ORIGINAL ARTICLEs
Advanced Burn Life Support for Day-to-Day Burn Injury Management and Disaster Preparedness: Stakeholder Experiences and Student Perceptions Following 56 Advanced Burn Life Support Courses Randy D. Kearns, DHA, MSA,*† Michael W. Hubble, PhD,‡ James. H. Holmes IV, MD, FACS,§║ Graydon C. Lord, MS, NREMTP,¶ Rear Admiral Clare Helminiak, MD, MPH,¶ Bruce A. Cairns, MD, FACS,# ** Educational programs for clinicians managing patients with burn injuries represent a critical aspect of burn disaster preparedness. Managing a disaster, which includes a surge of burninjured patients, remains one of the more challenging aspects of disaster medicine. During a 6-year period that included the development of a burn surge disaster program for one state, a critical gap was recognized as public presentations were conducted across the state. This gap revealed an acute and greater than anticipated need to include burn care education as an integral part of comprehensive burn surge disaster preparedness. Many hospital and prehospital providers expressed concern with managing even a single, burn-injured patient. While multiple programs were considered, Advanced Burn Life Support (ABLS), a national standardized educational program was selected to help address this need. The curriculum includes initial care for the burn-injured patient as well as an overview of the burn centers role in the disaster preparedness community. After 4 years and 56 classes conducted across the state, a survey was developed including a section that measured the perceptions of those who completed the ABLS educational program. The study specifically examines questions including whether clinicians perceived changes in their burn care knowledge, skills and abilities, and burn disaster preparedness following completion of the program? including whether clinicians (J Burn Care Res 2015;36:455–464)
Burn surge disaster planning activities for the state referenced in this paper evolved to include meeting a substantial burn care educational need as a component From the *Department of Healthcare Management, Tillman School of Business, University of Mount Olive; †University of North Carolina School of Medicine (retired); ‡Emergency Medical Care Program, Western Carolina University; §WFBMC Burn Center, Wake Forest University Baptist Health System; ║Department of Trauma Surgery, Wake Forest University School of Medicine; ¶Office of the Assistant Secretary for Preparedness and Response, United States Department of Health and Human Services; #North Carolina Jaycee Burn Center; and **Department of Surgery/Microbiology and Immunology, University of North Carolina School of Medicine. This work is supported in part by the US DHHS/ASPR Hospital Preparedness Program Grant CDC-RFA-TP12-1201 through the North Carolina Office of Emergency Medical Services Contract 00027162. We would also like to acknowledge the support of our educational programs through FEMA Grant EMW-2011-FP-01131. Address correspondence to Randy D. Kearns, DHA, MSA, CEM, School of Medicine, Department of Surgery/Department of Emergency Medicine, University of North Carolina, 101 Manning Drive CB 7600, Chapel Hill, NC 27599-7600. Copyright © 2014 by the American Burn Association 1559-047X/2015 DOI: 10.1097/BCR.0000000000000155
of burn surge preparedness.1 The education program selected to meet this need was Advanced Burn Life Support (ABLS).2 Thus, a critical link in disaster preparedness included burn care education for the hospital and emergency medical service (EMS) clinicians. The education profession points to the importance of measuring student perceptions as a marker to determine what may have been gained and the expertise developed by the student who attended an educational course.3–5 For this state, a consensus of the representatives for both the granting agency and the university concluded that a retrospective survey that included a student perceptions focus would provide vital insight regarding the effectiveness of this program. Several of the more often cited sources regarding the value of student educational perceptions target on-line course experiences, but reaffirm the importance of student perceptions as a critical marker in identifying successes and areas for improvement.6,7 Therefore, after completing 56 ABLS courses, a comprehensive survey was distributed to those 455
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who completed one of these programs. The purpose of this paper is to examine and report the perceptions of those who completed the survey regarding the program. The survey tool included the core elements of burn care and burn disaster preparedness.
Background The September 11, 2001 (9/11) attacks changed the course and intensity of medical disaster planning to include a focus on burn and trauma surge in the United States (US).8–17 What began as bioterrorism, evolved into an all-hazards approach for medical disaster preparedness.18–20 This included managing a surge of burn-injured patients as a critical component of overall medical disaster management preparedness.10,21–24 Training and education programs were critical factors for improved preparedness.25 In 2004, the Bioterrorism Hospital Preparedness Program (BTHPP) was overseen by the US Department of Health and Human Services (DHHS) Health Resources and Services Administration (HRSA).25 The US DHHS/HRSA/ BTHPP required all states to develop a burn surge plan as a component of their preparedness activities. However, several states reported finding it difficult to convey a coherent message of managing multiple burn-injured patients, when the general audience felt uncomfortable managing even the first burn-injured patient.1,26–31 (The BTHPP is now located in the U.S. DHHS Office of the Assistant Secretary for Preparedness and Response [ASPR] and referred to as the Hospital Preparedness Program [HPP].)32 The first year this program included offering a wide-reaching series of presentations regarding the aims for the burn surge disaster program and focused on historical burn disasters that wreaked havoc for first responders, first receivers, trauma, and burn centers alike. Following these presentations, initial feedback from class participants representing a variety of clinical care settings, made clear that managing the care of a burn-injured patient must be included in the overall solution. The solution was to offer educational programs that included the care of burn-injured patients in the context of overall disaster preparedness. Critical partners include EMS agencies as well as hospitals with and without burn centers.30,31,33,34 To meet the educational need, those involved with the burn surge disaster program evaluated national standardized educational programs. Key criteria for
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selection included; current science validated by a national stakeholder organization for the care of a burn-injured patient,35 a core component involving the management of a surge of burn-injured patients, and was approved to offer the relevant educational credits recognized by the various professional organizations to include physicians, nurses, and paramedical personnel.
Educational Programs Used to Supplement Disaster Preparedness Over the past 10 years, multiple educational programs emerged—each containing some aspect of disaster management. While most offered a more generalized approach to disaster management, one specific curriculum met the objectives, which included burn care as well as a module regarding burn disaster management.3,35,36 The American Burn Association (ABA) program, known as ABLS, was selected. Selecting ABLS was based on an analysis of the course content by subject-matter experts involved. Unfortunately at that point, the various programs evaluated, had a scarce representation in the academic literature. They ranged from an experience of using ABLS in Japan37 to the role of using ABLS for nursing staff in U.S. burn centers.35 A similar program (to ABLS) commonly taught in Europe, Australia, New Zealand, and southeast Asia—Emergency Management of Severe Burns (EMSB)38 exists, and the curricula are similar with similar objectives to include preparation for major burn events.38,39 They also had similar experiences reporting educational programs (such as EMSB) improved competence and comfort with the individual responder involved in the management of a mass casualty burn disaster.39 Aside from the aforementioned benefits seen with ABLS, other advantages were identified, including the portability of the program.37 This was essential since access demanded program delivery where the first responders and first receivers live and work. Other advantages include the use of a validated program as a means of creating consistent care of the burn-injured patient as well as the ability to enhance burn surge disaster preparedness by using ABLS courses to discuss burn care of the individual patient in the context of disaster preparedness.40
Educational Program Costs Despite the advantages noted, several concerns were also identified. The first was cost. The national
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certification fee for each non-physician clinician (eg, physician assistants, nurses, respiratory therapists, and EMS personnel) was $200. The cost for a physician was $325. (These have since increased to $225 and $350, respectively.) ABLS, in terms of costs, compares unfavorably to other national programs that focus specifically on a topic such as Advanced Cardiac Life Support (ACLS), International Basic Life Support (ITLS), and Trauma Nurse Core Curriculum (TNCC). Their average cost was $50 to $150 per person. While the costs varied, one key aspect for those programs included how local hospitals and EMS agencies could develop their own cadre of instructors and therefore conduct their own programs based on the national standards. This allows them to create their own program fees based on their costs. The options with ABLS are limited given the instructor requirements. These requirements include the fact that all instructors must currently work in a burn center providing care for a burn-injured patient. This limitation leads to a very small potential pool of candidates for selecting instructors. It was also learned that most clinicians had little to no historical exposure to ABLS. According to the ABA, 245 NC clinicians completed ABLS between 2000 and 2007—with the primary audience being clinicians who work in, or in support of, area burn centers. Given the fact that for this particular state, there were 60,000+ nurses who work in critical care or emergency medicine and 35,000+ EMS personnel. Thus, the participation level was vastly underwhelming. Nevertheless, ABLS offered stakeholders an educational program that did answer many of the needs identified. Work began to expand the cadre of ABLS instructors. To address the ABLS costs barrier, grant funding was secured to defray a portion of the costs through a grant from the HPP.25 (The HPP was managed locally by the state EMS agency.) With the educational program chosen, the audience identified and the funding secured, the first course was offered April, 2008. By December, 2011, a total of 56 ABLS classes had been delivered statewide. Locations ranged from urban to rural communities, with classes being held in local EMS stations, fire departments, hospitals, and community colleges. The attendees included physicians, nurses, paramedics, emergency medical technicians, pharmacists, nurse practitioners and physician assistants, respiratory therapists, and other clinicians involved in the care of the burn-injured patient. Most of this group would be involved locally in the initial management of a surge of burn-injured patients or were listed in the state version for the Emergency System for
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Advance Registration of Volunteer Health Professionals (ESAR-VHP)41 and could be deployed to a community where a medical disaster occurred.
METHODS During the final 18 months of offering ABLS, a multifaceted retrospective survey was developed. The survey tool was developed with input from instructors and program coordinators, which included a focus group activity during ABLS instructor training. The working draft was submitted to the NCOEMS32 for review and input. Based on the input from instructors, coordinators, and state medical disaster officials, a final version was adopted. The final version of the survey as well as a description of the study was submitted to the university Institutional Review Board (IRB) for approval. The study Burn Care Education Assessment, Study No.: 11–1614 was granted a determination that the research did not require IRB approval. The “Burn Education Survey” was converted from a draft paper format to an online system relying on a commercially available online survey and analysis tool.42 The final version of the survey included several sections totaling 31 total questions. A link to the survey as well as a description of the survey and its importance was distributed by email notification. For the purpose of this paper, those who received the email notification soliciting their participation included everyone who completed ABLS and had provided a valid email address at the time of participating in ABLS. The survey targeted the 1014 individuals who completed the ABLS course during the 56 classes offered over the aforementioned four-year period and had provided a working email address during the time of attending ABLS or at the time they registered in ESAR-VHP and could be matched to the ABLS rosters. There were five requests over a fivemonth period urging participation from the targeted survey population. It should be noted that there were 1382 students who completed ABLS during the 56 courses. However, during the first 18 to 24 months of the program, an email address was not a required field for the paper/telephone registration process used at that time. Thus, an email address was not captured, or was illegible from approximately 500 ABLS participants. However, a portion of this group was matched with names in ESAR-VHP. Therefore, of the 1382 who attended, 1014 email addresses could be identified that at some point worked either when they registered or attended ABLS or when they registered in ESAR-VHP. (It should be noted that after
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converting to a web based online registration system for ABLS, RegOnline,43 a working email address was required to complete the registration.) A descriptive analysis was recorded based on the Observed results. A second set of data; the Expected results were developed based on a 50/50 assumption. The χ2 test for independence was used to measure the significant relationship between the two categorical variables (Observed versus Expected). Mathematically stated, where the Observed, frequency count and the Expected frequency count are represented by O and E, and r is the number of levels for one categorical variable and c is the number of levels for the other categorical value, the calculation used was:
χ2 =
∑ [(0r , c − Er , c)
2
Er , c]
RESULTS There were 1014 physicians, nurses, EMS personnel, and others involved in the immediate care of a burn-injured patient, who successfully completed ABLS during this four-year period and provided a working email address at the time of completing the educational program (or was matched and validated through ESAR-VHP). From this population of 1014, 52 (4.9%) were returned as “undeliverable” during the first survey attempt indicating the email address was no longer valid and 20/1014 (2.0%) were delivered, but the recipient of the email selected the option to opted out of the survey, leaving 942 potential respondents for survey participation. There were 526 total respondents who completed at least the Demographics Section and the Perceptions Section of the survey. Thus, the focus of this work was directed at the results from the 526 who responded to the survey, 526/942 (55.84%). The decision making process regarding those surveyed and the analysis is graphically represented in Figure 1.
Certification/License/Credential, Work Environment, and Participant Experience The Demographics Section of the survey for the 526 respondents represents clinical roles as graphically displayed in Figure 2. Respondents were almost equally divided when identifying their workplace as graphically displayed in Figure 3. The seven questions found in the Perceptions Section of the survey, as well as potential answers for the respondents are found in Appendix. Fifty-two percent (52%) of the respondents reported holding their current clinical credential for more than 10 years (Figure 4, Column 2). Seventy
percent (70%) reported they had more than 10 years of experience in clinical care (Figure 4, Column 1).
Perceptions Section 1. The respondents reported (Observed Values) the ABLS program contributed to improved greater understanding of estimating (TBSA). The Observed Values were statistically significant (P < .001) as noted in Figure 5, Question 1. 2. The respondents reported (Observed Values) that the ABLS program had contributed to an improved understanding of IV fluid infusion rates for an adult burn patient to flow rates that are similar to, or consistent with, the Consensus/Modified Formula. The Observed Values were statistically significant (P < .001) as noted in Figure 5, Question 2. 3. The respondents reported (Observed Values) that the ABLS program had contributed to either the respondent having changed or influenced others to change the type of IV fluid to Lactated Ringer as soon as it is available. The Observed Values were statistically significant (P < .001) as noted in Figure 5, Question 3. 4. The respondents reported (Observed Values) that the ABLS program had contributed to an improved awareness for the respondent to more closely monitor or influence others to more closely monitor (and to treat) the pain management needs of a burn patient. The Observed Values were statistically significant (P < .001) as noted in Figure 5, Question 4. 5. The respondents reported (Observed Values) that the ABLS program had contributed to an improved understanding of the value of using, where available, verified burn centers for burninjured patients. The Observed Values were statistically significant (P < .001) as noted in Figure 5, Question 5. 5. The respondents reported (Observed Values) that the ABLS program had contributed to an improved understanding of the value of using, where available, verified burn centers for burninjured patients. The Observed Values were statistically significant (P < .001) as noted in Figure 5, Question 5. 7. The respondents reported (Observed Values) that the ABLS program had contributed to an improved awareness of the role burn centers, as well as other specialty centers, play in a medical disaster. The Observed Values were statistically significant (P < .001) as noted in Figure 5, Question 7.
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Figure 1. The graphical representation of the decision-making process for how survey participants were surveyed and their responses analyzed.
DISCUSSION Evaluation and selection of the ABLS program relied on the stakeholders who chose the course that best met the objectives for the educational program to be selected.4,5,36 Relying on Posner et al offered a structured approach to evaluate the various curricula for each of the programs and their measurable objectives to be covered by the specific program. Furthermore, there is a direct link between the perceptions of the student and their aim to develop expertise and expert performance.3,6,7 It seems both intuitive and logical that the link between the perceptions of someone completing a class, and their development of expertise exists. What is known from the literature however, is the bottleneck is similar to that found in other disciplines where the “training bottleneck” is getting knowledge to the novices, in this case many of those who reported a
discomfort and uneasiness with managing the care of burn-injured patients44 with outcomes first being measured through perceptions of the students who completed the educational program, in this case, ABLS.3 There are limitations when the focus is merely the perceptions of those who completed an educational program. Nevertheless, the first hurdle when demonstrating the value of an education program that had almost no use outside of the burn care community and developing expertise is to measure the perceptions of those who completed the program. The basic tenants of a burn care educational program include airway management, TBSA assessment, fluid resuscitation, and pain management. Additionally, it was important to the stakeholders that key components of how the burn centers, and other specialty centers connect with the first responders and first receivers, to assure the flow of injured patients are
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Figure 2. Graphical representation of participant distribution. There were more registered nurses (46%) than any other group who completed ABLS. There were (39%) of the participants who reported being paramedics, with (4%) being physicians. The balance (11%) included all others such as pharmacists, midlevel practitioners, respiratory therapists, emergency medical technicians, firefighters, and physical therapists.
managed appropriately and distributed accordingly in a disaster. Future research is needed to assess the effectiveness of ABLS and other similar training programs that contribute to medical disaster preparedness. For example, table-top exercises with ABLS trained clinicians will allow participants to test their skills in
Figure 3. Graphical representation of the work environments for ABLS course participants. Respondents were almost equally divided when identifying their workplace: Emergency Medical Service personnel (EMS) or first response (248/526, 49.3%) and those clinicians who worked in a hospital (243/526, 48.3%).
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Figure 4. Experience of survey participants.
a simulated environment while evaluating the effectiveness of ABLS in preparing people for disaster situations. Although the data were collected in a manner that identified each year that the participants reported completing ABLS, the trends remained proportionally constant within each question across the years. The focus of the analysis will remain the seven perception questions. Nevertheless, the results clearly demonstrate that two thirds of participants perceived a benefit from the training that they received during ABLS. The benefit of ABLS may be even greater in other sub-populations of providers, such as those first responders and first receivers who manage a majority of the patients long before they arrive at a Burn Center. Nevertheless, further investigation is warranted to explore the impact of such a course on selected populations and the retention of this vital information. Two of the questions focused on intravenous fluids. The typical student attended their most recent presentation regarding burn injury in the format of a 45–60 minute lecture that was part of a trauma course. During the day long trauma program the lasting impression may lead to excessive intravenous fluid infusion in the hours between the initial burn injury and the time the patient arrives at a burn center. Thus, two key ABLS objectives include fluid infusion rates, which followed the formula used at the time these classes were offered. The second question related to intravenous fluids focused on the type of fluid selected for the
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Figure 5. Compares actual scores registered by the solid bars for the perceptions reported by ABLS participants to the null hypothesis represented by the solid line.
burn-injured patient. Lactated Ringers is the preferred intravenous fluid for burn-injured patients. However, that fluid is not uniformly available to all EMS agencies, most of whom will start a saline solution until Lactated Ringers is available. Thus, one aim of the program included the emphasis of either selecting the correct fluid or changing it to the correct fluid as soon as it became available. In both cases for these two questions, the respondents reported (Observed Values) that the ABLS program had contributed to an improved understanding of IV fluid infusion rates for as well as selecting the correct fluid type for the burn-injured patient. The Observed Values for both questions were statistically significant (P < .001). Two additional survey questions focused on patient care issues that have unique characteristics with the burn-injured patient. They include pain and airway management. Clinicians are typically unaccustomed to caring for the pain management needs of a burn-injured patient given amount of medication that may be needed over the duration of the first 6 to 24 hours following the injury. The quantity used and the ongoing monitoring for both therapeutic effects as well as endpoints for use can be substantially different from most pain management scenarios. With airway management, complications of steam inhalation injury, smoke inhalation, or being burned in a confined space can each lead to critical airway management issues in the hours following the burn injury. Key indicators are taught in ABLS and while Blind Insertion Airway Devices (BAIDs) are more commonly used today in the prehospital environment, this remains a situation where the
advanced airway selection should stay with the endotracheal tube. The two remaining questions from the perceptions section of the survey dealt with the importance of burn and other specialty centers in the planning and preparedness for medical disasters. This includes reliance on verified Burn Centers when available for burn-injured patients. Burn Centers, Trauma Centers, and other specialty centers can play a critical role in medical disaster preparedness and planning. Identifying where these centers are and involving them in planning, exercise, and operation activities before disaster strikes, is a proactive way to improve the overall management and outcomes of the single or dozens of burn-injured patients. There are challenges associated with selecting a proprietary educational program that can serve as a barrier for prospective participants who lack ongoing fiscal support. These challenges include the participant fees that must be paid to the governing body for the proprietary program, governance of how, when and where courses are conducted, and national standards for instructors that may limit local personnel participating in the instruction. Other challenges include ongoing maintenance of the credential. Given the recertification costs are the same as the initial costs and there are no current curriculum in place for recertification (other than repeating the initial course) maintaining the certification has limitations. Before the program began, clinicians reported they were far more likely to accept their role in managing multiple burn-injured patients once they felt comfortable with managing one burn-injured patient.
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It should be noted that this research confirms that a significant majority of the participants, based on their reported perceptions, are better equipped to manage a burn-injured patient after completing the course than they were before attending the program. Burn Centers play a vital role in the management of a medical disaster. Another aim of the program included a discussion regarding the role of the Burn Center in the myriad of special care situations that may confront responders to a medical disaster. Knowing who to call, their role and having a better understanding of the differences between those Burn Centers who self-identify and those who are verified by an outside agency such as the ABA is also important.
CONCLUSIONS The survey results offer a small yet important first step in understanding if ABLS has a value outside of the mainstream burn care profession to include the first responder, first receiver and medical disaster clinicians. Furthermore, does that value extend into managing a surge of patients with burn injuries such as in a burn disaster? These initial findings support the belief that there is role for ABLS to prepare first responders and first receivers in the care of one or many patients with a burn injury. The academic world of adult education suggests that goals for an educational program and developing expertise include the perceptions of the course participants. Course participants are more likely to retain the information and less like to abandon the core concepts when challenged by potentially conflicting information when the participant perceives/ believes their learning activity was validated through later experiences. In this case, participants were questioned regarding their perceptions as it related to the core objectives for ABLS. They included: patient assessment (to include size of the burn), fluid resuscitation (rate and fluid selection), pain management, airway control, and the role of the burn center in a disaster to include where available, the use of a verified burn center. Aside from the patient care lectures, the ABLS disaster lecture also served as a conduit to link the care of one to the management of multiple patients with burn injuries and the importance of involving the burn center in medical disaster planning. This lecture also offered that final chance to connect the day to day management of a burn-injured patient with the rare and episodic nature of a burn disaster. As such, it is reasonable to conclude with statistically significant data, that ABLS as a component of a broad disaster planning initiative, was perceived
to be useful in managing one or many burn-injured patients. These findings are preliminary and the results only examine basic topics. Nevertheless, this promising work represents the most complete examination thus far of a large scale use for ABLS in this setting and suggests a more comprehensive evaluation should be conducted.
ACKNOWLEDGMENTS Conducting 56 ABLS classes required many clinicianinstructors willing to travel and teach these programs. The success of these classes reflects the time and dedication of national faculty: Ernest Grant, RN MSN, from UNC Hospitals; Katie Hollowed from MedStar and the Washington Hospital System in Washington, DC; and David Thompson, RN, and retired firefighter from Erlanger Medical Center in Chattanooga, TN. All of the burn surgeons in North Carolina have participated in the success of this program to include: Dr. Bruce Cairns, Dr. Samuel Jones, and Dr. James Hwang at UNC Hospitals; and Dr. James Holmes IV and Dr. Joseph Molnar at Wake Forest Baptist Health. Furthermore, contributions were made by physician assistants and nurse practitioners as well as other nursing staff. Those who taught more than 10 classes include: Derek Miller RN and Renee Edkins RN, FNP as well as co-authors; Dr. Shiara M. Ortiz-Pujols, Mr. Christopher K. Craig, PA-C, Dr. Jeffery Carter, and Dr. Amy Rezak Alger. It should also be noted that dozens of the courses were managed by Mr. James R. Gusler. REFERENCES 1. Kearns RD, Cairns BA, Holmes JH 4th, Sagraves SG. The North Carolina burn surge disaster plan for emergency medical services and hospitals. Chapel Hill: University of North Carolina; 2012. p. 85. 2. American Burn Association Advisory Committee. American Burn Association provider manual. Chicago: American Burn Association; 2011. 3. Ericsson KA. The Cambridge handbook of expertise and expert performance. Cambridge; New York: Cambridge University Press; 2006. 4. Nijhuis JFH, Segers MSR, Gijselaers WH. Influence of redesigning a learning environment on student perceptions and learning strategies. Learn Environ Res 2005;8:67–93. 5. Karns GL. An update of marketing student perceptions of learning activities: structure, preferences, and effectiveness. J Market Educ 2005;27:163–71. 6. Song L, Singleton ES, Hill JR, Koh MH. Improving online learning: student perceptions of useful and challenging characteristics. Internet Higher Educ 2004;7:59–70. 7. Rovai AP, Barnum KT. On-line course effectiveness: an analysis of student interactions and perceptions of learning. J Distant Educ 2003;18:57–73. 8. McFee RB, Leikin JB, Kiernan K. Preparing for an era of weapons of mass destruction (WMD)—are we there yet? Why we should all be concerned. Part II. Vet Hum Toxicol 2004;46:347–51. 9. Murphy JK. After 9/11: priority focus areas for bioterrorism preparedness in hospitals. J Healthc Manag 2004;49:227–35. 10. Cairns BA, Stiffler A, Price F, Peck MD, Meyer AA. Managing a combined burn trauma disaster in the post-9/11 world:
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lessons learned from the 2003 West Pharmaceutical plant explosion. J Burn Care Rehabil 2005;26:144–50. 11. Feeney JM, Goldberg R, Blumenthal JA, Wallack MK. September 11, 2001, revisited: a review of the data. Arch Surg 2005;140:1068–73. 12. Jordan MH, Hollowed KA, Turner DG, Wang DS, Jeng JC. The Pentagon attack of September 11, 2001: a burn center’s experience. J Burn Care Rehabil 2005;26:109–16. 13. Niska RW, Burt CW. Bioterrorism and mass casualty preparedness in hospitals: United States, 2003. Adv Data 2005;391:1–14. 14. Yurt RW, Bessey PQ, Bauer GJ, et al. A regional burn center’s response to a disaster: September 11, 2001, and the days beyond. J Burn Care Rehabil 2005;26:117–24. 15. Barillo DJ, Wolf S. Planning for burn disasters: lessons learned from one hundred years of history. J Burn Care Res 2006;27:622–34. 16. Jeng JC, Hollowed K, Owen CT, et al. Contemplating the Pentagon attack after five years of space and time: unheard voices from the ramparts of our burn center. J Burn Care Res 2006;27:612–21. 17. Yurt RW, Bessey PQ, Alden NE, et al. Burn-injured patients in a disaster: September 11th revisited. J Burn Care Res 2006;27:635–41. 18. Pandemic and All Hazards Preparedness Act (PAHPA) Public Law 109-417 (2006). 19. Coleman CN, Lurie N. Emergency medical preparedness for radiological/nuclear incidents in the United States. J Radiol Prot 2012;32:N27–32. 20. Limehouse W, Foster R. Creating a standardized system for allocation of scarce clinical resources in response to an all hazards mass casualty disaster. J S C Med Assoc 2011;107:70-3. 21. Hick JL, Barbera JA, Kelen GD. Refining surge capacity: conventional, contingency, and crisis capacity. Disaster Med Public Health Prep 2009;3(2 Suppl.):S59–67. 22. Hick JL, DeVries AS, Fink-Kocken P, Braun JE, Marchetti J. Allocating resources during a crisis: you can’t always get what you want. Minn Med 2012;95:46–50. 23. Hick JL, Hanfling D, Cantrill SV. Allocating scarce resources in disasters: emergency department principles. Ann Emerg Med 2012;59:177–87. 24. Hick JL, Weinstock DM, Coleman CN, et al. Health care system planning for and response to a nuclear detonation. Disaster Med Public Health Prep 2011;5 Suppl. 1:S73–88. 25. Healthcare Preparedness Capabilities, National Guidance for Healthcare System Preparedness; 2012: 73. Available from http://www.phe.gov/Preparedness/planning/hpp/ reports/Documents/capabilities.pdf; accessed 9 Dec. 2012. 26. Vandenberg V, Amara R, Crabtree J, Fruhwirth K, Rifenburg J, Garner W. Burn surge for Los Angeles County, California. J Trauma 2009;67(2 Suppl.):S143–6. 27. Leahy NE, Yurt RW, Lazar EJ, et al. Burn disaster response planning in New York City: updated recommendations for best practices. J Burn Care Res 2012;33:587–94. 28. Yurt RW, Lazar EJ, Leahy NE, et al. Burn disaster response planning: an urban region’s approach. J Burn Care Res 2008;29:158–65.
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29. Ruhren C, Conlon KM, Johansen S, et al. Developing and implementing a plan for large-scale burn disaster response in New Jersey. J Burn Care Res 2013;35:e14-20. 30. Wetta-Hall R, Berg-Copas GM, Cusick Jost J, Jost G. Preparing for burn disasters: predictors of improved perceptions of competency after mass burn care training. Prehos Disaster Med 2007;22:448–53. 31. Wetta-Hall R, Jost JC, Jost G, Praheswari Y, Berg Copas GM. Preparing for burn disasters: evaluation of a continuing education training course for pre-hospital and hospital professionals in Kansas. J Burn Care Res 2007;28:97–104. 32. North Carolina Office of Emergency Medical Services; 2013. Website for the North Carolina Office of EMS. Available from http://www.ncems.org/; accessed 6 Feb. 2013. 33. Barillo DJ. Burn centers and disaster response. J Burn Care Res 2006;27:558–9. 34. Kearns RD, Holmes JH 4th, Alson RL, Cairns BA. 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. J Burn Care Res 2013;35:e33-42. 35. Wolak E, Klish K, Smith E, Cairns BA. Educational opportunities for experienced staff: do they make a difference? J Nurses Staff Dev 2006;22:181–6. 36. Posner GJ. Analyzing the curriculum. 2nd ed. New York: McGraw-Hill; 1995. 37. Sasaki J, Takuma K, Oda J, et al. Experiences in organizing Advanced Burn Life Support (ABLS) provider courses in Japan. Burns 2010;36:65–9. 38. Stone CA, Pape SA. Evolution of the Emergency Management of Severe Burns (EMSB) course in the UK. Burns 1999;25:262–4. 39. Breederveld RS, Nieuwenhuis MK, Tuinebreijer WE, Aardenburg B. Effect of training in the Emergency Management of Severe Burns on the knowledge and performance of emergency care workers as measured by an online simulated burn incident. Burns 2011;37:281–7. 40. Wachtel TL, Cowan ML, Reardon JD. Developing a regional and national burn disaster response. J Burn Care Rehabil 1989;10:561–7. 41. Emergency System for Advance Registration of Volunteer Health Professionals; 2012. Available from http://www. phe.gov/esarvhp/Pages/default.aspx; accessed 29 Jun. 2012. 42. Kearns R. Burn Education Survey; 2012. Web based Available from http://www.surveymonkey.com/s/ NCBurnCareEducationDisasterSurvey; accessed 6 Feb. 2013. 43. Regonline. Active/RegOnline; 2013. Online registration system. Available from http://www.regonline.com/; accessed 6 Feb. 2013. 44. Klein GA, Hoffman RR. Seeing the invisible: perceptual-cognitive aspects of expertise. In Cognitive Science Foundations of Instruction. 1993. p. 203–6.
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APPENDIX The Perceptions Section of the survey included seven questions. Each question offered the answer selections of “Yes,” “No,” and “Other” with other including options of “Not Applicable” or “I have not completed ABLS.” While the focus of this work was to measure the binary options of Yes/No, (“Other”) was offered to provide the respondent an opportunity to offer an alternative answer. If “Other” was selected, the survey tool forced the respondent to a narrative box and required text insertion to offer an expanded explanation for the answer selection. The seven questions from the survey tool regarding perception are: 1. In your professional opinion, are you are better prepared to estimate the size (TBSA) of the burn injury following the training/education you received in ABLS? Results are identified in Figure 5, Question 1. 2. Following the training/education you received in ABLS, have you either changed or influenced others to change IV fluid infusion for an adult burn patient to flow rates that are similar to, or consistent with, the Consensus/Modified Formula? Results are identified in Figure 5, Question 2.
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3. Following the training/education you received in ABLS, have you either changed or influenced others to change the type of IV fluid infusion for an adult burn patient to Lactated Ringers Solution as soon as it was available? Results are identified in Figure 5, Question 3. 4. Following the training/education you received in ABLS, have you either changed or influenced others to monitor more closely (and to treat) the pain control needs of a burn patient? Results are identified in Figure 5, Question 4. 5. Following the training/education you received in ABLS, have you either changed or influenced others to be certain burn patients are managed at a verified burn center? Results are identified in Figure 5, Question 5. 6. Following the training/education you received in ABLS, have you either changed or influenced others to monitor more closely burn patients for inhalation injuries and to manage more aggressively airway control where indicated? Results are identified in Figure 5, Question 6. 7. Following the training/education you received in ABLS, do you have a better understanding of the role that burn centers, as well as other specialty centers, play in a medical disaster? Results are identified in Figure 5, Question 7.
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Advanced Burn Life Support for Day-to-Day Burn Injury Management and Disaster Preparedness: Stakeholder Experiences and Student Perceptions Following 56 Advanced Burn Life Support Courses Randy D. Kearns, DHA, MSA,*† Michael W. Hubble, PhD,‡ James. H. Holmes IV, MD, FACS,§║ Graydon C. Lord, MS, NREMTP,¶ Rear Admiral Clare Helminiak, MD, MPH,¶ Bruce A. Cairns, MD, FACS,# ** Educational programs for clinicians managing patients with burn injuries represent a critical aspect of burn disaster preparedness. Managing a disaster, which includes a surge of burninjured patients, remains one of the more challenging aspects of disaster medicine. During a 6-year period that included the development of a burn surge disaster program for one state, a critical gap was recognized as public presentations were conducted across the state. This gap revealed an acute and greater than anticipated need to include burn care education as an integral part of comprehensive burn surge disaster preparedness. Many hospital and prehospital providers expressed concern with managing even a single, burn-injured patient. While multiple programs were considered, Advanced Burn Life Support (ABLS), a national standardized educational program was selected to help address this need. The curriculum includes initial care for the burn-injured patient as well as an overview of the burn centers role in the disaster preparedness community. After 4 years and 56 classes conducted across the state, a survey was developed including a section that measured the perceptions of those who completed the ABLS educational program. The study specifically examines questions including whether clinicians perceived changes in their burn care knowledge, skills and abilities, and burn disaster preparedness following completion of the program? including whether clinicians (J Burn Care Res 2015;36:455–464)
Burn surge disaster planning activities for the state referenced in this paper evolved to include meeting a substantial burn care educational need as a component From the *Department of Healthcare Management, Tillman School of Business, University of Mount Olive; †University of North Carolina School of Medicine (retired); ‡Emergency Medical Care Program, Western Carolina University; §WFBMC Burn Center, Wake Forest University Baptist Health System; ║Department of Trauma Surgery, Wake Forest University School of Medicine; ¶Office of the Assistant Secretary for Preparedness and Response, United States Department of Health and Human Services; #North Carolina Jaycee Burn Center; and **Department of Surgery/Microbiology and Immunology, University of North Carolina School of Medicine. This work is supported in part by the US DHHS/ASPR Hospital Preparedness Program Grant CDC-RFA-TP12-1201 through the North Carolina Office of Emergency Medical Services Contract 00027162. We would also like to acknowledge the support of our educational programs through FEMA Grant EMW-2011-FP-01131. Address correspondence to Randy D. Kearns, DHA, MSA, CEM, School of Medicine, Department of Surgery/Department of Emergency Medicine, University of North Carolina, 101 Manning Drive CB 7600, Chapel Hill, NC 27599-7600. Copyright © 2014 by the American Burn Association 1559-047X/2015 DOI: 10.1097/BCR.0000000000000155
of burn surge preparedness.1 The education program selected to meet this need was Advanced Burn Life Support (ABLS).2 Thus, a critical link in disaster preparedness included burn care education for the hospital and emergency medical service (EMS) clinicians. The education profession points to the importance of measuring student perceptions as a marker to determine what may have been gained and the expertise developed by the student who attended an educational course.3–5 For this state, a consensus of the representatives for both the granting agency and the university concluded that a retrospective survey that included a student perceptions focus would provide vital insight regarding the effectiveness of this program. Several of the more often cited sources regarding the value of student educational perceptions target on-line course experiences, but reaffirm the importance of student perceptions as a critical marker in identifying successes and areas for improvement.6,7 Therefore, after completing 56 ABLS courses, a comprehensive survey was distributed to those 455
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who completed one of these programs. The purpose of this paper is to examine and report the perceptions of those who completed the survey regarding the program. The survey tool included the core elements of burn care and burn disaster preparedness.
Background The September 11, 2001 (9/11) attacks changed the course and intensity of medical disaster planning to include a focus on burn and trauma surge in the United States (US).8–17 What began as bioterrorism, evolved into an all-hazards approach for medical disaster preparedness.18–20 This included managing a surge of burn-injured patients as a critical component of overall medical disaster management preparedness.10,21–24 Training and education programs were critical factors for improved preparedness.25 In 2004, the Bioterrorism Hospital Preparedness Program (BTHPP) was overseen by the US Department of Health and Human Services (DHHS) Health Resources and Services Administration (HRSA).25 The US DHHS/HRSA/ BTHPP required all states to develop a burn surge plan as a component of their preparedness activities. However, several states reported finding it difficult to convey a coherent message of managing multiple burn-injured patients, when the general audience felt uncomfortable managing even the first burn-injured patient.1,26–31 (The BTHPP is now located in the U.S. DHHS Office of the Assistant Secretary for Preparedness and Response [ASPR] and referred to as the Hospital Preparedness Program [HPP].)32 The first year this program included offering a wide-reaching series of presentations regarding the aims for the burn surge disaster program and focused on historical burn disasters that wreaked havoc for first responders, first receivers, trauma, and burn centers alike. Following these presentations, initial feedback from class participants representing a variety of clinical care settings, made clear that managing the care of a burn-injured patient must be included in the overall solution. The solution was to offer educational programs that included the care of burn-injured patients in the context of overall disaster preparedness. Critical partners include EMS agencies as well as hospitals with and without burn centers.30,31,33,34 To meet the educational need, those involved with the burn surge disaster program evaluated national standardized educational programs. Key criteria for
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selection included; current science validated by a national stakeholder organization for the care of a burn-injured patient,35 a core component involving the management of a surge of burn-injured patients, and was approved to offer the relevant educational credits recognized by the various professional organizations to include physicians, nurses, and paramedical personnel.
Educational Programs Used to Supplement Disaster Preparedness Over the past 10 years, multiple educational programs emerged—each containing some aspect of disaster management. While most offered a more generalized approach to disaster management, one specific curriculum met the objectives, which included burn care as well as a module regarding burn disaster management.3,35,36 The American Burn Association (ABA) program, known as ABLS, was selected. Selecting ABLS was based on an analysis of the course content by subject-matter experts involved. Unfortunately at that point, the various programs evaluated, had a scarce representation in the academic literature. They ranged from an experience of using ABLS in Japan37 to the role of using ABLS for nursing staff in U.S. burn centers.35 A similar program (to ABLS) commonly taught in Europe, Australia, New Zealand, and southeast Asia—Emergency Management of Severe Burns (EMSB)38 exists, and the curricula are similar with similar objectives to include preparation for major burn events.38,39 They also had similar experiences reporting educational programs (such as EMSB) improved competence and comfort with the individual responder involved in the management of a mass casualty burn disaster.39 Aside from the aforementioned benefits seen with ABLS, other advantages were identified, including the portability of the program.37 This was essential since access demanded program delivery where the first responders and first receivers live and work. Other advantages include the use of a validated program as a means of creating consistent care of the burn-injured patient as well as the ability to enhance burn surge disaster preparedness by using ABLS courses to discuss burn care of the individual patient in the context of disaster preparedness.40
Educational Program Costs Despite the advantages noted, several concerns were also identified. The first was cost. The national
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certification fee for each non-physician clinician (eg, physician assistants, nurses, respiratory therapists, and EMS personnel) was $200. The cost for a physician was $325. (These have since increased to $225 and $350, respectively.) ABLS, in terms of costs, compares unfavorably to other national programs that focus specifically on a topic such as Advanced Cardiac Life Support (ACLS), International Basic Life Support (ITLS), and Trauma Nurse Core Curriculum (TNCC). Their average cost was $50 to $150 per person. While the costs varied, one key aspect for those programs included how local hospitals and EMS agencies could develop their own cadre of instructors and therefore conduct their own programs based on the national standards. This allows them to create their own program fees based on their costs. The options with ABLS are limited given the instructor requirements. These requirements include the fact that all instructors must currently work in a burn center providing care for a burn-injured patient. This limitation leads to a very small potential pool of candidates for selecting instructors. It was also learned that most clinicians had little to no historical exposure to ABLS. According to the ABA, 245 NC clinicians completed ABLS between 2000 and 2007—with the primary audience being clinicians who work in, or in support of, area burn centers. Given the fact that for this particular state, there were 60,000+ nurses who work in critical care or emergency medicine and 35,000+ EMS personnel. Thus, the participation level was vastly underwhelming. Nevertheless, ABLS offered stakeholders an educational program that did answer many of the needs identified. Work began to expand the cadre of ABLS instructors. To address the ABLS costs barrier, grant funding was secured to defray a portion of the costs through a grant from the HPP.25 (The HPP was managed locally by the state EMS agency.) With the educational program chosen, the audience identified and the funding secured, the first course was offered April, 2008. By December, 2011, a total of 56 ABLS classes had been delivered statewide. Locations ranged from urban to rural communities, with classes being held in local EMS stations, fire departments, hospitals, and community colleges. The attendees included physicians, nurses, paramedics, emergency medical technicians, pharmacists, nurse practitioners and physician assistants, respiratory therapists, and other clinicians involved in the care of the burn-injured patient. Most of this group would be involved locally in the initial management of a surge of burn-injured patients or were listed in the state version for the Emergency System for
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Advance Registration of Volunteer Health Professionals (ESAR-VHP)41 and could be deployed to a community where a medical disaster occurred.
METHODS During the final 18 months of offering ABLS, a multifaceted retrospective survey was developed. The survey tool was developed with input from instructors and program coordinators, which included a focus group activity during ABLS instructor training. The working draft was submitted to the NCOEMS32 for review and input. Based on the input from instructors, coordinators, and state medical disaster officials, a final version was adopted. The final version of the survey as well as a description of the study was submitted to the university Institutional Review Board (IRB) for approval. The study Burn Care Education Assessment, Study No.: 11–1614 was granted a determination that the research did not require IRB approval. The “Burn Education Survey” was converted from a draft paper format to an online system relying on a commercially available online survey and analysis tool.42 The final version of the survey included several sections totaling 31 total questions. A link to the survey as well as a description of the survey and its importance was distributed by email notification. For the purpose of this paper, those who received the email notification soliciting their participation included everyone who completed ABLS and had provided a valid email address at the time of participating in ABLS. The survey targeted the 1014 individuals who completed the ABLS course during the 56 classes offered over the aforementioned four-year period and had provided a working email address during the time of attending ABLS or at the time they registered in ESAR-VHP and could be matched to the ABLS rosters. There were five requests over a fivemonth period urging participation from the targeted survey population. It should be noted that there were 1382 students who completed ABLS during the 56 courses. However, during the first 18 to 24 months of the program, an email address was not a required field for the paper/telephone registration process used at that time. Thus, an email address was not captured, or was illegible from approximately 500 ABLS participants. However, a portion of this group was matched with names in ESAR-VHP. Therefore, of the 1382 who attended, 1014 email addresses could be identified that at some point worked either when they registered or attended ABLS or when they registered in ESAR-VHP. (It should be noted that after
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converting to a web based online registration system for ABLS, RegOnline,43 a working email address was required to complete the registration.) A descriptive analysis was recorded based on the Observed results. A second set of data; the Expected results were developed based on a 50/50 assumption. The χ2 test for independence was used to measure the significant relationship between the two categorical variables (Observed versus Expected). Mathematically stated, where the Observed, frequency count and the Expected frequency count are represented by O and E, and r is the number of levels for one categorical variable and c is the number of levels for the other categorical value, the calculation used was:
χ2 =
∑ [(0r , c − Er , c)
2
Er , c]
RESULTS There were 1014 physicians, nurses, EMS personnel, and others involved in the immediate care of a burn-injured patient, who successfully completed ABLS during this four-year period and provided a working email address at the time of completing the educational program (or was matched and validated through ESAR-VHP). From this population of 1014, 52 (4.9%) were returned as “undeliverable” during the first survey attempt indicating the email address was no longer valid and 20/1014 (2.0%) were delivered, but the recipient of the email selected the option to opted out of the survey, leaving 942 potential respondents for survey participation. There were 526 total respondents who completed at least the Demographics Section and the Perceptions Section of the survey. Thus, the focus of this work was directed at the results from the 526 who responded to the survey, 526/942 (55.84%). The decision making process regarding those surveyed and the analysis is graphically represented in Figure 1.
Certification/License/Credential, Work Environment, and Participant Experience The Demographics Section of the survey for the 526 respondents represents clinical roles as graphically displayed in Figure 2. Respondents were almost equally divided when identifying their workplace as graphically displayed in Figure 3. The seven questions found in the Perceptions Section of the survey, as well as potential answers for the respondents are found in Appendix. Fifty-two percent (52%) of the respondents reported holding their current clinical credential for more than 10 years (Figure 4, Column 2). Seventy
percent (70%) reported they had more than 10 years of experience in clinical care (Figure 4, Column 1).
Perceptions Section 1. The respondents reported (Observed Values) the ABLS program contributed to improved greater understanding of estimating (TBSA). The Observed Values were statistically significant (P < .001) as noted in Figure 5, Question 1. 2. The respondents reported (Observed Values) that the ABLS program had contributed to an improved understanding of IV fluid infusion rates for an adult burn patient to flow rates that are similar to, or consistent with, the Consensus/Modified Formula. The Observed Values were statistically significant (P < .001) as noted in Figure 5, Question 2. 3. The respondents reported (Observed Values) that the ABLS program had contributed to either the respondent having changed or influenced others to change the type of IV fluid to Lactated Ringer as soon as it is available. The Observed Values were statistically significant (P < .001) as noted in Figure 5, Question 3. 4. The respondents reported (Observed Values) that the ABLS program had contributed to an improved awareness for the respondent to more closely monitor or influence others to more closely monitor (and to treat) the pain management needs of a burn patient. The Observed Values were statistically significant (P < .001) as noted in Figure 5, Question 4. 5. The respondents reported (Observed Values) that the ABLS program had contributed to an improved understanding of the value of using, where available, verified burn centers for burninjured patients. The Observed Values were statistically significant (P < .001) as noted in Figure 5, Question 5. 5. The respondents reported (Observed Values) that the ABLS program had contributed to an improved understanding of the value of using, where available, verified burn centers for burninjured patients. The Observed Values were statistically significant (P < .001) as noted in Figure 5, Question 5. 7. The respondents reported (Observed Values) that the ABLS program had contributed to an improved awareness of the role burn centers, as well as other specialty centers, play in a medical disaster. The Observed Values were statistically significant (P < .001) as noted in Figure 5, Question 7.
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Figure 1. The graphical representation of the decision-making process for how survey participants were surveyed and their responses analyzed.
DISCUSSION Evaluation and selection of the ABLS program relied on the stakeholders who chose the course that best met the objectives for the educational program to be selected.4,5,36 Relying on Posner et al offered a structured approach to evaluate the various curricula for each of the programs and their measurable objectives to be covered by the specific program. Furthermore, there is a direct link between the perceptions of the student and their aim to develop expertise and expert performance.3,6,7 It seems both intuitive and logical that the link between the perceptions of someone completing a class, and their development of expertise exists. What is known from the literature however, is the bottleneck is similar to that found in other disciplines where the “training bottleneck” is getting knowledge to the novices, in this case many of those who reported a
discomfort and uneasiness with managing the care of burn-injured patients44 with outcomes first being measured through perceptions of the students who completed the educational program, in this case, ABLS.3 There are limitations when the focus is merely the perceptions of those who completed an educational program. Nevertheless, the first hurdle when demonstrating the value of an education program that had almost no use outside of the burn care community and developing expertise is to measure the perceptions of those who completed the program. The basic tenants of a burn care educational program include airway management, TBSA assessment, fluid resuscitation, and pain management. Additionally, it was important to the stakeholders that key components of how the burn centers, and other specialty centers connect with the first responders and first receivers, to assure the flow of injured patients are
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Figure 2. Graphical representation of participant distribution. There were more registered nurses (46%) than any other group who completed ABLS. There were (39%) of the participants who reported being paramedics, with (4%) being physicians. The balance (11%) included all others such as pharmacists, midlevel practitioners, respiratory therapists, emergency medical technicians, firefighters, and physical therapists.
managed appropriately and distributed accordingly in a disaster. Future research is needed to assess the effectiveness of ABLS and other similar training programs that contribute to medical disaster preparedness. For example, table-top exercises with ABLS trained clinicians will allow participants to test their skills in
Figure 3. Graphical representation of the work environments for ABLS course participants. Respondents were almost equally divided when identifying their workplace: Emergency Medical Service personnel (EMS) or first response (248/526, 49.3%) and those clinicians who worked in a hospital (243/526, 48.3%).
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Figure 4. Experience of survey participants.
a simulated environment while evaluating the effectiveness of ABLS in preparing people for disaster situations. Although the data were collected in a manner that identified each year that the participants reported completing ABLS, the trends remained proportionally constant within each question across the years. The focus of the analysis will remain the seven perception questions. Nevertheless, the results clearly demonstrate that two thirds of participants perceived a benefit from the training that they received during ABLS. The benefit of ABLS may be even greater in other sub-populations of providers, such as those first responders and first receivers who manage a majority of the patients long before they arrive at a Burn Center. Nevertheless, further investigation is warranted to explore the impact of such a course on selected populations and the retention of this vital information. Two of the questions focused on intravenous fluids. The typical student attended their most recent presentation regarding burn injury in the format of a 45–60 minute lecture that was part of a trauma course. During the day long trauma program the lasting impression may lead to excessive intravenous fluid infusion in the hours between the initial burn injury and the time the patient arrives at a burn center. Thus, two key ABLS objectives include fluid infusion rates, which followed the formula used at the time these classes were offered. The second question related to intravenous fluids focused on the type of fluid selected for the
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Figure 5. Compares actual scores registered by the solid bars for the perceptions reported by ABLS participants to the null hypothesis represented by the solid line.
burn-injured patient. Lactated Ringers is the preferred intravenous fluid for burn-injured patients. However, that fluid is not uniformly available to all EMS agencies, most of whom will start a saline solution until Lactated Ringers is available. Thus, one aim of the program included the emphasis of either selecting the correct fluid or changing it to the correct fluid as soon as it became available. In both cases for these two questions, the respondents reported (Observed Values) that the ABLS program had contributed to an improved understanding of IV fluid infusion rates for as well as selecting the correct fluid type for the burn-injured patient. The Observed Values for both questions were statistically significant (P < .001). Two additional survey questions focused on patient care issues that have unique characteristics with the burn-injured patient. They include pain and airway management. Clinicians are typically unaccustomed to caring for the pain management needs of a burn-injured patient given amount of medication that may be needed over the duration of the first 6 to 24 hours following the injury. The quantity used and the ongoing monitoring for both therapeutic effects as well as endpoints for use can be substantially different from most pain management scenarios. With airway management, complications of steam inhalation injury, smoke inhalation, or being burned in a confined space can each lead to critical airway management issues in the hours following the burn injury. Key indicators are taught in ABLS and while Blind Insertion Airway Devices (BAIDs) are more commonly used today in the prehospital environment, this remains a situation where the
advanced airway selection should stay with the endotracheal tube. The two remaining questions from the perceptions section of the survey dealt with the importance of burn and other specialty centers in the planning and preparedness for medical disasters. This includes reliance on verified Burn Centers when available for burn-injured patients. Burn Centers, Trauma Centers, and other specialty centers can play a critical role in medical disaster preparedness and planning. Identifying where these centers are and involving them in planning, exercise, and operation activities before disaster strikes, is a proactive way to improve the overall management and outcomes of the single or dozens of burn-injured patients. There are challenges associated with selecting a proprietary educational program that can serve as a barrier for prospective participants who lack ongoing fiscal support. These challenges include the participant fees that must be paid to the governing body for the proprietary program, governance of how, when and where courses are conducted, and national standards for instructors that may limit local personnel participating in the instruction. Other challenges include ongoing maintenance of the credential. Given the recertification costs are the same as the initial costs and there are no current curriculum in place for recertification (other than repeating the initial course) maintaining the certification has limitations. Before the program began, clinicians reported they were far more likely to accept their role in managing multiple burn-injured patients once they felt comfortable with managing one burn-injured patient.
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It should be noted that this research confirms that a significant majority of the participants, based on their reported perceptions, are better equipped to manage a burn-injured patient after completing the course than they were before attending the program. Burn Centers play a vital role in the management of a medical disaster. Another aim of the program included a discussion regarding the role of the Burn Center in the myriad of special care situations that may confront responders to a medical disaster. Knowing who to call, their role and having a better understanding of the differences between those Burn Centers who self-identify and those who are verified by an outside agency such as the ABA is also important.
CONCLUSIONS The survey results offer a small yet important first step in understanding if ABLS has a value outside of the mainstream burn care profession to include the first responder, first receiver and medical disaster clinicians. Furthermore, does that value extend into managing a surge of patients with burn injuries such as in a burn disaster? These initial findings support the belief that there is role for ABLS to prepare first responders and first receivers in the care of one or many patients with a burn injury. The academic world of adult education suggests that goals for an educational program and developing expertise include the perceptions of the course participants. Course participants are more likely to retain the information and less like to abandon the core concepts when challenged by potentially conflicting information when the participant perceives/ believes their learning activity was validated through later experiences. In this case, participants were questioned regarding their perceptions as it related to the core objectives for ABLS. They included: patient assessment (to include size of the burn), fluid resuscitation (rate and fluid selection), pain management, airway control, and the role of the burn center in a disaster to include where available, the use of a verified burn center. Aside from the patient care lectures, the ABLS disaster lecture also served as a conduit to link the care of one to the management of multiple patients with burn injuries and the importance of involving the burn center in medical disaster planning. This lecture also offered that final chance to connect the day to day management of a burn-injured patient with the rare and episodic nature of a burn disaster. As such, it is reasonable to conclude with statistically significant data, that ABLS as a component of a broad disaster planning initiative, was perceived
to be useful in managing one or many burn-injured patients. These findings are preliminary and the results only examine basic topics. Nevertheless, this promising work represents the most complete examination thus far of a large scale use for ABLS in this setting and suggests a more comprehensive evaluation should be conducted.
ACKNOWLEDGMENTS Conducting 56 ABLS classes required many clinicianinstructors willing to travel and teach these programs. The success of these classes reflects the time and dedication of national faculty: Ernest Grant, RN MSN, from UNC Hospitals; Katie Hollowed from MedStar and the Washington Hospital System in Washington, DC; and David Thompson, RN, and retired firefighter from Erlanger Medical Center in Chattanooga, TN. All of the burn surgeons in North Carolina have participated in the success of this program to include: Dr. Bruce Cairns, Dr. Samuel Jones, and Dr. James Hwang at UNC Hospitals; and Dr. James Holmes IV and Dr. Joseph Molnar at Wake Forest Baptist Health. Furthermore, contributions were made by physician assistants and nurse practitioners as well as other nursing staff. Those who taught more than 10 classes include: Derek Miller RN and Renee Edkins RN, FNP as well as co-authors; Dr. Shiara M. Ortiz-Pujols, Mr. Christopher K. Craig, PA-C, Dr. Jeffery Carter, and Dr. Amy Rezak Alger. It should also be noted that dozens of the courses were managed by Mr. James R. Gusler. REFERENCES 1. Kearns RD, Cairns BA, Holmes JH 4th, Sagraves SG. The North Carolina burn surge disaster plan for emergency medical services and hospitals. Chapel Hill: University of North Carolina; 2012. p. 85. 2. American Burn Association Advisory Committee. American Burn Association provider manual. Chicago: American Burn Association; 2011. 3. Ericsson KA. The Cambridge handbook of expertise and expert performance. Cambridge; New York: Cambridge University Press; 2006. 4. Nijhuis JFH, Segers MSR, Gijselaers WH. Influence of redesigning a learning environment on student perceptions and learning strategies. Learn Environ Res 2005;8:67–93. 5. Karns GL. An update of marketing student perceptions of learning activities: structure, preferences, and effectiveness. J Market Educ 2005;27:163–71. 6. Song L, Singleton ES, Hill JR, Koh MH. Improving online learning: student perceptions of useful and challenging characteristics. Internet Higher Educ 2004;7:59–70. 7. Rovai AP, Barnum KT. On-line course effectiveness: an analysis of student interactions and perceptions of learning. J Distant Educ 2003;18:57–73. 8. McFee RB, Leikin JB, Kiernan K. Preparing for an era of weapons of mass destruction (WMD)—are we there yet? Why we should all be concerned. Part II. Vet Hum Toxicol 2004;46:347–51. 9. Murphy JK. After 9/11: priority focus areas for bioterrorism preparedness in hospitals. J Healthc Manag 2004;49:227–35. 10. Cairns BA, Stiffler A, Price F, Peck MD, Meyer AA. Managing a combined burn trauma disaster in the post-9/11 world:
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lessons learned from the 2003 West Pharmaceutical plant explosion. J Burn Care Rehabil 2005;26:144–50. 11. Feeney JM, Goldberg R, Blumenthal JA, Wallack MK. September 11, 2001, revisited: a review of the data. Arch Surg 2005;140:1068–73. 12. Jordan MH, Hollowed KA, Turner DG, Wang DS, Jeng JC. The Pentagon attack of September 11, 2001: a burn center’s experience. J Burn Care Rehabil 2005;26:109–16. 13. Niska RW, Burt CW. Bioterrorism and mass casualty preparedness in hospitals: United States, 2003. Adv Data 2005;391:1–14. 14. Yurt RW, Bessey PQ, Bauer GJ, et al. A regional burn center’s response to a disaster: September 11, 2001, and the days beyond. J Burn Care Rehabil 2005;26:117–24. 15. Barillo DJ, Wolf S. Planning for burn disasters: lessons learned from one hundred years of history. J Burn Care Res 2006;27:622–34. 16. Jeng JC, Hollowed K, Owen CT, et al. Contemplating the Pentagon attack after five years of space and time: unheard voices from the ramparts of our burn center. J Burn Care Res 2006;27:612–21. 17. Yurt RW, Bessey PQ, Alden NE, et al. Burn-injured patients in a disaster: September 11th revisited. J Burn Care Res 2006;27:635–41. 18. Pandemic and All Hazards Preparedness Act (PAHPA) Public Law 109-417 (2006). 19. Coleman CN, Lurie N. Emergency medical preparedness for radiological/nuclear incidents in the United States. J Radiol Prot 2012;32:N27–32. 20. Limehouse W, Foster R. Creating a standardized system for allocation of scarce clinical resources in response to an all hazards mass casualty disaster. J S C Med Assoc 2011;107:70-3. 21. Hick JL, Barbera JA, Kelen GD. Refining surge capacity: conventional, contingency, and crisis capacity. Disaster Med Public Health Prep 2009;3(2 Suppl.):S59–67. 22. Hick JL, DeVries AS, Fink-Kocken P, Braun JE, Marchetti J. Allocating resources during a crisis: you can’t always get what you want. Minn Med 2012;95:46–50. 23. Hick JL, Hanfling D, Cantrill SV. Allocating scarce resources in disasters: emergency department principles. Ann Emerg Med 2012;59:177–87. 24. Hick JL, Weinstock DM, Coleman CN, et al. Health care system planning for and response to a nuclear detonation. Disaster Med Public Health Prep 2011;5 Suppl. 1:S73–88. 25. Healthcare Preparedness Capabilities, National Guidance for Healthcare System Preparedness; 2012: 73. Available from http://www.phe.gov/Preparedness/planning/hpp/ reports/Documents/capabilities.pdf; accessed 9 Dec. 2012. 26. Vandenberg V, Amara R, Crabtree J, Fruhwirth K, Rifenburg J, Garner W. Burn surge for Los Angeles County, California. J Trauma 2009;67(2 Suppl.):S143–6. 27. Leahy NE, Yurt RW, Lazar EJ, et al. Burn disaster response planning in New York City: updated recommendations for best practices. J Burn Care Res 2012;33:587–94. 28. Yurt RW, Lazar EJ, Leahy NE, et al. Burn disaster response planning: an urban region’s approach. J Burn Care Res 2008;29:158–65.
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APPENDIX The Perceptions Section of the survey included seven questions. Each question offered the answer selections of “Yes,” “No,” and “Other” with other including options of “Not Applicable” or “I have not completed ABLS.” While the focus of this work was to measure the binary options of Yes/No, (“Other”) was offered to provide the respondent an opportunity to offer an alternative answer. If “Other” was selected, the survey tool forced the respondent to a narrative box and required text insertion to offer an expanded explanation for the answer selection. The seven questions from the survey tool regarding perception are: 1. In your professional opinion, are you are better prepared to estimate the size (TBSA) of the burn injury following the training/education you received in ABLS? Results are identified in Figure 5, Question 1. 2. Following the training/education you received in ABLS, have you either changed or influenced others to change IV fluid infusion for an adult burn patient to flow rates that are similar to, or consistent with, the Consensus/Modified Formula? Results are identified in Figure 5, Question 2.
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3. Following the training/education you received in ABLS, have you either changed or influenced others to change the type of IV fluid infusion for an adult burn patient to Lactated Ringers Solution as soon as it was available? Results are identified in Figure 5, Question 3. 4. Following the training/education you received in ABLS, have you either changed or influenced others to monitor more closely (and to treat) the pain control needs of a burn patient? Results are identified in Figure 5, Question 4. 5. Following the training/education you received in ABLS, have you either changed or influenced others to be certain burn patients are managed at a verified burn center? Results are identified in Figure 5, Question 5. 6. Following the training/education you received in ABLS, have you either changed or influenced others to monitor more closely burn patients for inhalation injuries and to manage more aggressively airway control where indicated? Results are identified in Figure 5, Question 6. 7. Following the training/education you received in ABLS, do you have a better understanding of the role that burn centers, as well as other specialty centers, play in a medical disaster? Results are identified in Figure 5, Question 7.
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