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
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
Morgan County
West Liberty, KY
Only two HVAC units can be saved.
ER Entrance
Clinic
Lobby area
Patient Room
Exterior
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 Health
Operations 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 Form
Disaster-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
2. Facility type (info source): Please check one that best
1.Type of disaster:
applies.
 Hurricane (name_______________)
 Hospital  LTC
 Shelter providing medical care
 Heat wave
 Other (specify)_____________________
 Tornado
 Winter Storm
If Hospital or LTC: Is the facility operational?
 Technological disaster
 YES
 NO
 Flood
Is the facility on Diversion?
 Terrorism
 YES
 NO
 Earthquake
 Other (specify)________
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:
4. Contact person (informant) at facility:
Facility Name:______________________________
Name________________________________________
Street _____________________________________
Phone number_________________________________
County/parish_________________
Email Address_________________________________
State_______
Part II
Aggregate Injury Information
5. Total number of patients with disaster-related
7. Number transferred to this facility ______
injuries: ________
From:____________________________________________
6. Severity of Injuries Counts:
8. Number transferred from this facility ______
Life Threatening: ________
Serious: ________
Minor: ________
Deaths:________
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) _____/_____/______
Form v1.1
Rev.03/3/2012
12. Name of person submitting:
___________________________________________
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
Fri
MAR
3
Sat
MAR
4
Sun
MAR
5
Mon
MAR
6
Tues
MAR
7
Wed
MAR
8
Thurs
MAR
9
Fri
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 forms
3/2
3/3
3/4
3/5
3/6
3/7
3/8
F
Sa
Su
M
T
W
Th
Long-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)
3 (1)
43 (21)
5 (2)
77 (38)
35 (17)
15 (7)
25 (12)
203
Total
Type of Facility
Total
Surveillance Findings
Table 2. Frequencies of storm-related injuries by severity
3/2
3/3
3/4
3/5
3/6
3/7
3/8
Total
F
Sa
Su
M
T
W
Th
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%)*
31
92
18
13
0
2
2
158
Injury Severity
Total
* 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
Not everything went as planned
HPP Region 8 Supply Trailer at Morgan County Appalachian
Regional Hospital
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
56
Contact Information
Doug Thoroughman
Kentucky Department for Public Health
Phone: (502) 564-3418 x3562
Email: douglas.Thoroughman@ky.gov
57
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
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
•Prescription Assistance Program