See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/283426758 Advanced Burn Life Support for Day-to-Day Burn Injury Management and Disaster Preparedness Article in Journal of burn care & research: official publication of the American Burn Association · October 2015 DOI: 10.1097/BCR.0000000000000311 CITATIONS READS 0 345 11 authors, including: Randy D. Kearns University of New Orleans Shiara M Ortiz-Pujols 34 PUBLICATIONS 160 CITATIONS 70 PUBLICATIONS 162 CITATIONS SEE PROFILE SEE PROFILE Christopher K Craig M. B. Skarote Wake Forest School of Medicine Veteran Corps of America 5 PUBLICATIONS 21 CITATIONS 8 PUBLICATIONS 41 CITATIONS SEE PROFILE Some of the authors of this publication are also working on these related projects: Smoke Inhalation, Burns, Trauma View project Burn Care Best Practices Series View project All content following this page was uploaded by Randy D. Kearns on 30 October 2017. The user has requested enhancement of the downloaded file. SEE PROFILE Advanced Burn Life Support for day to day Burn Injury Management and Disaster Preparedness; Stakeholder Experiences and Student Perceptions following 56 ABLS courses. Manuscript – Original Research Targeted Journal: Journal of Burn Care and Research Randy D. Kearns, DHA MSA Program Director, North Carolina Burn Disaster Program Administrator, EMS Performance Improvement Center University of North Carolina School of Medicine Shiara M. Ortiz-Pujols, MD Burn Clinical Research Fellow University of North Carolina Christopher K. Craig, MMS, PA-C Senior Physician Assistant WFBMC Burn Center Wake Forest University Baptist Health System Mary Beth Skarote, NREMT-P, LPN North Carolina Office of EMS Healthcare System and Hospital Preparedness Program Coordinator James R. Gusler, NREMT-P, BSPH Program Coordinator, Burn Education and Certificate Programs University of North Carolina School of Medicine Jeffery Carter, MD Burn Clinical Fellow University of North Carolina School of Medicine Captain Paul Link, MSHS, BSN Field Project Officer, Region IV Hospital Preparedness Program HHS Office of the Assistant Secretary for Preparedness and Response Amy Rezak Alger, MD Assistant Professor of Surgery University of North Carolina School of Medicine Charles B. Cairns, MD FACEP FAHA Professor and Chair, Department of Emergency Medicine University of North Carolina School of Medicine Daniel Lofald, PhD Director/Associate Professor; EdD/DHSc Program University of St. Augustine of Health Sciences James. H. Holmes IV, MD FACS Director WFBMC Burn Center, Wake Forest University Baptist Health System Associate Professor of Surgery, Wake Forest University School of Medicine Bruce A. Cairns, MD FACS Director North Carolina Jaycee Burn Center John Stackhouse Distinguished Professor of Surgery/Microbiology and Immunology University of North Carolina School of Medicine Corresponding Author Randy D. Kearns [email protected] Phone (919) 843 5754 Running title: burn education Abstract Educational programs for clinicians managing patients with burn injuries represent a critical aspect of burn disaster preparedness. Managing a disaster which includes a surge of burn-injured patients remains one of the more challenging aspects of disaster medicine. During a six year period that included the development of a burn surge disaster program for one state, a critical gap was recognized as public presentations were conducted across the state. This gap revealed an acute and greater than anticipated need to include burn care education as an integral part of comprehensive burn surge disaster preparedness. Many hospital and prehospital providers expressed concern with managing even a single, burn-injured patient. While multiple programs were considered, Advanced Burn Life Support (ABLS), a national standardized educational program was selected to help address this need. The curriculum includes initial care for the burn injured patient as well as an overview of the burn centers role in the disaster preparedness community. After four years and 56 classes conducted across the state, a survey was developed including a section that measured the perceptions of those who completed the ABLS educational program. The study specifically examines questions including; did clinicians attribute perceived changes in their burn care knowledge, skills and abilities and burn disaster preparedness following completion of the program? Introduction Burn surge disaster planning activities for the state referenced in this paper evolved to include meeting a substantial burn care educational need as a component of burn surge preparedness.1 The education program selected to meet this need was Advanced Burn Life Support (ABLS).2 Thus, a critical link in disaster preparedness included burn care education for the hospital and EMS clinicians. The education profession points to the importance of measuring student perceptions as a marker to determine what may have been gained and the expertise developed by the student who attended an educational course.3-5 For this state, a consensus of the representatives for both the granting agency and the university concluded that a retrospective survey which included a student perceptions focus would provide vital insight regarding the effectiveness of this program. Several of the more often cited sources regarding the value of student educational perceptions targets on-line course experiences but reaffirm the importance of student perceptions as a critical marker in identifying successes and areas for improvement.6,7 Therefore, after completing 56 ABLS courses a comprehensive survey was distributed to those who completed one of these programs. The purpose of this paper is to examine and report the perceptions of those who completed the survey regarding the program. The survey tool included the core elements of burn care and burn disaster preparedness. Background The September 11, 2001 (9/11) attacks changed the course and intensity of medical disaster planning to include a focus on burn and trauma surge in the United States (US).8-17 What began as bioterrorism, evolved into an all-hazards approach for medical disaster preparedness.18-20 This included managing a surge of burn-injured patients as a critical component of overall medical disaster management preparedness.10,21-24 Training and education programs were critical factors for improved preparedness.25 In 2004, the Bioterrorism Hospital Preparedness Program (BTHPP) was overseen by the US Department of Health and Human Services (DHHS) Health Resources and Services Administration (HRSA).25 The US DHHS/HRSA/BTHPP required all states to develop a burn surge plan as a component of their preparedness activities. However, several states reported finding it difficult to convey a coherent message of managing multiple burn-injured patients when the general audience felt uncomfortable managing even the first burn-injured patient.1,26-31 (The BTHPP is now located in the US DHHS Office of the Assistant Secretary for Preparedness and Response (ASPR) and referred to as the Hospital Preparedness Program (HPP).32 The first year this program included offering a wide-reaching series of presentations regarding the aims for the burn surge disaster program and focused on historical burn disasters that wreaked havoc for first responders, first receivers, trauma and burn centers alike. Following these presentations, initial feedback from class participants representing a variety of clinical care settings, made clear that managing the care of a burn-injured patient must be included in the overall solution. The solution was to offer educational programs that included the care of burn injured patients in the context of overall disaster preparedness. Critical partners include emergency medical service (EMS) agencies as well as hospitals with and without burn centers.30,31,33,34 To meet the educational need, those involved with the burn surge disaster program evaluated national standardized educational programs. Key criteria for selection included; current science validated by a national stakeholder organization for the care of a burninjured patient,35 a core component involving the management of a surge of burn-injured patients, and was approved to offer the relevant educational credits recognized by the various professional organizations to include physicians, nurses, and paramedical personnel. Educational Programs used to supplement Disaster Preparedness Over the past 10 years, multiple educational programs emerged --- each containing some aspect of disaster management. While most offered a more generalized approach to disaster management, one specific curriculum met the objectives which included burn care as well as a module regarding burn disaster management.3,35,36 The American Burn Association (ABA) program, known as ABLS, was selected. Selecting ABLS was based on an analysis of the course content by subject-matter experts involved. Unfortunately at that point, the various programs evaluated, had a scarce representation in the academic literature. They ranged from an experience of using ABLS in Japan37 to the role of using ABLS for nursing staff in US burn centers.35 A similar program (to ABLS) commonly taught in Europe, Australia, New Zealand and southeast Asia - Emergency Management of Severe Burns (EMSB)38 exists, and the curricula are similar with similar objectives to include preparation for major burn events.38,39 They also had similar experiences reporting educational programs (such as EMSB) improved competence and comfort with the individual responder involved in the management of a mass casualty burn disaster.39 Aside from the aforementioned benefits seen with ABLS, other advantages were identified, including the portability of the program.37 This was essential since access demanded program delivery where the first responders and first receivers live and work. Other advantages include the use of a validated program as a means of creating consistent care of the burn-injured patient as well as the ability to enhance burn surge disaster preparedness by using ABLS courses to discuss burn care of the individual patient in the context of disaster preparedness.40 Educational Program Costs Despite the advantages noted, several concerns were also identified. The first was cost. The national certification fee for each non-physician clinician (e.g., Physician Assistants, Nurses, Respiratory Therapists, and EMS personnel) was $200. The cost for a physician was $325 (These have since increased to $225 and $350 respectively). ABLS, in terms of costs, compares unfavorably to other national programs that focus specifically on a topic such as Advanced Cardiac Life Support (ACLS), International Basic Life Support (ITLS), and Trauma Nurse Core Curriculum (TNCC). Their average cost were $50-$150 per person. While the costs varied, one key aspect for those programs included how local hospitals and EMS agencies could develop their own cadre of instructors and therefore conduct their own programs based on the national standards. This allows them to create their own program fees based on their costs. The options with ABLS are limited given the instructor requirements. These requirements include the fact that all instructors must currently work in a burn center providing care for a burn injured patient. This limitation leads to a very small potential pool of candidates for selecting instructors. It was also learned that most clinicians had little to no historical exposure to ABLS. According to the ABA, 245 NC clinicians completed ABLS between 2000 and 2007 - with the primary audience being clinicians who work in, or in support of, area burn centers. Given the fact that for this particular state, there were 60,000+ nurses who work in critical care or emergency medicine and 35,000+ EMS personnel. Thus, the participation level was vastly underwhelming. To address the ABLS costs barrier, grant funding was secured to defray a portion of the costs through a grant from the HPP.25 (The HPP was managed locally by the state EMS agency.) With the educational program chosen, the audience identified and the funding secured, the first course was offered April, 2008. By December, 2011, a total of 56 ABLS classes had been delivered statewide. Locations ranged from urban to rural communities, with classes being held in local EMS stations, fire departments, hospitals, and community colleges. The attendees included physicians, nurses, paramedics, emergency medical technicians, pharmacists, nurse practitioners and physician assistants, respiratory therapists, and other clinicians involved in the care of the burn-injured patient. Most of this group would be involved locally in the initial management of a surge of burn-injured patients or were listed in the state version for the Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP)41 and could be deployed to a community where a medical disaster occurred. Methods During the final 18 months of offering ABLS, a multifaceted retrospective survey was developed. The survey tool was developed with input from instructors and program coordinators which included a focus group activity during ABLS instructor training. The working draft was submitted to the NCOEMS32 for review and input. Based on the input from instructors, coordinators and state medical disaster officials, a final version was adopted. The final version of the survey as well as a description of the study was submitted to the university Institutional Review Board (IRB) for approval. The study: Burn Care Education Assessment, Study#: 11-1614 was granted a Determination that the research did not require IRB approval. The “Burn Education Survey” was converted from a draft paper format to an online system relying on a commercially available online survey and analysis tool.42 The final version of the survey included several sections totaling 31 total questions. A link to the survey as well as a description of the survey and its importance was distributed by email notification. For the purpose of this paper, those who received the email notification soliciting their participation included everyone who completed ABLS and had provided a valid email address at the time of participating in ABLS. The survey targeted the 1014 individuals who completed the ABLS course during the 56 classes offered over the aforementioned four-year period and had provided a working email address during the time of attending ABLS or at the time they registered in ESAR-VHP and could be matched to the ABLS rosters. There were five requests over a fivemonth period urging participation from the targeted survey population. It should be noted that there were 1382 students who completed ABLS during the 56 courses. However, during the first 18-24 months of the program, an email address was not a required field for the paper/telephone registration process used at that time. Thus, an email address was not captured, or was illegible from approximately 500 ABLS participants. However, a portion of this group was matched with names in ESAR-VHP. Therefore, of the 1382 who attended, 1014 email addresses could be identified that at some point worked either when they registered or attended ABLS or when they registered in ESAR-VHP. (It should be noted, that after converting to a web based online registration system for ABLS, RegOnline,43 a working email address was required to complete the registration.) A descriptive analysis was recorded based on the Observed results. A second set of data; the Expected Results were developed based on a 50/50 assumption. The Chi Square test for independence was used to measure the significant relationship between the two categorical variables (Observed versus Expected). Mathematically stated, where the Observed, frequency count and the Expected frequency count are represented by O and E, and r is the number of levels for one categorical variable and c is the number of levels for the other categorical value, the calculation used was: Results There were 1014 physicians, nurses, EMS personnel, and others involved in the immediate care of a burn-injured patient, who successfully completed ABLS during this four-year period and provided a working email address at the time of completing the educational program (or was matched and validated through ESAR-VHP). From this population of 1014, 52(4.9%) were returned as “undeliverable” during the first survey attempt indicating the email address was no longer valid and 20/1014 (2.0%) were delivered but the recipient of the email selected the option to opted out of the survey, leaving 942 potential respondents for survey participation. There were 526 total respondents who completed at least the Demographics Section and the Perceptions Section of the survey. Thus, the focus of this work was directed at the results from the 526 who responded to the survey, 526/942 (55.84%). The decision making process regarding those surveyed and the analysis is graphically represented in Figure 1. Certification/License/Credential, Work Environment and Participant Experience The Demographics Section of the survey for the 526 respondents represent clinical roles as graphically displayed in Figure 2. Respondents were almost equally divided when identifying their workplace as graphically displayed in Figure 3. The seven questions found in the Perceptions Section of the survey, as well as potential answers for the respondents are found in Appendix I. Fifty-two percent (52%) of the respondents reported holding their current clinical credential for more than 10 years (See Figure 4, Column 2). Seventy percent (70%) reported they had more than 10 years of experience in clinical care (See Figure 4, Column 1). Completed ABLS with Valid Email Address Assessed for eligibility (n= 1014) Excluded (n=72) Undeliverable (n=52) Declined to participate/Opted Out (n=20) Surveyed Potential Respondents (n= 942) Did not respond (n=416) Analysis Analyzed (n= 526) Actual Results Null Hypothesis Figure 1. The graphical representation of the decision-making process for how survey participants were surveyed and their responses analyzed. Figure 2. Graphic representation of participant distribution. There were more Registered Nurses (46%) than any other group who completed ABLS. There were (39%) of the participants who reported being Paramedics, with (4%) being Physicians. The balance; (11%) included all others such as Pharmacists, Midlevel Practitioners, Respiratory Therapists, Emergency Medical Technicians, Firefighters, and Physical Therapists. Figure 3. Graphical representation of the work environments for ABLS course participants. Respondents were almost equally divided when identifying their workplace; Emergency Medical Service personnel (EMS) or First Response (248/526, 49.3%) and those clinicians who worked in a Hospital (243/526, 48.3%). Overall Years in Healthcare Observed % Observed 33 0-2 Years 6.3% 102 2-5 Years 19.4% 115 5-10 Years 21.9% 276 Greater than 10 Years 52.5% Total 526 Years with Current Credential Observed % Observed 9 0-2 Years 1.7% 63 2-5 Years 12.0% 86 5-10 Years 16.3% 368 Greater than 10 Years 70.0% Total 526 Figure 4. The first column graphically represents the overall years the survey respondents have been involved in healthcare. 70% of the respondents reported being involved in healthcare as a profession, for more than 10 years. The second column graphically represents the overall years the survey respondents have held their current credential in the healthcare profession. Even so, more than half (52.5%) reported that they have held their respective clinical credential for 10 or more years. Perceptions Section 1. The respondents reported (Observed Values) the ABLS program contributed to improved greater understanding of estimating (TBSA). The Observed Values were statistically significant. (p < 0.001) as noted in Figure 5, Question 1. 2. The respondents reported (Observed Values) that the ABLS program had contributed to an improved understanding of IV fluid infusion rates for an adult burn patient to flow rates that are similar to, or consistent with, the Consensus/Modified Formula. The Observed Values were statistically significant. (p < 0.001) as noted in Figure 5, Question 2. 3. The respondents reported (Observed Values) that the ABLS program had contributed to either the respondent having changed or influenced others to change the type of IV fluid to Lactated Ringer as soon as it is available. The Observed Values were statistically significant. (p < 0.001) as noted in Figure 5, Question 3. 4. The respondents reported (Observed Values) that the ABLS program had contributed to an improved awareness for the respondent to more closely monitor or influence others to more closely monitor (and to treat) the pain management needs of a burn patient. The Observed Values were statistically significant. (p < 0.001) as noted in Figure 5, Question 4. 5. The respondents reported (Observed Values) that the ABLS program had contributed to an improved understanding of the value of using, where available, verified burn centers for burn injured patients. The Observed Values were statistically significant. (p < 0.001) as noted in Figure 5, Question 5. 6. The respondents reported (Observed Values) that the ABLS program had contributed to an improved awareness to more closely monitor or influence others to more closely assess and manage the airway with respect to the unique aspects of an inhalation injury. The Observed Values were statistically significant. (p < 0.001) as noted in Figure 5, Question 6. 7. The respondents reported (Observed Values) that the ABLS program had contributed to an improved awareness of the role burn centers, as well as other specialty centers, play in a medical disaster. The Observed Values were statistically significant. (p < 0.001) as noted in Figure 5, Question 7. Figure 5. Compares actual scores registered by the solid bars for the Perceptions reported by ABLS participants to the null hypothesis represented by the solid line. Discussion Evaluation and selection of the ABLS program relied on the stakeholders who chose the course that best met the objectives for the educational program to be selected. 4,5,36 Relying on Posner et al. offered a structured approach to evaluate the various curricula for each of the programs and their measurable objectives to be covered by the specific program. Furthermore, there is a direct link between the perceptions of the student and their aim to develop expertise and expert performance.3,6,7 It seems both intuitive and logical that the link between the perceptions of someone completing a class, and their development of expertise exists. What is known from the literature however, is the bottleneck is similar to that found in other disciplines where the “training bottleneck” is getting knowledge to the novices, in this case many of those who reported a discomfort and uneasiness with managing the care of a burn injured patients44 with outcomes first being measured through perceptions of the students who completed the educational program, in this case, ABLS.3 There are limitations when the focus is merely the perceptions of those who completed an educational program. Nevertheless, the first hurdle when demonstrating the value of an education program that had almost no use outside of the burn care community and developing expertise is to measure the perceptions of those who completed the program. The basic tenants of a burn care educational program include airway management, TBSA assessment, fluid resuscitation and pain management. Additionally, it was important to the stakeholders that key components of how the burn centers, and other specialty centers connect with the first responders and first receivers, to assure the flow of injured patients are managed appropriately and distributed accordingly in a disaster. Future research is needed to assess the effectiveness of ABLS and other similar training programs that contribute to medical disaster preparedness. For example, table-top exercises with ABLS trained clinicians will allow participants to test their skills in a simulated environment while evaluating the effectiveness of ABLS in preparing people for disaster situations. Although the data were collected in a manner that identified each year that the participants reported completing ABLS, the trends remained proportionally constant within each question across the years. The focus of the analysis will remain the seven perception questions. Nevertheless, the results clearly demonstrate that two thirds of participants perceived a benefit from the training that they received during ABLS. The benefit of ABLS may be even greater in other sub-populations of providers, such as those first responders and first receivers who manage a majority of the patients long before they arrive at a Burn Center. Nevertheless, further investigation is warranted to explore the impact of such a course on selected populations and the retention of this vital information. Two of the questions focused on intravenous fluids. The typical student attended their most recent presentation regarding burn injury in the format of a 45-60 minute lecture that was part of a trauma course. During the day long trauma program the lasting impression may lead to excessive intravenous fluid infusion in the hours between the initial burn injury and the time the patient arrives at a burn center. Thus, two key ABLS objectives include fluid infusion rates which followed the formula used at the time these classes were offered. The second question related to intravenous fluids focused on the type of fluid selected for the burn injured patient. Lactated Ringers is the preferred intravenous fluid for burn injured patients. However, that fluid is not uniformly available to all EMS agencies, most of whom will start a saline solution until Lactated Ringers is available. Thus, one aim of the program included the emphasis of either selecting the correct fluid or changing it to the correct fluid as soon as it became available. In both cases for these two questions, the respondents reported (Observed Values) that the ABLS program had contributed to an improved understanding of IV fluid infusion rates for as well as selecting the correct fluid type for the burn injured patient. The Observed Values for both questions were statistically significant. (p < 0.001). Two additional survey questions focused on patient care issues that have unique characteristics with the burn-injured patient. They include pain and airway management. Clinicians are typically unaccustomed to caring for the pain management needs of a burn injured patient given amount of medication that may be needed over the duration of the first 6-24 hours following the injury. The quantity used and the ongoing monitoring for both therapeutic effects as well as endpoints for use can be substantially different than most pain management scenarios. With airway management, complications of steam inhalation injury, smoke inhalation, or being burned in a confined space can each lead to critical airway management issues in the hours following the burn injury. Key indicators are taught in ABLS and while Blind Insertion Airway Devices (BAIDs) are more commonly used today in the prehospital environment, this remains a situation where the advanced airway selection should stay with the endotracheal tube. The two remaining questions from the perceptions section of the survey dealt with the importance of burn and other specialty centers in the planning and preparedness for medical disasters. This includes reliance on verified Burn Centers when available for burn injured patients. Burn Centers, Trauma Centers and other specialty centers can play a critical role in medical disaster preparedness and planning. Identifying where these centers are and involving them in planning, exercise and operation activities before disaster strikes, is a proactive way to improve the overall management and outcomes of the single or dozens of burn injured patients. There are challenges associated with selecting a proprietary educational program that can serve as a barrier for prospective participants who lack ongoing fiscal support. These challenges include the participant fees that must be paid to the governing body for the proprietary program, governance of how, when and where courses are conducted, and national standards for instructors that may limit local personnel participating in the instruction. Other challenges include ongoing maintenance of the credential. Given the recertification costs are the same as the initial costs and there are no current curriculum in place for recertification (other than repeating the initial course) maintaining the certification has limitations. Before the program began, clinicians reported they were far more likely to accept their role in managing multiple burn injured patients once they felt comfortable with managing one burn injured patient. It should be noted that this research confirms that a significant majority of the participants, based on their reported perceptions, are better equipped to manage a burn injured patient after completing the course than they were before attending the program. Burn Centers play a vital role in the management of a medical disaster. Another aim of the program included a discussion regarding the role of the Burn Center in the myriad of special care situations that may confront responders to a medical disaster. Knowing who to call, their role and having a better understanding of the differences between those Burn Centers who self-identify and those who are verified by an outside agency such as the ABA is also important. Conclusions The survey results offer a small yet important first step in understanding if ABLS has a value outside of the mainstream burn care profession to include the first responder, first receiver and medical disaster clinicians. Furthermore, does that value extend into managing a surge of patients with burn injuries such as in a burn disaster? These initial findings support the belief that there is role for ABLS to prepare first responders and first receivers in the care of one or many patients with a burn injury. The academic world of adult education suggests that goals for an educational program and developing expertise include the perceptions of the course participants. Course participants are more likely to retain the information and less like to abandon the core concepts when challenged by potentially conflicting information when the participant perceives/believes their learning activity was validated through later experiences. In this case, participants were questioned regarding their perceptions as it related to the core objectives for ABLS. They included: patient assessment (to include size of the burn), fluid resuscitation (rate and fluid selection), pain management, airway control, and the role of the burn center in a disaster to include where available, the use of a verified burn center. Aside from the patient care lectures, the ABLS disaster lecture also served as a conduit to link the care of one to the management of multiple patients with burn injuries and the importance of involving the burn center in medical disaster planning. This lecture also offered that final chance to connect the day to day management of a burn injured patient with the rare and episodic nature of a burn disaster. As such, it is reasonable to conclude with statistically significant data, that ABLS as a component of a broad disaster planning initiative, was perceived to be useful in managing one or many burn injured patients. These findings are preliminary and the results only examine basic topics. Nevertheless, this promising work represents the most complete examination thus far of a large scale use for ABLS in this setting and suggests a more comprehensive evaluation should be conducted. Acknowledgements It should be noted that to conduct 56 ABLS classes, it was necessary for a number of personnel to be willing to take time from their personal and work life to travel and teach these programs. The success of these classes reflects the time and dedication of more than a dozen instructors including national faculty: Ernest Grant, RN MSN, from UNC Hospitals; Katie Hollowed from MedStar and the Washington Hospital System in Washington DC; and David Thompson, RN, and retired firefighter from Erlanger Medical Center in Chattanooga, Tennessee. All of the burn surgeons in North Carolina have participated in the success of this program to include: Dr. Bruce Cairns, Dr. Samuel Jones, and Dr. James Hwang at UNC Hospitals; and Dr. James Holmes IV and Dr. Joseph Molnar at Wake Forest Baptist Health. Furthermore, contributions were made by Physician Assistants and Nurse Practitioners as well as other nursing staff. Those who taught more than 10 classes include: Derek Miller RN and Renee Edkins RN, FNP. The authors of this work who have taught numerous classes include Dr. Shiara M. Ortiz-Pujols, Mr. Christopher K. Craig, PA-C, Dr. Jeffery Carter, and Dr. Amy Rezak Alger. It should also be noted that dozens of the courses were managed by Mr. James R. Gusler. Grants and Funding This work is supported in part by the US DHHS/ASPR Hospital Preparedness Program Grant CDC-RFA-TP12-1201 through the North Carolina Office of Emergency Medical Services Contract 00027162. We would also like to acknowledge the support of our educational programs through FEMA Grant EMW-2011-FP-01131. Appendix I. The Perceptions Section of the survey included seven questions. Each question offered the answer selections of “Yes”, “No” and “Other” with other including options of “Not Applicable” or “I have not completed ABLS”. While the focus of this work was to measure the binary options of Yes/No, (“Other”) was offered to provide the respondent an opportunity to offer an alternative answer. If “Other” was selected, the survey tool forced the respondent to a narrative box and required text insertion to offer an expanded explanation for the answer selection. The seven questions from the survey tool regarding perception are: 1. In your professional opinion, are you are better prepared to estimate the size (TBSA) of the burn injury following the training/education you received in ABLS? Results are identified in Figure 5, Question 1. 2. Following the training/education you received in ABLS, have you either changed or influenced others to change IV fluid infusion for an adult burn patient to flow rates that are similar to, or consistent with, the Consensus/Modified Formula? Results are identified in Figure 5, Question 2. 3. Following the training/education you received in ABLS, have you either changed or influenced others to change the type of IV fluid infusion for an adult burn patient to Lactated Ringers Solution as soon as it was available? Results are identified in Figure 5, Question 3. 4. Following the training/education you received in ABLS, have you either changed or influenced others to monitor more closely (and to treat) the pain control needs of a burn patient? Results are identified in Figure 5, Question 4. 5. Following the training/education you received in ABLS, have you either changed or influenced others to be certain burn patients are managed at a verified burn center? Results are identified in Figure 5, Question 5. 6. Following the training/education you received in ABLS, have you either changed or influenced others to monitor more closely burn patients for inhalation injuries and to manage more aggressively airway control where indicated? Results are identified in Figure 5, Question 6. 7. Following the training/education you received in ABLS, do you have a better understanding of the role that burn centers, as well as other specialty centers, play in a medical disaster? Results are identified in Figure 5, Question 7. References 1. Kearns RD, Cairns BA, Holmes t, J. H., Sagraves SG. The North Carolina Burn Surge Disaster Plan for Emergency Medical Services and Hospitals. Chapel Hill: University of North Carolina; 2012:85. 2. American Burn Association Advisory Committee. American Burn Association Provider Manual. 2011. 3. Ericsson KA. The Cambridge handbook of expertise and expert performance. 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