Introduction: Burn mass casualty incidents (BMCI) produce a sudden surge of burn-injured patients that will stress healthcare resources, including supplies, space, and experienced workforce. Existing guidelines for standard of care and catastrophic circumstances fail to account for contingency and crisis situations. This work attempts to align existing data with recommendations of the Committee on Crisis Standards of Care for the Institute of Medicine, National Academies of Sciences.

Methods: The Triage Tables- Seriously Resource-Strained Situations (Version 2), derived based on data from the National Burn Registry, and literature from various burn disasters regarding triage methods were reviewed. Using discussion with a multidisciplinary team of burn experts, four new triage tables were developed to assist secondary burn center triage during disasters. These prototype tables were tested in a burn mass casualty functional exercise.

Results: We created four tables that were designed to sort patients into three triage categories: 1. Outpatient status or non-burn center with burn center consultation for patients with ABA referral criteria; 2. Burn center; 3. Expectant care or secondary triage awaiting further resources. The category assignment was based on age and burn size. The first three tables align with the National Academies guidelines; (Conventional, Contingency, and Crisis Care). However, Comparing the known resources of approximately 2000 burn beds (all of the capacity of the American burn care system in conventional care) to the patient needs predicted by the current national disaster planning scenarios, we recommend dividing crisis care into a lower order and higher order (adding a fourth echelon at least when burn injuries are considered) to reflect the profound gap between current capacity and potential demand in certain scenarios. The burn care community, calling on all burn centers, could manage approximately 2000 patients if time permits (up to 120 hours) and transportation resources exist to initially treat and redistribute the patients to centers across the US. While crisis care may be the standard at the onset of an incident with 2000 patients, over the coming days, as patients are treated and distributed, surge equilibrium is reached, and the standard reverts to contingency or conventional care. We identified this higher-order event as catastrophic care which would be an austere environment for a prolonged period. Most every scenario can be addressed by conventional, contingency, and crisis care standards. However, there are rare but real scenarios that exist and led us to this conclusion.

Conclusions: The use of the triage tables added clarity to the triage process during a burn surge MCI exercise. Applicability to Practice: The use of Crisis Standard of Care Burn Triage Tables could potentially improve resource utilization during disasters.

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