Sniper, terrorist threats teach lesson to SDS managers: Be prepared
Emergency preparedness takes on new emphasis as violence spreads
On Oct. 7, 2002, a 13-year-old victim of a sniper shooting is brought by his aunt to the nearest medical facility: an outpatient clinic. The clinic makes a quick call to the attached surgery center; a surgeon, anesthesiologist, and several nurses come running to help stabilize the patient. In November, hospitals in Chicago, Houston, San Francisco, and Washington, DC, were alerted about a terrorist threat, and the outpatient surgery providers in those areas have been reviewing and revising their disaster plans in preparation for a worst-case scenario.
Many outpatient surgery managers have thought they’d never have to be prepared for anything worse than a single patient "crashing" in the OR. However, with the current threat of violence, you have to be prepared for disasters of every type and proportion.
"All communities are beginning to take a close look at all the available medical resources that are available in the community and the important role that ambulatory surgery centers can play in the initial care of the walking wounded,’" says Ramona Conner, RN, MSN, perioperative nursing specialist at the Association of periOperative Registered Nurses (AORN) in Denver.
With this role in mind, AORN has assembled a task force to prepare an emergency preparedness manual for perioperative services. The manual will address internal and external disasters and will be released at the March 22 annual AORN meeting, according to Donna Pritchard, RN, BSN, MA, CNOR, CNA, director of nursing, perioperative services, at NYU Downtown Hospital in New York City. Pritchard, whose facility is located four blocks from Ground Zero, is a member of the AORN task force.
To those who think that a disaster will never happen to them, keep in mind that no one thought that terrorists would fly into the World Trade Center either, says Theresa Levert, RN, continuous quality improvement coordinator for Gastroenterology and Associates/Louisiana Endoscopy Center (LEC) in Baton Rouge. "No one thought a sniper would be able to hit as many people as he did over several days," she says. "It’s always best to be prepared."
When the sniper victim showed up next door to Dimensions Surgery Center, the team of physicians and nurses helped to sedate the teen and put him on a ventilator. A chest tube was inserted, and three intravenous lines were set up. An X-ray was taken that showed damage to his spleen. Once the teen was stabilized, the hospital was contacted. Maryland state troopers transported the victim by helicopter. The team from the surgery center was praised for an "amazing job" of stabilizing the victim. According to one media report, much of the work that the physicians expected to do before sending the teen to surgery already had been done. The victim spent five weeks in the hospital and has returned home.
To prepare for an unexpected disaster, consider these suggestions:
• Ensure your employees are prepared. Hold disaster exercises. Work closely with organizations in your community and coordinate your response with the hospitals and first responders, Conner says. "I recommend that their staff be involved in a community disaster exercise at least once a year," she adds. Gastroenterology and Associates/LEC held its own disaster drill this year that simulated an explosion at a local oil refinery that resulted in eight patients being brought to the center. "Our facility is in the city near the Exxon chemical plant, which potentially could be a target for terrorist attack," Levert says.
The drill was held on a Friday after hours. A room with a television and telephone was set up as the command center so that the center would be able to keep in touch with the media. Clinical staff had various responsibilities, including triage in the preoperative and postoperative areas. Clerical staff and one manager went to the conference room and were called out individually by an in-house speaker as needed. "That way, they weren’t running around not knowing what to do, without a specific assignment," Levert says.
Some clerical staff directed traffic outside, while others assisted those designated as family members. Those "family members" presented staff with various demands, such as information on the cases or food and drink. Key staff, including the manager in the conference room, used cell phones. This system was determined to be less chaotic than paging, Levert says. "Also, we had cell phones as a backup in case something happened to our in-house phone," she says.
Patients were brought in wheelchairs and on stretchers. A nurse met them at the door and triaged them using 3"x5" homemade cards in four colors that designated the patients’ acuity levels. The cards were attached to patients’ wrists with large rubber bands. The pseudo-patients were "stabilized" and then "transported" using the 911 system. The drill lasted approximately 30 minutes.
Keep in mind that in an actual mass disaster, the ambulances may be tied up, Levert warns. "Our stabilization may require more time with the patient," she acknowledges.
In terms of lessons she learned, Levert urges managers to know staff members’ strengths and weaknesses. "Know that some of these people are going to be stronger at triage, or a person may be stronger with IV skills," she says.
After the drill, managers contacted one of the local hospitals to let administrators know that they were prepared to respond in an emergency. After the drill, the plans were put in the form of a policy. [See Emergency Management Plan at www.same-daysurgery.com. Click on "toolbox." Your user name is your subscriber number. Your password is sds (lowercase) plus your subscriber number. The checklist is under "disaster planning."] "The staff have the idea and layout of our plan and the areas they will be in, and they are familiarized with it and what they’re supposed to do," she says. "It would help prevent a chaotic situation."
• To meet accreditation requirements, have a policy in place. The Joint Commission on Accreditation of Healthcare Organizations and the Wilmette, IL-based Accreditation Association for Ambulatory Health Care (AAAHC) require that facilities have a disaster plan. How organizations respond to a disaster may vary from organization to organization, says Michael Jarema, associate project director at the Joint Commission.
They may call 911, because they may say, We’re just basic life support and CPR-certified,’" Jarema says. Their disaster plan may be to call employees and tell them to stay home because they don’t want people in the disaster area, he says. "Or they may work with their public health department which says, We want you to bring physicians and be part of our triage system.’ But each organization has to decide what its role is, and what its role is in the community," Jarema says.
Your disaster plan needs to be scalable and sustainable, "meaning that if they have an effective disaster plan in place, they can respond to one victim or multiple victims showing up at their doors," Conner says.
NYU Downtown Hospital’s plan calls for an assessment of the current status of the operating room and the postoperative care unit (PACU). [See NYU Downtown Hospital policy on disaster plan and Emergency Management & Disaster Plan for operating rooms and for PACU at www.same-daysurgery.com. Click on "toolbox" and look under "disaster planning."]
• Stabilize and transfer. SurgiCenter of Baltimore in Owings Mill, MD, has a policy for handling patients that come off the street looking for emergency care. "Even if it is not a patient who is expressly looking for an urgent care center, we get all the patients who fall in the parking lot or like situations, just because they know we are a medical facility," explains Jerry Henderson, executive director. "We stabilize and transfer to an emergency department if indicated."
Although it’s sometimes tempting, the last thing you would want to do is simply direct a person who presents to your facility with a medical condition to the hospital for care, says Joseph Hageman, RN, executive director of perioperative services at Craven Surgery Center in New Bern, NC. "Murphy’s law would be in full effect that some tragic result would occur during that drive," Hageman says. The center’s policy is to provide supportive care until emergency medical services arrives and transports the patient to the medical center, Hageman says. "This might mean we deliver a baby or initiate CPR, but that hasn’t happened at the surgery center in 20 years," he says.
People in need of medical care are apt to look to your facility as medical professionals, regardless of what their needs might be, Levert warns. "If in an emergency situation, they don’t say, you’re a gastroenterology facility; you can’t help me.’ If you’re the closest facility, [there’s] no telling what might walk through your door," she warns.
Resources
For more information on disaster planning, contact:
• Ramona Conner, RN, MSN, Perioperative Nursing Specialist, Association of periOperative Registered Nurses, 2170 S. Parker Road, Denver, CO 80231. Telephone: (800) 755-2676. Fax: (303) 338-5165. E-mail: [email protected].
• Joseph Hageman, RN, Executive Director Perioperative Services, Craven Surgery Center, P.O. Box 12446 New Bern, NC 28561. Tele-phone: (252) 633-2000. Fax (252) 633-9045. E-mail: [email protected].
• Jerry Henderson, Executive Director, Surgi-Center of Baltimore, 23 Crossings Drive, Suite 100, Owings Mill, MD 21117. Telephone: (410) 356-0300. E-mail: [email protected].
• Theresa Levert, RN, Continuous Quality Improvement Coordinator, Gastroenterology and Associates — Louisiana Endoscopy Center, 8150 Jefferson Highway, Baton Rouge, LA 70809. Telephone: (225) 927-1190. Fax: (225) 927-6605.
• Donna Pritchard, RN, BSN, MA, CNOR, CNA, Director of Nursing, Perioperative Services, NYU Downtown Hospital, New York City. E-mail: [email protected].
For information on accreditation standards from the Joint Commission on Accreditation of Healthcare Organizations, contact: Standards Interpretation Group. Telephone: (630) 792-5900. To submit a question by e-mail, go to www.jcaho.org. Under "Latest from JCAHO," click on "standards FAQ." Then click on "Go to the Standards Online Question Submission Form."
Many outpatient surgery managers have thought theyd never have to be prepared for anything worse than a single patient crashing in the OR. However, with the current threat of violence, you have to be prepared for disasters of every type and proportion.
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