EDs credit drills, community engagement with helping them manage casualties from tornado crises

For optimal preparedness, push emergency operations plans to the limit in practice

Weather forecasters had much of the Southeast on high alert for dangerous storms on Wednesday, April 27, but the clinical and administrative staff at Cullman Regional Medical Center (CRMC) in Cullman, AL, got a particularly vivid view of what these storms were capable of at about 3 o'clock in the afternoon. "We actually watched from the hospital windows a tornado develop and hit the city of Cullman," recalls Jim Weidner, MBA, the hospital's president and CEO. "We realized there was probably going to be a lot of casualties, so we immediately implemented what we call our code HICS, and went into our hospital incident command system mode."

Two hours later, emergency department staff at DCH Regional Medical Center in Tuscaloosa, AL, began triaging tornado victims from the worst disaster they had ever experienced at the hospital. "We saw more than 600 patients that day," explains Charles Lacey, BSN, MPPM, the emergency director at DCH RMC, noting that a typical day's volume is in the neighborhood of 200 patients. "We use our emergency operations plan a lot...but we have never, ever had that volume of patients previously." (Also, see "Emergency planning: Every event is an opportunity to analyze and improve," below.)

In addition to handling a rapid intake of patient casualties, both hospitals had power outages to contend with, as well as unprecedented staffing needs. But administrators at both facilities say they were able to manage the intense demands on their resources primarily because their disaster plans were well thought out and well drilled.

"I am very appreciative of the regulatory bodies that have mandated that you have an emergency operations plan and that you practice it because things wouldn't have gone as well otherwise," says Lacey. "We had just gone through a Joint Commission survey back in October, and we had practiced these things."

Administrators at CRMC express similar sentiments, pointing out that they were able to manage through the crisis even though their director of emergency services, Cindy Hawkins, RN, MSN, CCNS, was not on site when the tornado swept through Cullman. "Given that she wasn't there, I actually stayed in the ED and assumed the role of HICS incident command liaison between the ED and the command center," explains Weidner. "There are pre-designated phone numbers for employees to call to find out whether they are needed or not, and there are pre-designated spots where employees who are available will show up, so all of that is practiced and rehearsed as part of our drills."

It also helped that CRMC had dealt with another weather emergency as recently as this past February, when the area was hit by a severe winter storm that blanketed the region with seven inches of snow. "From a traffic perspective, that will cripple a place like Cullman, says Weidner. "At that time, we had 54 ambulance responses within a one-hour period from motor vehicle accident victims that required some type of medical treatment."

There were valuable lessons learned from dealing with the H1N1 flu epidemic as well, says Hawkins. "We had to do a lot of preparation for the influx, so we were ready with alternative-care sites in our facility to flex up for those patients," she says.

The winter storm and the H1N1 epidemic were not nearly as serious or intense as the tornado disaster, but there is no question that these experiences helped to get the ED used to implementing the hospital's emergency plans. "We had a very good chance to drill and practice with that snow emergency," says Weidner. "That is why we felt we were as well prepared as we possibly could be for this type of trauma."

Establish community links

While ED personnel are trained to deal with medical crises, the ability to manage disasters of this magnitude requires careful planning and constant refinement, according to Michael Chisholm, CPE, CHFM, an associate director of the standards information group, engineering team, at the Oakbrook Terrace, IL-based Joint Commission. This is why the accrediting agency requires hospitals to regularly carry out disaster drills, he explains.

Chisholm emphasizes that the drills help organizations to understand their limitations and capabilities — a key competency that Joint Commission reviewers look for when surveying hospitals. "An important part of emergency operations planning is communicating your capabilities to the community and understanding what the community's capabilities are," he says. "Without that link, your plan and your organization will fail hands-down. That is one common theme that we try to teach and we survey for." (Also, see "Will your emergency operations plans hold up to Joint Commission scrutiny?" below.)

Lacey explains that the centralized command system that DCH RMC set up to handle the tornado emergency was in constant communication with the state trauma system. "We did that through a computer terminal located in our communications room," he says. "We let them know that we were physically OK, but that we were probably going to need some assistance with patients, and that we would let them know as we found out."

The command system also took charge of finding electricians when the hospital lost power in the midst of the storm and had to rely on a backup generator. "The electricians worked to get the power back on for the hospital grid," adds Lacey.

Relationships deliver dividends

Likewise, the command center set up at CRMC was equipped with 12 phone banks and mounds of contact information so that resources could be accessed quickly, says Weidner, who served as the liaison between the ED and the command center. Weidner worked closely with Josiah Daily, MD, the physician who took medical command of the ED during the crisis. "I was the one doing the calling to the command center based on what resources were required," says Weidner.

For example, early on in the crisis, Daily issued a request for an ophthalmologist because a patient came in with severe lacerations to the eye. "At that time, we didn't have an ophthalmologist that was available, and my job was to call the command center and indicate that this was a physician request," says Weidner. "We were never without medical staff in every subspecialty that we needed."

Other needs that the command center took care of that day included a request for lab equipment so that some diagnostic tests could be completed right in the ED rather than sent off to the lab, a request for more walkie talkies so that the ED could communicate more effectively with the ambulances that were coming in, and a request for food to sustain ED staff who worked for several hours at high intensity, explains Weidner. The command center also arranged for "runners" when the pneumatic tube system the ED typically uses to send and retrieve samples from the lab went down.

The relationships with community organizations that were established during community-wide drills proved invaluable in helping CRMC respond to the crisis, stresses Hawkins. "We had those relationships when we really needed them, and it made a huge impact to our success," she says.

Hawkins, who had been in the ED that morning when an earlier band of storms came through the area, and was in constant contact with her staff by phone in the hours following the tornado strike in Cullman, says everyone was up to speed on what needed to be done. "If you prepare your staff properly, then they know what to do whether you are [on site] or not," she says.

Be prepared for extended demand

During the seven-hour period immediately following the tornado, CRMC's ED treated about 99 patients, says Hawkins. But even two weeks after the storm, volumes have remained high. "We had been averaging about 114 per day before the storm, and now we are averaging about 128 per day. We peaked at about 155," she says.

Many of the newer patients are workers who were injured trying to clean up all the storm damage and people who may have delayed seeking care during the height of the storm. "Now they have arrived in the ED and they have a very high acuity," she says.

One stroke of good luck for CRMC is that it just opened a greatly expanded ED about two and a half months before the tornado hit, says Weidner. "It was actually built with the planning to be able to handle a disaster such as this," he says. "We had extra space in the hallways, extra gas capacity that we could plug in, and the capability to expand almost 50% beyond our normal capacity."

By the time the storm hit, ED staff were used to the new facility, as well as the patient flow, from an efficiency standpoint, says Weidner. "To watch the teamwork between ED nurses, physicians, and ancillary staff was about as good as I have seen in my career. The staff just stepped up, and it was about as well-orchestrated as one could have given the disaster that we faced."


  • Michael Chisholm, CPE, CHFM, Associate Director, Standards Information Group, Engineering Team, Joint Commission, Oakbrook Terrace, IL. Phone: 630-792-5900.
  • Cindy Hawkins, RN, MSN, CCNS, Director of Emergency Services, Cullman Regional Medical Center, Cullman, AL. E-mail: cindy.hawkins@crmchospital.com.
  • Charles Lacey, BSN, MPPM, Emergency Director, DCH Regional Medical Center, Tuscaloosa, AL. E-mail: clacey@dchsystem.com.
  • Jim Weidner, MBA, President and CEO, Cullman Regional Medical Center, Cullman, AL. E-mail: jim.weidner@crmchospital.com.

Emergency planning: Every event is an opportunity to analyze and improve

The biggest challenge in handling a community disaster similar to the tornadoes that swept through the South this past April will always involve triaging patients for the appropriate level of care as they come through the system, explains Charles Lacey, BSN, MPPM, the emergency director at DCH Regional Medical Center in Tuscaloosa, AL.

"We had physicians doing triage as the patients came through the ambulance bay, but that was not the only way that patients were coming to the hospital," he says. "Some injured patients were able to make it here by limping through the front door, so they were not at the triage areas where the physicians were."

Another challenge involved dealing with all the people who were trying to get information about loved ones who had been injured. "We had an ED lockdown secured, but there were so many people looking for a mother, brother, or children that they were just walking amongst the masses of patients on stretchers trying to find their family members. We couldn't allow that, and that upset some people," says Lacey.

To improve the process, Lacey plans to assign specific coordinators to manage each area of the hospital in future practice drills. "These coordinators will make sure that patients in their particular purview receive appropriate care," he says. "Then we will know what coordinator is working with what group of patients. This is something that we can do better."

In addition, Lacey plans to place security guards at all the gates of the hospital so that only ambulances and injured patients are allowed through to triage. "We will have another area where visitors can wait and see if we have a particular patient," he says. "We will be able to handle patient information better the next time."

Other plans include finding ways to boost some of the hospital's capabilities when it is operating under emergency power. "We have never had our emergency power tested to this point," says Lacey. "We were self-contained, on our own for 12 hours, and that was phenomenal for the number of patients we had, but we wish we had had some extra power that we didn't have that night to do more radiology and ultrasound."

Diagnostic capability is critical when you have a surge of patients coming in with the potential for internal injuries or internal bleeding, says Lacey, so this is an area that the hospital will definitely address for the future. "We found lots of ways to improve our emergency plan, and that is what you do," he says. "You plan, you do, something doesn't work right, and then you make changes and reset the plan."

Will your emergency operations plan hold up to Joint Commission scrutiny?

When reviewing hospital emergency operations plans, surveyors from the Oakbrook Terrace, IL-based Joint Commission seek to establish that organizations have adequately prepared for six critical functions, explains Michael Chisholm, CPE, CHFM, an associate director of the standards information group, engineering team, at the accrediting agency.

These include:

  • communications;
  • resources and assets;
  • security and safety;
  • staffing;
  • utilities management; and
  • patient needs.

Further, Chisholm emphasizes that reviewers want to see that each hospital's plan is uniquely designed for the success of the facility's own mission and operations, and that it is well practiced. "We expect that hospitals will have at least two practice exercises per year, and that one of these practices is a community-based exercise, and that one of them encompasses an influx of patients," he says.

Chisholm emphases that these exercises should be designed to really press the institution's capabilities. "You should be driving your plans to the edge so that you can find out where the breaking point is," he says. It is crucial to understand where that limit is, says Chisholm, because facilities need to know at what point they will need to seek resources and assistance from the community.

Exercises or drills require a lot of resources, so you need to set goals and have a well-developed scenario in place, says Chisholm. "Make sure the actual event is something that has all the elements in place to fully exercise the emergency operations plan," he says.

The most important aspect of any drill is the critique that goes on afterward, adds Chisholm. He advises organizations to always bring in an outside observer to offer fresh insight. Local law enforcement, fire department personnel, and military officials can offer good perspective on opportunities to improve emergency-preparedness plans, he says.

"Particularly at hospitals, there is tunnel vision. We lose some insight that could be gained from someone looking from the outside in," says Chisholm. "Once you do your critique and identify opportunities for improvement, re-drill to make sure you have put the right action in place to take advantage of those opportunities."

Consider these common deficiencies

While accreditation standards require hospitals to have some type of incident command structure, the Joint Commission doesn't specify that hospitals must use a particular model. However, Chisholm stresses that it is important to select a model that is well understood by the community. "If your incident command structure is completely different than what is at the community level, there can be some likelihood for miscommunication," he says.

What do Joint Commission reviewers frequently find fault with when reviewing emergency operations plans? Chisholm says that there are often problems with the hospital's hazard vulnerability analysis (HVA). "A lot of the elements of an emergency operations plan are wrapped around an organization's determination of what their hazard vulnerabilities are, so if that HVA is not current and accurate, there could be problems with their emergency operations," he explains. "What we require is that hospitals have very specific mitigation plans for the top three to five vulnerabilities cited in their HVAs."

Another common deficiency with emergency plans is that hospitals often fail to assess their capacity to carry on without outside assistance for 96 hours. "If they can't make it to 96 hours, at what point do they need to evacuate?" says Chisholm, noting that plans should specify alternative sites of care in the event that the hospital needs to transport some or all of its patients elsewhere. "That evaluation is very intensive. It not only goes to staffing, but also a lot of utility-based issues, fuel, food, and supplies."

A third issue that frequently comes under the critical eye of Joint Commission surveyors is the way in which emergency credentials of licensed independent practitioners (LIP) are verified. "If a physician comes in as a volunteer, how do you know he is who he says he is?" says Chisholm. "The bylaws of an organization should indicate what identification means are acceptable for determining that a clinician is who he says he is, and can perform effectively."