By John Palmer
In today’s environment of mass shootings and other mass casualty incidents (MCI), hospitals need to be prepared to deal with a surge of patients at a moment’s notice.
According to the Department of Health and Human Services (HHS), the term medical surge refers to a hospital’s ability to provide “adequate medical evaluation and care during events that exceed the limits of the normal infrastructure of an affected community. It encompasses the ability of healthcare organizations to survive a hazard impact and maintain or rapidly recover operations that were compromised.” Additionally, “[t]he surge requirements may extend beyond direct patient care to include such tasks as extensive laboratory studies or epidemiological investigations.”
When the call comes in, healthcare facilities need to know where to immediately get blood supplies and pharmaceuticals, and how to properly keep their patients healthy and well fed. A new resource center developed by the federal government aims to help hospitals prepare better by taking advice from their peers who have experienced such tragedies as mass shootings, such as the ones in Las Vegas, Orlando, and Aurora, Colorado, as well as natural disasters like Hurricane Katrina.
Developed by HHS and a division of the Assistant Secretary for Preparedness and Response (ASPR), the Technical Resources, Assistance Center, and Information Exchange (TRACIE) aims to provide information and technical assistance to regional ASPR staff, healthcare coalitions, hospitals, and other public health emergency preparedness agencies.
Periodically, ASPR publishes a magazine called The Exchange highlighting lessons learned, trends, and future initiatives shared by support service staff in response to MCIs.
“Whether [an MCI] is anticipated (e.g., a hurricane) or no-notice (e.g., an incident of mass violence), the keys to a successful response are the ability to perform triage, manage patient surge, and ensure that all staff needs are addressed, during and after the incident,” wrote Denis FitzGerald, MD, acting director of the ASPR’s Office of Emergency Management and Medical Operations, in the foreword to one of The Exchange’s issues. “This is a shared goal, and calls upon a multitude of support services throughout a hospital (e.g., pharmacy, nutrition, blood labs, security, and waste management) to operate collaboratively.”
Have a look at some of the advice gleaned from the pages of the publication and apply it to your own training and preparation. Click here to access the TRACIE website.
Emergency nutrition management
When disaster strikes, there are many things that a hospital needs to be ready for, and unfortunately, providing proper nutrition to patients mid-crisis has not historically been a high priority. Because of this, some data examining 20 years’ worth of disaster responses suggest that after major disasters, poor nutrition delivery during the events may have led to exacerbation of health conditions and increased mortality and morbidity.
“The first emergency food plan I wrote in the mid-1970s basically said, ‘Offer everyone a peanut butter or cheese sandwich and wish them luck,’ ” says Lee Tincher, MS, RDN, president of Meals for All, Inc., in Sacramento, California, and a major planner and contributor of emergency nutrition planning for healthcare facilities. “Extensive plans for nutritional needs were not required back then, and it was assumed we would be able to rely on our food service skills to get through any disaster. Over the years, and as we have seen and been through numerous disasters, the thought process and the industry have both changed.”
Check on your supplies. Yes, this is a tedious process, but you don’t want to wait till a disaster strikes to realize your food stores are low. It’s estimated that in a 100-bed skilled nursing facility with three days of stockpiled resources on hand, it will take about four hours per month to count emergency food supplies. Anything missing needs to be ordered, and expired food supplies need to be reordered. Then everything needs to be recounted and stored.
Prepare for varying dietary needs. Gone are the days when nursing staff would toss together some egg salad sandwiches and hand them out to help feed patients during a disaster. Part of disaster preparedness is knowing the dietary needs of your community and preparing ahead.
Some experts recommend preparing for five types of dietary needs, ranging from patients who do not have special needs, to those who need soft food mashed with a fork, to patients who require therapeutic liquid diets to limit salts and fats.
Next, who will prepare the food? What is your plan if food service staff are not able to report to work? Will you be able to make the necessary staffing changes on the fly? You need to design a menu plan that accounts for preparation, food safety, and easy deployment no matter who is available.
Where will you get power? Surprisingly, despite the CMS mandates that stress emergency preparedness, some hospital kitchens still are not included on hospital backup power systems. Some states such as California require hospital drills to test the ability to keep food services up and running. In some facilities, so-called “red plugs,” or sockets that indicate they are connected to emergency backup power, are being installed.
Blood supply demand management
In a disaster that involves large quantities of blood transfusions, time and coordination will be of the essence. Victims of blast and penetrating trauma may require massive transfusions, and when multiple victims present at once, this may create challenges for local blood banks. If your hospital doesn’t have on-site storage capacity, it will need to rely on outside vendors. That won’t be easy, considering that donation rates are low.
“From a national perspective, across the board, the industry appears to be struggling with inventory,” says Julie Scott, national marketing director for Vitalant, a blood supply services organization that helped coordinate delivery of emergency blood supplies to hospitals during the mass shootings in Aurora and Las Vegas. “It is starting to reach a fever pitch.”
Help get the message out. Hospitals need to be doing a better job at encouraging the public to give blood, not just during the immediate aftermath of a tragedy, but throughout the year. After the Aurora mass shootings, which happened in a normally slow donation time during the summer, donations skyrocketed, leading to overwhelmed staff and long lines for trailers parked outside hospitals. While donations are of course always welcome, it’s much more efficient to make sure they are steady throughout the year to ensure proper stockpiles. Doctors and first responders need to be part of that messaging.
Work with couriers before you need them. In the event of an MCI such as a shooting, large quantities of blood will need to get to you quickly. You must make sure that couriers will have clear routes (what will happen if traffic is bad?) and that they can communicate with you in case phone lines are busy. Some couriers take online orders for blood in an emergency to “pull” from other hospitals, and some even have licensed vehicles with lights and sirens on them to help speed the process. Know who you are working with, and include them in your annual drills.
Pharmacy response to surges
A hospital’s pharmacy is often an overlooked part of the overall patient treatment and safety community, but in a disaster surge, it can be a key player in helping control chaos.
“Pharmacies are often considered among the most accessible part of the healthcare system,” says Nicolette A. Louissaint, PhD, executive director of Healthcare Ready, a company that helps hospital pharmacies prepare for and respond to emergencies. “As recent hurricane seasons and other events such as the California wildfires have underscored, pharmacies continue to play an important role in diminishing surge on hospitals and helping meet the health and medical needs of shelters in impacted areas.”
Keep your crash carts stocked. During the patient surge after the mass shooting in Las Vegas, pharmacy staff at Sunrise Hospital were overwhelmed with patients who needed large amounts of medications quickly. Nursing staff generally keep crash carts stocked with the most commonly needed drugs, but in a surge, you will need to know where to get replacements in a hurry.
“We ran out of stocked crash carts in-house, and techs were basically emptying out our automated medication dispensing systems, filling buckets with various medications, and running to the ER,” says Lynsee Knowlton, clinical pharmacy manager at Sunrise.
Make sure you know who your available staff is and what their roles are, and be able to change the game as needed. During the triage after the shooting, Sunrise set up two primary “stations” for drugs—the main pharmacy plus an ER “satellite”—which helped get medications to patients as quickly and efficiently as possible. One of their techs scrubbed in and was stationed in the operating room (OR), and another served as a runner between the OR and pharmacy. In a surge situation, it’s all hands on deck.
Security is still paramount. In an MCI, the focus will be on getting medications to patients as fast as possible. Unfortunately, inventory and accountability will take a back seat—which can be dangerous, with controlled substances such as opioids being some of the most abused and diverted substances in hospitals. Many facilities have automated dispensing systems that nurses can access, and in some cases, those systems can be overridden throughout the hospital in an emergency, allowing nurses to pull whatever they need in their units to manage a surge. Precise accounting will come later. But that said, you need to know your staff, be familiar with your inventory, and have a way to account for where every controlled substance goes.
“We tracked what went where, and we did have a bit of amnesty from the state board on accounting for the amount based on the severity of the situation,” says Knowlton. “We worked very closely with regulatory bodies to explain the situation and account for whatever product we could through paper records, electronic health records, and documentation from the system. It might be helpful to have pre-stocked disaster kits, even though they are challenging to handle. This would certainly help with chain-of-custody information and inventory tracking of controlled substances.”
John Palmer is a freelance writer who has covered healthcare safety for numerous publications. Palmer can be reached at firstname.lastname@example.org.