Burn Annex

Overview

This document represents the burn patient surge plan for the Wyoming Region 1 Healthcare Coalition (R1HCC). This document is intended to offer general guidelines from which partner agencies can tailor their response to a burn surge event.

Introduction

A burn mass casualty incident (BMCI) is any incident where capacity and capability significantly compromise patient care, following Burn Center, local, state, regional, or federal disaster response plans. Additionally, several small, simultaneous incidents within a locality or region may also amount to a BMCI if taxing on burn staff, facilities, or resources. Burn care is limited, and in many cases, only one Burn Center exists for a state or large geographical area. No Burn Centers exist in the state of Wyoming. A BMCI, therefore, is likely to exceed the resources of a single jurisdiction and will require surge measures in non–burn facilities and possibly engage a broad array of state, regional, and national stakeholders, depending on the scope of the incident.

This plan is intended to be flexible to fit the needs of the response, covering all aspects of a tiered approach to a response from the local level up to federal assistance as necessary. It contains guidelines for burn surge events in R1HCC facilities, including resources for staff training and augmentation, supplies and equipment, and special considerations. The plan was developed in consultation with federal guidelines and requirements for all healthcare coalitions and is aligned with the Western Region Burn Disaster Consortium (WRBDC) BMCI Concept of Operations Plan.

Federal guidance provides more detail on the necessity and content of this plan. The 2019–2023 HPP Funding Opportunity Announcement (FOA) requires Healthcare Coalitions (HCCs) to develop a coalition-level burn annex that augments its base response plan. According to the 2017-2022 Health Care Preparedness and Response Capabilities, “All hospitals should be prepared to receive, stabilize, and manage burn patients. However, given the limited number of burn specialty hospitals, an emergency resulting in large numbers of burn patients may require HCC and ESF-8 lead agency involvement to ensure those patients who can most benefit from burn specialty services receive priority for transfer. Additionally, burn surgeons may help identify patients who do not require burn center care and who are appropriate for transfer to other health care facilities.” (Capability 4, Objective 2, Activity 6).

Purpose

This annex provides guidance to support a BMCI in which the number and severity of burn patients exceed the capability of R1HCC healthcare facilities. The annex identifies the resources (both within and external to the R1HCC) that must be engaged in a BMCI response. It also defines the processes used to determine when patients require transfer to burn facilities.

The overarching goal is to ensure the highest standard of care possible for the greatest number of patients during an extreme burn surge event, with the following objectives:

• Plan and coordinate activations, notifications, logistics, and resources;
• Recognize roles, responsibilities, and organizational structure; and
• Solidify operations, including triage, treatment, and transfer flow and support.

Scope

This annex is intended for use by the R1HCC to assist in providing coordination during a BMCI. The primary focus is on identifying resources for local and regional coordination and non-burn facility support as they care for burn patients.

This document is intended to support, not replace, existing policies and plans by providing uniform response considerations in the case of a BMCI. This plan will utilize existing command structures and communication protocols. Internal documents and policies that address specific organizational responses impacting BMCI will be provided to participating parties.

The response strategies and processes described herein do not supersede the authority of participating entities. A coordination body is intended to assist healthcare systems when overwhelmed by leveraging resources and supplies to assist in treating and transferring patients.

Legal Authorities

The response strategies and processes described herein are not legally binding, and there is no legal obligation to participate. However, participation by hospitals, healthcare systems, and their partners is encouraged to ensure the best possible outcomes for patients treated in the jurisdiction. The plan leaves the majority of the decisions and processes up to the healthcare systems and transfer centers. The processes outlined herein do not supersede local or state protocols and will be implemented only when requested or required.

Background and Situation

The R1HCC includes the five counties in northeast Wyoming, specifically Campbell, Crook, Johnson, Sheridan, and Weston counties. This area covers nearly 17,000 square miles and is home to over 100,000 residents (about 17% of Wyoming’s total population). The region is primarily rural, with a handful of population centers. Key communities include Buffalo, Gillette, Newcastle, Sheridan, and Sundance. The region contains six hospitals (including one Veterans Affairs Medical Center), ten licensed ambulance service providers, five emergency management agencies, and five governmental public health organizations. Patients who cannot receive the appropriate level of medical care within the region are frequently transferred to medical facilities in Billings, Montana; Casper, Wyoming; Denver, Colorado; and Rapid City, South Dakota.

The nearest burn treatment center is the Western States Burn Center at North Colorado Medical Center in Greeley, Colorado. The average drive time from Gillette (the approximate geographic center of the R1HCC) to Greeley is five hours during favorable weather. The second-closest burn center is the University of Utah Health Burn Center in Salt Lake City, Utah, a drive of more than eight hours in good weather. The significant distance of these burn centers means that organizations in the R1HCC must be prepared to provide initial stabilizing treatment to burn patients and arrange prompt transfer to a higher level of care.

Assumptions

The following assumptions provide the basis for the emergency response procedures outlined within this plan. It is expected that all participating facilities and supporting agencies are aware of and agree to the following:

• All hospitals providing emergency care may receive burn patients and should be able to provide initial assessment and stabilization.
• Care for critical burn patients is extremely resource-intensive and requires specialized staff, expert advice, and critical care transportation assets.
• Severe burn patients often become clinically unstable within 24 hours of injury, complicating transfer plans after this time frame.
• Implementing a MOCC at the sub-state or state level may be necessary to ensure contingency care strategies are utilized evenly by all healthcare facilities.
• The Western Region Burn Coordination Center will activate and operate as a regional-level MOCC in collaboration with applicable partners if local/state capabilities are overwhelmed and require assistance.
• Though potentially available to assist, federal resources (e.g., ambulance contracts, National Disaster Medical Systems teams) cannot be relied upon to mobilize and deploy within the first 72 hours.
• The American College of Surgeons Committee on Trauma (ACS-COT) Guidelines for the transfer of patients to a burn center may need to be modified to do the greatest good for the greatest number of patients.

Concept of Operations

Medical Operations Coordination

Medical Operations Coordination

Federal guidance advocates the use of one or more Medical Operations Coordination Cells (MOCCs) to assist in an incident that overwhelms the capacity of hospitals in a given area. The Establishing Medical Operations Coordination Cells webinar, delivered by the Assistant Secretary of Preparedness and Response, provides the following general description of MOCC utilization:

• Some hospitals are overwhelmed with burn patients, while successful mitigation has created excess capacity in nearby hospitals, creating an opportunity to transfer patients.
• MOCCs are a strategy to optimize patient distribution by augmenting EOCs with clinical experts that synthesize and coordinate healthcare capacity.
• The MOCC strategy can be implemented nationwide (at sub-state, state, and regional levels), permitting flexibility for states while optimizing patient distribution.

To meet the goal of best possible patient outcomes after a BMCI, the R1HCC, if overwhelmed and requiring assistance outside of the jurisdiction, will request state health representatives authorized to establish a sub-state or state MOCC to help coordinate patient transfer and resource sharing. If assistance is required beyond the state level, the Western Region Burn Coordination Center (WRBCC) will be activated to provide regional-level response assistance. The following steps outline the potential flow of activations and responses during a BMCI:

1. A mass casualty incident involving burns occurs. The local 911 system is activated.
2. Local EMS begins notifications, patient triage, and distribution from the incident scene per existing protocols and typical “hub and spoke” procedures. Local receiving facilities notify R1HCC to assist with coordination and resource sharing.
3. If local response agencies and the HCC are overwhelmed, state assistance is requested. A sub-state or state MOCC is activated to work with transfer centers to help inform in-state patient distribution and resource coordination.
4. If out-of-state assistance for patient care, burn bed availability, or resources is required, the Western Region Burn Coordination Center (WRBCC) may be activated. The WRBCC will work with the sub-state or state MOCC for situational awareness, existing burn center telemedicine programs, and appropriate patient transfer agencies to help facilitate appropriate transfer to regional burn beds for definitive care.

Additional details for activation, notification, and the roles and responsibilities of each level of the response are provided in the sections below.

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Activation and Notifications

HCC Activation and Notifications

The R1HCC can be notified of a BMCI by any R1HCC member. The R1HCC Burn Surge Annex is activated by contacting Whitney Montgomery, R1HCC Healthcare Readiness and Response Coordinator (HRRC). Upon notification and Burn Surge Annex activation, the HCC will notify all R1HCC members using the Juvare notification system.

State Activation and Notifications

Sub-state and state MOCC activation will occur by contacting the Hospital Preparedness Program Manager, Wyoming Department of Health.

Regional Activation and Notifications

When a medical surge beyond local capacity is anticipated, the R1HCC will call the WRBDC 24/7 Hotline at 866-364-8824. Activating the WRBCC will immediately initiate a burn bed census for all Western Region Burn Centers to identify possible patient transfer destinations. The WRBCC also provides the opportunity for consultation with burn physicians via telemedicine and other assistance as needed. The WRBDC BMCI Operations Plan offers more details on the assistance available at the regional level. Below is the Activation Algorithm for the Western Burn Coordination Center.

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Roles and Responsibilities

Local organizations and agencies within the impacted jurisdiction will have primary responsibility for response, including initial triage and casualty distribution. Suggested response roles for local, state, and national stakeholders and partner agencies are summarized below. These roles were adapted from the ASPR TRACIE Mass Burn Event Overview.

Partner	Roles and Responsibilities
EMS Local Healthcare Coalition Public Health (PH) Emergency Management (EM)	Rescue, transport, and distribute casualties to appropriate local facilities. Request and mobilize any coalition or regional caches of burn supplies. Activate coalition coordination mechanisms and any burn-specific plans. Coordinate local lists of casualties and clinical information. Triage/prioritize patients for transfer to specialty centers under established BMCI protocols and expert input. Coordinate with burn experts to determine appropriate destinations for patients that cannot be accommodated in the local healthcare system with assistance from the state and ABA. Assure that appropriate clinical information is relayed between the referring and receiving facilities during the transfer process. Secondary Roles Coordinate information with state/federal ABA partners.
Closest ABA Burn Center	Provide patient care. Activate facility and regional surge plans to accommodate multiple patients. Liaison between local response and regional ABA coordinating center. Secondary Roles Assist with triaging patient transfers. Support facilities providing care for burn patients in the area via telemedicine or request support from the WRBDC coordination center. Ensure burn surge facilities use existing resources (96 Hour Plan).
State PH/EM	Support local jurisdiction with state-level coordination and requests for assistance (e.g., state and federal declarations). Assure that patient triage, tracking, and transport needs are addressed. Make requests for burn care assets, including dressings and other materials from the Strategic National Stockpile (SNS). Engage Emergency Management Assistance Compact (EMAC) assets to provide inter-state support for transportation, staff, or other logistics. Secondary Roles Liaise between local, state, and federal resources. Support bed polling and matching functions as required in coordination with ABA regional center.
Sub-state/State MOCC	Optimize burn patient distribution and healthcare capacity by augmenting EOCs with clinical experts that assist with coordination Coordinate burn resource and supply needs between healthcare systems
Western Region Burn Coordination Center	As warranted and requested by the local response: Serve as the point of contact (POC) for the ABA system. Conduct bed polling initially and as needed within the ABA region (and request assistance from adjacent regions if necessary). Assist the affected local burn center and state PH in determining appropriate patient destinations and transportation. Assist with the tracking of patient movement, including arrival to destination centers. Provide updates as requested. Facilitate requests for tissue bank products, graft equipment, and other specialized supplies. In collaboration with state and regional partners, establish when the BMCI has concluded. Establish any post-incident system needs and initiate the AAR process. Secondary Roles Assist with bed matching (right patient to right bed/facility, while considering family cohesion). Facilitate the exchange of patient transfer information between referring and receiving facilities once patients are matched to destinations. Assist the affected local burn surge facility by providing expert advice or telemedicine as requested. Engagement of other WRBDC facilities will be imperative. Disseminate resource requests. Provide situational awareness to all appropriate agencies.
ABA National Headquarters	Provide expertise and advice on request from a member center. Secondary Roles Provide expertise and guidance to inform the federal response.
Health & Human Services, Assistant Secretary for Preparedness & Response (HHS ASPR)	Provide federal support to local and state activities as requested and authorized under the National Response Framework. Support may include supplies, staff, and transportation assistance through the Federal Coordinating Officer (FCO) appointed to the state for the incident. Coordinate approved use of National Disaster Medical System (NDMS) personnel or transportation assets. Secondary Roles Coordinate information and access to burn expertise during BMCI. Support/assist states and ABA information and system needs (e.g., bed polling/data management).

Logistics

Space

Patient care areas can typically be divided into three categories: conventional space, contingency space, and crisis space. Due to the absence of Burn Centers in Wyoming, the only space available for burn patients is crisis space. In the event of a BMCI, the MOCC can assist in determining the availability of crisis space. If the MOCC determines that the scale of the event warrants additional consultation, the WRBDC will be contacted to assist in locating additional hospital bed space.

Staff

Burn Care Training Resources

Before a BMCI, the R1HCC will assist all member facilities in gaining access to training for staff on The Prolonged Care of the Burn Patient in a Non-Burn Facility Following a Mass Casualty Incident (also known as the 96 Hour Plan). The WRBC created this collection of training modules and quick-reference response guides in response to ASPR’s mandate that all HPP-funded facilities are required to be able to provide care to a burn patient for up to 96 hours. The E-learning Modules and Quick Reference Guides include Initial Assessment and Management, Patient Care during 0–48 and 48–96 hour intervals, and Transfer and Transport of patients. (Guidelines found in the WRBDC Burn Mass Casualty Operations Plan, pages 44-60). If just-in-time training is required, facilities can use the Burn Crisis Standards of Care Guidelines, Hospital Burn Management Algorithm (Appendix F), and Burn Injury Guidelines for Care Second Addition (Appendix G). Additional resources are available in the Burn Resources Table in the Appendix of this document.

ICU Augmentation

Immediately following a BMCI, R1HCC leadership and members should develop strategies for ICU augmentation in the region, such as the following:

• All hospitals should redeploy staff into the emergency department, ICU, and transport roles. Hospitals should utilize existing resources and just-in-time training to assist with patient management.
• All non–burn-receiving facilities should begin to enact alternative ICU strategies in their emergency operations plans to expand ICU capacity and capabilities.
• Remote training and outreach resources should focus on supporting mass burn casualties across the state in expanding ICU capacity and capability and preparing staff to function in critical care roles.

Rural Clinical Care Strategies

The MOCC or Western Region Burn Coordination Center can provide support to rural healthcare providers to increase their ability to care for burn victims by:

• Maximizing existing real-time telehealth-based provider support for critical care;
• Providing healthcare providers with clinical support and training on crucial considerations in burn care; and
• Assisting with discharge criteria, outpatient management, and aftercare programming.

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Supplies

Burn Supplies

The R1HCC will work with all non-burn facilities to ensure they are aware of and have access to the supplies and equipment necessary to treat a burn patient, as found in the Wound Care Supply Guideline for Burns and the Pediatric Equipment and Supplies list. Please note that these lists are not exhaustive and are intended to supplement standard supply items.

Resource Request Coordination

Hospitals encountering a need for burn care resources will first attempt to acquire the needed items using their usual or emergency procurement methods. This can be done in collaboration with state, regional, and federal partners. The WRBCC may assist in acquiring scarce or specialized resources when necessary. The R1HCC will use the following process to ensure a locally-driven, tiered response.

1. Healthcare Facility/SystemWhen an unmet resource need exists, the facility will first utilize existing channels within its hospital system to acquire the needed items. If the system cannot meet the request, the local jurisdiction ESF-8 desk or HRRC should be notified.
2. State ESF-8R1HCC will initiate efforts to obtain the needed items by contacting facilities in their jurisdiction. If unmet, the request is then sent to the State ESF-8. ESF-8 staff or R1HCC will make arrangements for any available resources to be sent to the requesting facility. Note that scarcity of resources may prompt prioritization recommendations to be established by local and state health officials, shared with hospitals through disaster communication channels.
3. Regional WRBCCIf the resource need is unable to be met by the healthcare system, healthcare coalitions, or local and state emergency support, the facility may request resource assistance from the WRBCC. The WRBCC will assist in identifying another facility that is able to provide the resource. The requesting facility is responsible for completing any necessary paperwork and will work with the WRBCC to coordinate the transportation of the resource. If region-wide resources are scarce or unavailable, including tissue bank products and specialized supplies, the WRBCC task force will convene to discuss available options and recommendations.

Operations: Medical Care

Triage

The impacted healthcare organizations will immediately begin triage and treatment according to local protocols. A description of the hospitals in the R1HCC, including their trauma level and ability to care for burn patients, is listed in the Regional Hospital Tier Designations for a BMCI table found in the Appendix. The EMS and Hospital Triage Flowcharts on the following pages show the response flow from initial on-scene triage to hospital re-triage, including burn-specific considerations.

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Burn Patient Transfer Decision

The decision to transfer a patient to another facility for definitive care is complex and relies on several factors to determine which patients are transported to which facilities and when. The Burn Patient Transfer Decision Flowchart (Appendix), developed by the WRBDC with partners, can guide non–burn hospitals in making transport decisions in collaboration with a burn physician from either a nearby Burn Center or the WRBCC.

If an R1HCC facility requires patient transfer to a Burn Center, the MOCC or WRBCC can assist in determining appropriate patient destinations, transportation methods, and patient documentation and tracking. The MOCC or WRBCC can coordinate these needs between the referring and receiving facilities.

Burn Center Referral Criteria

• Partial thickness burns greater than 10% TBSA.
• Burns involving the face, hands, feet, genitalia, perineum, or major joints.
• Full-thickness (third-degree) burns in any age group.
• Electrical burns, including lightning injury.
• Chemical burns.
• Inhalation injury.
• Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality.
• For any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk, the patient may be initially stabilized in a trauma center before being transferred to a burn unit. Physician judgment is necessary for such situations and should consider the regional medical control plan and triage protocols.
• Burned children in a hospital without qualified personnel or equipment for the care workers.
• Burn injury in a patient who will require special social, emotional, or rehabilitative intervention.

Patient Transfer Checklist

Use the Burn Patient Transfer Checklist included in the Appendix to prepare, package, and transport patients who have been identified for transfer to a Burn or Trauma Center.

Patient Transfer Coordination

The following Patient Transfer Coordination chart depicts how the WRBCC can be activated to assist patient transfer to definitive care.

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Treatment

The Appendix includes the BMCI Hospital Acute Burn Management Algorithm that outlines the process for initial treatment and care of a burn patient with detailed care instructions. Also included in the algorithm is the contact information for the Western States Burn Center at North Colorado Medical Center to use for burn care consultation and possible patient transfer.

Special Considerations

The following section contains considerations for special populations and special situations, including behavioral health concerns, pediatric patients, combined injuries, and crisis standards of care.

Behavioral Health

Burn Survivor Mental Health

Given the nature and scope of a BMCI, it can be expected that a number of those who witnessed, were injured by, or responded to the event will experience some mental trauma in relation to the incident. Research about trauma in burn survivors indicates that “experiencing some post-traumatic stress symptoms immediately following a burn trauma is normal.”  “According to the literature, about 90% of both adults and children with burn injuries report at least one symptom of acute stress disorder right after the traumatic event, but only about 30% develop PTSD. PTSD is more likely to occur if the burn injury is an assault or a repeated trauma (such as ongoing abuse). Burn survivors most at risk for PTSD have a history of anxiety disorders (generalized anxiety, panic disorder) or depression. Burn survivors who have a history of traumatic events and past PTSD are also at risk for developing PTSD from the current burn injury” (Wiechman, 2017; https://msktc.org/burn/factsheets/PTSD-After-Burn-Injury).

The National Institute for Mental Health strongly recommends a thorough psychosocial screening following trauma exposure to help identify individuals at risk for PTSD. Clinicians need to utilize a trauma-informed approach. They should begin by creating a sense of safety through education about what to expect, orientation to their care team and unit, and reconnection to known coping tools and support systems. It is also important to note that in addition to traumatic stress, many burn victims also deal with grief from loss (of a home, a loved one, a limb, etc.) and fear that something like this may happen again with little ability to predict or prevent it.

Mental Health Screening and Treatment

The R1HCC will work with member facilities to be prepared to identify and appropriately respond to potential mental health concerns in their patients, patients’ families, and staff. The R1HCC advocates for resources and training in “psychological first aid” to help clinicians and emergency response workers understand the victim’s worldview, project a sense of calm, normalize feelings and reactions, provide the information needed to deescalate acute distress, and provide information on next steps. The WRBDC CONOPS Plan includes Behavioral Health Tips & Resources, containing brief suggestions and several resources for psychological first aid and aftercare support.

R1HCC facilities will ensure burn victims treated in the jurisdiction receive mental health screening and treatment in accordance with these recommendations. Facilities will provide patients with information on available burn survivor support and aftercare programming in the region. Through the American Burn Association, national-level burn survivor support resources may also be provided, accessed online at ABA Burn Survivor Resources.

Pediatric

It is critical that healthcare facilities, including burn and non–burn centers, have the education and resources necessary to assess and treat pediatric patients. A general planning figure is to assume that a minimum of 25% of victims from any mass casualty incident will be children.

The R1HCC Pediatric Annex includes detailed information on pediatric care and planning at the coalition level.

General Planning Aides

The Appendix includes the Helping Children and Adolescents During a Disaster guideline. The PedsReady Emergency Department Checklist, with a goal to ensure emergency departments are set up to appropriately care for the pediatric patient, is available online. It is additionally recommended that HCC members take the online FEMA Independent Study course IS-366: Planning for the Needs of Children in Disasters.

Pediatric Burn Treatment and Supplies

The Appendix contains an excerpt of the Burn Crisis Standards of Care that includes useful information for treating pediatric and adult burn patients. The Burn Crisis Standards of Care is a comprehensive resource for pediatric and adult burn patients, including initial care and management across a range of available resources and conditions. These resources are accessed online under the “Burn Guidelines” tab.

The Western Region Burn Coordination Center will be available to assist in coordinating real-time telemedicine support from pediatric and burn specialty physicians. Where telemedicine is not available, facilities can use image sharing and provider-to-provider discussions to assist in caring for a pediatric burn patient. The Western Region Burn Mass Casualty Operations Plan includes the following resources:

• Pediatric Burn Patient Considerations (page 17)
• Pediatric Rule of Nines for Calculation of Total Burn Surface Area (page 47)
• Pediatric Planning Recommendations (page 60)
• Pediatric Equipment and Supplies (page 61)
• Pediatric Psychological First Aid (page 65)

Additionally, the Western Regional Alliance for Pediatric Emergency Management (WRAP-EM) has an extensive collection of pediatric resources available online. A new resource for pediatric behavioral health is Psychological Simple Treatment and Rapid Triage (PsyStart). This system offers real-time triage and case management for children affected by a disaster. Contact Dr. Merritt Schreiber at m.schreiber@ucla.edu to access the system.

Combined Injury

Combined injury (i.e., burns in addition to other trauma, radiation, or chemical injuries) markedly increases mortality. These patients may be better served at trauma and other centers depending on the severity of each injury. Expert clinical input should support decision-making, including decontamination considerations if chemical agents are involved. Initial triage by EMS should always focus on traditional trauma triage guidelines when trauma is present, and secondary triage providers will need to consider the combined injury.

Crisis Standards of Care

An overwhelming public health emergency, such as a BMCI, may greatly impact the availability of appropriate hospital beds, staff, and resources. Providers may not be able to provide the same level of care that they otherwise would like to, given shortages or other difficulties resulting from the disaster. The Burn Disaster Crisis Standards of Care Guidelines were created to guide the allocation of patient care resources and assist with patient care priorities during such an event. Guidelines are available for adult and pediatric patients and can be found online under the “Burn Guidelines” tab. The application of these resources and guidelines will depend on physician judgment at the point of patient care or regional CSC decision-making bodies if activated.

Transportation

A significant limiting factor in a regional response may be the availability of emergency medical services (EMS) transport (i.e., ambulances). EMS support and coordination are essential to the logistical goals of this effort. Note that patient transfer coordination will include step-down transfers and assistance to local authorities as needed for family reunification efforts. Patient movement should occur following local protocols and in collaboration with appropriate state, national, and federal agencies. To expedite the safe, efficient, and appropriate transfer of burn patients, the R1HCC will adhere to the following guidelines.

• Whenever possible, an Advanced Life Support (ALS)/critical care–capable vehicle shall be used to transport a critical burn patient.
• Hospitals needing to transfer patients to a local Burn or Trauma Center should follow their routine EMS transport procedures.
• An individual facility may make arrangements directly or request assistance from local ESF-8 (R1HCC).
• The R1HCC, in collaboration with Emergency Medical Resource Centers (EMRCs), where applicable, will utilize internal policies and procedures to solicit immediate assistance from EMS agencies.
• If local transport resources have been exhausted or patients need to be transported to another state, transport requests can be made directly to the MOCC or WRBCC.
• Before transporting any patient, facility acceptance for the patient should be confirmed by the MOCC or WRBCC.
• The requesting facility will notify the MOCC or WRBCC of what transportation arrangements have been made.
• The facility arranging air or ground transportation will coordinate with the NOAA National Weather Service for current or future weather conditions. They will gather information for local and en route forecast conditions, including wind speed, ambient temperature, and inclement weather.
• Facilities should utilize aeromedical transportation when available and as weather permits. The facility arranging air transportation will coordinate with aeromedical transports to determine whether medical rotor aircraft can land and take off due to complex conditions (e.g., extremely high temperatures and elevation).

Tracking

Healthcare facilities will follow routine or disaster protocols for tracking patient movement within their hospital system. The MOCC or WRBCC may facilitate less common transfers in collaboration with state and regional partners. If the WRBDC is activated, it will utilize the BMCI Patient Tracking Sheet. Referring facilities are encouraged to use the WRBDC BMCI Patient Medical Data Form or similar documentation. This form records important patient data needed for transfer and receiving facility information and should accompany the patient to the receiving facility.

Deactivation and Recovery

The R1HCC will assist in establishing when a BMCI has concluded, in collaboration with other local, state, regional, and federal partners such as the MOCC or WRBCC. Triggers for incident conclusion include decreased patient volumes and near-normal levels of hospital staffing and supplies. The R1HCC emergency response personnel will demobilize when these triggers occur and when there is no longer a need for coordinated burn-specific activities.

The healthcare coalition will initiate the local after-action review process, soliciting and compiling feedback from all responding member agencies. Identified gaps and areas of strengths will be noted in an after-action report, which will be distributed to all relevant agencies and partners. Changes to plans and procedures, including this document, will be based on identified gaps.