EXECUTIVE SUMMARY

A small hospital was the main facility receiving patients after a serious bus crash. The hospital coordinated with other facilities in the health system to manage the incident.

  • Planning for such a mass casualty event made the response successful.
  • A language barrier presented a challenge.
  • The hospital saw room for improvement in personnel management and radiology reviews.

Leaders at a hospital in Utah saw the value of mass casualty planning and communication with other facilities when a tour bus crash killed four people and seriously injured 25 more. To make matters even more challenging, all victims were from China and spoke no English.

The incident was a significant challenge for Intermountain Garfield Memorial Hospital in rural Panguitch, located in the southwest part of Utah, that sees about 2 million tourists per year. About 1,500 people live in Panguitch, and Garfield Memorial is a critical access hospital that serves the region with 15 beds, four physicians, two advanced practice practitioners, and 125 employees.

The ED includes two trauma bays and two exam rooms, for a total of four emergency beds. On its busiest days, at the height of the summer tourist season, the ED might see 20 patients — few of them trauma. Responding to an incident of this size would require coordination with other Intermountain facilities and resources.

Garfield Memorial had planned for such a mass casualty event, and was ready to activate its teams and protocols. Ironically, health system leaders were on site that day to assess the hospital’s plans for a mass casualty event. Instead of going through PowerPoints and three-ring binders, they saw the hospital respond to a disaster.

In Salt Lake City, Intermountain Garfield Memorial Hospital Administrator Alberto Vasquez had just left a meeting at 11:30 a.m. on a Friday when an assistant texted him to ask if he heard about the tour bus that crashed 18 miles from the hospital.

“This was only about 20 minutes from our hospital, so we knew that we would be the primary resource for responding and caring for these patients,” Vasquez says. “It was a tour bus with about 30 tourists from China that overcorrected on a highway, turned over, slid, and hit a rail.”

Four passengers died at the scene. Everyone else was injured, many of them seriously. Several other tourists passing by happened to be first responders and medical professionals, so they assisted the passengers until local authorities could respond.

Trauma Response Under Review

The scope of the accident triggered the Garfield County 911 center to notify all emergency responders and hospitals in the region. Despite its size, Garfield Memorial would be the key medical facility because the other closest hospitals are Intermountain’s facilities in St. George, about 90 minutes away, and Salt Lake City, nearly four hours away.

At Intermountain Garfield Memorial, Nurse Administrator Deann Brown, RN, was about to attend a meeting led by Rachelle Rhodes, RN, Intermountain’s executive director of clinical operations in the specialty-based care group. Rhodes is an experienced trauma nurse, and was visiting the hospital with three team members to review Garfield’s trauma response, among other issues.

When they heard about the bus crash, Brown and Rhodes canceled the meeting and rushed to Garfield Memorial’s ED. They found that the ED staff was gathering supplies and had texted off-duty nurses to come in if they could.

Rhodes and her team gowned up and prepared to assist with incoming patients. It was not long before patients began arriving by ambulance and helicopter. The health system had immediately dispatched two helicopters and two airplanes to Panguitch after assessing the scope of the bus accident, delivering additional personnel, medical supplies, equipment, and blood.

Intermountain coordinators determined that 19 crash victims would to be sent to Garfield Memorial for initial treatment and stabilization, although many likely would be transferred to other facilities for further care because Garfield Memorial did not have enough beds. First responders triaged patients on site, sending three or four to Garfield Memorial every 20 minutes. The first patients arrived around noon.

Garfield Memorial’s ED manager was in the ambulance bay triaging patients as they arrived, sending green noncritical patients to the clinic, while those needing immediate emergency care were sent to the ED, Brown explains.

Significant Language Barrier

Adding to the challenges, the ED received two cardiac arrest patients unrelated to the bus crash — one just before the crash, and the other just as the accident victims began arriving.

The health system’s virtual hospital, Intermountain Connect, helped coordinate the response, explains Bill Beninati, MD, senior medical director. The virtual hospital provided two-way audio and video connections to the Garfield Memorial trauma rooms so that trauma and critical care experts at other Intermountain facilities could consult and coordinate care plans, he says.

The communication was particularly important for planning the transfer of patients from Garfield Memorial after their stabilization, to keep that hospital and others in the health system from becoming overwhelmed, Beninati says.

Intermountain’s APP team also assisted Garfield Memorial. The APP director of anesthesia, based at Cedar City Hospital, texted staff at Garfield Memorial and confirmed they need more personnel. She dispatched four APPs from Cedar City, and another APP moved from a different hospital to provide coverage at Cedar City.

To address the language barrier with the Chinese patients, Intermountain’s Language Services team sent four iPads the hospital staff could use to help with translations. A volunteer Panguitch firefighter also helped with translations. Additionally, Chinese-speaking students at Southern Utah University, about 60 miles away, drove to the hospital after hearing about the accident so they could help translate and comfort the patients.

“They were not certified translators, so we tried to keep it to just basic information that they discussed with the patients. It wasn’t ideal but we worked with what we had available to us at the time,” Vasquez says. “That could be a risk issue, but we did what we had to do to care for the patients.”

At Intermountain Dixie Regional Hospital in St. George, where some of the patients were transferred, a clinical dietitian had the entire room service menu translated into Mandarin.

Good Response, But Lessons Learned

Garfield Memorial responded well overall to the bus crash, Vasquez says, although there are lessons to be learned from any incident of this size. Communication with local first responders was excellent because hospital leaders had worked closely with them to coordinate and include them in all incident response plans, he says.

“Our folks fell into the roles that they had trained for, positions like incident commanders, and they performed very well,” Vasquez says. “We learned that we didn’t have some of the more formal procedures ingrained in us, things like grabbing the incident commander vest so that everyone can see who is in that role. Everyone did their part and worked well with the other facilities, but we could have been more formal in some of the things we did.”

Being part of a health system greatly improved the hospital’s response, Brown notes. Personnel at Garfield Memorial could focus on patient care more because of the support provided by Intermountain leaders elsewhere, she explains.

“Life Flight just dispatched, and when they were here, they said ‘Don’t worry about the arrangements because it’s been taken care of by Intermountain.’ Normally, in a trauma transfer, we’d have to make the arrangements with specific hospitals, but in this case they said, ‘Don’t worry about it, we’ll take them where they need to go,’” Brown says. “That freed us to focus on the patients we still had coming in and needing more care.”

The air ambulances made repeated round trips between Garfield Memorial and the other Intermountain hospitals, transferring patients and ferrying supplies to Garfield. The hospital had enough supplies on hand, but the health system resupplied some critical material and delivered particular blood types to Garfield Memorial so it did not have to take the time to cross-match its own supplies to patients.

Many Volunteers to Manage

Another potential lesson from the experience was the need to manage the influx of additional staff and volunteers, Brown says. The community responded so quickly that it might have been useful to have more coordination and oversight of the off-duty personnel from its own hospital and neighboring facilities, as well as private citizens like the college students who provided translations, she says.

There were no problems with them, but the hospital was not quite prepared to manage the number of people who stepped up to help, she says. Vetting the skills and credentials of people who volunteer to help would improve the incident response, Brown says.

The hospital’s radiology group also is studying how to notify radiologists from other facilities who can help read CT scans and similar images, Vasquez notes. There was some delay in reading images the day of the crash, so leaders are arranging to notify radiologists at other locations and allow them to access the queue of images.

Garfield Memorial used numbers as patient identifiers for the bus crash victims because most came in without identification, and the language barrier made it difficult to obtain their names. The hospital changed the patient identification to the name when it became known, but Vasquez says the hospital may stick with numbers through the initial triage and stabilization process because the foreign names were difficult for staff.

The hospital also is looking at tightening security during a mass casualty incident. With the hospital running full throttle, all the doors were open and people were coming and going without much vetting or restrictions, Vasquez says. Nothing problematic occurred, but hospital leaders realized that there should be more formal security.

“Someone was being nice and ordered in pizza for our ED staff, and the pizza delivery person just walked right into the ED in the middle of all this,” Vasquez recalls. “It was OK, but we realized that is the kind of thing you probably shouldn’t have going on when you’re dealing with a mass casualty event. We also had some looky-loos come by just to see what was going on. We could tighten that up a bit.”

The hospital also received scam calls during and after the incident, Vasquez says. Some callers claimed to be from the FBI and wanted information on the Chinese patients, such as what province they were from, which the hospital did not know. There were other calls from people claiming to be from insurance companies offering to pay the patients’ bills and asking for personal information about them. The hospital also had to deal with several state and federal investigators who needed to gather information from the patients, Brown notes.

When Vasquez left the hospital at 11 p.m. on the night of the accident, only one patient from the accident remained. He says he left feeling proud of his team’s performance and confident they could handle another such incident if necessary.

“We were more prepared than I realized, more prepared than any of us realized,” he says. “You do all the planning, and put all the right processes in place, and hope that it works when needed, but you don’t know until you’re tested. We were tested, and Intermountain rose to the occasion by working together.”

SOURCES

  • Deann Brown, RN, Nurse Administrator, Intermountain Garfield Memorial Hospital, Panguitch, UT. Phone: (435) 676-8811.
  • Alberto Vasquez, Administrator, Intermountain Garfield Memorial Hospital, Panguitch, UT. Phone: (435) 676-8811.