations
to
cope
with
the
influx
of
burn
patients
under
an
overwhelmed
disaster
surge
capacity.
The
FFCDE
disaster
was
a
sudden-onset,
no-notice
disaster.
The
study
revealed
several
irregular
adaptations
initiated
by
individuals
or
groups.
Five
additional
adaptation
patterns
were
identified:
1)
Utilize
patients’
youthful
stability
to
provide
additional
buffering
capacity,
(e.g.
placing
patients
in
wheelchairs
or
chairs,
patients
flush
themselves
to
reduce
wound
heat)
2)
Compromise
lower
priority
goals
to
achieve
higher
priority
ones
(e.g.
limiting
non-FFCDE
patients
care,
discharging
non-FFCDE
patients,
and
postponing
patient
registration
to
prepare
patients
referral
documents)
3)
Relax
regulation
barriers,
giving
personnel
additional
authority
to
attain
timely
supplies
and
extend
treatment
area
(e.g.
opening
the
warehouse
door
to
move
required
materials
promptly
with
inventory
accounting
check
afterwards
and
opening
additional
spaces
in
ED
for
low-
acuity
patients
to
flush
their
own
wounds)
4)
Downplay
clinicians’
position
level
to
extend
the
best
use
of
manpower
(e.g.
ED
senior
attending
doctors
escorted
the
transferred
patients
to
other
hospitals
when
usually
this
was
done
by
residents
and
nurses)
5)
Initiate
anticipatory
deployment
and
mobilization
of
external
resources
(e.g.
mobilization
of
ICU/GW
beds
across
hospitals
and
initiation
of
medical
material
suppliers
by
a
young
physician)
The
immediate
care
given
to
stabilize
mass
burn
patients
in
ED
was
a
highly
distributed
and
specialized
effort.Development
of
surge
capacity
requires
augmenting
existing
capacity
as
well
as
generating
capacity
to
resolve
resource
limitations
in
real
time.
This
is
fully
dependent
on
effective
coordination
and
integrationbetweenindividualsas wellasacross
unitsandroles
during
critical
stages
of
the
MCI
[20].
The
study
revealed
evidence
of
effective
coordination
including
the
staff’s
willing-
ness
to
take-on
additional
workload
and
risk
for
others
and
the
clearly
communicated
actions
taken
to
mobilize
and
deploy
resources.
Coordination
requires
implementation
of
various
mechanisms
that
allow
team
members
to
manage
interde-
pendencies
between
their
roles
and
tasks
and
to
manage
8b
u
r
n
s
x
x
x
(
2
0
1
8
)
x
x
x
–
x
x
x
JBUR
5722
No.
of
Pages
10
Please
cite
this
article
in
press
as:
S.
Chuang,
et
al.,
Beyond
surge:
Coping
with
mass
burn
casualty
in
the
closest
hospital
to
the
Formosa
Fun
Coast
Dust
Explosion,
Burns
(2018),
https://doi.org/10.1016/j.burns.2018.12.003

conflicts
between
their
goals
[21].
Burstein
showed
that
effective
coordination
is
built
on
people
frequently
practicing
coordination
through
regular
and
simple
drills;
thus
they
know
how
to
communicate
correctly
in
disasters
[22].
Beyond
the
challenges
of
coordination
and
mass
treatment
of
burn
patients,
the
hospital
examined
had
to
cope
with
high
tempo
and
uncertainty
due
to
unsuccessful
communication
with
the
EOC
during
the
disaster
response
[20].
It
was
the
closest
medical
facility
to
the
disaster
scene
and
normally
operates
beyond
nominal
surge
capacity.
Aside
from
the
high
acuity
burn
patients
sent
by
the
EOC,
56%
of
victims
self-
evacuated
and
arrived
at
the
hospital
for
treatment.
Further,
the
hospital
had
no
knowledge
of
how
many
acute
patients
would
arrive
due
to
unsuccessful
communication
with
the
EOC
or
the
difficulties
for
the
EOC
to
collect
detailed
patient
information
on
ambulance-transported
and
self-evacuated
burn
patients.
All
challenges
combined
created
a
highly
uncertain
and
immediately
chaotic
environment
[23,24].
The
staff
demonstrated
anticipatory
abilities
to
overcome
the
uncertainty.
Multi-level
individuals
including
the
VP
(high-
level
manager),
the
ED
directors
of
two
hospital
branches
(middle
-level
managers),
and
a
young
physician
showed
their
anticipatory
abilities
to
make
effective
decisions
throughout
the
event.
Effective
response
in
this
beyond-surge
capacity
incident,
especially
under
the
context
of
uncertainty,
de-
pended
on
anticipation
of
potential
bottlenecks
and
on
dynamically
reconfiguring
coordination
across
roles
and
units.
In
addition,
timely
anticipatory
action
requires
that
an
organization
looks
ahead
to
read
the
signs
that
its
adaptive
capacity
as
it
currently
is
configured
and
performs
is
becoming
inadequate
to
meet
the
demands
it
will
or
could
encounter
in
the
future
[25].
Failing
to
anticipate
forces
a
working
group
to
generate
the
means
to
respond
in
the
middle
of
a
challenging
event
—
greatly
increasing
the
risk
of
failure
to
keep
pace
and
tempo
with
dynamic
events.
This
implies
that
anticipatory
ability
is
an
imperative
core
ability
for
disaster
response.
It
not
only
comes
from
senior
staff
who
have
greater
familiarity
with
the
hospital’s
resources
and
conditions
but
also
relies
on
routine
practice
coping
with
unexpected
scenarios
and
reconfiguring
adaptive
capacity
to
fit
the
environment
of
changing
pressures
and
opportunities
[22,25].
The
study
shows
successful
responses
to
a
MBCI
rely
on
the
abilities
of
organizations,
units
and
individuals
to
adapt
in
a
timely
manner,
to
empower
initiative
and
support
pre-
planned
and
emergent
coordination,
as
well
as
to
anticip