burns 48 (2022) 1794–1804

Available online at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/burns

Burn mass casualty incidents in Europe: A

European response plan within the European
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Union Civil Protection Mechanism

⁎
Stian Kreken Almeland a,b,c, , Evelyn Depoortere d, Serge Jennes e,
Folke Sjöberg f, J. Alfonso Lozano Basanta d, Sofia Zanatta d,
Calin Alexandru g, José Ramón Martinez-Mendez h,
Cornelis H. van der Vlies i,j, Amy Hughes k,l,m, Juan P. Barret n,
Naiem Moiemen o,p, Thomas Leclerc q
a
Norwegian National Burn Center, Department of Plastic, Hand, and Reconstructive Surgery, Haukeland University
Hospital, Bergen, Norway
b
Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Norway
c
Norwegian Directorate of Health, Department of Preparedness and Emergency Medical Services, Oslo, Norway
d
European Commission, Brussels, Belgium
e
Charleroi Burn Wound Center, Skin-burn-reconstruction Pole, Grand Hôpital de Charleroi, Charleroi, Belgium
f
Linköping Burn Center, Linköping University, Sweden
g
Department for Emergency Situations, Ministry of Internal Affairs, Bucharest, Romania
h
Burn Unit, Hospital Universitario La Paz, Madrid, Spain
i
Department of Trauma and Burn Surgery, Maasstad Hospital, Rotterdam, the Netherlands
j
Trauma Research Unit Department of Surgery, Erasmus MC, Rotterdam, the Netherlands
k
Interburns, International Network for Training, Education and Research in Burns, Swansea, Wales, UK
l
Bart’s Health NHS Trust, London, UK
m
Essex and Herts Air Ambulance Charitable Trust, UK
n
Department of Plastic Surgery and Burns, Vall d'Hebron Barcelona Hospital Campus, Universitat Autonoma de
Barcelona, Barcelona, Spain
o
University Hospitals Birmingham Foundation Trust, Birmingham, UK
p
University of Birmingham, College of Medical and Dental Sciences, Birmingham, UK
q
Percy Military Teaching Hospital, Paris, France

Abbreviations: DG ECHO, Directorate General of Civil Protection and Humanitarian Aid Operations; EBA, European Burns Association;
EU, European Union; UCPM, European Union Civil Protection Mechanism; WHO, World Health Organization
⁎
Correspondence to: Norwegian National Burn Center, Department of Plastic, Hand, and Reconstructive Surgery, Haukeland
University Hospital, Jonas Lies vei 65, 5021 Bergen, Norway.
E-mail address: stian.almeland@gmail.com (S.K. Almeland).

https://doi.org/10.1016/j.burns.2022.07.008
0305-4179/© 2022 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creative-
commons.org/licenses/by/4.0/).
 burns 48 (2022) 1794–1804 1795

a rt i cl e in fo ab strac t

Article history: Background: Burn care is centralized in highly specialized burn centers in Europe. These
Accepted 19 July 2022 centers are of limited capacity and may be overwhelmed by a sudden surge in case of a
burn mass casualty incident. Prior incidents in Europe and abroad have sustained high
Keywords: standards of care through well-orchestrated responses to share the burden of care in
Burns several burn centers. A burn mass casualty incident in Romania in 2015 sparked an in-
Mass casualty incident itiative to strengthen the existing EU mechanisms. This paper aims to provide insight into
Burn mass casualty developing a response plan for burn mass casualties within the EU Civil Protection
Disaster planning Mechanism.
Disaster medicine Methods: The European Burns Association drafted medical guidelines for burn mass ca-
European Union sualty incidents based on a literature review and an in-depth analysis of the Romanian
incident. An online questionnaire surveyed European burn centers and EU States for burn
mass casualty preparedness.
Results: The Romanian burn mass casualty in 2015 highlighted the lack of a burn-specific
mechanism, leading to the late onset of international transfers. In Europe, 71% of re-
spondents had existing mass casualty response plans, though only 35% reported having a
burn-specific plan. A burns response plan for burn mass casualties was developed and
adopted as a Commission staff working document in preparation for further im-
plementation. The plan builds on the existing Union Civil Protection Mechanism frame-
work and the standards of the WHO Emergency Medical Teams initiative to provide 1) burn
assessment teams for specialized in-hospital triage of patients, 2) specialized burn care
across European burn centers, and 3) medevac capacities from participating states.
Conclusion: The European burn mass casualty response plan could enable the delivery of
high-level burn care in the face of an overwhelming incident in an affected European
country. Further steps for integration and implementation of the plan within the Union
Civil Protection Mechanism framework are needed.
© 2022 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC
BY license (http://creativecommons.org/licenses/by/4.0/).

normal standards of care are therefore not applicable [8]. The

1. Introduction aftermath of the medical response to the Haiti earthquake in
2010 truly challenged this paradigm [9]. In the past decade,
Burn patients require highly specialized and centralized burn the WHO Emergency Medical Teams initiative established
care, which has been shown to increase survival and improve minimal care standards for all medical teams in disasters
outcomes [1]. Maintaining a resilient burn care. [10,11]. Even in a crisis, the WHO Emergency Medical Teams
system with adequately funded and verified centers that initiative has raised the standards for acceptable care, aiming
provide high care standards, and can confidently respond to to convert strategy from the lowest acceptable standards to the
mass causality surges, is the foundation of burn mass ca- highest achievable ones. Lessons learned from burn mass ca-
sualty preparedness [2,3]. Burn mass casualty incidents are sualty incidents have resulted in the development of man-
rare events that lead to a sudden surge of victims that over- agement strategies and plans for burn-specific responses to
whelm local burn care capacities and capabilities [4,5]. Pre- mass casualties in different regions of the world [5,12–15]. In
paredness should include robust local major incident plans a large-scale burn mass casualty incident in Taiwan in 2016,
describing the system, space, staff, and supplies needed for a impressive logistics and a well-organized medical response
timely response [6]. Historically, burn mass casualties have proved near-normal care standards achievable in well-re-
posed significant sourced environments [16]. Recently, worldwide re-
challenges that have elicited ad-hoc mutual aid in dif- commendations encouraging such structured disaster
ferent ways to support local, regional, and even national burn responses were issued by the WHO Emergency Medical
care capacities [4,7]. Teams Technical Working Group on Burns [7]. They support
One of the most challenging features of a disaster is the organizing both the triage and expert assessment of burns
enormous gap between usual care standards and the avail- and initial burn care in first receiving hospitals with the
ability of care capabilities and capacities amid an over- support of burns rapid response teams. These re-
whelming surge [6]. The resource gap may result in a commendations set minimal standards to be applied world-
discrepancy between public expectations for standard care wide with locally adjusted implementations.
and the real-time contextual care capacities. This gap has led Most previous large-scale burn mass casualties, both in
to a mitigation strategy of claiming “a situation of crisis” Europe and across the globe, have involved victim numbers
where “anything is better than nothing,” proclaiming that that would be problematic for any European country to deal
1796 burns 48 (2022) 1794–1804

Fig. 1 – Timeline for progress on developing a European response plan for burn mass casualty incidents. The DG ECHO
invited all European Union Civil Protection Mechanism Member and Participating States to join a workshop on burn mass
casualties in response to a request from Romanian authorities. The workshop was held in May 2016 and started the process
of developing a response mechanism for European burns disasters. A follow-up teleconference in September 2016 led to the
involvement of EBA to prepare medical guidelines for a proposed mechanism. Draft response plans were made with
contributions from Member and Participating States and in collaboration with the European Burns Association. Member and
Participating States were again invited to a follow-up workshop in Bucharest in October 2018, after which the EBA expert
panel revised and validated the plan in May 2019 before the plan was presented to the Civil Protection Committee. Internal
procedures and revisions within DG ECHO processed the plan towards its final adopted version of January 2020.
UCPM: European Union Civil Protection Mechanism. MS: Member States of the EU. PS: Participating States in the Union Civil
Protection Mechanism.

with singlehandedly [4,7]. However, Europe is a high-resource eventually possible; there was a lack of means, tools, and
environment with extensive cumulative specialized burn protocols to activate and organize the response. Romania and
care capabilities and would thus be able to deal with the ty- involved partners spent precious time creating ad-hoc deals
pical burn mass casualties and still abide by high standards and solutions. The incident in Romania highlighted the need
of care, though only if responding collectively in a structured for pre-arranged established protocols for international col-
way. In the past decades, lessons learned from burn mass laboration to achieve proper access to specialized burn care
casualties have been the primary fuel for developing new for victims in large-scale burn mass casualties in Europe.
disaster management plans in individual European coun- Post-incident, Romanian authorities brought the incident to
tries. For instance, the Volendam incident in 2001 sparked the attention of the European Commission, asking for a burn
preparedness plan revisions in the Netherlands and Belgium mass casualty response to be included under the UCPM. The
[14,17]. Nevertheless, a pan-European response mechanism European Commission responded by initiating the first steps
has not been available until now. In other areas of crisis toward developing a European response plan for burn mass
management, the EU has long developed a common frame- casualty incidents. Mass casualty planning and preparedness
work to aid its member states through the Union Civil Pro- requires training, resources, and maintaining an updated
tection Mechanism (UCPM). This system has made it possible stockpile of supply [3]. Fortunately, large-scale burn mass
to request, accept, and offer pre-verified assets for assistance, casualties are not common, making it difficult for an in-
both within Europe and worldwide [18,19]. Though plans dividual country, let alone any single hospital, to provide
were in the pipeline to expand the UCPM with medical teams, enough funding for such comprehensive programs. [14].
no such mechanism was implemented when the “Colectiv" However, structuring a robust pan-European plan for burn
nightclub fire occurred in Bucharest in October 2015. At the mass casualty incidents may mitigate the financial burden on
time, Romania was left without the option of a UCPM acti- individual countries by establishing a cross-border mutual
vation for burns clinical care support. The incident became a aid program. In addition, this emergency response could be
grim example of how unprepared Europe was to support a utilized in other parts of the world when needed.
Member or Participating State expeditiously when over- This article aims to provide detailed insight into the de-
whelmed with burn victims. Though an international re- velopment of a European response plan for burns mass ca-
sponse was present and cross-border transfers were sualty incidents within the framework of the UCPM.
 burns 48 (2022) 1794–1804 1797

generalizations from the data were apt. The complete ques-

2. Methods
tionnaire is provided as supplementary material
(Appendix A).
The Directorate General of Civil Protection and Humanitarian
Aid Operations (DG ECHO) of the European Commission in-
vited the European Burns Association (EBA) in September
2016 to provide medical guidelines that could be integrated
3. Designing a European response plan
into a European response mechanism for burn mass casualty
3.1. Analysis of the burn mass casualty incident in
incidents. The EBA disaster committee led this work, which
Romania
consisted of a literature review, an in-depth case analysis of
the “Colectiv” mass casualty in Romania in 2015, and a con-
On October 30th, 2015, Bucharest, Romania, experienced a
sensus report. Moreover, to further investigate the level of
tragic mass burn casualty incident. During an indoor rock
burn mass casualty preparedness across Europe, a ques-
concert in the “Colectiv” nightclub, pyrotechnics caused
tionnaire was developed to map national preparedness plans
flammable materials in the ceiling to catch fire. It resulted in
in the UCPM States and burn centers across Europe. The
an overwhelming mass casualty with a sudden surge of 162
questionnaire was distributed to the UCPM States by the DG
burn victims that required immediate attendance. Patients
ECHO and through the EBA Secretariat to all 90 burn centers
were distributed to eleven different hospitals in the
in Europe registered with the EBA. The survey accepted re-
Bucharest area. In the days following the incident, the
sponses from May through December 2019 using Google
Romanian authorities dealt with a confusing situation with
Forms™.
conflicting demands and advice to manage the over-
The initial consensus report from the EBA became the
whelming medical situation. An immense public pressure
point of reference for further developments of the European
grew on the Romanian government to acknowledge an in-
response plan within the existing EU framework, led by the
ability to handle the medical disaster. The political turmoil
DG ECHO and supported by the EBA, ready for sharing with
resulted in a change in government amidst the medical crisis
Member and Participating States of the UCPM. A timeline of
[21]. Thus, the Romanian authorities were dealing with the
the work and progress is presented in Fig. 1. The burns re-
pressure to handle the ongoing surge, assess the medical si-
sponse plan was presented to the UCPM Member and Parti-
tuation at hand, and organize international assistance. At the
cipating States’ civil protection authorities in June 2019 and
time, the European Member States had no existing frame-
adopted as a Commission staff working document in pre-
work for burn care assistance. Romanian authorities resolved
paration for implementation into the UCPM on January 7th,
to bilateral communications with European states who were
2020 [20].
offering aid. Though with late onset and not a straightfor-
ward operation, the resulting ad-hoc solution led specialized
2.1. Data analysis burn teams from Israel, Belgium, Finland, the UK, and
Norway to support burn assessments and transfer priorities.
The data for this paper was derived from a non-systematic An early and prominent effort was conducted by the Belgian
literature review and expert consensus, further processed Burn Team, who reported to find victims impressively well-
through thorough integrative cooperation with the DG ECHO managed in the intensive care environment but reported an
staff to adapt to European Commission standards. The na- evident lack of capacity and capability to provide high-level
tional survey data are presented as counts and percentages. surgical care in the face of the massive surge. The burn teams
Due to a low response rate, no further analyses or found overworked surgical staff and overbooked surgical

Table 1 – International transfers following the “Colectiv” fire incident in 2015.

Post accident day of transfer Total No. of patients
transferred
1 - 4 5 6 7 8 9 10 11 12 13 - 17 - 30
No. of patients transferred per
day per country
Austria 2 1 1 1 5
Belgium 8 8
France 1 1
Germany 1* 1* 1* 2 5
Israel 1* 1* 1* 3
The Netherlands 8 8
Norway 1 1
United Kingdom 9 9
Total No. of patients transferred 0 1 1 1 19 11 1 2 1 0 1 1 1 40
*
Privately funded.
1798 burns 48 (2022) 1794–1804

Fig. 2 – Schematic presentation of the European Union Civil Protection Mechanism. ERCC: Emergency Response Coordination
Centre.

theaters, making surgery a significant bottleneck for care. May through December 2019. Only 9/34 (26%) national au-
Local hospitals and authorities agreed that international thorities responded to the survey, and 8/90 burn centers (9%)
transfers would be needed to increase survivability and out- replied. Thereby, the overall response rate for the survey was
comes for burn patients. However, the situation was further as low as 14% (17/124). Since many responding burn centers
complicated by the severe clinical presentation of the burn and authorities were the single respondents from their
victims. Due to the indoor nature of the incident with country, there were replies from 17 different countries alto-
melting, burning acoustic foam running from the ceiling and gether. Twelve respondents (71%) indicated that they had an
immersing the victims from the top downwards, most pa- existing national preparedness plan for mass casualty in-
tients had burns in their head and neck area combined with cidents. However, only six (35%) stated that they had a plan
other injuries and had sustained inhalation injuries. These that included specific responses in case of burn-related in-
circumstances complicated transportation and international cidents.
transfers. Even though some international transfers were The UCPM relies on the communication between national
made in the first few days, most international transfers were civil protection authorities in all Member and Participating
delayed until a week or more after the incident. Due to the States through the Emergency Response Coordination
late onset of many possible transfers, many patients had Center. However, still, in all states where the respondents
developed respiratory complications, such as ARDS, and se- indicated they had a national preparedness plan for mass
vere sepsis complications rendering them unfit for aero- casualty incidents, national health authorities were re-
medical transportation. Eventually, 40 patients were sponsible for coordinating their plan's activation. Fourteen
transferred internationally. An overview of international respondents (82%) said they were interested in being able to
transfers from the “Colectiv” incident is presented in Table 1. request and offer assistance through the UCPM in a possible
Overall, several obstacles to international transfers were future burn mass casualty response plan.
identified and agreed upon: 1) Lack of a specific response
mechanism to activate 2) Late onset of international trans-
3.3. Existing framework – the European Union Civil
fers 3) Lack of predefined economic and legal structures for
Protection Mechanism (UCPM)
hospitals in European countries to accept patients by 4) Lack
of a centralized communication structure for request and
Since its establishment in 2001, the overall objective of the
offers of assistance in sudden onset health incidents 5) Lack
UCPM has been to strengthen the cooperation among
of medical transportation capacities and capabilities 6) No
Member and Participating States in the field of civil protec-
common European framework identifying burn care facilities
tion and to facilitate the coordination and effectiveness of
in Europe.
systems for preventing, preparing for, and responding to
disasters [19]. Currently, thirty-three states - the 27 EU
3.2. Survey of national preparedness member states and six other countries (Norway, Iceland,
Montenegro, North Macedonia, Serbia, and Turkey) partici-
Ninety burn centers across Europe and national authorities in pate, collectively referred to as “Member and Participating
34 UCPM Member and Participating States (at the time, there States.” The Mechanism can activate support upon the re-
were 28 EU Member States and six additional Participating quest of a Member or Participating State, or indeed any other
States as the survey was conducted before the UK left the EU) affected country in the world overwhelmed by a disaster. By
received the questionnaire. Responses were accepted from pooling the capacities and capabilities of the Member and
 burns 48 (2022) 1794–1804 1799

Table 2 – The first hours of a disaster response in an affected country. Typical timeline and responses mobilized within
the disaster-stricken country before international assistance is requested.
Step Typical time frame
First emergency response < 1h
Initial rescue to safe environment and early support < 1h
(trauma assessment, early ABC)
Primary on scene triage < 2h
Activation of local or national plans < 2h
Early stabilization at or close to the scene (i.e. hemorrhage control, fluid resuscitation) < 2h
Primary evacuation to first-receiving hospital < 2–4 h

Participating States, the Mechanism can ensure better pro- template for UCPM activation for burn mass casualties, a re-
tection. An activation is coordinated by the Emergency Re- quest for assistance to the Emergency Response Coordination
sponse Coordination Center through its 24/7 hub in Brussels Center will typically consist of one or all of three elements:
[22]. The Emergency Response Coordination Center commu-
nicates resource needs, requests, and offers through the civil 1) Burn assessment teams to aid specialized in-hospital
protection focal points in every Member and Participating triage of patients and preparations for patient distribution
State (Fig. 2). 2) Specialized burn care bed capacities in European burn
These permanent and well-established lines of commu- centers
nication ensure a swift and coordinated response to dis- 3) Medevac capacities from participating states
asters. The European Commission established the European
Medical Corps as part of the UCPM in response to the Ebola 3.5.2. Basic premises and rationale
Crisis in West Africa in 2014 [23]. The tragic incident in Ro- The EBA’s guidance to the European Commission underlined
mania brought attention to the vulnerability of Member and the importance of timing if wanting to respond meaningfully.
Participating States to burn mass casualty incidents, and The central presumption for any international response re-
Romania subsequently asked the European Commission to volves around the practicalities dependent on timing. Firstly,
consider integrating the response to such disasters under the when analyzing the typical timeframes of UCPM responses,
European Medical Corps. The civil protection and health au- one would find that activation, capacity selection, and ac-
thorities in participating states were invited to join a work- ceptance/rejection typically take days to achieve. Indeed, it
shop in Brussels in May 2016 to initiate work on a burn- seems impossible to activate and deploy an international
specific response plan (Fig. 1). response within the first 24 h, even in a well-prepared and
sped-up process. Secondly, provided that initial management
3.4. Existing global framework – the WHO Emergency was appropriate, severely burned patients typically achieve
Medical Teams initiative relative stability and remain fit for transportation in a short
window during the first four days [24]. A UCPM activation for
While drafting the European response plan for burns, there burn mass casualties will need to aim for patient assessment
was a simultaneously ongoing process within the WHO and transfer between 24 and 96 h post-burn.
Emergency Medical Teams initiative to generate worldwide Since an international deployment of resources is not in-
recommendations for the management of burn mass ca- stantly organized, there will always be a time frame within
sualty incidents [7]. The EBA was actively engaged in this which any disaster-stricken country would have to manage
work. Additionally, the European Commission has been a the local situation unassisted until international assistance
critical WHO partner in implementing Emergency Medical becomes available. The affected country will have to handle
Teams standards, performing conjoined verifications of Eur- much of the disaster management efforts and initial logistics
opean Emergency Medical Teams [23]. Recommendations according to their local or national mass casualty response
from the WHO Emergency Medical Teams Technical Working mechanism. This temporary capability to sustain a local ca-
Group on Burns have been essential foundations in devel- pacity increase might be referred to as the response-depen-
oping a European response [7]. One of the key re- dent surge capacity [3,4,14,25]. Considering typical time
commendations from the WHO working group was to frames, Table 2 presents a core rationale of presumptions for
strengthen national planning for burn mass casualty in- burn mass casualties that will have to be addressed by the
cidents. disaster-stricken country’s surge capacity in their national
planning. With this timeline in mind, the national disaster
3.5. The European response plan management plans will be the only foreseeable guidance to
rely on for primary triage, transport to hospitals, and initial
3.5.1. Objectives stabilization at the local first receiving hospitals.
The overall aim of implementing a burns-specific plan within A burns response activation of the UCPM would rely on a
the UCPM is to ensure specialized burn care for all victims clear national leadership in an emergency response to burns.
suffering severe burns following a mass casualty incident in Thus, if needed, an early and coherent request for external
any Member and Participating State in Europe. In the agreed support creates the basis for any UCPM activation [20].
1800 burns 48 (2022) 1794–1804

Table 3 – Key recommendations for national preparedness planning for burn mass casualty incidents in coordination
with a European response.
Early request and offer for assistance Prepare national management plans with clear thresholds for activation and
communication
Expert assessment by burn assessment National or international burn assessment teams to primary hospitals
teams
Prioritize burn patients for transfer In-hospital/secondary triage targeted at final care decision, including evaluation of
possibility for safe transportation
MEDEVAC to definitive care facility Timely and safe transportation in the preferred care level

Successful UCPM activation for burn mass casualties would 2) Fitness for transportation is equally important to assess. It
depend on a well-integrated response at the national and EU is dictated by the severity of organ failures and the level of
levels. Therefore, key recommendations for burn mass ca- dependency on replacement therapies. This assessment is
sualties were developed to guide Member and Participating best performed by an anesthesiologist or critical care
States in mass burn preparedness planning with an efficient specialist trained in burn care. Designation of the correct
UCPM activation and coordination for such incidents level of care and expertise during air transfer is an integral
(Table 3). part of this assessment to ensure the safety of secondary
There are few available burn specialists in each European transfers [26,27].
country since European burn care is highly centralized in
specialized burn centers. This scarcity of specialists makes The provided assessment helps establish the patients’
deployable teams a practical solution to enable reinforce- priority for transfer to specialist care in burn centers, as
ment to affected countries' national experts in the critical available. Thereby, the end goal of burn assessment teams’
assessment phase. Learning from existing burn mass ca- deployment would be to support informed priority decisions
sualty plans in other countries and the WHO recommenda- for transferring burn patients to adequate specialized care.
tions, the development of burn assessment teams was the Based on the offer of assistance by Member and
suggested mechanism to aid affected countries in a European Participating States of the UCPM, patients will finally be dis-
context [5,7,12–15]. patched to appropriate specialized burn care facilities. For
patients to safely reach their chosen destination, their
3.5.3. Structure and activation transportations will be conducted by MEDEVAC capacities
The burn assessment teams may be deployed from within contributed by Member and Participating States or by specific
the affected country or from other Member and Participating MEDEVAC capacities developed under the newly established
States. The standard composition of EU burn assessment European reserve of resources (rescEU) within the UCPM [28].
teams is outlined in Table 4. These expert teams should be During transport and at the intended destination, care level
trained to be familiarized with UCPM activations. Upon re- decisions should be informed by the care needs identified by
quest and acceptance from the local authorities, their mis- burn assessment teams. Though, final decisions on priorities
sion is to be of assistance to the disaster-stricken country in of care and transportation always remain with the re-
providing a specialized assessment of burn patients (“sec- sponsible national authorities.
ondary” or “in-hospital” triage) and guidance on needed level The proposed activation mechanism through a national
of care. Burn assessment teams should always perform their request for assistance to the Emergency Response
patient assessments within a hospital environment. Their Coordination Center is outlined in Fig. 3. The Emergency
evaluation of the patients’ condition in a burn mass casualty Response Coordination Center may make these offers avail-
setting has two deeply interrelated goals: able to the disaster-stricken state by pooling all available of-
fers. The affected country may then accept the offer(s) that
1) Burn severity must be assessed based on standardized best answers their request. The pooling of resources also
criteria. This expert assessment dictates which level of enables the state needing assistance to combine offers to fit
specialized burn care the patient requires and is best any evolving needs. The Emergency Response Coordination
performed by a trained burn surgeon. Center will coordinate the UCPM activation and distribute the

Table 4 – European Burn Assessment Team composition and profiles.

Function No. Profile Organization
Burn Assessment Team coordinator 1 Coordination expert Countries participating in
the UCPM
Senior Burn Physician 1 Surgeon or anesthesiologist/ intensivist with high Countries participating in
level of seniority the UCPM
Second Burn Physician 1 Burn surgeon or intensivist Countries participating in
the UCPM
Burn nurse 1 Burn nurse Countries participating in
the UCPM
 burns 48 (2022) 1794–1804 1801

Fig. 3 – UCPM Burns Plan Activation. Activation of a national response plan in case of a burn mass casualty incident leading
to UCPM activation through a request for assistance from the affected country. The Emergency Response Coordination Center
will inform all civil protection authorities in Member and Participating States that will in turn explore their capacities,
according to their national response plans, to provide support to the requesting country through an offer of assistance.
Support is only put in effect once accepted by the requesting country.
ERCC: Emergency Response Coordination Centre. BAT: Burn Assessment Team. UCPM: Union Civil Protection Mechanism.

request for assistance to all UCPM Member and Participating objectives, outline, content, and delivery, DG ECHO decided
States. Each country's civil protection authorities will receive to implement an improved course program starting at the
this request and coordinate with their health authorities and end of 2022. The European Commission also funded the EBA
burn centers. The civil protection authorities will then com- verification of 5 new European burn centers in 2021.
municate their offers of assistance back to the Emergency
Response Coordination Center, which would coordinate the
response and utilize the offered resources to support the af- 4. Discussion
fected country. The affected country requesting assistance
can then choose where the patients will go. Accordingly, burn The European burn mass casualty response plan is meant to
assessment teams can be invited by the affected country to develop a central European structure, creating a hub where
assist locally in primary hospitals, and MEDEVAC capacities the Member and Participating States of the UCPM may con-
can be accepted to transport patients to burn centers in other nect their national plans. By providing a centralized system
Member or Participating States. for logistics and coordination in the Emergency Response
Coordination Center, the plan may contribute to the over-
3.5.4. Implementation arching support goal by lowering the local burden and im-
A preliminary version of the European burn response plan proving outcomes in burn mass casualties. Burn
was tested early at a UCPM exercise, and adaptations were professionals participate in a very well-connected global
made accordingly. The proposed plan received input from community of burns experts. Historically, burn professionals
Member and Participating States through discussions in the have always been willing to support large-scale incidents, but
European Commission’s Civil Protection Committee and they have lacked the tools to properly organize such support
Health Security Committee. After resulting adjustments, it [29,30]. The most significant accomplishment of a European
was adopted as a Commission staff working document, burn response plan within the UCPM would be to enable the
meaning the plan is among items in the process for further European burns community to aid each other in disasters in a
implementation [20]. Furthermore, the EBA endorsed the meaningful and organized way.
plan and its accompanying medical recommendations in the The European survey had a disappointingly low response
2019 general assembly. A pilot training course for burn as- rate, either reflecting a low interest or worryingly no real
sessment teams was developed in response to an open call by national preparedness for burn mass casualty incidents.
the DG ECHO as an important first step of implementation. Notably, the European burn mass casualty response relies on
The course aimed at preparing burn assessment teams to initial local and national response mechanisms to recognize
fulfill their missions within the UCPM framework and in- the needs and then activate a coordinated response through
cluded a practical simulation exercise to ensure assessment the Emergency Response Coordination Center. National pre-
reliability and reproducibility. After evaluating the course paredness is the core of both the WHO Emergency Medical
1802 burns 48 (2022) 1794–1804

Teams initiative and the UCPM. The UCPM mass causality possible to scale responses to different settings and demands
plan activation, like WHO Emergency Medical Teams activa- and might even be crucial to success.
tion, should be only in response to a formal request from the
disaster-stricken state. Only through National leadership and 4.2. Prioritization of patients for specialized care and air
organized response in the affected country can successful transfer
coordination of assistance be achieved [7,30]. At the national
level, different actors could be involved in responding to Even with optimal planning, there will remain limitations
mass casualty events. It is fundamental to streamline na- in the available capacity of specialized burn center beds,
tional coordination since any response requires strong lo- available assets, and teams for air transportation.
gistics and communicational support offered by the UCPM Furthermore, some burn victims’ conditions may be too
and the Emergency Response Coordination Center. A vital critical, and evacuation would be futile. The American Burn
feature of the burn plan activation within the UCPM is timely Association has made an important secondary triage and
requests and offers. Successful UCPM activation is dependent priority tool available through several publications and re-
on an early request from the affected country. This can finements [31–33]. The American priority tool may create a
sometimes be politically difficult but a critical decision, basis for developing a European priority tool to aid autho-
knowing that stepping down from a response is far more rities and burn assessment teams in decision-making
beneficial for the affected country than a late request for around priorities for transfer.
mutual aid. Hence, the UCPM plan activation relies on in-
ternal mechanisms and communication lines within each 4.3. Verification of expertise
country, rendering the existence of local and national dis-
aster plans a crucial asset. For international cooperation to happen, there is a basic need
for trust in inter-state care levels to ensure no degradation of
care. The trust needed may be built through transparent
4.1. Burn assessment teams
training programs for burn assessment teams, establishing
the level of expertise expected from team members. In ad-
European countries differ significantly in the number of
dition, the care the patients receive in other Member and
available burn beds and personnel and their geography.
Participating States should be of high and transparent stan-
Some of the larger countries, with sufficiently staffed burn
dards, especially since activation of the European burn re-
specialized bed capacity, might be able to manage over a
sponse plan will involve not only immediate emergency
hundred casualties properly. In contrast, the smaller
management but also long-term care in distant burn centers.
countries would need outside help even with a low number.
An affected country's national authorities may need to base
Smaller countries would probably also have a lower
their trust on an objective assessment of the quality of care
threshold at which outside mutual expert help would be
provided in the burn centers in Member and Participating
required for the in-hospital assessment and triage.
States, both as responsible health authorities and for political
Importantly, even if an affected country will indeed be self-
justification to their public. Additionally, involved clinicians
sufficient with burn assessment teams, the need for cross-
need to be able to justify referrals to patients and affected
border transfer logistics to definitive burn centers in other
families. Although burn centers are often verified nationally
countries could remain. Therefore, the European burn re-
by their authorities, there are currently no available common
sponse plan must include all combinations of the above
standards for burn center verification within the EU system.
options of requesting experts, transportation, and final care
The EBA verifications program, following EBA guidelines for
in burn centers.
burn care [34] is currently the only pan-European system for
The burn assessment team comprises four members: A
quality of care recognition and may easily be adopted within
coordination expert, two Burn Physicians (one intensivist/
national verification programs. However, the UCPM Member
anesthetist and one surgeon), and a burn nurse. This team
and Participating States are currently not obliged to have
composition is one member short of the burns rapid response
their burn centers partake in such verification, and the pro-
teams suggested by the WHO Technical Working Group on
cess remains voluntary in nature. Nevertheless, States may
Burns [7], purposely reduced to enable Member and Partici-
indicate the verification status of their burn centers when
pating States to train and roster such teams effectively. The
offers of assistance are submitted. Burn center verification is
limited number of specialists available, and the need to offer
a quality guarantee. We believe this feature might be the
a complete team when responding to an urgent request,
appropriate quality of care system for all internationally
speak to limit the required number of team members in a
dispatched patients and represents an identified challenge
burn assessment team. Additionally, each team must train
for further implementation.
several optional team members for each role to ensure 24/7
availability. The presumption of self-sufficiency is an essen-
4.4. Remaining issues for future developments
tial difference in the purpose of WHO burns rapid response
teams and the EU burn assessment teams. Within Europe,
As the burn assessment teams perform their task, their work
the teams will not need to deal with medical supplies and
must be safely and reliably communicated to local autho-
complex logistics. They would only be working within ex-
rities, involved UCPM Member and Participating States, and
isting hospital facilities, supported by the local staff and
burn centers. Electronic burn mass casualty assessment,
structures. The simplicity of the team composition makes it
 burns 48 (2022) 1794–1804 1803

tracing, and tracking systems have been developed in some competing interests: Stian Kreken Almeland: No conflicts of
countries [35,36]. However, an adaptable and secure system, interests to declare, Evelyn Depoortere: No conflicts of inter-
in line with existing EU regulations, is still needed. In fact, ests to declare, Serge Jennes: No conflicts of interests to de-
there is a clear need to develop standardized operational clare, Folke Sjöberg: No conflicts of interests to declare, J.
procedures for all operational levels of the European burn Alfonso Lozano Basanta: No conflicts of interests to declare,
response plan to enable safe and efficient implementation. Sofia Zanatta: No conflicts of interests to declare, Calin
Additionally, specific regulations for cross-border transfer of Alexandru: No conflicts of interests to declare, José Ramón
patients and care coverage have not yet been developed, nor Martinez-Mendez: No conflicts of interests to declare,
have liability issues for involved cross-border health per- Cornelis H van der Vlies: No conflicts of interests to declare,
sonnel in burn assessment teams and medevac teams. Such Amy Hughes: No conflicts of interests to declare, Juan Pedro
regulations may be developed as part of the ongoing im- Barret: No conflicts of interests to declare, Naiem Moiemen:
plementation. Currently, it is advised that the requesting No conflicts of interests to declare, Thomas Leclerc: No con-
country specify these issues (i.e., cost coverage for definitive flicts of interests to declare.
care and a temporary waiver of licensing requirements) in
the request forms submitted to the Emergency Response
Acknowledgments
Coordination Center for plan activation. Further im-
plementation of the burn response plan into the UCPM will
This work was supported by funding from the European
require the continuation of centralized training courses and
Commission, Directorate-General for European Civil
integration of burn assessment teams in the regular EU
Protection and Humanitarian Aid Operations (ECHO),
Module Exercise program.
Directorate B - Disaster Preparedness and Prevention, Unit B1
- Civil Protection Horizontal Issues by tender contract ECHO-
5. Conclusion B1-NP-2019-05 regarding a European response to mass burn
casualty disasters.
The European burn mass casualty response plan provides a
well-structured basis to ensure good quality care for burn
Appendix A. Supporting information
victims in the event of a burn mass casualty incident in
Europe. Local and national plans will dictate the initial dis-
Supplementary data associated with this article can be found
tribution of patients to primary hospitals, resource distribu-
in the online version at doi:10.1016/j.burns.2022.07.008.
tions within every country, and identify thresholds for
national capacities and the need to request cross-border
mutual assistance through a UCPM activation. Further de-
references
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