1. On the Fly Injury Surveillance: Tracking Injuries in a Kentucky Tornado Outbreak Doug Thoroughman, PhD, MS CAPT, USPHS CDC Career Epidemiology Field Officer Kentucky Department for Public Health October 25, 2012

2. 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

3. Background

4. Situation Report

5. Eastern Kentucky Tornados

6. West Liberty, KY

7. 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

9. West Liberty, KY

10. Only two HVAC units can be saved. Morgan County West Liberty, KY

11. Lobby area Clinic ER Entrance

12. Exterior Patient RoomInterior Hallway Parking Lot

13. West Liberty, KY

19. 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

20. 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

21. 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

22. Kentucky Department for Public Health Operations Center

23. 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?

24. 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

25. 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

26. 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

27. 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

28. Data Collection Form

29. 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

30. Injury Surveillance Operation Patient seen in emergency room

31. Injury Surveillance Operation Patient seen in emergency room

32. Injury Surveillance Operation Patient seen in emergency room

33. Injury Surveillance Operation Patient seen in emergency room

34. Injury Surveillance Operation Patient seen in emergency room

35. Injury Surveillance Operation Patient seen in emergency room

36. Injury Surveillance Operation Patient seen in emergency room

37. Injury Surveillance Operation Patient seen in emergency room

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. Timeline of Response Events MAR 2 MAR 3 MAR 4 MAR 5 MAR 6 MAR 7 MAR 8 MAR 9 FriSat SunMonTuesFriThursWed

45. 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

46. Surveillance Findings Table 1. Submitted injury surveillance forms 3/23/33/43/53/63/73/8 Total FSaSuMTWTh Type of Facility Long-Term Care Facilities03014124222120 (59) Hospitals313329912372 (35) Shelters/Other Facilities001721011 (6) Total3 (1)43 (21)5 (2)77 (38)35 (17)15 (7)25 (12)203

47. Surveillance Findings Table 2. Frequencies of storm-related injuries by severity 3/23/33/43/53/63/73/8Total FSaSuMTWTh Injury Severity Minor26561211002107 (68%) Serious2273200034 (22%) Life Threatening1101000012 (8%)* Total31921813022158 * 34 (19%) out of 180 Total injuries if the 22 direct fatalities are included

48. 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?

49. 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

50. Evaluation Methods

51. Strengths Simple Flexible Stable Timely

52. Areas for Improvement Data Quality Acceptability Representativeness

53. HPP Region 8 Supply Trailer at Morgan County Appalachian Regional Hospital Not everything went as planned

54. 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

55. 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

56. Acknowledgements Kentucky Department for Public Health –Alex Freiman, MPH –TJ Sugg, MPH –Sara Robeson, MPH –Elizabeth Hoo, MPH, CLC –Margaret Riggs, PhD, MPH, MS 56

57. Contact Information Doug Thoroughman Kentucky Department for Public Health Phone: (502) 564-3418 x3562 Email: douglas.Thoroughman@ky.gov 57

58. Questions?

59. 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

60. 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