Mass casualty plan puts point-of-care testing in the ED

Valerie Neff Newitt

May 2019—If a mass casualty event brings patients to Le Bonheur Children’s Hospital in Memphis, Tenn., clinical laboratory staff will head straight to the bedside.

Le Bonheur Children’s Hospital is a level-one trauma center. Its new mass casualty response plan, two years in the making, has laboratory staff in the emergency department and triage areas, where they will perform point-of-care testing for frontline providers.

“Having medical lab scientists just sitting in the lab waiting for blood to come to them made no sense,” says laboratory director Lisa M. Griffin, BS, MT(ASCP). “Instead of keeping them away from where all the injured patients are, we decided to send the techs to them. It’s the best way to use the trained, professional human resources we already have.”

The plan grew out of a conversation Griffin had with Kelley Benson, BS, MT(ASCP), point-of-care specialist, about the challenges mass casualties present, and it led to their working with the trauma team and the ED on the plan’s details. Griffin and Benson’s first thought was to recruit respiratory therapists who are already trained and competent in accordance with CLIA regulations and could easily run the lab’s CG8+ test cartridge on the POC i-Stat machines instead of the G3+ cartridges that the respiratory therapists typically use. “However, in a mass casualty disaster situation,” Griffin says, “the RTs would be overwhelmed and not a good fit.”

The next thought, Benson says, was to train the more than 100 ED nurses on the i-Stat, which on further consideration seemed impractical, too. Keeping RNs competent on an analyzer they would rarely use, she says, “would be a nightmare,” and nurses would already be needed for countless tasks in the course of a disaster.

“I had an epiphany,” Griffin says. “We had medical laboratory scientists sitting in the core services laboratory who are all competent on the i-Stat and other assays needed by physicians.” They could be partnered with phlebotomists who could collect the specimens that technologists would process at the bedside.

The efficiency of the idea was appealing. Anissa Revels, MSN, RN, trauma program director, says, “Having technicians who focus on labs, know exactly what the doctor is asking for, and know what we have in place to draw for critical situations like these could be monumental in the ED. Because lab professionals have that duty and maintain that capability and readiness, they could save a lot of time for the rest of the frontline staff who otherwise would have to figure out things like which tubes to use for various tests, and muddle through that process in the midst of possible chaos.”

The result is a new laboratory response team composed of 10 MLS volunteers. The request for volunteers was made by email, “using very explicit language,” Griffin says. “It asked lab staffers to consider if they could handle the sights and sounds of trauma. A lot of people can’t. Like me, for example. I like my blood in a tube, not all over the floor.”

Two staff members from every shift stepped up. “And of course they are all competent on the i-Stat, which was the critical piece,” Griffin says.

The emerging plan called for the team to perform essential tests on disaster victims, but someone had to decide which tests were essential. Blake Robertson, Le Bonheur’s director of support operations and emergency preparedness coordinator, turned to Le Bonheur medical director Rick Hanna, MD, for input.

“I said to him, ‘Here is your current list of lab tests in your downtime packet.’ It looked like a complex tax form,” Robertson says. “It had to be pared down to essentials; simplicity would be the key. Dr. Hanna said he’d only need this, this, and this.” That direction translated into a test menu that consists of:

• urine pregnancy test (needed if the patient must have an x-ray).
• hematuria test for blood in the urine, possibly indicative of internal injuries.
• i-Stat CG8+ cartridge tests, which include sodium, potassium, glucose, ionized calcium, hematocrit, pH, PO2, and PCO2.

As each phase of the mass casualty plan took shape, new considerations emerged. Primary among them was finding a way to identify and keep track of patients in a chaotic and transient environment. If systems were down, where would lab results be recorded? How would physicians find results for specific patients whose identities might still be unknown?

Robertson had attended a disaster planning conference after the 2011 Tuscaloosa-Birmingham tornado in Alabama (64 fatalities, 1,500 injuries). He learned that Tuscaloosa’s 500-bed, “disaster-prepared” DCH Regional Medical Center, which escaped devastation by a scant quarter-mile margin, had provided care for about 1,000 emergency patients within nine hours.

“What stood out to me most was that of those 1,000 patients, only 131 actual medical records were generated,” he says. “They lost systems, lost information on those patients. They had no way to follow up with them, locate them, or recoup any costs on them. They were in really bad shape.”
DCH Regional realized post-disaster it needed a paper chart of sorts to employ in situations when electronic health records are not usable. So they put a few basic forms into a manila envelope and were done.

“I took what they had done and started a journey of discovery with all the key departments at Le Bonheur,” says Robertson, who formed an ongoing focus group which began with frontline clinicians and care providers in the ED, then grew to include laboratory, radiology, registration, and the full trauma team. The aim was to design and build a medical record that would be given to, and remain with, every patient who entered the door during a disaster. It would contain basic and precise information that clinicians would need to treat each patient as they moved through the steps needed for their care.

The resulting portable medical record packet is a spiral-bound booklet that has a barcode on its front, specific to the patient to whom the record is given. A similarly barcoded wristband and additional barcoded identification strips that can be removed easily and affixed to such things as records and test tubes are inside the book and travel with the patient. The book also contains a few essential forms that make up the paper medical record that can be used during a disaster.

“A barcode is slapped onto any form completed within the book and thus corresponds with the patient’s wristband,” Robertson says. “Everything is designed to be easy to access, easy to use. We stripped out all of the unnecessary lab tests and took it to the bare essentials that lab techs, ED doctors, and nurses would need to manage that patient’s care.” In chaos, he adds, “simplicity is paramount.”

The hospital also employs a patient tracking system. “We have two iPads and an iPhone staged to be deployed in these situations,” Robertson explains. “Our registration team is trained to enter the identifying barcode, enter in whatever basic information we have—name, age, acuity. And if the patient is unconscious, can’t speak, or won’t speak, we can take a quick picture or video as part of this digital record.” The app stores everything on the device and then uploads to a secure server if the network is in place. If networks are down, it will save the information to the device; when network activity is reestablished, it will transfer the information to the secure server.

Other means of tracking patients would also be required, Robertson says. “There will be needs for actual written records, so registration is on board with taking the portable packets and, after the fact, scanning them into the electronic medical record when feasible. We will also use runners to carry messages, and other communication methods, such as walkie-talkies, to help track where patients are and to get the right results to the right doctors.”