Resource Requirements in a Burn Mass Casualty Event

: Burn mass casualty event occurrences are rare but will place significant burdens on any burn unit or healthcare system. Effective disaster preparedness plays a significant role in mitigating the aftermath of a burn mass casualty. The aim of this study was to assess the resource requirements during the initial two weeks of a burn mass casualty event. Eight patients in a burn mass casualty event were simulated using the Emergo Train System ® . These simulated patients were matched with real historical patients treated in our burn centre, and their resource requirements were analysed. An average of eight staff is required to care for a patient per day along with almost 75 h of operating time (excluding anaesthesia and turnover time). A substantial quantity of consumables was used in the first two weeks. This study has demonstrated the substantial material consumption and staff requirements in the first two weeks of management in a burn mass casualty event. Such findings will offer valuable insight for disaster preparedness planning and resource management strategies.


Introduction
The occurrence of a burn mass casualty event poses significant challenges to healthcare systems [1].Beyond the complexities inherent in managing multiple trauma victims, the nature of extensive burn injuries demands substantial resources, from the onset and over an extended duration [2,3].An example is the 2019 Whakaari White Island volcanic eruption in New Zealand, where 14 patients required 124 operative visits and nearly 400 h of surgical time over a span of four months [4].In contrast, in the Boston Marathon Bombing in 2013 when 55 patients were treated at Brigham and Women's Hospital and Brigham and Women's Faulkner Hospital, 83 operative procedures were performed.Full coverage of patients was completed in 5.7 days (0-18 days), with an average length of stay of only 12.3 days (1-26 days) [5].Furthermore, the initial phase of a burn mass casualty event can be overwhelming.This can be attributed to the sudden influx of many patients, severity of injuries, limited resources (consumables and personnel) and the need for rapid decision making.This has led to the development and implementation of burn disaster preparedness recommendations, guidelines and predictive models to help organisations prepare for these challenging events [2,3,[6][7][8][9].
There are two burn centres in Sweden with resources for the management of complex and severe burns, one in Uppsala and another in Linköping.The combined maximum capacity for severe burn care in Sweden stands at 16 patients (8 in Uppsala and 8 in Linköping).If there are more than 16 patients in Sweden, the Nordic Mass Burn Casualty Incident (MBCI) response mechanism will be activated, and patients will be transferred to other available Nordic countries for treatment [10].In the event that any Nordic country has more than 25 severe burns patients, the European Civil Protection Mechanism (via the Emergency Response Coordination Centre) should be activated [10,11].This mechanism not only provides disaster support but also coordinates disaster preparedness and prevention activities.It further promotes the exchange of best practices among national authorities [11].This context underscores the importance of efficient resource allocation and management, especially in the face of a burn mass casualty event that can overwhelm the existing capacity of burn centres [12][13][14].
The Emergo Train System ® , a simulation system developed in Sweden, has gained international recognition for its utility in education and training in emergency and disaster management [15].Its applications span healthcare organizations, rescue services, police forces, crisis support organizations and military entities, facilitating the simulation of emergency response processes [16,17].
Despite research on various facets of mass casualty events, there is a notable gap in comprehending the resource requirements for burn incidents.This paper aims to address this gap by conducting a thorough analysis of consumables and human resource needs associated with a burn mass casualty event.By identifying these requirements, the study endeavours to contribute valuable insights to the field and propose effective solutions for resource management in the context of burn mass casualty incidents.

Materials and Methods
Eight patients in a burn mass casualty event, reflecting the maximum capacity of our burns unit, were simulated using the Emergo Train System ® .These simulated patients were then meticulously matched by extent of total burn surface area with real historical patients treated in our burn centre in Uppsala by cross referencing our clinical records.Data were then extracted from these patients' clinical notes using a standard data template in an Excel ® workbook to estimate resources used in the first two weeks of admission.
Data collected included baseline patient characteristics and % total body surface area (%TBSA).Consumables such as wound dressings were estimated from the size of burn injury and number of recorded dressing changes; personal protective equipment (PPE) and disinfectant were estimated from standard ward procedures; and medications, fluids and blood products were directly calculated from the Patient Data Management System (PDMS) MetaVision for each specific patient.
Concurrently, we undertook a calculation of the human resource requirements vital for the care of these patients.This encompassed a diverse spectrum of healthcare professionals, including surgeons, intensivists, nursing staff, paramedical personnel, theatre staff, specialists from various medical disciplines and additional non-medical staff crucial for the effective functioning of the burn centre.
ChatGPT was used sparingly in the manuscript writing process to check grammar, improve readability, assist language translation and aid in reference formatting.Examples of prompts used are "make this more readable/polish this paragraph" or "create reference according to ACS style guide".

Results
Eight burn patients were simulated using the Emergo Train System ® .Four were male, and four were female.The mean age was 43.3 (range 25-71).The mean %TBSA was 50.4% (range 25-86%).Table 1 shows the characteristics of the patients simulated.
A total of 7216 staff hours were required for the care of these eight patients in two weeks.This is equivalent to 64 staff hours per patient per day.Table 2 shows the total staff hours for some of the health professional involved.Table 3 lists the consumables utilised by these eight patients in two weeks.The extensive list of consumables and human resources (414 items) can be seen in Appendix A.

Discussion
These findings highlight the significant consumables and human resource requirements in a burn mass casualty event.To our knowledge, this is the first paper that has attempted to estimate all resources required in the event of burn mass casualty.The importance of a multidisciplinary team approach in burn care is well recognised, especially in the context of a burn mass casualty event [18,19].A team comprising health professionals from various specialties plays a pivotal role in addressing the multifaceted challenges associated with burn injuries.This study further reinforces the notion that caring for burn patients truly requires a collective effort from a community of dedicated healthcare professionals.
A full-time work schedule in Sweden is eight hours per day with a 40 h week.This means that the staff requirement for caring for eight patients per day is 3.7 plastic surgeons, 49.5 ward nurses, one intensivist, one anaesthetist and eight theatre nurses.For allied health professionals, the requirement is 0.4 physiotherapists, 0.4 occupational therapists, 0.2 dieticians and 0.04 social workers.This is equivalent to 64 staff per day or eight staff for each patient, per day.This also means that our unit will need at least twice the number of staff to maintain a two cycle, five days a week roster.Considering that a week comprises seven days, this staffing requirement becomes even more pronounced.
The numbers above suggest that during a burn mass casualty event, a surge plan is vital to addressing the high staff requirements (especially with surgeons and nurses).This plan may involve several strategies while being mindful of the concern with burnout, especially when the patient management will extend over a significant period of time:

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Recruitment from Other Areas/Units: Recruitment of medical staff from other hospital departments or external agencies to temporarily bolster the burn unit's workforce.However, this strategy will need to be executed with caution as the recruited staff may lack familiarity with the unit or with burn care, potentially resulting in additional inefficiencies.Additionally, this will likely inadvertently put strain on other services from which the staff is recruited [9,20].• Adjustment of Patient-to-Nurse Ratio: Temporary modification of the patient-to-nurse ratio to accommodate the increased workload while ensuring patient safety and care quality.

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Modify Shifts for Staff: Implement longer shifts for existing staff members to ensure adequate coverage and continuity of care.This needs to be performed with finesse to avoid burnout and fatigue [21].This will unlikely be feasible long term but may be a stopgap if needed.

Consumables and Supply Chain Management
In light of the lessons learned from the COVID-19 pandemic, the significance of a robust supply chain management in healthcare is highlighted [22].The demands of a burn mass casualty event necessitate ample stocks of consumables, prompting a call for proactive measures to ensure sustainability.As illustrated in Table 3, the magnitude of consumable requirements is substantial in the first 14 days-over 50,000 cm 2 of allografts, 600 L of Ringer acetate, 37 L of blood, 7000 disposable gowns, 400 rolls of paraffin gauze, 10 L of propofol, etc.This highlights the critical role of meticulous supply chain planning and readiness to meet the challenges posted by such events, ensuring continuous and effective delivery of essential medical resources.
This suggests that there is a need for redundancies within the healthcare system to enhance its ability to withstand and respond effectively to unexpected challenges [20,23].A strategic approach will be to maintain a two-week supply of essential items, thus allowing sufficient time for replenishment and reinforcing resilience in the face of unforeseen events.

Surge Testing and Disaster Preparedness
The Emergo Train System ® is recognised as a valuable tool for evaluating the disaster management capability of hospitals and other emergency response agencies by simulating mass casualty scenarios.While it aids in identifying weaknesses and implementing targeted improvements, challenges persist in accurately gauging resource needs during simulations.This underscores the ongoing need for technological advancements to enhance the precision and effectiveness of such training exercises.

Automation in Inventory Management
Traditional inventory management relies on manual processes and can often lead to inefficiencies and inaccuracies.Automated inventory management systems and artificial intelligence (AI) technologies such as "Just Walk Out technology" can potentially revolutionise resource management in healthcare [24].Moreover, automated tracking of consumables can enable real-time updates on availability and prompts for reordering when stocks are low.Such systems can also provide valuable insights into resource utilisation patterns and facilitate optimisation.

Limitations and Future Directions
This study utilised simulated patients (albeit using data from matched patients), which may not fully reflect the true resource utilisation in managing simultaneous arrivals of multiple burn victims.Whilst having a small sample size increases the margin of error of the actual resource utilised, the study highlights the substantial resource demands inherent in responding to a burn mass casualty event.For a more precise prediction of resource requirement, comprehensive data on all admissions need to be acquired and analysed to be able to develop a more robust prediction model.Notably, this undertaking need be executed at individual centres as different facilities will possess varied management routines and consumable requirements.
The identified challenges underscore the importance of robust resource planning strategies for effective disaster preparedness and response.The study's significance lies not only in its immediate applicability to our centre but also in its potential to inform broader disaster management practices.
Additionally, exploring innovative approaches to resource management, such as predictive analytics and AI, holds promise for enhancing preparedness in burn mass casualty events.

Conclusions
This is, to the best of our knowledge, the first study to reflect the substantial material and staff consumption required in the first two weeks of management in a burn mass casualty event.The findings hold particular relevance within the current logistical landscape characterised by persistent funding shortages, the transition from local stock supplies to on-demand delivery and the consolidation of a system where only a handful of international producers supply specific fundamental resources.This research forms part of a broader investigation with the aim to delineate the number of staff and consumables for the subsequent weeks and months following a mass burn casualty incident.

Institutional Review Board Statement:
The study was performed in accordance with the ethical principles for medical research involving human subjects that have their origin in the updated Declaration of Helsinki, and the study was approved by the Swedish Ethical Review Authority approval no: 2022-05457-01, approved 7 December 2022.The need for informed consent from each participant was waived since this was a retrospective observational study of resources and consumables used for the patients' care without patient specific interventions.

Informed Consent Statement:
The need for informed consent from each participant was waived since this was a retrospective observational study of resources and consumables used for the patients' care without patient specific interventions.

Data Availability Statement:
Underlying data can be obtained by contacting the senior author: fredrik.huss@akademiska.se.

Conflicts of Interest:
The authors declare no conflicts of interest.

Table 3 .
Example of consumables/resources used.

Table A1 .
Complete list of consumables and human resources used.