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

As the overall mass casualty plan came together, Griffin says, various groups broke off from the original focus group to better determine how each area could fine-tune its emergency response. For the laboratory, this meant devising a way to have the required equipment available and quickly en route to the ED during a crisis.

“We didn’t want to buy anything we don’t normally need or waste resources since, hopefully, we will never have to put this plan into action. So we will use equipment we already have,” she says. What is new are equipment carts for the lab response team. “Each cart is labeled with every item the team member needs to put on it—test cartridges from the POC office, an i-Stat device, a printer, a tape dispenser, an ink pen, et cetera. We estimate it will take less than 20 minutes to get the cart equipped, to the ED, and operational.” Once there, the technologist will not leave the patient until all results are complete. “Typically it would take 30 to 45 minutes to get those results from the lab to the ED; now it will take three to five minutes. It’s a huge difference,” Griffin says.

Robertson says one of the first challenges he encountered was convincing clinicians to pare to the bare bones their must-have lists to be included in the portable medical record. “People initially wanted too much information in the book. We had to get rid of the ‘we might need’ items and get it down to the ‘we must have’ items. You must insist on something easy to work with or you will end up with something the size of a phone book,” he warns others who want to implement a similar plan.

Robertson is still experiencing challenges as the plan evolves. “We are still trying to figure out blood typing—how to get the right blood type to the right patient. We are teaming with the blood bank on that,” he says. “The current plan calls for the barcode to go on one of the vials that will go to the blood bank. When whatever needs to be done with the blood is accomplished, the blood bank folks would make a record however they are able, considering that systems could be up or down. That record would then go back to the ED via a runner or a two-way radio communication.”

Although one might reasonably expect there to be pushback against the plan to have medical laboratory scientists show up in a busy, crowded, and frenetic ED, that has not been the case. “Instead of saying they didn’t want us there,” Griffin says, “clinicians have actually said they want more of us there. In the beginning, we had planned for lab folks to run tests on patients in an intermediate triage zone, not on patients who were critical. We thought we might find something like blood in the urine indicating internal trauma that doctors didn’t know about. We thought we would find those who look like they just have a broken arm but whose injuries may be worse than that. But as we got into this discussion the doctors said, ‘We need you even more on the critical side.’ Our goal now—admittedly optimistic—is to have three carts that we can respond with. That way we can lend adequate coverage.”

An inevitable difficulty is that emergency preparedness is not a return-on-investment activity, Robertson notes, yet it requires a lot of work in an already taxing and work-intensive setting.

“It’s just plain hard for people to carve out the time to figure out these plans and know what the right response will be. Everybody acknowledges it is important, but a lot of organizations meet just the bare minimum and don’t go into the depth required when a disaster happens. Our leadership does have awareness and understanding of this imperative,” he says. Griffin credits lab leaders Alex Ryder, MD, PhD, medical director of clinical laboratories, and Ali Saad, MD, chief of pediatric pathology, as being fully supportive of the time invested.

It’s impossible to know if a mass casualty plan is sound unless disaster strikes. “We don’t have all the details ironed out and don’t know that we ever will,” Griffin admits. “Every time we have another drill, issues emerge.”

The hospital conducted a “tabletop drill” in January to test the utility of the new plan. “We got everyone in the room,” Robertson says, “and created a mini-version of the hospital on tabletops, with one for incident command, the lab, ED, central supply, registration, et cetera. Then we brought in a bunch of paper victims and ran them through our process in this simulated hospital. It was a frustrating and eye-opening experience, confounding at times.”

Communication was the primary area found to be in need of improvement. “People on the floors do not always know what is coming their way,” Robertson says. “And we realized these paper disaster medical records might be completely foreign to clinicians on the floor if they’ve never seen one before. We realized we needed more internal training about what they are, how to use them, and when they might see them. So many little things came up when we walked through processes of specific scenarios or situations. Often they created more issues, more questions, more challenges. And that was exactly the intent.”

The mass casualty response will be put through its paces this summer when the hospital participates in an emergency preparedness drill as part of Centers for Medicare and Medicaid Services requirements. “It will be our first opportunity to fully test the lab response team and our disaster medical records,” Robertson says. Staff will go through the whole process with simulated patients. “And we will see all of the additional challenges and problems that will reveal and that we will need to solve,” he says, “the things that are still beyond our imagination.”

Griffin says the experience of working toward broadening the lab’s emergency response within the hospitalwide effort has shifted the hospital staff into what she calls “possibility thinking.”

“We are all so used to being regulatory people, doing everything by the book. But in times of disaster, adjustments have to be made. At first it was hard for us to push past thinking, ‘I have to have a date of birth, I have to have a weight, I have to have an age.’ In an emergency it is about what is possible to have now and what can wait for later. When someone walks in with a tree limb through his abdomen, his first stop is not going to be registration. That can wait.”

Trauma program director Revels says events like the Tuscaloosa-Birmingham tornado, the Las Vegas shooting, or any number of other such events require providers and hospitals “to step up and meet the needs we would have if this were to happen to us. These events around the world are not fiction. They are real; they are happening. We hope and pray this does not happen here, but if it does, we’ll be ready.”

Robertson recalls that at the DCH Regional Medical Center in Tuscaloosa after the tornado, health care workers were using Sharpies to put identifying names and numbers on the foreheads and arms of the injured patients. “Our ED now has three cases of Sharpies squirreled away,” he says. “And from the Las Vegas event we heard that one of the facilities experienced so much blood in the ED that it was freaking out the nonclinical and non-ED folks who weren’t used to seeing floors wet with blood. Now our ED has a 50-pound bag of blood-absorbent material stowed away.”

In preparing for extraordinary events, “Anything we can do to talk about the what-if situations creates a readiness mindset,” Robertson says. “It builds relationships between all of the departments working toward a preparedness goal.” Since he and the others undertook this work, he has heard: It’s great that we have this entire collective of departments able to work together. . . . It’s wonderful to be able to put faces to names. . . . It’s comforting to know what people are going to be able to do.

“And I hear clinicians say, ‘Wow, lab is actually going to come to the ED to do this work. That eliminates the giant step of having to send a sample to the lab and wait for it to come back. It eliminates the possibility of misidentifying, misplacing, or losing track of a patient. It is amazing.’”

Valerie Neff Newitt is a writer in Audubon, Pa.