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Theroleofpreliminaryhospitalsinthe managementofamass
burncasualtydisaster
Ling-Wei Kuo a, Cheng-I Yen b, Chih-Yuan Fu a,*, Chun-Hao Pan c,

Chih-Po Hsu a, Yen-Chang Hsiao b, Chi-Hsun Hsieh a, Yu-Pao Hsu a

a Chang GungMemorial Hospital, Trauma and Critical CareCenter, Linkou, Taoyuan, Taiwan b Chang Gung
MemorialHospital, Burn Center, Linkou, Taoyuan, Taiwan
c Chang GungMemorial Hospital, Department of Plastic &Reconstructive Surgery, Keelung, Taiwan

articlein fo deeperburns on greater than 40% of the total bodysurface area (TBSA). Questions were raised regarding whether these
victims were sent to the appropriate hospitals or not. Therefore, we analyzed the effect of the initial admission
destination inthis study.
Article history: Material and methods: We retrospectively reviewed all of the victims from the explosion who were sent to the
Accepted 30 November 2017 emergency department of Linkou and Keelung Chang Gung Memorial Hospitals. Patients were divided by direct
Available online xxx admission and received via transfer. The basic demographics, the efficacy of the initial resuscitation and the clinical
outcomes were analyzed.
Results:In total, forty-sixpatients were included. Thirty-five of them were primarily admitted, and eleven ofthem were
Keywords: received via transfer. Between the two groups, there was no significant difference in the resuscitation outcome. The
Burn ratio of delaying intubation was similar (14.3% vs 27.3%, p=0.322). The rate of delayed-detected ischemic events was
Mass-casualty significantlyincreased in the referral group (0% vs 27.3%, p=0.001). However, there was no amputation event in either
Disaster group. Nodifference in mortalitywas observed between groups (5.7% vs9.1%,p=0.692).
Pre-hospital Conclusion: Our preliminary findings suggest that local hospitals are capable of providing high-quality acute care to
Patient distribution Scene mass casualtyburn victims.Ourresultssuggestthatpatients with suspected limbischemiashouldbe rapidlytransferred
triage to a regional burn center to ensure optimal care. Systemic pre-planning such as employing telemedicine and personnel
ab stract collaboration, should be considered by the administration to maximize the function of preliminary hospitals in burn
care.
© 2017 Elsevier Ltd and ISBI. Allrights reserved.
Purpose: The Formosa Fun Coast
explosion is an internationally-

*Correspondingauthorat:ChangGungMemorialHospital, Linkou, Trauma andCriticalCare Center, No. 5, FuxingSt.,GuishanDist., Taoyuan333, Taiwan.

E-mailaddress:fucy@cgmh.org.tw(C.-Y. Fu).
https://doi.org/10.1016/j.burns.2017.11.014
0305-4179/©2017 Elsevier Ltdand ISBI. Allrights reserved.
known event that occurred in 1. Introduction
Taiwan on June 27th, 2015. The blast
involved 495 casualties in total, with
A mass burn casualty disaster (MBCD) is defined as a catastrophic event in which the number of burn victims
253 patients receiving2nd degree or
exceeds thecapacityofthelocalburncentertoprovideoptimal burn care[1]. Although rarein civilian settings, an

Please citethis article in press as:L.-W. Kuo, et al., Therole ofpreliminaryhospitalsinthe management ofa mass burn casualty disaster, Burns (2017),
https://doi.org/10.1016/j.burns.2017.11.014
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MBCD poses an extreme stress to A review of published studies found that some of the data suggested that direct admission to a burn center or
the pre-hospital rescue and health transfer after admitting the patients to preliminaryhospitals does not affect the outcomes of burn victims [3–5],
service system. To minimize whereas other studies suggested that admission topreliminaryhospitals may behazardous[6,7]. However, allof
morbidity and mortality, an these studies were based on longitudinal data acquired over multiple years and were not focused on a single
MBCD requires advanced mass-casualtyevent. Furthermore, many countries havedeveloped massburn casualtyplans,and many ofthese
nationwide planning before the nationwideguidelines recommend sendingburn patients tolocalhospitals first[1,8–10],butnostrongstatistical
disaster event by allocating evidencesupportsthispractice. Therefore, whetherinitial patientdestination hospitalinfluences theoutcomeof
limited resources by the burn patients in an MBCD is still not fully clarified, and we analyzed the effect of the initial admission choice in
government administration. thisstudy.
The Formosa Fun Coast (FFC)
explosion, also known as the
Baxian explosion incident, is an
2. Materialsand methods
internationally known event that
occurred in northern Taiwan on
This is a retrospective single-center study. All of the victims from the FFC explosion who were sent to the
June 27th, 2015. A blast ignited by
emergency department (ED) of Linkou Chang Gung Memorial Hospital (CGMH LK) or Keelung Chang
colored starch powder turned a fun
GungMemorialHospital(CGMH KL) werestudied. CGMH LKisthelargest level 1 trauma center in Taiwan,
party at the water park into a
with a 21-bed burn unit and an additional plastic surgery intensive care unit (ICU) of 20 beds that serves as a
disaster involving 495 casualties.
reserve for the burn unit when supplementary beds are needed. CGMH KL is a level 1 trauma center on the
In total, 253 patients received 2nd
northern coast of Taiwan with a 2-bed burn unit and a surgical ICU of 16 beds that serves as reserve for the burn
degree or deeper burns on greater
unit. The geographic location is presented in Fig. 1. The burn units in the two hospitals both fulfilled the
than 40% of the total body surface
requirements of the Joint Commission ofTaiwan (JCT) and the Ministryof Health and Welfare (MOHW), and
area (TBSA), and 32 patients had
all patient care was integrated by board-certified burn surgeons. The patients sent to our hospital, primary or
such burns on greater than 80% of
referral, were all managed under the American Burn Association (ABA) practice guidelines for burn care [11].
the TBSA [2]. Similar to other
Patient injuries were assessed immediately, and burn surface area and depth were diagnosed by both
countries, burncenters arescarcein
emergencyroomphysicians and plasticsurgeons.
the medical service system in
Anesthesiologists were called upon in the ED for airway management. After injuryclassification, patients
Taiwan, and many of these patients
were transferred to different surgical wards based on injury severity. All of the patients who were admitted
were sent to preliminary care
primarilyvia ourED reachedthe ICUor ward within6h aftertheincident. Patients admitted tothe ICUreceived
hospitals for initial resuscitation
resuscitativeprocedures within 3h ofarrivaltotheED. TheParkland formula was used forfluid resuscitationin
before referral to burn centers for
all patients [12]. Patients who met the ABA burn center referral criteria [13] were included in the analysis, and
definitive care. As a consequence,
those with minor burns who did not meet the criteria above were excluded. Patients were further divided into
many questions were raised
those whowere directlyadmittedtotheregionalburncenterand thosewereinitiallyadmittedtoa localhospital
regarding whether these victims
and subsequently transferred to the regional burn center. Basic demographics including age, body weight
were sent to the appropriate
(BW), totalbody surfacearea (TBSA)of burn,thepresenceofinhalationburn, and therevised Bauxscorewere
hospitals.
analyzed. Multiple clinical parameters, including vital signs, acid-base status, electrolyte imbalance, and

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Fig. 1 – The geographic relationship among FFC, CGMH LK, and CGMH KL. FFC=Formosa Fun Coast. CGMH LK=Linkou Chang Gung Memorial Hospital.
CGMHKL=KeelungChangGungMemorialHospital[33].
JBUR 5430 No. of Pages 7

bu r ns xxx ( 2 01 7) xx x– x xx 3

renal function, were also IBM SPSS Version 22.0 (IBM Corp. Released 2013. IBM SPSS
considered. Clinical outcomes Statistics forWindows, Version 22.0. Armonk, NY: IBM Corp.).
of limb ischemic events, delayed
intubation, and mortality were
calculated.
3. Results
All lab data were acquired
from the first blood test drawn In total, weadmitted60patients fromthebeginningofthe explosion (20:32, June27th,2015)to18:33 onJuly2nd,
24h after the explosion to reflects 2015. Forty-nine patients were sent to our ED. Of these patients, twelve did not meet the ABA criteria (seven of
the adequacy of fluid these patients were admitted to the regular ward, and the remaining 5 patients were discharged from the ED).
resuscitation during the first 24h Another two patients who were admitted to the burn unit were later transferred to hospitals near their residence
under the Parkland formula. (one to Hsinchu, Taiwan, and the other to Japan) according to the will of the patient and family. Therefore, these
Ischemic events were defined as patients were excluded from this study. Eleven patients fulfilled the ABA criteria and were transferred from
compromised limb perfusion other hospitals with a previous treatment course (eight to LK, 3 to KL). Finally, 46 patients were included in this
undergoing surgical analysis. Thepatientdistribution is presented in Fig. 2.
intervention beyond 48h fromthe Overall, the mean age of these patients was 23.1 years. The mean burn TBSA was 49.89%, and the mean
explosion incident [14]. revised Baux score was 81.83 (Table 1). Table 2 presents the basic demographics between the direct admission
Inotropic and vasopressor use group and thetransferred group, and nostatisticallysignificant difference was observed between the2 groups.
was defined as the need for an
In Table 3, the clinical parameters and the outcome of the two groups are compared. No significant
inotropic or vasopressor agent at
differences in vital signs, acid-basestatus, and electrolytes weredetected. The urineoutput andcreatininelevels
the 25th hour–48th hour or the were similar. No differences were detected in the incidence of delayed intubation and mortality rate. However,
first 24h after admission to our the incidence of ischemic limb events was significantly increased in the transferal group, whereas amputation
hospital. Delayed intubation was not used in eithergroup.
was defined byanyintubation not
performed upon first arrival at the Table1 – Generaldemographics ofmajorburn victims fromtheFormosa
Fun Coast explosion that weresent to ourinstitute.
ED, regardless of the initial
hospitaldestination.
The demographic and Variables Allpatients (N=46)
clinical variables and the
outcomes between the direct
admission group and the
transferalgroup werecompared.
For statistical analysis, we used
theChisquaretest and Student’sT
test where appropriate. We
performed statistical analysis
usingthesoftwarepackages of
1 1

Please citethis article in press as:L.-W. Kuo, et al., Therole –Patientdistribution

Fig.of2preliminary hospitalsinin current
the study. ofa mass burn casualty disaster, Burns (2017),https://doi.org/10.1016/j.burns.2017.11.0
management
JBUR 5430 No. of Pages 7
4 b ur n s xxx ( 20 17 ) xxx – xx x
Age (year)
Gender, no. (%)
Female 24 (58.7%) Male
TBSA (%)
Body weight (kg)
Revised Bauxscore
Admissionroute, no. (%)
Primaryadmission
Via transfer
Values are presented as the meanSD.
4. Discussion
Mass burn casualty disasters are
rarely encountered in civilian
settings. When such events occur,
turmoil is inevitable in the
emergency medical service (EMS)
system because burn care is time
sensitive and resource demanding.
The ideal management for such
events should involve a well-
established central command
system that can integrate
communication among command
and control elements, triage
stations, receiving hospitals and
regional burn centers. However,
this coordination maynot be easyto
accomplish, especially in
developing countries, in response
to terrorist attacks, or in combat
zones [15]. A potentially
challenging dilemma involves
whether the patient should be sent
to a regional burn center directly or
to local hospitals within the region
for first aid and subsequently
transferred to a burn center for
definitive treatment when
appropriate. It is straightforward to
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presume that major burn victims should be sent to burn centers given that local hospitals may not be able to
23.16.77
respond to such patients appropriately. However, it is impractical to send all the patients in an MBCD to burn
centers, and evidence has demonstrated that over-triage can result in the loss of potentially salvageable lives in
18 (41.3%)
this setting [16]. Therefore, scene triage for proper patient distribution is an important issue for survival. Public
49.8917.46
disputeonthisissuehasbeen raised inthemediaandamongmedicalprofessionals[17].Thedata fornon-disaster
60.213.51
burn patients are conflicting in published studies, especially mass-casualty situations. Therefore, we
81.8321.77
conducted a retrospective study to clarify the issue. To our knowledge, this is the first statistical analysis
regarding patienttransportand transferin a singleMBCD.
35this
In (76.1%)
study, we set the time point as 24h after the incident for evaluating the results of initial management
11
because(23.9%)
most of the life support procedures are performed in the first 24h. Resuscitation according to
Parkland’s formula is one example. Although many newer resuscitation methods have been proposed,
Parkland’s formula remains the most universally accepted fluid administrating protocol [18]. In addition,
resuscitation under Parkland’s formula is a progressive and dynamic process, and variation might exist among
hospitals and physicians [19,20]. Therefore, the performance between local hospitals and a regional burn
centermightbedifferent. However, in thisstudy, wefound nodifferencein resuscitation
outcomebetween thelocal admission group and thetransferred group, includingvitalsigns, theuseof inotropic
agents, electrolyte balance, acid-base status, and renal function. This finding implies that the performance of
the staff at the local hospitals was similar to a level I burn center regarding the proficiency of fluid
administration.
The airway is another major issue in managing burn patients. Acute upper airway obstruction occurs in
approximately one-fifth to one-third of hospitalized burn victims with inhalation injury and is a major hazard
given the possibility of rapid progression from mild pharyngeal edema to complete upper airway obstruction
with asphyxia [21]. However, equipment and professional personnel can be scarce in mass-casualty settings
[22]. Therefore, we evaluated the incidence of delayed intubation between the local admission group and the
transferred group, as we hypothesized that manpower or resource shortages regarding airway management
might exist in local hospitals. However, no significant difference was noted. Therefore, these results suggest
that the ability to protect the airway at local hospitals was similar and not inferior to the ability to protect the
airwayat a regional burncenter.
Managing perfusion is another issue in burn treatment. Surgical decompression, such as escharotomy or
fasciotomy, is often utilised for patients with major burns. Without decompression, tissuedamage, including
muscle necrosis and peripheral nerve dysfunction, can occur. Muscle necrosis can lead to myoglobinuria,
resultingin renaldysfunction [23].
Burd et al. [24] reported that 37% of patients who underwent surgical decompression were not appropriately
treated prior to transfer in a study in 2006. Therefore, in a mass-casualty setting, we postulate the same could
occur in local hospitals. Here, we set the incidence of limb ischemic events undergoing surgical
decompression beyond the initial 48h as our outcome measurement. Although there is no consensus in the
literature, most surgicaldecompressionareconducted withinthe initial48h in ourgeneralpracticeexperience.
Burd et al. present a similarpoint ofview, statingthatit isperhapsbetter toerron thesideofdecompression inthe
earlypresentation (<12h after burn) and against decompression in the late presentation (>24h after burn) [24].
In the present study, the incidence of ischemic events after 48h was significantly increased in the transferred
group (27.3% vs 0%, p=0.001). This finding indicates that the ability to recognize the need for surgical
decompression or the abilityto perform surgical decompression is compromised in local hospitals. However,
JBUR 5430 No. of Pages 7

bu r ns xxx ( 2 01 7) xx x– x xx 5
Table3 –Primaryoutcomeafterthe1st24h ofresuscitation formajorburnpatients who were primarilyadmitted orreceived via transfer.

Variables Allpatients (N=46) p-value

Primaryadmission (N=35) Received via transfer(N=11)

Generalcondition
7.383 7.348
SBP (mmHg) 127.619.42 131.625.51 0.580 pH 0.503 0.777 0.182 Base excess 4.403.52 3.916.13 0.804

Inotropic use no. (%) 0.624

Yes 10 (28.6%) 4 (36.4%)
No 25 (71.4%) 7 (63.6%)

Resuscitationstatus
Creatinine (mg/dL) 0.670.476 0.550.168 0.413

Na imbalance, no. (%) 0.267

Yes 28 (80%) 7 (63.6%)
No 7 (20%) 4 (36.4%)
K imbalance, no. (%) 0.186
Yes 10 (28.6%) 1 (9.1%)
No 25 (71.4%) 10 (90.9%)

Airway management
Delayed intubation, no. (%) 0.322
Yes 5 (14.3%) 3 (27.3%)
No 30 (85.7%) 8 (72.7%)

Morbidity and mortality

Limb ischemia event, no. (%) 0.001
Yes 0 (0%) 3 (27.3%)
No 35 (100%) 8 (72.7%)
Mortality (N) 0.692
Yes 2 (5.7%) 1 (9.1%)
No 33 (94.3%) 10 (90.9%)

Na imbalance=serumsodium<136mEq/L or>145mEq/L; K imbalance=serumpotassium<3.5mEq/Lor>5.0mEq/L.

after transfer to our hospital,
these patients were managed in a
timely manner, and amputation
was not done for any patient.
Finally, the mortality rate was not
different between the two
groups.
In general, we conclude that
the performance of local
hospitals was not inferior with
respect to initial resuscitation
and airway management, which
are the two most fundamental
elements for acute care of burn
patients [25]. This finding also
led to a similar mortality rate
between the transferred group
and the local admission group for
the end outcome. The ability of
surgical decompression is in
question for the local hospitals in
Taiwan in this event, and it
reflects the clinical scenario of a
shortage of certified surgeons
and emergency physicians in the
local hospitals [26,27].
However, when transferred to a burn center in a timely manner, this can be compensated by the high quality of
care in the second-line centers, along with the assistance from the health administration in Taiwan.
Immediately after the blast, the MOHW activated its two Regional Emergency Medical Operation Centers,
notifying all emergency designated hospitals to recall their medical personnel and prepare for mass burn
casualties. Also, theMinistryassisted incollaboration with thehospitals to set up on-site medical stations, and
urged local health departments to ensure that all burn units and intensive care units under their jurisdictions
were well-prepared for the injured. In addition to telephone contact, the administrative staffs of the Ministry
werestationedintheofficewithin2hof theblastforreal-timemonitoringofmedicalresource utilization, andto
speed the control of casualties [28]. Nevertheless, further action can be taken by the administration to enhance
the performance of the local hospitals in burn care, such as telemedicine and inter-institutional personnel
collaboration that have shown benefits in many countries [29– 32]. For example, the plastic surgery alumni
from CGMH helped with patient debridement and provided second opinions at four local hospitals [12], and
we are looking to the administrative to offer more official guidance to conduct such collaboration to form a
closerbondagebetween regional burncenters and localhospitals.
The limitations of this study include its retrospective design and small sample size. Importantly, our sample
was too small todetect differences in relativelyrare events such as mortalityor amputation duetolimb ischemia.
Also, this is a single institutional study, which may not reflect the patients admitted to other burn centers and the
patient who were not transferred to burn centers. We have initiated a multiinstitutional study to discover more
facts ofthe event. Another shortcoming is that thehomogeneityof CGMH LKand CGMH KLin burn care could
not bestatisticallyevaluated inthisstudy and might beapotentialconfoundingfactorin ouranalysis. In addition,
the management of these patients in the subacute stage was not considered in the analysis and may lead to
differences in mortality.

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5. Conclusion
Local hospitals may be capable of
providing high quality acute care
for burn patients in an MBCD
incident. As long as a hospital is
equipped with experienced critical
care staff who can provide
appropriate fluid resuscitation and
airway management, it can be
considered to be a primary site for
initial management in an MBCD
incident. Based on our analysis,
systemic pre-planning such as
employing telemedicine and
personnel collaboration, should be
considered by the administration
to maximize the function of local
hospitals in burn care.
Authorcontributions
Ling-wei Kuo and Chih-Yuan Fu
conceived the study and designed
the study. Cheng-I Yen was in
charge of the data collection of the
burn unit of Chang Gung Memorial
Hospital, Linkou. Chun-Hao Pan
was in charge of the data collection
of the burn unit in Chang Gung
Memorial Hospital, Keelung.
Chih-Po Hsu conducted the data
collection in the emergency
department in both hospitals. Ling-
wei Kuo, Cheng-I Yen, and Chih-
Yuan Fu undertook recruitment of
participating centers and patients
and managed the data, including
qualitycontrol. Yen-Chang Hsiao
and Yu-Pao Hsu provided
statistical advice on study design
and analyzed the data. Chi-Hsun
Hsieh added great opinion during
the revision and collected the
statistics from the official. Ling-
wei Kuo and Cheng-I Yen drafted
the manuscript, and all authors
contributed substantially to its
revision. Chih-Yuan Fu takes
responsibility for the paper as a
whole.
Conflict of intereststatement
Dr Ling-Wei Kuo, Dr. Cheng-I
Yen, Dr. Chih-Yuan Fu, Dr. Chun-
Please citethis article in press as:L.-W. Kuo, et al., Therole ofpreliminaryhospitalsinthe management ofa mass burn casualty disaster, Burns (2017),https://doi.org/10.1016/j.burns.2017.11.01
Hao Pan, Dr. Chih-Po Hsu, Dr. Yen-Chang Hsiao, Dr. Chi-Hsun Hsieh, and Dr. Yu-Pao Hsu declare that we and
our institutes did not receive payment or service from a third party at any time during the study. We do not have
relevant financial relationship with a third party outside the submitted work either. No patents nor copyrights
were related to the submitted work. No other relationships present a potential conflict of interest. Dr Ling-Wei
Kuo, Dr. Cheng-I Yen, Dr. Chih-Yuan Fu, Dr. Chun-HaoPan, Dr. Chih-PoHsu, Dr. Yen-ChangHsiao, Dr. Chi-
Hsun Hsieh, and Dr. Yu-Pao Hsu havenothingtodisclose.
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