Patient Safety Quarterly: Practice drills, careful job outlines improve emergency response
Job action sheets promote accuracy
No matter what type of emergency faces your health care organization, how well you fare will largely depend how well your staff knows its individual roles. Careful planning, practice drills, and clear job descriptions can make the difference.
You can never practice enough. That was the primary lesson learned when personnel at Atlanta’s Grady Memorial Hospital kicked into high gear with the aftermath of a bombing in Centennial Olympic Park downtown.
When tragedy hit during the 1996 Olympics, the admitting and registration staff — such as personnel throughout the hospital — already had been repeatedly drilled on what to do if an emergency occurred while the city was hosting thousands of visitors from all over the world, says Linda Leatherman, director of admitting and registration. Possibilities ranging from a large influx of heat-related cases to terrorist attacks were covered.
"We did hold a lot of drills, but we could have held more," she says. "If you’re going to have an emergency preparedness process, you need to practice it and get staff comfortable with it."
About 100 people were injured by the blast that early morning in July, but most were treated at the scene. Thirty-four patients were taken to Grady for treatment; 13 were admitted, and 10 needed surgery. At one point, Leatherman notes, 257 reporters, camera crews, and other news media personnel were clustered on the street outside the emergency clinic.
Leatherman gives her employees and other hospital staff high marks for doing an outstanding job of everything from taking care of patients and family members to cleaning up the floors. However, a post-event analysis of the disaster
plan did bring to mind some procedures that will be done differently the next time disaster strikes, she notes. These included:
• During pre-Olympics planning, each department was asked to draw a flowchart outlining who does what if disaster strikes.
But when staff began dealing with the real emergency, assumptions were made that were not included in those algorithms.
"On ours, for example, it says that [when a disaster occurs], admitting coordinators are to begin an emergency bed count — what’s available, who could be moved out of [the intensive care unit]," Leatherman says.
"What actually happened is that the inpatient nursing staff started moving patients. In critiquing our emergency preparedness, we realized we didn’t effectively communicate each algorithm to each department," she says.
Next time, Leatherman adds, admitting will perform the bed count and will do a better job of communicating with nursing.
• Since Grady’s emergency clinic is approximately the size of a football field, it’s quite a distance from the care area to registration.
When patients started arriving during the lowest-staffed shift, there were enough employees in each of the four care zones to obtain identifying information, but no one to run the information back to the registration desk.
"For the first 15 or 20 minutes, we were really hurting for staff," Leatherman recalls. "There were a lot of nurses ready to help, but they didn’t think about helping with registration. In the future, they will take on those duties."
After the initial crunch, she adds, there was plenty of help as off-duty employees heard the news and began reporting for work.
• Patient data weren’t entered into the computer system quickly enough.
Although the information was efficiently gathered , Leatherman says, it existed only on paper for too long. Information clerks and nursing floors didn’t have up-to-date information to share, for example, with relatives of the injured.
"If you’re taking in lots of patients, you have to have a way of knowing who you have in the house," she says. "For the benefit of family members who weren’t allowed in the emergency department, this needs to be in the system and communicated. We ended up having to do a lot of cleanup after everyone caught their breath."
• Practice sessions focused on bringing the patients in for treatment quickly, but no one was assigned to handle discharges.
Patients who weren’t badly hurt and were ready to go home waited to be told what to do next, Leatherman explains. "There was no one designated to say, Take this medication and go home,’ to close the loop for those who weren’t going to be admitted."
When the real thing happens, people tend to forget what’s listed on the disaster plan, she says. Although it had been agreed that the shift supervisor in emergency registration would be in charge of the admission and registration process, that supervisor found this to be a difficult role to play when Leatherman showed up to help out.
"When I said, What’s my assessment?’ it was hard for her [to respond]," she recalls. "People came to me and asked what they should do."
Leatherman’s admitting manager and emergency registration manager currently are working on clarifying and expanding their algorithms, and on adding more "job-action sheets" that describe specific duties that need to be performed in responding to a disaster. The action sheets are invaluable when personnel who don’t normally perform a certain function are called upon to fill in, she explains.
Action sheets spell it out
For example, there is an action that describes exactly what needs to be done during an emergency bed count, Leatherman says. Rather than spending time explaining the procedure, the person in charge can simply hand the sheet to the employee assigned to that task.
Meanwhile, her department continues to be involved in meetings with nursing and other departments as Grady continues to evaluate its emergency plan, Leatherman adds. "Improving communication is always something to work on."
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