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After Riverside HealthCare in Kankakee, IL, dealt with the crash of an Amtrak train in March of 1999, hospital officials took a hard look at their disaster response plan and decided some changes were in order, says Sherry Mayes, RN, BSN, trauma coordinator and disaster chairwoman.
Riverside took a year to rewrite its plan, modeling it on the Hospital Emergency Incident Command System (HEICS), a plan first tested by six hospitals in Orange County, CA, and released in 1992 for general use. Copies of the plan have been sent to facilities throughout the United States and Canada, as well as to other countries, according to information on a web site devoted to HEICS. (To download a copy of the third edition of HEICS, go to www.emsa.cahwnet.gov.)
HEICS features a flexible management organizational chart that allows for a customized approach to the crisis at hand, according to the web site. The organizational chart has 49 positions grouped into one of four sections, a structure designed to provide a platform for common terminology to enhance communication and improve documentation.
"We have tested the [HEICS] plan and it works a lot better," says Cindy Hagenow, director of patient access. "You have a command center set up, and the incident commander will open that center and assign people on that [organizational] chart.
Under the HEICS plan, Mayes says, "all of the key players have job action sheets’ and know who to report to immediately and what to do." If the disaster occurs at 3 or 4 a.m., she points out, "I may have to do three or four people’s jobs temporarily, but at least the little details won’t be missed because it’s all written down in order of priority."
In line with the HEICS plan, she says, people in key positions now have vests to wear that say "incident commander" or "public information officer" in bold letters. "You can go to any area and know who’s in charge."
Another change has been the addition of portable radios, which become critical to communication when all the telephone lines are tied up, Mayes adds.
Registration personnel "have a big job" when a disaster occurs, Hagenow notes. "When we’ve done some of our drills, one of the pitfalls has been that an access person was not initially assigned to one of the other victim care areas [apart from the main triage area] where patients were being treated."
If the drill was being conducted after normal business hours, there would be no registration personnel in, for example, the outpatient center, she says. That resulted, Mayes adds, in some of the "walking wounded" patients being treated and released without any type of registration occurring.
With the revised plan, she says, "we get staff in key areas right off the bat. With the job action sheets, the manpower unit leader assigns a registrar to each area."
As victims arrive under the ED canopy, Mayes explains, the triage physician takes a look at them, even though they may already have been triaged in the field and given color-coded tags indicating the severity of their conditions. "Red is for critical patients, yellow is for serious but not life-threatening conditions, and green is for first-aid’ patients."
Registration staff, who are under the canopy with the physician, put pre-numbered bracelets on the patients, and record the same number on a patient log sheet, Hagenow says. That number is used to identify blood specimens or any other items associated with that patient, she adds.
Under the plan, Mayes says, patients are taken to various care areas, depending on the color of their tags. "Red" patients go to the ED, "green" patients are assigned an escort who takes them to the hospital’s outpatient center, and "yellow" patients are taken the endoscopy procedure lab.
"[Access employees] are assigned to all of the victim care areas," Hagenow notes, "and their job is to make sure that as the patients arrive, the number on the bracelet goes on the log sheet." When they get to the various care areas, the patients are "mini-admitted," she says, with admitters entering just their name and basic demographic information into the computer. In some cases, she adds, patients may be listed simply as John Doe, with a number instead of a middle initial to distinguish one from the other.
"In a disaster, the other hospitals, Red Cross, everybody wants to know where this or that person is," Hagenow says. "Anybody from any area can pull up the list [on the computer] and get an up-to-the-moment list of where these people are."
Identifying the location of patients was one of the biggest challenges during the Amtrak disaster, Mayes notes. "We had people calling from all over the world. Now we’ve redesigned the system so we can get that list in an expeditious manner."
If the computers go down, Hagenow says, staff fall back on the disaster log, which has three-ply sheets. "We have runners that come from the command center to pick up the log sheets. That’s our backup system."
In Mayes’ opinion, HEICS "is the way to go. The advantage of it is that if all hospitals had that plan, we would all be on the same page," she says. "If I call [another hospital] and want to talk to the incident commander, they know who I’m talking about."
Having the support of hospital administration is crucial to the successful adoption of the HEICS, Mayes points out. "It costs money and it takes a lot of time to educate people. You have to educate the whole hospital from the top down."