Some movie goers thought it was just part of the show when the man in the Batman suit suddenly stood before them during a midnight screening of “The Dark Knight Rises.”
Within six minutes, 12 were dead and 58 others were wounded. When police arrived, James Holmes was outside the Aurora, CO, theater in a Batman outfit. He was later charged with the murders.
When news of the shootings broke over the police radio, the leading tertiary care and referral center in the Rocky Mountain region – The University of Colorado Hospital (UCH) just 3.5 miles from the theater – officially was on diversion because of a jammed emergency department.
Minutes later, 22 shooting victims were in the hospital’s ED. Most had wounds to the chest and abdomen and many required blood transfusions. Meanwhile, other emergent cases unrelated to the shootings continued to arrive.
The hospital immediately launched its mass casualty protocol and began calling medical staff from home to help. When they arrived, they first saw shock and paralysis among the staff, and the crush of victims with head, back, torso and leg wounds. All of the shooting victims needed blood. Many had perforated and collapsed lungs that needed to be rapidly expanded. Some could not breathe for themselves.
By Nanne Finis, RN, MS, VP, TeleTracking Consulting Services
The horror of mass shootings in the U.S. makes their occurrence seem more frequent than statistics bear out. Still, hospitals must constantly refine their disaster emergency plans to deliver the best care for their service areas. Using automation technology to compensate for seemingly overwhelming numbers of casualties is one idea that is gaining popularity across the country. Medical professionals at the University of Colorado Hospital say it played a large role in successfully dealing with one of the largest mass shooting incidents in history.
Some movie goers thought it was just part of the show when the man in the Batman suit suddenly stood before them during a midnight screening of "The Dark Knight Rises."
Within six minutes, 12 were dead and 58 others were wounded. When police arrived, James Holmes was outside the Aurora, CO, theater in a Batman outfit. He was later charged with the murders.
When news of the shootings broke over the police radio, the leading tertiary care and referral center in the Rocky Mountain region – The University of Colorado Hospital (UCH) just 3.5 miles from the theater – officially was on diversion because of a jammed emergency department.
Minutes later, 22 shooting victims were in the hospital's ED. Most had wounds to the chest and abdomen and many required blood transfusions. Meanwhile, other emergent cases unrelated to the shootings continued to arrive.
The hospital immediately launched its mass casualty protocol and began calling medical staff from home to help. When they arrived, they first saw shock and paralysis among the staff, and the crush of victims with head, back, torso and leg wounds. All of the shooting victims needed blood. Many had perforated and collapsed lungs that needed to be rapidly expanded. Some could not breathe for themselves.
Physicians who had experienced combat equated it with a war zone battle triage situation. UCH had been training for mass casualty events regularly since shortly after 9/11, when regulations from the Federal Emergency Management Agency (FEMA) required that training protocols be put in place. The staff's diligence also was driven, to some degree, by the fact that UCH is just 20 minutes away from Columbine High School, where 12 students were gunned down by two classmates in 1999. Also, the 2008 Democratic National Convention in Denver prompted hospital leadership to double preparations for any kind of mass shooting.
The first response to such an event is shock that it actually happened, then the drilling kicks in and everyone addresses reality with a level of confidence that they could do what needed to be done.
All 22 Aurora victims treated at UCH that night survived. The heroic effort mounted that night has received national recognition for disaster planning and response.
Clarity Amidst Chaos
Still, with all the training and all the skill involved, a newly installed automated system which tracked capacity at the 550-bed facility received a good deal of credit for the outcomes.
UCH had deployed the new automated system to replace a handwritten clipboard process for assigning beds, tracking patients and monitoring bed availability. The automated capacity management system removed a great deal of lag time from the patient flow process, which decreased length of stay, dropped bed turn times to 55 minutes from 85 minutes, and raised one-hour patient placement from 22 percent to 60 percent.
On this night, however, the system's features would play a different role in addressing the chaos. The ability to track patient location, movement and capacity in would prove to be invaluable in helping make room for the critically injured patients, track their status and provide appropriate details to family, law enforcement and media on a real-time basis.
One feature, in particular, came into immediate play. In the chaos of that night, ED registration staff didn't designate the Aurora patients as "disaster" victims. Previously, this oversight would have required staff to use hand written lists or work from pages of patient labels for weeks. However, the new capacity management system did permit a new designation under a single "disaster" code via the system's patient placement indicators (PPIs).
This gave UC personnel the ability to quickly register the shooting victims and keep them under that designation throughout their stay and wherever they went.
The designation also allowed staff members to assemble victim spreadsheets in the aggregate and alerted them to the mental and physical trauma each victim had endured. It also helped in addressing intense family inquiries and extensive press coverage, allowing UCH to better protect the victims' privacy.
It also helped staff accommodate patient wishes, as in the case of a wounded couple who were expecting a child. The wife was treated and released, but the husband was in a coma. She asked to deliver at UCH where staff knew her situation and would make every effort to assist her. When the baby was born, staff members brought it to the father who, although comatose, responded to his child's cries.
"Live" Information
In a fluid, mass casualty event, the ability to gather and disseminate information as it happens is invaluable. This is especially true now, given the surge capacity reduction which has occurred in the U.S. over the past couple of decades.
For example, although the EMS system used by Colorado hospitals to track available beds showed UCH was on diversion, UCH's own real-time capacity management system told hospital staffers just how many victims it could safely handle.
Throughout treatment, the system allowed UCH staff to pull up instant reports of the victims' status and coordinate patient placement to keep the OR operating at its maximum.
An interface between the capacity management system and the hospital's electronic medical record system allowed Patterson to track the patients throughout their stay; not only regarding location, but vital demographics, physician information, length-of-stay, and diagnosis. The "disaster patient" designation meant that medical personnel could pull a report with that attribute and instantaneously have all the victims' names, demographics and diagnosis.
By combining that data with EMR information into a spreadsheet, staff knew where patients were and where they had to go next. When UCH needed to open its PACU for inpatient care to make room for the wounded, the system identified in-house patients who could be moved from the intensive care unit (ICU) to the post-anesthesia care unit (PACU) in order to free up ICU beds. And, it identified in-house patients who could be discharged early to make more room for those who needed additional treatment.
Hospital officials said the technology helped them make decisions under pressure by providing a clearer picture of various situations and highlighted the most relevant information.
Skilled triage identified those patients who needed to go to the OR immediately and those who needed surgery but could go to a room first. Previously, employees had to make numerous calls to locate available rooms, but the patient flow technology showed bed availability as well as who was in the OR, in radiology, or undergoing a procedure.
The "live" data feed allowed UCH to establish a public hotline (which received 2,000 calls within the first 12 hours) and collaborate with other hospitals to help people looking for loved ones. It also helped to relay information to the City of Aurora.
Expanded Disaster Planning
The interest in using hospital automation technology for disaster preparedness increased after 9/11 and Hurricane Katrina revealed massive communication breakdowns with first responders. Health officials now acknowledge much more needs to be done.
The great challenge is coordinating a whole spectrum of regional health assets, including blood supply, medication, equipment, beds, tracking victims shuttled from one care site to another and providing community information to avoid further casualties. The exchange of "live," up-to-date information can be a huge advantage and it is becoming more feasible as hospitals with automated patient tracking, robot pharmacies and other online assets can feed their information electronically to a regional command center in streaming fashion, provided the technologies are interoperable.
However, hospitals which continue to perform most information processes manually must call, fax or e-mail data periodically, resulting in the loss of valuable time.
About the author
Nanne M. Finis, RN, MS, is VP TeleTracking Consulting Services, where she leads a seasoned team of former hospital nurses and administrators in helping hospitals apply Lean Six Sigma methods and technology to process redesign and workflow automation.
A passionate nursing leader with more than a decade with Joint Commission Resources (JCR), a not-for-profit affiliate of The Joint Commission, Ms. Finis has vast experience in health reform and regulatory policies, front-line leadership in the patient-safety movement, and deep understanding of how hospitals can meet patient quality and safety requirements.
Previously, she served as executive director of Northwestern Memorial Hospital, capping a 22-year career during which she held several nursing administrative positions and was operationally responsible for more than 300 full-time employees and several in-patient and out-patient care areas. Ms. Finis received her undergraduate degree in nursing from St. Mary's College, Indiana, and earned a master of nursing degree from the University of Illinois at Chicago. You can reach Nanne at nanne-finis@teletracking.com
