When violence hits home: Lessons for hospitals

Trustee talking points

Three blocks away, 29-year-old security guard Omar Mateen had opened fire at Pulse, a dance club with a primarily gay clientele. It wasn’t long before victims started trickling into central Florida’s only Level I trauma center.

“Our first patient came in, and then we got to work. That’s what we do in the emergency department. We get to work,” Brown told attendees at the Institute for Healthcare Improvement's annual conference in Orlando in December, six months after the incident. “And then another patient came in. And then another patient came in. And another patient came in, and they just kept coming, and they had wounds like I had never seen before, and I started to get really scared, and I looked in the other nurses’ eyes, and they were scared, too.”

In what turned out to be worst mass shooting in U.S. history, 50 people died, including the gunman. All told, 44 victims were rushed to ORMC. Nine died, but clinicians at the hospital performed more than 50 surgeries on 35 patients. Everyone who made it to the operating room survived.

Amid the turmoil, ORMC’s leaders were calm and collected. Just three months earlier, Orlando Health had conducted a communitywide mass casualty drill to prepare for such a situation. Mark Jones, senior vice president of the system and president of ORMC, says he believes that without that practice, many more people could have died.

“There is no question that the work that was done that day helped to save lives,” he told the rapt audience at the IHI forum. “Hospitals, we would really, really urge you to practice incident command. Drill often. Do the tabletop exercises as often as you can.”

And, Jones emphasized, don’t hold those drills only when it’s convenient. “You always think that, you know what, the hospital is too busy,” he said. “We would urge you to drill when you’re busy. Drill at night. Practice on the weekends. Because what comes out of that are lessons and learnings and gaps that are identified that allow you to address them and prepare.”

Call to action

Less than a month after the Pulse tragedy, a sniper opened fire during a protest in downtown Dallas, killing five police officers and wounding nine others. Ten days later, a different gunman shot six police officers in Baton Rouge, La., killing three before he was gunned down by a SWAT officer. All told, there were 385 mass shootings — defined as four or more individuals shot or killed in a single event — in the U.S. last year, according to the Gun Violence Archive. More than 1,500 individuals were injured, and 458 died, a 24 percent uptick from mass shooting homicides the previous year.

Such violent events are prompting a re-evaluation of how well-prepared the hospital field is for handling mass casualty events. The American Hospital Association began talking internally with its board of trustees — comprising hospital leaders from across the country — about how the field can respond to these tragedies beyond mending the broken bodies in the ED, says Melinda Reid Hatton, senior vice president of the association, who is spearheading the effort.

“It was certainly an accumulation of things, but I think the tipping point came as a result of the tragedies and carnage in both Orlando and Dallas,” she says. “We asked whether or not we in the hospital community should be doing more to combat violence, both in the community, that inevitably ends up on the doorsteps of the hospital, and also violence in our facilities that is inflicted on our colleagues and staff.”

Following that call from its board, the AHA in the fall launched Hospitals Against Violence, an initiative focusing on what it calls “one of the major public health and safety issues throughout the country.” This year, the organization and its 5,000 hospital members will build coalitions with community institutions, share best practices and conduct research to gain deeper insights into the effect that violence has on both hospitals and the patients they serve. Health care leaders are eager to find ways to thwart violence, and the association is making sure to include all facets of an organization — from its diversity in management group to nurse leadership, engineering and human resources — in the initiative.

“This is very much a coalition of the willing at the AHA, and we have a very big and very diverse group that has signed up to work on this,” Hatton says. “We’re really trying to make sure that we involve the whole AHA family because this is something that affects everyone in our hospitals.”

Plan and practice

Leaders with both ORMC and Dallas-based Parkland Memorial Hospital, which treated victims of the July 7 sniper attack on police officers in the city, have shared their stories across the country in the months following the incidents. They say they’re alarmed that their peers elsewhere aren’t taking the need to address the potential for mass casualty incidents in their own communities more urgently.  

“You would be surprised by how many have the mentality of ‘it won’t happen here,’ or people who truly underestimate the threat of what is capable of happening in their own community or, for that matter, at their facility,” says Dan Birbeck, a captain with the Dallas County Hospital District Police Department. “Some of the places that we go to are more robust and prepared and get the big picture of preparedness, but there are others that are way behind the curve.”

Preparedness was never a question for Massachusetts General Hospital and other hospitals that responded to the Boston Marathon bombings in April 2013. They’d been working together for years to brace for the possibility of such an event.

But luck also played a part, says Paul Biddinger, M.D., chief of emergency preparedness and head of Mass General’s Center for Disaster Medicine. The two homemade bombs planted by the Tsarnaev brothers detonated in a centralized location, near the finish line at Copley Square, making it much easier to disperse patients evenly to the numerous trauma centers across the city. Moreoever, the explosions occurred just before a shift change at 3 p.m., meaning there were twice as many staff members on hand to tend to the hundreds injured.

That’s where matters of chance ended. In the decade-plus following the 9/11 terrorist attacks, Boston hospitals had developed a coordinated response plan, just in case, Biddinger says. Each year, medical leaders reviewed literature from others who had experienced similar incidents. And, in 2008 and 2009, the Harvard School of Public Health and the Centers for Disease Control and Prevention hosted symposia featuring speakers from London; Madrid; Mumbai, India; and other cities that had been targeted by terrorists.

Marathon organizers and health care leaders had long treated the annual race as a “planned mass casualty event,” Biddinger says, enabling emergency management services, hospitals, fire and police leaders, and other key players to coalesce and determine how such events might be managed.

One key lesson, Biddinger says, is the importance of establishing a plan about how to distribute patients among institutions. Many cities rely too heavily on just one hospital, and even the largest institutions can become overrun by a multitude of patients appearing quickly.

And all hospitals must have a mass casualty protocol in place, Biddinger says, one that specifies all the actions that have to happen following an attack and lays out how to make space in an already packed ED when dozens of victims start trickling in.

“Very few hospitals in America have a true mass casualty protocol,” he says. “Most hospitals have systems by which they can call surgeons, extra emergency physicians, you name it, but rarely are a whole series of actions embedded deeply across the institution, including their admitting office, their laboratories, their radiology."

Mass General was already swamped before the marathon bombings, with 97 patients in its 49-bed ED. However, because of pre-existing plans to rapidly transport patients from the ED to inpatient floors and open up operating rooms by delaying certain pending cases, the hospital took in 31 patients in about one hour, with room for others had it had been needed. In total, more than 260 people injured in the bombing were dispersed among hospitals in the city, and none of them died.

Beyond the obvious

Organizations like the Joint Commission and Centers for Medicare & Medicaid Services require that hospitals create emergency operations plans and exercises. But it’s essential that leaders go beyond those regulatory requirements, says John Hick, M.D., an emergency medicine expert with Hennepin County Medical Center in Minneapolis, who’s written numerous articles on the topic and took part in that hospital’s response to the 2012 Accent Signage shooting in the city.

Hick highlights three key areas hospitals should strengthen when planning for violent mass casualty incidents, areas that aren’t necessarily spelled out in usual hospital preparedness plans. These include:

• Heightened security in the event that an attack continues inside the hospital, and the need for access controls on a hospital campus.
• Accepting victims of penetrating trauma from blast or bullet injuries requires a higher level of surgical planning — specifically, the ability to ramp up surgical services and have sufficient doctors and supplies on hand.
• You must be prepared with a robust blood bank response to make sure that victims of mass casualty events are transfused in a timely manner.

To target preparedness gaps that are unique to a facility, Hick says, you must push your hospital to the limit in practice drills and engage employees in discussions about what needs to be strengthened. There are also tools available to help analyze any vulnerabilities.

Room for innovation

While it is crucial to establish policies before a violent incident, experts also stress the importance of flexibility if a plan fails to address a certain scenario. That was the case for clinicians at Loma Linda University Health, who responded to a December 2015 shooting at a public health training event and Christmas party in San Bernardino, Calif., that left 14 people dead and two injured. The perpetrators, a husband and wife, were killed in a shootout with police.

Although the preparedness plan did not specify it, triage tents were set up outside the hospital to help treat less-acute patients, which provided space in the ED for victims of the attack, says Connie Cunningham, R.N., executive director of emergency and trauma services at Loma Linda. “What works today doesn’t always work tomorrow,” she says. “When you practice, you hope that you’ve remembered everything, but when you actually have the people coming in, you need the latitude to be able to shift gears and do things a different way.”

Chadwick Smith, M.D., a trauma surgeon and team leader in the OR at Orlando Health, says that drills and training may not completely prepare you for responding to a mass trauma incident, but they place you in the right position. “Like a play, it gets you to your point on stage,” he says. “You have a good starting point, and you have supplies in order, you have people who have gone through the motions of at least practicing where patients are going to go and who’s going to do what. It doesn’t totally prepare you, but it gets you to a good starting point.”

The night of the Pulse attack, Smith was tasked with triaging victims, making sure that those in the worst shape received care first. In one instance, he had to make the tough call of ceasing CPR on one unresponsive patient and moving to another who did not have an attending surgeon.

Smith says the “culture of teamwork” at his hospital proved critical to its success, with empowered doctors and nurses confident in making tough choices without asking for permission. “Enabling them to make decisions on the fly is imperative, and embracing a culture of team member empowerment is key,” he says. 

Marty Stempniak is senior writer at Trustee.

---

Tragedy can take its toll on staff, too 

Hospital disaster drills often focus on transporting patients to the emergency department and moving them into the appropriate operating room. And that’s where the drills stop. It’s what happens next that hospital leaders really need to focus on, particularly the emotional toll that incidents like the June 12, 2016, Pulse nightclub attack in Orlando, Fla., take on patients and staff, says Michael Cheatham, M.D., chief surgical officer for Orlando Health.

The hospital set up counseling sessions for its team members just four hours after the Pulse shootings. In conversations with those who treated victims of the 2012 Aurora, Colo., movie theater shooting, Cheatham learned that trauma can linger for a long time. “We’re fully cognizant of the fact that the disaster doesn’t stop the next day and that we will continue to be looking out for the mental health of our team members for years to come,” he says.

Staff at Loma Linda University Health were similarly shaken after the Dec. 2, 2015, shooting in San Bernardino, Calif., that left 14 victims dead and 22 injured. The academic medical center accepted five of the shooting victims and feared the attack might spread into the hospital’s corridors. A week after the incident, staff huddled to debrief. That’s when they decided to bake cookies for people outside the hospital who helped in the response. It was “therapeutic,” says Connie Cunningham, R.N., executive director of emergency and trauma services, and she said she hopes others dealing with similar circumstances will find their own healing process. Too often, emergency physicians and nurses present tough exteriors when they’re crumbling inside, she says.

“As health care providers, we really need to start taking care of ourselves, because everything you see becomes part of you, and it does affect you whether you want to admit that or not,” Cunningham says. “Self-care is really important, and I think Dec. 2 showed us that. You have to debrief the ugly out of your brain.”

Sometimes, certain strategies during an initial response to a mass tragedy can help to alleviate secondary stress later on, says Paul Biddinger, of Massachusetts General Hospital, which treated victims of the Boston Marathon bombings in 2013. He’s a proponent of “micro zoning,” which involves placing a doctor and a nurse in a single emergency department room to wait for a patient, rather than in a hallway or other open area. This way, Biddinger says, they can focus solely on the patient in front of them and avoid experiencing some of the cumulative psychological trauma of seeing wounded patients pass by.

Mass General also found it crucial to offer support to staff immediately after the bombings, as well as in the short, medium and long terms. “Because so far, we’ve found that basically all of it will be needed,” Biddinger says. Often, anniversaries of an attack can trigger stress in employees, and leaders should anticipate that some may ask for time off or for shifts away from sites that may trigger trauma.

Leaders must avoid the urge to push toward continuity in the wake of a mass casualty incident, says Alex Eastman, M.D., medical director of the Rees-Jones Trauma Center at Parkland Hospital in Dallas and lieutenant and deputy medical director with the Dallas Police Department.

The day after the July 7 sniper shooting of police officers in the city, Eastman came into work at Parkland and attempted to lead his weekly morbidity and mortality discussion about what had gone wrong or right at the trauma center in the previous week. That quickly turned into a healing session to discuss the aftermath of the attack, and pressing on with the regular agenda just didn’t seem right, he said. You don't have to shut down the emergency department and mandate that employees seek counseling after an incident of violence, Eastman says, but you should provide a full array of therapy resources — from casual peer gatherings to formal counseling — so staff can heal on their own terms.

“You’ve got to build in time, deviate from your normal routine, and get away from the idea that we have to continue business as usual, no matter what,” he says. “I think that’s really important, and it’s something that’s lost in most C-suites now. It’s actually not just about business. We’ve got to do a good job of taking care of each other so we can continue to take care of everyone else.” — Marty Stempniak

---