On the Fly Injury Surveillance: Tracking Injuries in a Kentucky

Tornado Outbreak

Doug Thoroughman, PhD, MSCAPT, USPHS

CDC Career Epidemiology Field OfficerKentucky Department for Public Health

October 25, 2012

National Weather Service Warnings

March 2, 2012• High Risk of Severe Weather • Significant Severe Weather Outbreak

expected across– Much of central Kentucky – South central Indiana...

• Potential for long-track/strong tornados. • Schools and businesses closed early

Background

Situation Report

Eastern Kentucky Tornados

West Liberty, KY

Damage Extensive• 650 homes completely destroyed

• 1,600 homes damaged

• 24 fatalities – 22 directly related to storms

• Communications and power out in affected areas

• >$10 million in federal disaster assistance

• 23 counties declared disasters

West Liberty, KY

Only two HVAC units can be saved.

Morgan CountyWest Liberty, KY

Lobby area

ClinicER Entrance

Exterior

Patient Room Interior Hallway

Parking Lot

West Liberty, KY

West Liberty, KY

West Liberty, KY

West Liberty, KY

West Liberty, KY

West Liberty, KY

Public Health Preparedness• KY Department for Public Health (KDPH)

– Preparedness focus since 2002• Funded through federal grants• Preparedness aggressively pursued • Experience with previous responses

– Ice Storm– Hurricanes Katrina, Gustav, & Ike– H1N1

– Public Health Preparedness (PHP) Branch • Exists to prepare for and managed public health

responses• Works closely with epidemiologists

Preparations

Friday, March 2• Set up Department Operations Center

(DOC)• Put initial ICS responders on alert• Created draft staffing plan• Had representative at State EOC• PHP staff kept abreast of situational

reports coming in from media and state sources during the afternoon and evening

Event Starts for Public Health• DOC Activated 8:00 pm• State EOC gives DPH mission requests:

– Get information on mortality– Get information on injury– Get situational awareness on medical

capacity and patient tracking– Get it NOW!

• State Epidemiologist calls 10:42 pm• Arrive at DOC just before midnight

Kentucky Department for Public HealthOperations Center

Why do Injury Surveillance?• First question I asked State Epi• “Governor’s office wants to know impact”

– Injuries– Death

• Situational awareness– Do we need to request federal assistance?

• DMAT, RDF, APHT teams, Federal Medical Station– Do we need additional clinical resources?– Are all hospitals functioning and/or diverting

pts due to overwhelming numbers of injured?

Public Health Surveillance• What is “Surveillance?”

– The “ongoing systematic collection, analysis, and interpretation of outcome-specific data for use in the planning, implementation and evaluation of public health practice

– I.e., collecting information regularly on morbidity and mortality

• How do we usually do it?– Lab reporting– Clinician Reporting– Hospital and other data gathering sources

How to do Injury Surveillance?• No standard way to collect injury data

– Needed standard tool to collect data– Needed method to get data from local areas

to state• What resources did we have?

– Other disaster data collection tools• Shelter surveillance forms• Mortality report forms• Environmental inspection forms

Developing a System• Tool: Settled on revamping Disaster

Mortality Report form– Developed by CDC for mass casualty reporting– Had most fields needed– Could be quickly revised and distributed

• Method: Regional Epidemiologists take lead in their area– Established relationship and knowledge base– Not immediately needed for direct response– Familiar with local medical establishment

Process• Draft data collection form created by 0300

– Sent for review to colleagues– Back on it by 0730 hrs

• Just in time training at 1100 hrs• Reviews/revisions complete and form

final by 1300 hrs, Saturday, March 3• Distributed to Regional Epidemiologists

1330 hrs with data collection methods• Reports begin arriving that afternoon

Data Collection FormDisaster-related Injury Surveillance Form

Complete the form for all known injuries related to a disaster: This information should be obtained from hospitals, LTC, or shelter administration. Please, complete one form per facility. Submit completed form daily

to KY Department for Public Health via Fax (502-564-0477). For questions phone (502-564-3418).

Part I General information 1.Type of disaster: Hurricane (name_______________) Heat wave Tornado Winter Storm Technological disaster Flood Terrorism Earthquake Other (specify)________

2. Facility type (info source): Please check one that best applies. Hospital LTC Shelter providing medical care Other (specify)_____________________ If Hospital or LTC: Is the facility operational? YES NO Is the facility on Diversion? YES NO

Are there any unconscious/non-communicative patients that still need to be connected with family members? YES NO Do you have any unidentified patients (John Smith/Jane Doe) YES NO

3. Facility:

Facility Name:______________________________

Street _____________________________________

County/parish_________________ State_______

4. Contact person (informant) at facility:

Name________________________________________

Phone number_________________________________

Email Address_________________________________

Part II Aggregate Injury Information 5. Total number of patients with disaster-related injuries: ________

6. Severity of Injuries Counts:

Life Threatening: ________ Serious: ________ Minor: ________ Deaths:________

7. Number transferred to this facility ______

From:____________________________________________

8. Number transferred from this facility ______

To:_____________________________________________

9. Number patients from out-of-state transported to

facility ______

10. Breakdown of Mechanism or Cause of Injuries (number of patients in each category) _____ Drowning _____ Electrocution _____Lightning _____Motor Vehicle occupant/driver _____ Fall _____ Structural collapse _____Pedestrian/bicyclist struck by vehicle _____Firearm/gunshot _____ Cut/struck by object/tool _____Suffocation/asphyxia _____ Burns (flame or chemical) _____ Extreme heat (e.g., hyperthermia) _____ Extreme cold (e.g., hypothermia) _____ Other (specify)___________________________________________________________________________ _____ Unknown cause of injury Poisoning/toxic exposure: (If any, has facility had to activate decontamination equipment? YES NO) _____ CO exposure _____ Ingestion of drug or substance _____ Inhalation of other fumes/smoke, dust, gases _____ Other Poisoning (specify) ___________________

11. Date of report completed: (MM/DD/YY) _____/_____/______

12. Name of person submitting: ___________________________________________

Form v1.1 Rev.03/3/2012

Next Problem!• How do we put the data together?• Needs to be quick, simple, easy to fill out

and return• DOC Epi Team worked on issue

simultaneously• Decided on dual method:

– Excel spreadsheet distributed to Epi’s • To be filled in electronically • Returned electronically to DOC daily

– Paper form faxed back to DOC daily also

Injury Surveillance Operation

Patient seen in emergency room

Injury Surveillance Operation

Patient seen in emergency room

Injury Surveillance Operation

Patient seen in emergency room

Injury Surveillance Operation

Patient seen in emergency room

Injury Surveillance Operation

Patient seen in emergency room

Injury Surveillance Operation

Patient seen in emergency room

Injury Surveillance Operation

Patient seen in emergency room

Injury Surveillance Operation

Patient seen in emergency room

Ongoing Process• Regional Epi’s to coordinate locally

– Go to sites daily and get information• Hospital ER’s• Prominent doctors who might treat injuries

– Call and get it from sites– Provide form to sites and let them submit

• Back to Epi • Or fax to state directly

• Data to flow to DPH DOC• DOC posts data to State EOC Governor

Overall Hospital Reporting Difficulties

• Hospital data systems down• Hospital staff in crisis themselves

– Working since tornados struck– Own families affected– Many staff missing– Shift changes lost all continuity for data

collection• Confusion on what to report daily

– All current patients– Or only new patients

Case Definition Issues• What counts as “tornado-related” injury?

– Only physical injuries?– What about exacerbation of chronic

conditions?– Stress-related injuries?

• Clean-up injuries• Occupational injuries due to fatigue

– What about non-direct effects?• Heart attack in elderly person the day after the

tornado• Prescription drug overdose due to

anxiety/stress/depression

Electronic Data Management• Started with Excel

– Each Regional Epi submitted their data electronically

– Collated at DOC• Quickly turned into a disaster

– Information lost between DOC shift changes• Tough to get all needed info to next person• Sticky notes not effective• Too many cooks in the kitchen

– Multiple persons over several days– Multiple persons even in one shift

Electronic Data Management II• Moved to new system on Day 5

– Epi Info 7.0• Designed for epidemiologic data collection• Can enter and analyze data• Easy to use• Can enter data from multiple computers in one

database• Created data entry form in Epi Info• Re-entered all data

Additional Challenges• Basic communication inconsistent

– Phones/computers down locally– Communication with some facilities occasional– Info being relayed by fax, phone, email– Multiple faxes, or methods in some cases

• Dealing with several other surveillance efforts:– Shelter surveillance– Mortality surveillance– Pharmacy tracking– Patient tracking– Pet food distribution

Timeline of Response Events

MAR 2

MAR 3

MAR 4

MAR 5

MAR 6

MAR 7

MAR 8

MAR 9

Fri Sat Sun Mon Tues FriThursWed

Fatality Management• State Coroner/ME Response Team activated• Hospital morgue and funeral homes without

power requested refrigerated body trailer• 22 fatalities + 2 non-storm fatalities• Mortality Data Management System

– Coordinated with County Coroners– Consistent fatality reports statewide – Detailed information on where victim was from

and where they actually died

Surveillance Findings

Table 1. Submitted injury surveillance forms3/2 3/3 3/4 3/5 3/6 3/7 3/8

TotalF Sa Su M T W Th

Type of FacilityLong-Term Care Facilities 0 30 1 41 24 2 22 120 (59)Hospitals 3 13 3 29 9 12 3 72 (35)Shelters/Other Facilities 0 0 1 7 2 1 0 11 (6)

Total 3 (1) 43 (21) 5 (2) 77 (38) 35 (17) 15 (7) 25 (12) 203

Surveillance Findings

Table 2. Frequencies of storm-related injuries by severity3/2 3/3 3/4 3/5 3/6 3/7 3/8 TotalF Sa Su M T W Th

Injury Severity

Minor 26 56 12 11 0 0 2 107 (68%)

Serious 2 27 3 2 0 0 0 34 (22%)

Life Threatening 1 10 1 0 0 0 0 12 (8%)*Total 31 92 18 13 0 2 2 158

* 34 (19%) out of 180 Total injuries if the 22 direct fatalities are included

Results• DPH was able to produce a workable, though

very imperfect, injury surveillance system “on the fly”

• Depended on:– Existing infrastructure– Existing data collection tools and software– Dedicated staff

• Learned many valuable lessons for future– Go to advanced software earlier– Establish needed relationships in advance of event

• EMS run data?

Results• Injury Surveillance aided in mortality

surveillance– Mortality system depends on coroners and

Medical examiners to enter data– If person is in hospital > 24 hours before

expiring, it is no longer a coroner’s case– We compared our injured patient list to a list of

recent deaths • Discovered at least one person who died as a result

of tornado-related injuries• Tracked another who died in transit to another

hospital

Evaluation Methods

Strengths• Simple

• Flexible

• Stable

• Timely

Areas for Improvement• Data Quality

• Acceptability

• Representativeness

HPP Region 8 Supply Trailer at Morgan County Appalachian Regional Hospital

Not everything went as planned

The van next to it was totaled; another trailer was last seen being lifted away by the tornado.

http://www.youtube.com/watch?v=-t16xXNhf3M&feature=relmfu

Conclusion• Successful implementation of an

impromptu injury surveillance system• Daily reports of observed injuries

– Maintained situational awareness– Improved messages promoting responder

and general public safety– Served the purpose required by State EOC

• Identified areas for improvements

Acknowledgements• Kentucky Department for Public Health

– Alex Freiman, MPH– TJ Sugg, MPH– Sara Robeson, MPH– Elizabeth Hoo, MPH, CLC– Margaret Riggs, PhD, MPH, MS

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Contact Information

Doug ThoroughmanKentucky Department for Public Health

Phone: (502) 564-3418 x3562Email: douglas.Thoroughman@ky.gov

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Questions?

Pharmaceuticals• Worked closely with Kentucky Pharmacists

Association• Governor Beshear signed Emergency Order for

emergency refills– For pharmacies in declared counties – 30 day supply for non-controlled/non-scheduled drugs

without a prescription– Information conveyed to all pharmacies across the

state• Assured that access to pharmacies was available

• Worked closely with Kentucky Pharmacists Association

• Governor Beshear signed Emergency Order for emergency refills

• For pharmacies in declared counties • 30 day supply for non-controlled/non-scheduled

drugs without a prescription• Information conveyed to all pharmacies across the

state• Assured that access to pharmacies was available• Prescription Assistance Program

Pharmaceuticals