Stanford Medicine Newsletter Updates For the Local Community

 

Prepared for the worst

Hospitals practice for emergency situations

Nurses and registration administrators enter patient information into the hospital electronic medical records system during a emergency drill

   

The woman in the emergency department waiting area was screaming for her friend. “Where is she? I lost her in the crowd!” she wailed.

Moments later, she dashed across the room to hug her missing comrade, who was covered in blood, with serious burns on her arms and legs.

Happily, the burns were fake—as was the blood. The two women were among several hundred volunteers taking part in a university-wide emergency preparedness drill that included Stanford Hospital & Clinics and Lucile Packard Children’s Hospital at Stanford. The drill involved a mock explosion at Stanford Stadium to coordinate evacuations and first-response teams, followed by an exercise to see how the hospitals would respond to a Code Triage, a major disaster involving dozens of casualties in a short time.

The event brought together university response teams and local and regional agencies that care for victims, including firefighters, ambulance crews, police and emergency services.

Volunteer patients were rushed by ambulance to the Marc and Laura Andreessen Emergency Department, where they were triaged based on the severity of their condition. They each were color coded and routed for immediate care or sent to the admissions station to be treated and released. Nurses from units throughout the hospitals received their assignments, along with security, housekeeping, pharmacy, social workers and other support services, to accommodate a patient surge while maintaining daily standards of care. Administrators set up a command center in a third-floor conference room with 40 officials tracking every aspect of the drill, using scripted dialogue to keep team members up-to-date.

“The objective is to identify and fix any flaws in the system before the hospital is faced with a real mass-casualty event,” said Brandon Bond, administrative director of the Office of Emergency Management (OEM) at Stanford Hospital & Clinics and Packard Children’s.
“Since an emergency by its very nature is not a normal part of operations, we must have a system in place and make sure that everyone knows their part in the process.”

Plans and preparations

Administrators set up a command center during an emergency drill to share updates on all aspects of hospital services.

   

As head of the emergency group, Bond is responsible for planning, organizing and rehearsing various scenarios should the hospitals have to respond to a natural or manmade disaster—an earthquake, flood, viral pandemic, explosion, bioterrorism incident or act of violence.
The group has established partnerships with local communities and businesses, works closely with the university to coordinate campus-wide response strategies and stocks emergency supplies and equipment. The team oversees two major drills each year, as well as smaller scenarios such as patient evacuations.

Major drills take months of preparation and involve more than 145 people, who consider various contingencies, chart processes and script dialogue. A top priority is to test communications systems and procedures.

“We think of the worst-case scenarios and then make a plan to prepare for them,” Bond said. “We look at every aspect of every system in the hospitals to find any vulnerabilities.”

Real-life test

These drills are particularly important because Stanford Medicine is the only designated Level I trauma center on the Peninsula, which means that patients with serious injuries are routed to its emergency department, where they have immediate access to trauma surgeons, operating rooms, highly skilled specialists and follow-up care. Stanford Hospital has been a Level I trauma center since 1998; Packard Children’s was verified as a Level I pediatric center this summer—the only one in the Bay Area recognized by the American College of Surgeons.

The practice sessions paid off in early July when the hospitals were notified about a “potential mass casualty occurrence” shortly after the Asiana Airlines crash at San Francisco International Airport. Within minutes, physicians, nurses, staff members and administrators were prepared for a Code Triage disaster plan. Officials established a command center, erected an orange tent for triage by the emergency department entrance and readied operating rooms. Fifty-five patients were treated within four hours that Saturday, almost a third of them children; 11 adults and seven children were admitted.

“The staff really rose to the occasion in large part because they knew what to expect,” said Bond. “The many hours we devote to disaster planning and training really paid off.

"In fact, shortly before the crash, the team had organized a mass casualty drill and discovered that patient paperwork was getting lost in the shuffle. The group ordered simple plastic sleeves to hold important documents that could be placed around each patient’s neck during initial triage, and the system proved invaluable during the real-life incident.

Tools for change

“The drills are not so much about medical care as they are about process and communication,” Bond said. “They touch every aspect of the hospitals at every level of organization. They are a training tool to examine what works and what can be improved.”

The stadium explosion scenario, for example, was designed to monitor a patient surge to track how patients were triaged and to see if there were bottlenecks or processes that could be streamlined. Thirty-three patients with problems ranging from dizziness to internal bleeding were transported to the hospital within an hour. Patients arrived with mock injuries, including blood spatters, burns and gaping wounds, and many acted out the trauma and confusion that a horrific incident would evoke. Each was carefully examined, processed, tracked and admitted.

“In previous drills we noted that the registration process could be reorganized more efficiently, so we made that a focus of this exercise,” said program manager Eric Giardini. “We saw a significant improvement in how the patients were admitted.”

While the focus was on the emergency department, all units had a playbook to prepare staff for possible contingencies. The team spent the weeks following the drill looking at the playbacks and notes from the official evaluators to identify any additional ways to streamline the system. They also went through reams of reports from hospital services, such as finance and Spiritual Care, that were not directly involved in the drill but would be affected in case of a real patient surge.

Normally the emergency department sees about 160 patients in a day, said Assistant Manager Anthony Siniscal, RN, MBA. The point of the day was to practice intake of the sudden influx of stadium victims, marking the names on a whiteboard and gathering the patients’ critical information as quickly and accurately as possible. “The earlier we learn about what to expect, the better,” he said.

“It was very helpful to be part of the step-by-step process,” said Vanessa Garma, RN, an emergency department nurse who came in on her day off to enter some of the color-coded patients into the hospital’s electronic medical records. She took care of nine patients in less than one hour; in a normal day she would see about five. “The system is well organized, so I feel more confident about my role if something like this took place in real life.”

Ongoing process

The new Stanford Hospital and the expansion of Packard Children’s raise new challenges for Bond and his team. The scenarios will have to be revised since the floor plans will be different, supplies and exit points moved, and internal operations reorganized.

“Emergency preparedness is an ongoing process,” Bond said. “It’s a cycle of preparing a number of response plans, scheduling and conducting drills, and evaluating our performance so we can constantly improve.”

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