VA Tech disaster response shows value of drills, planning

Response nearly flawless, say leaders

Despite the chaos and upheaval of the horrific tragedy that befell Virginia Tech on Monday morning, April 16, 2007, the orderly response from the medical community went pretty much according to plan. At Montgomery Regional Hospital, which received the majority of the patients, the lives of all 17 who arrived there were saved. What's more, say those in charge of disaster response, the staff responded so eagerly that in at least one department the manager had more than he needed.

The impressive response, hospital leaders agree, was due in large part to the regular disaster planning and drills conducted at the facility. "We generally have three or four drills of some type each year — some are full-scale drills, while others may be tabletop exercises," says David Linkous, RN, MEd, the hospital's emergency planner, noting that The Joint Commission requires at least one large-scale disaster drill and one tabletop drill per year.

"We also participate in statewide and regional drills," he adds. "For example, last April we utilized an old abandoned motel and staged the explosion of a chemical truck."

There were 36 "victims," all of whom were "contaminated" with chemicals, so staff had to deal with decontamination as well as with multiple injuries. "We utilized several EMS agencies, and the hospital had to decontaminate and treat the patients, while preventing the rest of the hospital from being contaminated," Linkous reports.

The hospital disaster plan delineates staff responsibilities, policies, and appropriate responses for different types of disaster. "It's basically the same 'tree,' modified by condition," notes Mike Hill, RN, the ED director.

The planning process is handled by the Emergency Management Committee, which includes department directors — ED director, director of pharmacy, infection control, the lab, X-ray, safety & security, and engineering; the chief nursing officer; the associate administrator; an emergency physician; and a PR representative.

The awareness of just how important planning is hit hard in August 2006, when a hospital security guard and a deputy sheriff were shot and killed in the hospital by a prisoner. "On any given Saturday in Blacksburg, we have 60,000 to 70,000 in the football stadium, so we always practiced 'what ifs,'" notes Hill. "But after that, it became, 'We have to have a plan.'"

In addition to honing the disaster plan, Linkous had a number of staff take the National Disaster Life Support Foundation's Basic Disaster Life Support class, after which they took an Advanced Disaster Life Support (instructor's) class. "We were told after that class that there were more people in our county with that designation than there are in the entire state of California," he says.

From drill to reality

Much of what was practiced during the drills was put into use in the aftermath of the Virginia Tech shootings. For example, as part of the hospital's HICS (Hospital Incident Command System) plan, all victims received either a red, yellow, green, or black tag after being triaged in the field.

Of the 17 patients, all but four were gunshot wounds. Four were critical (red); eight immediate (yellow), deemed able to wait an hour or so for treatment; and five green, which meant care could be delayed. Those patients were sent to outpatient surgery for holding, where they were cared for by nurses. (Patients with black tags, for "non-viable," were not even brought to the facility.)

"The majority of the 'immediates' were broken bones or 'through and throughs' [gunshot wounds]," recalls Hill. "You have to remember, any yellow can change to red, but they get reassessed if they turn pale, if their BP drops, and so forth." Still, he says, the tagging in the field done by EMS was "pretty much on the money."

In the event a patient arrives with a green tag but appears to be sicker than that, a nurse at the door can re-tag him or her. "That's what we practiced in our drills; placing an ED nurse there for quick assessment, to see if they are what the tag says they are," says Linkous.

Call hardly needed

While the disaster plan clearly outlines a method for calling in extra staff, this part of the plan was hardly needed on the day of the shootings. "If there is a large influx of patients, we go to condition green; we go on alert, call all the staff, including ancillary staff, which is what we did last Monday," says Hill.

Once employees arrived at the hospital, they reported to the cafeteria to sign in, indicated their skill level, and were then assigned to a unit based on what was needed where. "We did that on Monday, but we had a huge turnout," says Hill. "Most people in the ED did not even have to get a call; they saw a report on the TV or heard about it on the radio." Fortunately, he adds, it was 7:30 a.m. on a weekday, rather than 3:00 a.m. on the weekend, "when no one would be here."

When Code Green is activated, it is also announced internally over the hospital PA. In addition, each department has a list of names; the person at the top of the list calls the next person, and so on, until the entire department is called.

The ED had no problem getting staff to report. "I have 40 staff members, and 33 of them were here," says Hill. In addition, as Monday is a "big" surgery day, all of the surgeons were on hand. And, since a case had just been finished, there were three or four surgeons waiting for their next case. There also was an ENT available, and another surgeon came up from sister hospital Lewis Gayle.

"We even had an OB/GYN surgeon call and say he was glad to come over and work in a room and pass out instruments," says Linkous. "We had extra people come in — more staff than we needed, really."

In fact, says Hill, a list had to be made of staff who should be asked to leave the ED. "You don't want too many staff, because then you can't maneuver around," he explains. "If you can't get through the halls, you get a traffic jam, so to speak."

Communications an issue

One of the issues that became more serious as the day went on was communications — which called for the use of cell phones. "When you've got a school of 27,000 students and the shootings made the national news, the moms and dads all called, and all cell phones shut down," recalls Hill.

"We were getting conflicting reports," adds Linkous. "From once source, we were told we had gotten all the patients we would get; another said more were coming. That's where another part of our plan came into play."

That part of the plan involved putting a liaison at the scene, so when communication became a problem, Linkous headed down to the command center. "He was able to contact me directly, so we had a better understanding of what was going on," says Hill.

In the hospital debriefing that followed the incident, it was agreed that the committee would look into some portable radios, to be used as another source of communications. "That was definitely a big problem as the day went on," Linkous concedes. "There are several different cell phone companies, and none of them were working."

According to plan?

For the most part, Linkous is pleased with the hospital's response. "I think it went just like the plan predicted — a lot better than anticipated," he says. "I was very happy that people understood this was a collaborative event; it impacted the whole hospital. People from the lab, from X-ray, and nurses from other departments were in the ER. When you implement Code Green, you are supposed to send nurses there from each department. Other department directors also came down."

In addition, he notes, elective surgeries were cancelled to relieve pressure on the ED. "People who were there being prepped for outpatient surgery were sent home, and we called those who were scheduled for surgery [to cancel]; this opened up 24 beds for ED overflow," he notes.

Another aspect of pre-planning that proved very helpful involved disaster carts, which contained IV solution, bandages, and other general trauma supplies. "We had designed these carts several years ago, and they were rolled down to an area between the ED and outpatient surgery, in case they ran out of supplies," says Linkous. "We emptied a couple," Hill reports.

You can't plan for everything, Linkous concedes, but in some cases staff members anticipated things the formal plan did not. "A pharmacist came down and brought extra meds — mostly antibiotics and rapid-sequence intubation drugs — and stood at the nurses' station and dispensed them as needed," he says. "This will be in the plan from here on out."

In addition, he says, the committee determined to enhance patient tracking techniques. "Sometimes it was a little slow when we wanted to find out where a patient was," Linkous notes.

Still, he says, "This went incredibly well for a hospital our size. The biggest thing is teamwork among the staff; I can't say enough about them."

For more information, contact:

Mike Hill, RN, ED Director, Montgomery Regional Hospital, 3700 South Main Street, Blacksburg, VA 24060. Phone: (540) 953-5122.

David Linkous, RN, MEd, Emergency Planner, Montgomery Regional Hospital, 3700 South Main Street, Blacksburg, VA 24060. Phone: (540) 951-1111.