Briefings on Hospital Safety, July 2017
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June 29, 2017
Hospitals learn crisis response lessons after disasters strike unexpectedly
Hospital ER staff train hard to respond to almost any imaginable incident—it’s part of their accreditation requirements, and key to successful outcomes and saved lives. But any well-rehearsed plan depends on many things happening at once, and if circumstances change suddenly, the staff may need to be flexible.
A smoothly oiled response to any disastrous and quick-changing incident depends on hospital staff getting updated information about incoming patients from outside responders such as police, fire, and EMS so that equipment, employees, and other resources can be put into place. But what happens when hundreds of patients descend on the ER at once?
That scenario became real for the hospitals in the Denver suburb of Aurora, Colorado, on the night of July 20, 2012, when the community experienced a mass shooting at the Aurora Century 16 movie theater. That night, gunman James Holmes entered a packed midnight showing of the newest Batman movie with the intent to kill as many people as possible. In the end, Holmes killed 12 and injured several dozen more, and tested the response of emergency services throughout the Denver area.
Police and fire services responded almost immediately after the first 911 call at 12:38 a.m. and found a nightmare scene of hundreds of wounded people running out of the theater. The combination of panicking crowds, a scene that was not immediately declared safe, and a parking lot full of police and fire vehicles parked in roadways was blamed for the slow ambulance response—almost 25 minutes after the first call, ambulances still hadn’t reached the most mortally wounded of the victims, according to some reports.
Police commanders on scene who were stuck attending to patients with life-threatening gunshot wounds made a split-second decision that, while going against department protocol, was credited with saving many lives. Instead of waiting for ambulances to arrive, patients were packed into the back seats of police vehicles and rushed to area hospitals. The problem was that the hospitals didn’t know what was about to hit them.
Staff members at the University of Colorado Hospital (UCH) that night were attending to a full ER and a nearly full waiting room, unaware of what had just taken place. Shortly after 1 a.m., a request for bed counts went out over the EMSystem, an emergency notification system that automatically pages several members of the UCH staff as an all-hands warning. Minutes later, the first patients from the shooting, a mother and her 4-month-old child, arrived at the hospital by private vehicle. Within about five minutes, police officers began bringing more victims to the hospital for treatment, and within about 15 minutes, up to 27 victims had been transported to the ER by Aurora Police Department patrol cars.
“All this happened before an ambulance ever arrived at the hospital with patients,” said Patrick Conroy, manager of support services for UCH, in a report from Emergency Management magazine. In the end, UCH treated patients brought in by private vehicle and patrol cars, three victims transported by ambulance, and another that ran from the theater to the hospital.
Hospitals in recent years have seen their resources repeatedly tested by “no-notice incidents” like the Aurora shooting, which require hospital staff to essentially throw away the book and do the best they can with the resources they have at the time. While typical emergency responses rely on a ramping up of resources based on coordinated triage and communication from the scene, sometimes events unfold so quickly that hospital staff are overwhelmed.
A similar situation occurred on June 12, 2016, when Orlando Regional Medical Center (ORMC) experienced an overwhelming influx of patients injured in the deadliest mass shooting in U.S. history and the worst terror attack on American soil since 9/11. That shooting, which occurred at the Pulse nightclub just blocks away within a three-hour period in the middle of the night, taxed the hospital in a way few facilities could prepare for.
Over a two-hour span, 44 of the 53 wounded victims arrived at the hospital’s ER, whose staff scrambled to accommodate the sudden patient surge. Just as in Aurora, medical staff at ORMC had little to no warning about what was coming. There were reports of victims being transported by pickup trucks and literally dropped in the hallways, leaving overwhelmed nurses and physicians on the night shift scrambling to find room to accommodate them. To cope, they took existing patients out of the trauma ICU and moved them into other areas of the hospital; they also discharged as many patients as they could and diverted other emergency patients to other hospitals, NPR reported.
The hospital opened six operating rooms (OR) while dealing with the patient surge, with multiple surgeons working on one patient at a time. Doctors described walking out of one OR and into another to keep operating. In total, at least 28 lifesaving surgeries were performed on the night of the shooting.
A few years before the Aurora and Orlando shootings, one hospital faced a different kind of unexpected event—this one spawned by Mother Nature. On May 22, 2011, a monster EF-5 tornado tested the resolve of the residents of Joplin, Missouri, when an EF-5 tornado with winds approaching 300 miles per hour slammed through the center of the city of 50,000 and right into St. John’s Hospital. In the aftermath of the tornado, 161 people died, including six at the hospital itself.
Shortly before the tornado hit, a “Code Gray” was announced over the hospital loudspeaker system, giving employees just minutes to move patients to rooms and hallways in the center of the hospital, away from windows and outside walls. In the aftermath of the weather event, patients had to be evacuated down collapsed stairwells amid failing ceilings and lights that weren’t working.
Hospital staff and safety professionals are constantly told about the importance of training and drilling for “all hazards.” But that assumes you can plan for all hazards. The truth is, there are things that you might not be able to plan for, and if they happen to you, you’ll have to wing it when it comes to a response. Thankfully, by learning from all the disasters that hospitals have endured, there are takeaways that you can use to prepare your own facility.
Drill, drill, and drill some more. Yes, we just said you can’t drill for everything. But most facilities simply don’t practice enough for stressful crisis situations, and practice is what’s required to develop the quick-thinking capability, the bonds between staff, and (most importantly) the recognition of the mistakes that could be made during your staff’s emergency response. Practice is the time where you work out the kinks in your communications system, figure out that you don’t have enough of a certain type of emergency equipment, or learn that the phone numbers of key people in the hospital chain of command aren’t readily available at a moment’s notice. No, you can’t plan for everything, but the more you do plan—and practice what you’ve planned—the less you’ll have to worry about when the unthinkable occurs.
Form a SWAT team. Too many hospitals create emergency plans that are too specific—for instance, they might have separate plans for a shooting, a blizzard, a power outage, or a bus accident. The problem with these kinds of specific plans is that they’ll all use different strategies for mobilizing resources and equipment.
As an alternative, some hospitals have begun developing one scalable emergency plan that can be used in any emergency. With this approach, there’s always someone on duty (or at least there should be) who can be trained to be an incident commander. That person can gauge the event that’s unfolding and decide whether the emergency response needs to be scaled up or down—and how to bring in the right people.
“We got very lucky; we didn’t have an efficient way to bring people in to help them,” said Michael Barberio, PharmD, an emergency medicine clinical pharmacist at Children’s Hospital Colorado, in a report in Pharmacy Practice News. The hospital only received six of the theater victims after the Aurora incident, but staff realized that they needed a plan to help identify people who could get to the hospital in a reasonable time and to allocate someone off-site to get in touch with those people. This designated person, the hospital determined, would make the calls and then report back to the department with information on how many people would be arriving.
“We needed to establish a scaled response so that we didn’t end up with too many people coming in,” Barberio said. “We also needed to make sure the right people came in—with the right training, pharmacists and technicians included.”
Cement your security plan in place. The last thing you want to worry about in a crisis situation is throngs of people descending on your facility, milling around, and bombarding your busy staff with questions.
What’s more, all those people could present a huge security challenge. Before, during, and after a patient surge from a mass casualty incident, defense of your facility has to be a major priority, with swift and effective action taken to secure your grounds and protect the facility’s occupants, say experts.
“Always remember that hospitals can be secondary targets in a mass shooting or terrorist attack,” says Paul Biddinger, MD, FACEP, director of the Center for Disaster Medicine at Boston’s Massachusetts General Hospital (MGH), which treated 36 victims of the Boston Marathon bombing in 2013. After the Pulse shooting, there were several scattered reports that the shooter had actually made his way over to the hospital and continued his attack there (in actuality, the shooter was confronted and killed in Pulse by SWAT members).
“You have to preserve your facility’s ability to function as a working hospital by making crowd control an essential part of your security response,” Biddinger says. “That means limiting the number of reasons why people need to gather around your grounds and referring some outpatients to resources and counselors out in the community so they don’t congregate unnecessarily in your hospital.”
Coordinate with your first responders. It goes without saying that you should have a good relationship with your community’s fire and police department. However, there are still many hospitals that have not trained with or conducted a lifelike emergency drill with their police and fire counterparts. This is a mistake, because not only will they be the ones you can turn to for security in a crisis, but as was seen in the Aurora incident, first responders can become manpower to help you improve your response and patient treatment.
The decision to transport patients to the hospital in police vehicles “was a leadership moment, and it unequivocally saved lives,” said Dr. Richard Zane, chair of the University of Colorado School of Medicine’s Department of Emergency Medicine, in a report about the hospital response to the Aurora shooting in the Denver Post. “Time to hospital is most important … because of blood loss.”
Good relationships, clear communication, and a bond that allows all members of the first responder community to work together seamlessly will mean the difference between lives saved and a botched response during a crisis.
Safety by design: Baby boomers
Experts weigh facility designs that can help an aging population access hospitals safely
Editor’s note: This is the final part in a series of stories that address the ways that hospitals are using smart design to help increase facility safety and security for different populations of patients.
As hospitals study ways to update their facilities to meet the needs of a variety of patients both now and in the future, there’s one group of people who seem to be the most difficult to please.
That age group is the so-called baby boomers. If you have parents around this age, you know the type: about 65 years old and still pretty healthy for the most part, but beginning to face the realities of aging. But don’t tell them that—they still want to do things their way, and if they don’t like something, they’ll be sure to let you know.
As you’ve heard countless times by now, boomers are set to become more of a presence in your facilities. A study by the National Institute on Aging says that the U.S. senior population will double by 2030, climbing to approximately 70 million, and that Americans age 65 today can expect to live, on average, another 18 years. It stands to reason that this group is going to represent a growing percentage of the occupants of your building—and a growing safety and liability problem.
Essentially, hospital designers are looking to seamlessly integrate safety features into their facilities; they want to include softer features that add safety (perhaps not obvious to an outsider’s eyes) while inviting the patient in. Enter what is being called “universal design,” which is a “new and comprehensive design criteria, applicable to the boomer generation as well as all users of the built environment, including the aged, elderly, handicapped and bariatric patients, as well as persons with special needs,” according to Gary L. Vance, FAIA, FACHA, LEED AP, president of Vance Consulting LLC in Carmel, Indiana. Vance authored a column in the January 2017 issue of Healthcare Facilities Management about some of the more notable safety and design features being worked into hospitals these days to make the aging boomers feel more at home. The following are a few insights from that column:
Site access and entrances. A good first impression is everything. When it comes to how patients enter a facility, hospitals are trying to make those impressions count, while still prioritizing safety.
Access-related problem areas affecting baby boomer populations can include hospital parking facilities, stairwells, ramps, doorways, and elevators. In addition, hospitals should keep in mind any hard-to-reach locations of departments and areas that are visited frequently by seniors and other patients who are less mobile.
Boomers may not want to admit it, but their eyesight and coordination isn’t what it used to be, so hospitals are building straightforward entrances with easily visible features, such as canopies, so that visitors can easily find the front of the building when they pull in. Once they get there, large and prominent front doors and entrances allow for a direct path into the facility, Vance says. Gone are the days of traversing maze-like entryways and multiple elevators before even finding the main entrance of the building.
Keeping entrances and byways safe for foot traffic is also a concern. According to some estimates, some 700,000 falls occur in U.S. hospitals each year; of those, 30%–35% result in patient injury, and up to 11,000 are fatal. A big culprit is uneven walking surfaces, which pose easily overlooked tripping hazards for aging or mobility-challenged patients.
“Mix that with the fact that older folks are sometimes a little unsteady on their feet either because of a medical condition or prescribed medications, as well as weather-related conditions like ice and snow that can play havoc with footing, and you can have a fairly elevated risk of someone injuring themselves in any facility,” says Steven MacArthur, senior consultant and safety expert for The Greeley Company in Danvers, Massachusetts.
Corridors and getting around. Boomers are known as the “me generation,” and they like being able to do things themselves—including finding their ways around hospitals. They don’t want to be in the hospital in the first place (who does?) and during their stay, they expect to be just as comfortable as they would be visiting their doctor’s office, says Vance.
If you’ve ever seen one of your parents try to read the store directory at the mall, you’ll know why hospitals are trying to design calmer, more comfortable wayfinding areas that include lots of natural light and vestibules off to the side where visitors can contemplate where they are going. Also, corridors are being designed with fewer turns and intersections, to avoid confusion.
“Wayfinding maps should be oriented in the exact direction that the person is viewing,” notes Vance. “Additionally, wayfinding signs should not include too much information that may confuse readers. Letter sizes and fonts on signage should be legible to the visually challenged. All wayfinding terms, arrows, and information on directional signage should be simplified.”
Patient rooms. Boomers are used to being comfortable in their home, and if they need to stay over in the hospital, they want the same comforts they’d have in their residences. In addition, boomers are a social bunch, so they want rooms with social spaces. Think of how hotels are starting to build more “residential suites” with sofas, kitchens, and other amenities that remind guests of home. While designers need to keep in mind safety and ease of movement for hospital staff, along with the infection control aspects of making sure upholstered areas are easily cleanable, Vance says hospitals should consider the following to make patient rooms more inviting:
- Adding space for caregivers to move about and gather in the room
- Allowing for patient use of computer devices while hospitalized or in ambulatory settings
- Accommodating the use of earbuds or headphones by making connections available to the TV or entertainment system in the patient’s room
- Eliminating lighting that shines directly in the eyes of the patient
- Carefully considering the type of lighting used at night
- Improving patient comfort and bedside activities while resting and relaxing in both inpatient and outpatient settings
Surfaces and color patterns. Vance says that hospitals are toeing a delicate line here—on the one hand, they want to avoid making the facility look like an institution, but on the other hand, too much color or fancy design work on the walls and floors could be overstimulating to boomers. Research has shown that people 60 and older experience declines in their vision based on a number of factors, and specific colors, textures, and patterns can be disorienting to older patients and visitors—which can lead to avoidable trips and falls.
Most important, Vance says, is to make sure surfaces are installed that keep tripping and falling to a minimum. He suggests the following:
- Keep color changes of the flooring in main corridors to a minimum, as older visitors can become disoriented.
- Minimize the amount of level changes in the facility to eliminate the need for patients to step up or down (which could lead to trips) while going from place to place.
- Use non-skid floor materials that don’t become slippery to avoid a falling hazard.
- Use recessed floor mats instead of laying down throw mats in slippery conditions.
- Use patterns and textures with caution. Stick with primary colors and simple patterns that are easier on the eyes.
Technology upgrades. Anyone who has watched their parents play with their newly installed TiVo knows that boomers are a generation who, while relatively tech-savvy, also enjoy the freedom to do what they want.
With this in mind, many hospitals are beginning to add advanced medical technology to their facilities, as well as information technology tools like digital patient education, entertainment systems, and registration kiosks. In addition, since many boomers are taking advantage of home health monitoring devices and virtual visits, some facilities are accommodating telemedicine services by including spaces that contain appropriate lighting and backdrops for videoconferencing with off-site physicians.
Hospitals consider better patient handling equipment
Costs cited as a mitigating factor when it comes to installing new lifts
It’s no secret that America’s healthcare workers are in danger of injuries sustained from improperly lifting and moving hospital patients. Just ask OSHA.
According to the agency’s statistics, worker injuries from slips, trips, and falls are one of the country’s biggest concerns, especially in hospitals. Injury and illness rates in healthcare, at 5.2 cases for every 100 workers, remain well above the national average of 3.5 cases per 100.
In 2011, U.S. hospitals recorded 253,700 work-related injuries and illnesses—that’s a rate of 6.8 work-related injuries and illnesses for every 100 full-time employees, almost twice as much as for private industry in general.
NIOSH reports that there are 75 lifting-related injuries per year for every 10,000 full-time hospital workers, and 107 injuries annually for every 10,000 workers at nursing homes and residential facilities. Hospital rates are nearly twice the national average for all industries, and nursing home rates are nearly three times as high. The problem has gotten so bad that OSHA created an entire website devoted to the problem of lifting injuries in hospitals and solutions that hospitals can employ, including training tips and advice (www.osha.gov/dsg/hospitals).
“Reducing injuries not only helps workers, but also will improve patient care and the bottom line. If your hospital is considering developing or refining a comprehensive safe patient handling program to protect workers and patients, having the right data, evidence, examples, and tools can help ensure success,” according to the OSHA site.
OSHA says that the high rate of occupational musculoskeletal injuries among healthcare workers stems from hospitals not employing enough devices to help staff move patients safely. The agency still does not have any published mandates or standards related to reducing patient-handling injuries, just a recommendation that hospitals take steps to reduce them. See the attached .pdf (via the link at the top and bottom of this article) for a list of myths and truths about installing patient lifting equipment.
According to some reports, hospitals are trying to do their best with using new technologies and installing patient lifts. However, there still are many nurses and caregivers who prefer to lift and move patients themselves. The problem, of course, is that if they don’t lift the proper way, or if the patient shifts while being moved or lifted, the patient or caregiver could suffer injury.
There is some controversy around the protocols for when lift devices should be deployed vs. when it is OK for caregivers to do the moving themselves. Some research says nurses and other caregivers should not lift more than 35 pounds without an assist device. But most caregivers balk at that recommendation, noting that they regularly move children and adults of average weight without help.
The American Nurses Association (ANA), meanwhile, wants hospitals to deploy equipment and adopt protocols so that no staffer ever moves a patient without device assistance.
“There are too many opportunities for a wrong angle or a slip,” ANA President Pam Cipriano said in a June 2016 issue of Modern Healthcare. “It is one of the key areas where nurses fear injury in the workplace, because that could be career-ending.”
According to the Modern Healthcare report, many hospitals in healthcare systems such as Kaiser Permanente and the Veterans Health Administration have begun to install overhead lifts in their facilities, consisting of a motorized hoist that can lift patients into the air while they're secured in a sling. An overhead rail system allows nurses to move patients around the room or between rooms.
Some lift models designed for obese patients have two motors and can hoist as much as 1,000 pounds. They can be pricey, though. Permanent overhead lifts cost an average of $16,000 per room to install and can be used only in that one room. In contrast, mobile devices cost an average of $6,000. A few mobile devices can be sufficient for an entire hospital if workers take the time to find and use them while moving patients, according to statistics from the ECRI Institute.
The price tags on even mobile lifts might induce some sticker shock, but OSHA says that the devices are cost-effective and that their benefits far outweigh the expense, adding that the initial capital investment in policies and equipment can be recovered within two to five years. Consider the following benefits that OSHA says can be enjoyed by facilities that use lift-assist equipment:
- Reduced injuries
- Decreases in lost time and workers’ compensation claims
- Increased productivity
- Higher quality of work life and worker satisfaction
- Staff retention
- Better patient care and satisfaction
There are some success stories from hospitals that have decided to install lifts in their facilities. For instance, St. Joseph’s/Candler health system in Savannah, Georgia, installed ceiling lifts in 38 patient rooms as well as the critical care department of the 330-bed St. Joseph’s Hospital, plus selected departments in the 384-bed Candler Hospital, according to a story in Healthcare Facilities Management.
In 2011, the hospital installed the ceiling lifts along with a staff training program. Before the installation, staff had experienced a troubling number of injuries related to patient handling, but within a year—with the program only partially in place—the number of yearly injuries dropped to just 37 and has remained around that level since, according to the report.
“The safety of our coworkers and patients is a top priority, so installing lifts was an easy decision,” Teresa Warren, clinical nurse manager of the ICU and progressive care unit at Candler Hospital, told the magazine.
Hospitals take a stand against violence
Facilities that have seen the worst say now is the time to prepare for it
The frequency of violent incidents in U.S. hospitals and the communities surrounding them is increasing faster than the training needed to deal with those incidents. That’s the consensus of hospitals that have treated victims from some of America’s worst tragedies in recent history, including the Orlando Pulse nightclub shooting, the sniper-like shooting and killing of several police officers in Dallas, and the Boston Marathon bombing.
It’s time to start taking the threat for real, according to a series of recent stories in Hospitals and Healthcare Networks (H&HN) magazine, which feature sobering conversations with security and medical personnel from some of the U.S. hospitals that have dealt with such events.
In 2016 alone, there were 385 mass shooting incidents in the U.S., according to statistics from the Gun Violence Archive. More than 1,500 people were injured and 458 were killed in these shootings, which represents an increase of about 24% from just the year before. These events are real, they are frequent, and they don’t always make the national news.
Behind these shootings are first responders and the hospitals that serve the community, and along with every event, there are inevitable stories about overwhelmed ER staff and the need to beef up training to deal with future tragedies. This hasn’t escaped the notice of the American Hospital Association (AHA), which has begun serious discussions about overhauling the way U.S. hospitals deal with mass casualty incidents.
“It was certainly an accumulation of things, but I think the tipping point came as a result of the tragedies and carnage in both Orlando and Dallas,” Melinda Reid Hatton, senior vice president of the AHA, told the magazine. “We asked whether or not we in the hospital community should be doing more to combat violence, both in the community that inevitably ends up on the doorsteps of the hospital, and also violence in our facilities that is inflicted on our colleagues and staff.”
As a result, the AHA has launched perhaps the biggest discussion that hospital leaders in the U.S. have ever had about dealing with violent incidents, the response, and the aftermath. Called “Hospitals Against Violence,” the effort seeks to bring together the AHA’s 5,000 hospital members to share best practices and gain deeper insights into the impact that violence has on hospitals and their patients.
As the threat of an active shooter becomes more and more real, hospitals have been thinking more about the plans they have in place for dealing with such an event.
“Only in the last two years are hospitals talking about [active shooters],” says David Callaway, MD, FACEP, director of operational and disaster medicine at Carolinas Medical Center in Charlotte, North Carolina. Carolinas is one of many hospitals across the U.S. looking at ways to decrease the threats presented by armed intruders, while keeping the overall environment of the facility calm and welcoming—and the staff unarmed. “We are in an environment where underlying violence is considered acceptable. We are expected not only to survive, but turn right around, respond, and treat casualties.”
Despite the shock and terror an active shooter provokes, it’s important to remember that when a shooting occurs in a hospital, the incident can be contained. The hospital can be locked down, first responders can show up and isolate the threat, and a well-rehearsed plan can be executed to help keep p