After mass casualty incidents such as the recent mass shooting in Orlando, FL, patient access needs good processes to register unidentified patients and to call in additional registrars. Patient access leaders can prepare by doing the following:

  • designating a separate area for registration;
  • holding disaster drills during all shifts;
  • reviewing security protocols and providing security training to staff.

The patient access team at Orlando (FL) Regional Medical Center was informed a mass shooting had occurred only 10 minutes before patients started arriving, and it ended up registering a total of 44 people.

Ruthy Felipa-Daley, CHAM, CRCR, manager of patient access and revenue management, says “fear of the unknown” was the biggest challenge her team faced that day. “No one knew the severity of the patients until they reached on-site. We were not fully prepared to intake the amount of patients coming in.” The hospital, part of Orlando Health system, is Central Florida’s only Level One Trauma Center.

Registrars’ initial reaction was shock. “Once the team determined how serious the incident was, they were able to follow the proper protocol for registering patients” from a mass disaster, says Felipa-Daley.

For years, the patient access department participated in the hospital’s annual mass casualty incident (MCI) drills to prepare for a disaster such as this one. “You are never are fully prepared for the reality of such a tragic event,” says Felipa-Daley. Here is how the patient access team coped successfully:

• Registrars were stationed at both entry points: triage and ambulance bay.

“The main goal was to properly identify each patient and prevent poor handoffs, to avoid delaying care,” says Felipa-Daley.

The senior patient access representative onsite rounded throughout the ED to make sure registrars were coping and that all patients were captured and documented appropriately.

• The department used its established process for accurate registration of unidentified patients.

“The patient access team utilized our ‘Doe’ pre-registered accounts, and activated each account as the victims arrived,” Felipa-Daley says.

Registrars used pre-printed labels with unique downtime numbers. “Accounts have Doe as the last name, with a unique first name. We use a rotation between categories of states, cities, and fruits,” says Felipa-Daley.

Patient access pre-admits the “Doe” charts. Mary Ellen Daley, MHA, CHAM, CRCR, a patient access manager at Arnold Palmer Medical Center, also part of Orlando Health, says, “The ER maintains 50-100 pre-admitted charts using a naming convention specific to the facility.”

ED registrars make packets in advance that include the “Doe” face sheet, labels, and armband. “We have a very specific protocol for our team during an event,” explains Daley. “They work closely with our clinical partners to track the patients from intake to discharge.”

One registrar activated the accounts and printed paperwork, while others tagged the patients with armbands. “The main focus was to make sure all patients were accounted for and properly identified,” says Felipa-Daley.

An unexpected challenge occurred once patients were admitted. “There was little to no identification with the victims to truly identify their legal name,” explains Felipa-Daley. “Our team had to use all internal resources, including nonverbal cues from patients, to properly identify them.” Patients nodded or shook their heads when asked to confirm their names or dates of birth.

• An information hotline was established to accommodate the influx of calls regarding the event.

“The Orlando Health Community Relations team was on site and quickly set up a location for questions regarding patients and families,” says Felipa-Daley. The hotline was monitored and answered by community relations and the hospital’s Patient Experience team.

• Immediately after the event, the hospital made employee assistance program counselors available to all team members, including patient access.

“This created a safe environment for team members to express their emotions and feelings,” says Felipa-Daley. In addition, patient access leaders held their own “touch base” meetings with staff. “These were informal,” says Felipa-Daley. “We discussed anything the team wanted to talk about.”

• Patient access counterparts from other hospitals called to offer much-needed encouragement.

Other patient access employees within the health system brought pizza and gift baskets to the team members at Orlando Regional Medical Center. “Currently, team members across patient access are volunteering to cover shifts, to allow our access team involved in the event some time off to process and heal,” says Daley.

Michael S. D’Angelo, CPP, CHPA, director of security at South Miami (FL) Hospital, says that in the aftermath of any MCI, “Patient access will face a number of things that they likely have not encountered before.”

Working alongside clinicians, ED registrars “will bear witness to the traumatic injuries commonly associated with terrorist events,” says D’Angelo.

The biggest challenge he sees for patient access is finding a way to “better synchronize” the processes of registration and triage. “Under normal circumstances in the ED, those two processes flow together rather well,” says D’Angelo. However, during a significant surge after an MCI, registration has a difficult time keeping up with the clinical staff.

One solution is to designate a separate area to be used for registration, such as an auditorium or educational room in the hospital. “Clinical teams in the ED drill for setting up alternate care sites or additional triage stations for MCI events,” says D’Angelo. “Registration teams need to consider doing the same.”

Appropriate identification and routing information on each disaster patient is critical for patients, staff members, and family members. Thomas A. Smith, CHPA, CPP, president of Chapel Hill, NC-based Healthcare Security Consultants, says, “Registration can play a key role in ensuring this key information is collected and appropriately entered into the EMR or other patient tracking system.”

Here are some ways patient access can prepare for MCIs:

• Hold mass casualty drills during all shifts.

The mass casualty drills at Orlando Regional Medical Center previously were held during traditional business hours. The department now will hold them on different shifts. “Expanding the core hours of the exercise will ensure everyone has the exposure of an emergency intake event,” says Felipa-Daley.

• Have an emergency contact list that is readily accessible, to bring in more staff.

Orlando Regional Medical Center’s ED patient access supervisor used the department’s phone tree list to contact the team, informed them of the situation, and told them they were on standby in the event additional coverage was needed. “Luckily, we were fully staffed the day of the incident and were able to perform our duties without additional staffing,” says Felipa-Daley.

• Build a close relationship with the hospital’s security department.

Smith suggests providing patient access staff with quarterly security-related training. “Assign a staff member to be the designated liaison with security and emergency management staff to work on and improve routine and emergency plans,” he suggests.

• Routinely review security protocols regarding reporting suspicious activity, criminal behavior, and emergency response plans, including bomb threats and active shooters.

“Security is much more challenging if we only look at one aspect,” Smith says. “To be effective, it must be layered and include many disciplines.”

• Have a greeter direct patients.

During site visits to hospitals, Smith often sees patient access “multitasking in the extreme, with customer service, giving information to visitors, registration, and wayfinding.”

Instead, Smith likes to see each visitor entrance have someone greeting and directing people to the appropriate area for service, especially during off-hours. “It is good customer service, not to mention added security,” he says.


  • Mary Ellen Daley, MHA, CHAM, CRCR, Manager, Patient Access, Arnold Palmer Medical Center, Orlando, FL. Email: MaryEllen.Daley@orlandohealth.com.
  • Michael S. D’Angelo, CPP, CHPA, Director of Security, South Miami Hospital. Phone: (786) 662-8895.
  • Ruthy Felipa-Daley, CHAM, CRCR, Manager, Patient Access/Revenue Management, Orlando Regional Medical Center. Phone: (321) 843-4623. Email: Ruthy.Felipa-Daley@orlandohealth.com.