Preparation pays off for EDs in DC as millions visit for inauguration

Planning for special events varies based on expectations

When Sen. Edward M. Kennedy (D-MA) was brought to the ED at Washington (DC) Hospital Center on Jan. 20, 2009, following a seizure, the department was well prepared.

"Given traffic flow and ingress and egress, if something happened at the Capitol [where Kennedy was stricken], we knew we would be the quickest [place to move]; we knew they'd be coming our way," says William J. Frohna, MD, vice chairman of the ED.

The office of the attending physician of the U.S. Capitol had alerted the facility that there was an event going on (a post-inaugural luncheon), Frohna recalls, but he actually found out about Kennedy's health problem a split second before being alerted by that office. "My wife [who had been watching CNN,] texted me and told me about it even before we got the heads-up call," says Frohna, noting that he was just about to begin his shift. "As I got that text, our physician had just gotten off the line with the attending physician at the U.S. Capitol."

Several EDs in the district had TVs available to monitor inauguration events. Incidents such as these show they have more than just entertainment value.

Washington Hospital Center's ED had a special area designated for VVIPs (very VIPs); it only had one interior entrance and one exterior entrance, with controlled access and security. "It's an area that is normally part of what we call MedStart, a medical shock, trauma, and acute resuscitation area," Frohna explains.

It has five bays staffed with dedicated trauma nurses 24/7, as well as trauma physician coverage. The outside entrance comes from the helipad, and ambulances also can drop off patients there. The in-hospital entrance is keypad-activated. Because of the medical nature of Kennedy's condition, the chief of neurosurgery was made immediately available, and an ED physician was ready to treat the senator when he arrived.

As for the media, Frohna notes that any information to be released from the ED had to be approved by the hospital's media relations department and the senator's family. However, he adds, because of tight security, "the media assembled outside our boundaries and were beyond the realm of our control" and did not interfere in the case.

While other EDs in the city did not have similar high-profile situations, they nonetheless made they own detailed preparations, in some cases preparing for the worst. "After 9/11, we realized that anything can happen, and that you need total preparedness," says Fernando Daniels III, MD, the interim emergency medicine director for the ED at United Medical Center. "We set up an outside decontamination tent, prepared our bioterror equipment, and made sure everything was ready from that standpoint," he says. "We also made sure we did refresher training for our nurses on how to put on protective equipment."

Fortunately, that equipment never was needed. However, other preparations Daniels and his team made did come into play. "We absolutely expected a heavier census, so we discharged all patients who were stable to make available as many beds as possible," he says. "We moved our fast-track area into our primary clinic area [providing eight additional beds] and doubled staffing of RNs, techs, and PAs." An additional physician also was scheduled for peak times, he says. An additional triage area for fast-track patients was set up so there were two operating simultaneously, "which really expedited patient care."

Security also was enhanced. "Only cars with ID could get on site, and we checked [incoming] patients' IDs before they could get into the parking area," says Daniels. "All employees had to display their ID, and we placed security out front."

Although the patient load during the inauguration was double the normal census, this preparation paid off, says Daniels. "Waiting times actually went down," he shares.

Location and traffic patterns had a lot to do with how EDs were affected, adds Leena Salazar, RN, BSN, director of the ED at The George Washington University Hospital. "We added a nurse or two, figuring we'd see a lot of orthopedic stuff, but we did not get a lot of patients because of traffic hindrances," she says. "It was actually less than our normal census, so we were not able to really test our surge preparedness."

Sources

For more information on emergency preparedness, contact:

  • Fernando Daniels III, MD, Interim Emergency Medicine Director, United Medical Center, Washington, DC. Phone: (202) 574-6073.
  • William J. Frohna, MD, Vice Chairman, Emergency Department, Washington Hospital Center. Phone: (202) 877-7000.
  • Leena Salazar, RN, BSN, Director, Emergency Department, The George Washington University Hospital, Washington. Phone: (202) 715-4210.

Inauguration seen as four-day event

At Washington Hospital Center in Washington, DC, the presidential inauguration was not seen as a one-day affair.

"You not only had the weekend events preceding the inauguration, but also the [Martin Luther King Jr.] holiday and the inauguration, so it was a four-day break of routine care availability for patients with private physicians," notes William J. Frohna, MD, vice chairman of the ED. "You had to account for that, and then plan and prepare for anywhere from 1 million to 4 million visitors."

To do that, he says, he interfaced with hospitals inside and outside the District of Columbia, had liaison with the Secret Service, as well as local and regional EMS. The Secret Service, he notes, "kept us in touch with the latest crowd estimates."

During events such as this, it's not uncommon for the census to actually go down, Frohna says, but "we basically bumped physician staffing up about 20% for Sunday through Tuesday, which brought us up to as many as five." In addition, administrative leadership physicians were in scrubs to see patients as needed, and the hospital's emergency medicine residency program enabled him to add an eight-hour shift of resident coverage during what were expected to be peak hours.

In addition, notes Frohna, the ED had a head start on preparing to deal with disasters with its ongoing "ER One" program.

Finally, Frohna credits the medical resources deployed on the national mall with easing the burden of local EDs. They had warming tents and nearly 50 areas for treating patients on the scene," he says. "We had remarkably fewer individuals who had cold [exposure] injuries," Frohna says. "We had more medical conditions exacerbated by the elements, such as asthma, chest pain, or people who forgot their meds on the busses."

Managers generally pleased with results

By and large, ED managers in the Washington, DC, area were happy with how they prepared for the recent presidential inauguration.

"We're absolutely pleased with how things went," says Fernando Daniels III, MD, the interim emergency medicine director for the ED at United Medical Center. "If anything, we learned how to improve our own throughput process."

In particular, says Daniels, he enjoyed the dual fast-track principle he instituted from noon until 10 p.m. and is considering instituting a double fast-track permanently. "We will be renovating our space and meanwhile will look at temporary space to move the current fast-track to have space to expand the ED," he says.

At Washington Hospital Center, "Overall, we were very well prepared, although some fine tuning is needed," says William J. Frohna, MD, vice chairman of the ED. "It would be nice to have a passive way to access real-time information for the ED because rumors flow." For example, he notes, at one point the department was concerned there were crush injuries coming from an area where people had broken down barriers.

The ED was alerted by the hospital command center, which received information from a hospital employee who happened to witness the event. "We received the report, which was not erroneous, of multiple potential injured victims," says Frohna. However, he adds, the ED did no receive any casualties for several probable reasons:

  • Minor injuries self-treated and self-triaged away/at home, especially given the response time of EMS to the scene due to size of crowds.
  • Medical facilities and personnel on site and on the mall provided sufficient first aid.
  • Medical direction took patients elsewhere as their injuries were considered less severe (not requiring a trauma service) and designated routes for EMS away from the mall/scene were established and were not headed toward Frohna's facility.

For those potential crush injuries, "we asked how many beds we needed to have, but then we never received them," he says. "I'd like a way to access the system to know when real medical situations are coming in."

He'd also like to see case management capabilities in the ED proper. "For example, we needed to marry up patients with their busses that were going home, and that's something we should look at in the future," he says.