As the flow of victims to the ED subsided and order began to be restored, HICS shifted gears and took on a much broader role: coordinating activities with multiple agencies, including local law enforcement, the Federal Bureau of Investigation, news media, and an array of patient and family services. Again, the timing of this tragic event allowed the needs and functions of our hospital command to concentrate the focus in a more structured manner than might have been possible during regular operational hours.
Lessons Learned and Recommendations
As with any MCI, it is important to perform after-incident debriefings to reflect upon the prehospital, ED, and hospital care to assess for areas in need of improvement. Obviously, depending on the number and type of patients who are received and the resources available at the institution, such events can stress EDs that are already at or above their capacity. At the time of this writing (less than 2 months after the incident), although we are still in the early stages of our post-incident debriefing process, we offer the following suggestions and recommendations that we believe will be a benefit to other institutions faced with similar challenges.
Dedicated Disaster Preparedness Program
Depending on the size of the institution and whether or not it is a trauma-receiving center, it is vitally important to have a team of individuals dedicated to the development and maintenance of a disaster readiness program. Eric Alberts, manager of Emergency Preparedness at Orlando Heath, emphasized the need to harness and leverage preparedness efforts and relationships with community partners, law enforcement, and EMS. In addition, he noted that these trained individuals can provide education and coordination for mass-casualty drills, assist in developing and maintaining policies and protocols, and coordinate with hospital incident command during actual events.
Practice, Practice, Practice
In order for medical staff, nursing staff, and support personnel to understand their roles and responsibilities if an MCI occurs, they must practice simulated drills. Tabletop and full-scale emergency intake drills, with a range of scenarios occurring at different times of the day and night, will improve teamwork and coordination. At least once a year, a large, full-scale community exercise that involves scene casualty collection points, law enforcement and EMS involvement, multiple EDs, and hospital-wide integration will educate staff members on their duties. There should be enough patients in these drills to stress the entire system—both ED and in-hospital. Physician involvement in these exercises is crucial. In March 2016, a full-scale community exercise was performed in the Central Florida area in which more than 500 volunteers, 50 agencies, and 15 hospitals participated. A segment of that exercise involved an active shooter impersonating a patient brought to the ED. We feel this recent exercise, and others like it, were helpful in managing our actual mass casualty event.
Notification
When the shootings at the Pulse nightclub started, we were advised that there might be as many as 20 victims, but over the next few hours, we received more than twice as many injured patients. In any scenario where it is felt additional ED resources and personnel are needed, it is advantageous to begin the notification process as early as possible. Ideally, there are redundant methods in place to notify in-house and off-duty personnel, preferably in a multilayered system of electronic and voice communications that provides feedback as to staff availability. During daytime hours, it is easier for off-duty staff to learn of an event through news and social media. However, during early morning hours, such as when these shootings occurred, it may be difficult to notify sleeping staff that they are needed. With the trend of using mobile devices instead of landline phones, and with the ability to silence those devices during nighttime sleep hours, it has become increasingly difficult to “break through” the silence. In our event, group e-mail notifications were activated, but individual phone calls were also required. Initially, some calls to staff went to voice mail rather than being
answered directly.
Communication
Communication is an area of opportunity for improvement in almost any mass-casualty event. Redundant methods of electronic, voice, telephone, and radio communications are crucial for personnel to coordinate efforts. It is imperative that HICS and ED personnel receive updates about events on the scene and the status of potential incoming patients. An infrastructure of communications is paramount for the coordination that is needed between prehospital, ED, and in-house resources.
Throughput
Facilitating ED and hospital throughput and improving operational efficiencies are regular topics of discussion in most busy EDs. However, when it becomes necessary to intake large numbers of patients in an ED within a short period of time, the need to move patients out of the department intensifies. In many cases, to continue intake of patients, it will be necessary to quickly find areas outside of the ED—such as operating rooms, ICUs, and general floors—to transport patients to. At our facility, we normally have two operating rooms staffed throughout the night for traumas. On the night of the shootings, a total of six operating rooms were activated quickly to manage the penetrating injuries of these patients. Previously admitted medical patients were retrieved by in-house nursing staff to free up ED beds.
Media
It is important to recognize the intense social, print, online, and television media exposure that will occur with such tragedies, and have personnel and systems in place to manage it. The Pulse nightclub is located only a few short blocks south of ORMC, and the majority of all injured patients, including those with the most severe injuries, presented to our facility. As a result, the intense media coverage at our hospital physically overlapped the intense media coverage at the scene. Nearby businesses were shut down, access to several main thoroughfare roads were blocked, and some individuals mistakenly thought the hospital was closed. Our media relations department felt the most efficient way to manage information dissemination was to hold a “presser”—a press conference with a few of the health professionals involved in the care of the patients. The press conference helped to relieve some of the media presence and pressure, and provided welcomed transparency to the community.