Simulated disaster helps hospital fine-tune its plan

CMs worked to free up beds for influx of patients

When McLaren Regional Medical Center got the news that 50 people injured in an airplane crash were headed toward the hospital, the case management staff sprang into action.

In accordance with the Flint, MI, hospital's disaster plan, case managers left their unit and gathered in their department office to find out what happened, how many patients the hospital was expected to receive, and what kind of beds would be needed.

When the staff arrived, Diane Kallas, BSN, MBA, RN, director of case management and Tamar Swain, RN, BSN, MBA, manager of case management, assigned the case managers to units where beds were needed for the influx of patients. Their instructions were to work with the admitting physicians to determine which patients could be safely discharged to home or to another level of care.

The social workers on the units were sent to the emergency department to help family members get information about the injured patients. Kallas and Swain rushed to the emergency department to help with registration and do whatever else was needed.

The airplane crash on that day in May didn't really happen. It was a disaster drill, complete with mock "patients" from a local high school who were assigned simulated injuries.

"The 'patients' we saw during the disaster drill had the gamut of injuries you would see in a plane crash. The staff role-played and treated them just like we would in a real disaster. The exercise opened up a lot of ideas for discussion," Kallas says.

The hospital's disaster plan prepares the staff for everything from major automobile accidents and fires to plane crashes and environmental terrorism. A full-scale disaster drill is conducted at least once a year, Swain says. In between, the case management department regularly talks about its role in a disaster and how staff can best meet patients' needs during an emergency.

"Our safety office and quality experts update us and ask for our ideas about what we should do in specific situations. They communicate information from the community, what resources are available, and what role they play on the city and state level," Swain says.

In the event of a disaster, case managers may not necessarily be assigned to the units where they typically work, Kallas says. "We send the case managers where they are needed but we keep in mind where their areas of expertise are. For instance, we wouldn't send a case manager with little experience in critical care to the critical care unit," she says.

When the hospital got the announcement about the recent "disaster," Kallas and Swain went to patient registration to help obtain information about incoming patients and track where they were being treated. They found that the patient registration department was well prepared for the disaster and didn't need additional help, except from the social workers who were there to help family members of injured patients find their loved ones. The hospital has pre-made packets that included physician orders, laboratory slips, and other materials the staff could use to quickly get the treatment process started.

The registration department keeps tracking sheets, showing the name of every patient who comes in and where they are sent so family members can be guided to the appropriate area.

"We stepped in, as RNs, and helped triage patients coming into the emergency room. That's not a typical case management role but in a disaster, all staff should be able to cross over and help wherever they are needed," Kallas says.

After the drill was over, the staff met and talked about what could have gone more smoothly and areas where improvements could be made. "Some of the areas were tagging vitals for lab work, making sure we identified patients with at least three identifiers, and what we do with patients who just have minor injuries, like wounds cleaned or stitches," she reports.

The nurses cleaned and bandaged the wounds of patients with minor injuries but they still needed to be examined by a doctor before they could be discharged. They were sent to the church school cafeteria across the street where they waited until the patients with more serious injuries had been seen.

At McLaren Regional Medical Center, the case managers are bachelor's-prepared RNs and are assigned by unit. They work as a team with social workers who are assigned to two units each. In addition, the department provides coverage in the emergency department from 11 a.m. to 12:30 a.m. seven days a week.

The case management department has worked hard to develop a close working relationship with the physicians and the nursing staff, an effort that pays off every day but will be especially helpful in the event of a disaster, Swain says.

"We feel like we are the allies of the doctors and we work with them as a team. We make rounds with the nurses and use the opportunity to teach them how case management can help them. Our goal is that when someone calls our department, we'll answer any question they have or take care of any problem. We want that to be the last phone call they have to make," Swain says.

The case managers meet with staff on their units three days a week to identify patients who could go to the next level of care and work to overcome the barriers to discharging them.

On the other two days, Swain convenes a multidisciplinary team that includes case managers, social workers, and representatives from the hospital's long-term acute care facility and rehabilitation center.

"Each unit reports on their patients, why they are here, what their functional level is, what their chances are of getting back to their previous functional level, and what we have to do to help them get there," Swain says.

If a disaster strikes, the case managers already will have a good idea of which patients could be discharged to free up beds for injured patients, Kallas points out. Hospital plans call for the case managers to work with the physicians to discharge patients who can be safely moved to another level of care. They may call nearby nursing homes to find out if they can take some patients on a short-term basis.

"Everybody has to work together in a disaster. We stay in close touch with the hospital incident command center, which is coordinating all of the aspects of the disaster," Swain says.

In the event of a disaster, the case managers will alert Kallas or Swain if a patient can be discharged and either they can't get in touch with the physician or the physician won't agree to the discharge. The information will be relayed to the executive team, which includes physicians who can make an administrative decision to discharge the patients.

"I can see the case managers playing a big role in a disaster by pulling the staff together. We are familiar with the big picture and the entire continuum of care and have the ability to pull all the resources together," Swain says.