Hospitals learn crisis response lessons after disasters strike unexpectedly

Hospital ER staff train hard to respond to almost any imaginable incident—it’s part of their accreditation requirements, and key to successful outcomes and saved lives. But any well-rehearsed plan depends on many things happening at once, and if circumstances change suddenly, the staff may need to be flexible.

A smoothly oiled response to any disastrous and quick-changing incident depends on hospital staff getting updated information about incoming patients from outside responders such as police, fire, and EMS so that equipment, employees, and other resources can be put into place. But what happens when hundreds of patients descend on the ER at once?

That scenario became real for the hospitals in the Denver suburb of Aurora, Colorado, on the night of July 20, 2012, when the community experienced a mass shooting at the Aurora Century 16 movie theater. That night, gunman James Holmes entered a packed midnight showing of the newest Batman movie with the intent to kill as many people as possible. In the end, Holmes killed 12 and injured several dozen more, and tested the response of emergency services throughout the Denver area.

Police and fire services responded almost immediately after the first 911 call at 12:38 a.m. and found a nightmare scene of hundreds of wounded people running out of the theater. The combination of panicking crowds, a scene that was not immediately declared safe, and a parking lot full of police and fire vehicles parked in roadways was blamed for the slow ambulance response—almost 25 minutes after the first call, ambulances still hadn’t reached the most mortally wounded of the victims, according to some reports.

Police commanders on scene who were stuck attending to patients with life-threatening gunshot wounds made a split-second decision that, while going against department protocol, was credited with saving many lives. Instead of waiting for ambulances to arrive, patients were packed into the back seats of police vehicles and rushed to area hospitals. The problem was that the hospitals didn’t know what was about to hit them.

Staff members at the University of Colorado Hospital (UCH) that night were attending to a full ER and a nearly full waiting room, unaware of what had just taken place. Shortly after 1 a.m., a request for bed counts went out over the EMSystem, an emergency notification system that automatically pages several members of the UCH staff as an all-hands warning. Minutes later, the first patients from the shooting, a mother and her 4-month-old child, arrived at the hospital by private vehicle. Within about five minutes, police officers began bringing more victims to the hospital for treatment, and within about 15 minutes, up to 27 victims had been transported to the ER by Aurora Police Department patrol cars.

“All this happened before an ambulance ever arrived at the hospital with patients,” said Patrick Conroy, manager of support services for UCH, in a report from Emergency Management magazine. In the end, UCH treated patients brought in by private vehicle and patrol cars, three victims transported by ambulance, and another that ran from the theater to the hospital.

Hospitals in recent years have seen their resources repeatedly tested by “no-notice incidents” like the Aurora shooting, which require hospital staff to essentially throw away the book and do the best they can with the resources they have at the time. While typical emergency responses rely on a ramping up of resources based on coordinated triage and communication from the scene, sometimes events unfold so quickly that hospital staff are overwhelmed.

A similar situation occurred on June 12, 2016, when Orlando Regional Medical Center (ORMC) experienced an overwhelming influx of patients injured in the deadliest mass shooting in U.S. history and the worst terror attack on American soil since 9/11. That shooting, which occurred at the Pulse nightclub just blocks away within a three-hour period in the middle of the night, taxed the hospital in a way few facilities could prepare for.

Over a two-hour span, 44 of the 53 wounded victims arrived at the hospital’s ER, whose staff scrambled to accommodate the sudden patient surge. Just as in Aurora, medical staff at ORMC had little to no warning about what was coming. There were reports of victims being transported by pickup trucks and literally dropped in the hallways, leaving overwhelmed nurses and physicians on the night shift scrambling to find room to accommodate them. To cope, they took existing patients out of the trauma ICU and moved them into other areas of the hospital; they also discharged as many patients as they could and diverted other emergency patients to other hospitals, NPR reported.

The hospital opened six operating rooms (OR) while dealing with the patient surge, with multiple surgeons working on one patient at a time. Doctors described walking out of one OR and into another to keep operating. In total, at least 28 lifesaving surgeries were performed on the night of the shooting.

A few years before the Aurora and Orlando shootings, one hospital faced a different kind of unexpected event—this one spawned by Mother Nature. On May 22, 2011, a monster EF-5 tornado tested the resolve of the residents of Joplin, Missouri, when an EF-5 tornado with winds approaching 300 miles per hour slammed through the center of the city of 50,000 and right into St. John’s Hospital. In the aftermath of the tornado, 161 people died, including six at the hospital itself.

Shortly before the tornado hit, a “Code Gray” was announced over the hospital loudspeaker system, giving employees just minutes to move patients to rooms and hallways in the center of the hospital, away from windows and outside walls. In the aftermath of the weather event, patients had to be evacuated down collapsed stairwells amid failing ceilings and lights that weren’t working.

Hospital staff and safety professionals are constantly told about the importance of training and drilling for “all hazards.” But that assumes you can plan for all hazards. The truth is, there are things that you might not be able to plan for, and if they happen to you, you’ll have to wing it when it comes to a response. Thankfully, by learning from all the disasters that hospitals have endured, there are takeaways that you can use to prepare your own facility.

Drill, drill, and drill some more. Yes, we just said you can’t drill for everything. But most facilities simply don’t practice enough for stressful crisis situations, and practice is what’s required to develop the quick-thinking capability, the bonds between staff, and (most importantly) the recognition of the mistakes that could be made during your staff’s emergency response. Practice is the time where you work out the kinks in your communications system, figure out that you don’t have enough of a certain type of emergency equipment, or learn that the phone numbers of key people in the hospital chain of command aren’t readily available at a moment’s notice. No, you can’t plan for everything, but the more you do plan—and practice what you’ve planned—the less you’ll have to worry about when the unthinkable occurs.

Form a SWAT team. Too many hospitals create emergency plans that are too specific—for instance, they might have separate plans for a shooting, a blizzard, a power outage, or a bus accident. The problem with these kinds of specific plans is that they’ll all use different strategies for mobilizing resources and equipment.

As an alternative, some hospitals have begun developing one scalable emergency plan that can be used in any emergency. With this approach, there’s always someone on duty (or at least there should be) who can be trained to be an incident commander. That person can gauge the event that’s unfolding and decide whether the emergency response needs to be scaled up or down—and how to bring in the right people.

“We got very lucky; we didn’t have an efficient way to bring people in to help them,” said Michael Barberio, PharmD, an emergency medicine clinical pharmacist at Children’s Hospital Colorado, in a report in Pharmacy Practice News. The hospital only received six of the theater victims after the Aurora incident, but staff realized that they needed a plan to help identify people who could get to the hospital in a reasonable time and to allocate someone off-site to get in touch with those people. This designated person, the hospital determined, would make the calls and then report back to the department with information on how many people would be arriving.

“We needed to establish a scaled response so that we didn’t end up with too many people coming in,” Barberio said. “We also needed to make sure the right people came in—with the right training, pharmacists and technicians included.”

Cement your security plan in place. The last thing you want to worry about in a crisis situation is throngs of people descending on your facility, milling around, and bombarding your busy staff with questions.

What’s more, all those people could present a huge security challenge. Before, during, and after a patient surge from a mass casualty incident, defense of your facility has to be a major priority, with swift and effective action taken to secure your grounds and protect the facility’s occupants, say experts.

“Always remember that hospitals can be secondary targets in a mass shooting or terrorist attack,” says Paul Biddinger, MD, FACEP, director of the Center for Disaster Medicine at Boston’s Massachusetts General Hospital (MGH), which treated 36 victims of the Boston Marathon bombing in 2013. After the Pulse shooting, there were several scattered reports that the shooter had actually made his way over to the hospital and continued his attack there (in actuality, the shooter was confronted and killed in Pulse by SWAT members).

“You have to preserve your facility’s ability to function as a working hospital by making crowd control an essential part of your security response,” Biddinger says. “That means limiting the number of reasons why people need to gather around your grounds and referring some outpatients to resources and counselors out in the community so they don’t congregate unnecessarily in your hospital.”

Coordinate with your first responders. It goes without saying that you should have a good relationship with your community’s fire and police department. However, there are still many hospitals that have not trained with or conducted a lifelike emergency drill with their police and fire counterparts. This is a mistake, because not only will they be the ones you can turn to for security in a crisis, but as was seen in the Aurora incident, first responders can become manpower to help you improve your response and patient treatment.

The decision to transport patients to the hospital in police vehicles “was a leadership moment, and it unequivocally saved lives,” said Dr. Richard Zane, chair of the University of Colorado School of Medicine’s Department of Emergency Medicine, in a report about the hospital response to the Aurora shooting in the Denver Post. “Time to hospital is most important … because of blood loss.”

Good relationships, clear communication, and a bond that allows all members of the first responder community to work together seamlessly will mean the difference between lives saved and a botched response during a crisis.