Although hospitals drill and plan for disaster response, nothing but a true disaster can test systems and help fine tune preparedness plans. Washington Hospital Center (WHC), in Washington, D.C., was challenged by the events surrounding the September 11, 2001, terrorist attack on the Pentagon, while Massachusetts General Hospital (MGH) tested its disaster plan in the aftermath of The Station nightclub fire on February 20, 2003. Both institutions report their drills and planning served as excellent preparation, but some minor adjustments have been made in retrospect.

Washington Hospital Center received the major burn victims from the Sept. 11 terrorism-related plane crash into the Pentagon. Fortunately, WHC staff had been immensely proactive in disaster planning – especially for mass disaster or bioterrorism – before the events of Sept. 11. The Pentagon experience along with the organization’s comprehensive disaster plan helped advance disaster preparedness efforts.

Washington Hospital Center admitted the Pentagon’s nine burn patients. Society of Critical Care Medicine (SCCM) Member Arthur St. Andre, MD, FCCM, who is responsible for five surgical intensive care units with a total of 50 surgical ICU beds and nine intermediate care beds, was triage officer that day. He recounts WHC’s preparation and response efforts.

He recalls: “When we looked out the hospital window we could see the smoke from the Pentagon. The call came and our helicopter was the first medical service on the scene. We quickly flew two Pentagon burn victims to Washington Hospital Center. Unfortunately, we were not allowed to fly back because all nonmilitary air traffic was shut down. The additional seven patients were transported to us by ambulance.” The discontinuation of medical helicopter service may have been the first unanticipated disaster-related change in response.

Washington Hospital Center found that previous disaster preparations and drills were incredibly helpful. Automatically, patients scheduled for elective surgery were sent home and surgeries not fully started were cancelled to open the operating rooms for the Pentagon burn patients. Clinicians were immediately available in their assigned staging areas, and teams were dispatched to the disaster receiving area.

“We had a command center in our administrative office that set up a single source of communication to look for resources such as beds, supplies and personnel,” says Dr. St. Andre, director of surgical critical care services at WHC. “We had done enough planning and drilling that all of the typical preparations went exceedingly well.”

During the disaster, the authorities shut down the local telephone area codes. Dr. St. Andre said there presumably was a concern that a regional phone number might trigger a bomb. When the incoming calls were shut off, the internal phone system at the hospital closed down entirely. All phone communication was lost. “This was a situation we never considered during our planning,” Dr. St. Andre comments.

Lessons learned from the Sept. 11 events helped Washington Hospital Center improve its disaster preparedness plan. For example, the loss of telephone communications within the hospital made triage and spreading other information much more difficult. At the time, the hospital was not set up on a walkie-talkie system, however, key WHC people in a disaster now carry walkie talkies.

“September 11 also helped us to better define our triage process during normal hospital operations,” explains Dr. St. Andre. “Determining which bed a patient will be assigned to and when the patient can be moved into that bed is a complex process that combines a variety of people including the admitting office and nursing communication. After Washington Hospital Center lost all telephone service during the disaster, we had to find a way to streamline moving patients from the disaster resuscitation area to beds. One of the disaster leaders designed the new triage system on the fly.”

Under the new process, when disaster resuscitation receives word that a patient has been assigned a bed, this communication signifies that the bed is now ready and the patient can be transported immediately. The new protocol streamlined the system and eliminated several unnecessary phone calls to the resuscitation area. A patient-labeling system was also developed that indicates whether or not the patient is ready for assignment. This system helps the resuscitation triage officer know when to call for a bed.

The hospital, with the financial support of the federal government, continues to study the impact of biological and chemical disasters and terrorism on healthcare organizations under its ER1 program. This effort includes facility design for disasters and the study of how to scale resources to meet both large and small disaster events.

Massachusetts General Hospital
Successfully Responds Under Pressure
“Massachusetts General Hospital, a 900-bed facility, has an enormous depth and breadth of critical care resources that is probably unparalleled in most other tertiary care facilities,” says Society of Critical Care Medicine Member Katie Brush, RN, MS, CCRN, FCCM. “Additionally, Massachusetts General Hospital is a Magnet Hospital that specially recruits, rewards and appreciates nurses. These two factors combine to provide strength and flexibility in all areas, but specifically in disaster response.”

Indeed, MGH’s disaster preparedness was put to the test earlier last year, when it responded to The Station nightclub fire in West Warwick, Rhode Island, that injured 200 people and killed another 100 people. MGH treated 14 critically ill burn patients and numerous outpatients.

“If you pare a hospital down to the bare bones, I do not know how it would be able to respond to a major disaster,” continues Ms. Brush, a surgical critical care clinical nurse specialist on a 20-bed Surgical ICU at MGH. “The Station nightclub fire impacted the entire hospital, although only two units were caring for those patients.”

Massachusetts General Hospital has a five-bed burn ICU, and six patients were directed to other units within the hospital. Five were sent to the surgical ICU – the burn unit backup – and one patient was treated at the medical ICU until the following day, when he was transferred to the surgical ICU. The hospital created burn patient cohorts to coordinate services, including physical therapy, occupational therapy, nutrition, materials, and respiratory care. This system also eliminated surgeons losing time moving between units.

The MGH disaster plan is modeled after the Hospital Emergency Incident Command System (HEICS) for disaster response. The Rhode Island nightclub fire required enormous operational and logistics management. To further complicate matters, most of the MGH patients were unidentified and lived in another state. Consequently, part of the response required interagency and intergovernmental cooperation. Everyone had to cross state lines to do their jobs for the fire victims – insurers, state police and state agencies.

“Flexibility by senior leadership helped make Massachusetts General Hospital highly responsive,” says Ms. Brush. “Our senior vice president for anesthesia and surgery, the senior vice president for patient care services/chief nurse and the hospital president managed the leadership in such a way that clinicians wanted for nothing during The Station nightclub disaster. This went beyond what we needed for patients. Food was provided 24 hours a day until the crisis had completely passed. They also made sure that people got to rest and received stress debriefings.”

Massachusetts General Hospital also has a memorandum of understanding with the Department of Homeland Security and the U.S. Department of State as the sponsors of the International Medical Response Team. The team, including Ms. Brush, has most recently responded to the earthquake in Bam, Iran, and is readily prepared for future disasters worldwide.

Regardless of location, collaboration and effective communication are key to a successful disaster plan. “A resource-rich hospital environment, a strong disaster plan and flexible senior leadership are crucial to excellent disaster planning management,” concludes Ms. Brush.