when disaster strikes: university of colorado hospitals response to the july 20, 2012, aurora...
TRANSCRIPT
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When Disaster Strikes:University of Colorado Hospital’s Response
to the July 20, 2012, Aurora Shooting
Comilla Sasson, MD, MS
Patrick M. Conroy, MS
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No matter what lessons we ultimately learn from this tragedy, it is absolutely clear that the overall
response from the entire University of Colorado Hospital family was nothing less than extraordinary.
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UCH Overview
UCH Overview
• Only academic medical center in the region
• 400+ beds• 27,000 + annual admissions
and growing• 800,000 + outpatient encounters
– and growing• 73,000 annual ED visits – ADC
of 20 inpatients daily
• Over 5,000 staff and faculty• Magnet status for 10 years• 2011 and 2012 UHC Quality
Award winner• #1 hospital in Denver – US
News & World Report• Part of UCHealth
– PVHS/ Memorial
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Facility Information
• Current facility is Level 2 Trauma center• Currently licensed for 407 beds• Additional 14-story tower currently under
construction• Will initially add 144 new beds with shelled
space for 132 more• Entirely new Emergency Department
being added
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Facility Information• UCH is a quasi-governmental hospital
authority• UCH is co-located on the Anschutz Medical
Campus with the University of Colorado – Denver Campus and Children's Hospital Colorado – School of Medicine– School of Nursing– School of Dentistry– School of Pharmacy
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Medical Disaster
“When the destructive effects of natural or manmade forces overwhelm the ability of a given
area or community to meet the demand for health care”
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The University of Colorado Hospital Emergency Department
• 1 STARR room with two beds• 34 rooms (red, green, yellow)• 10 regular hall beds• 1 ENT room• 2 minor casualty rooms
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The State of the Department at 0100 on 7/20/12
• 49 patients in the emergency department• 25 patients currently admitted without an available bed in the
hospital (“boarders”)• 11 patients in the waiting room
– 2 patients ESI level 2– 8 patients ESI level 3– 1 patient ESI level 4
• On divert (placed on divert at 1900 on 7/19/12)
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Brief Pre-Hospital Course
0030
0039: First 911 call
0040 0100
0054: Request to transport victims by police car
0049: First patients to Aurora South
0050
0055: Request notification of all hospitals
0041: First officers on scene
Full emergency department with a full
waiting room
0056: Notified of 3-5 GS victims likely to ED
0101: First patient arrives at University Hospital
0057: Dr Kim notifies General Surgery of likely GSW victims
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Incident Timeline
01:01 First patient is taken from private car– Patient describes to staff the scene in Theater
9: “gas canisters” – “black clad gunman” – “shooting” – “screaming”
– Numerous APD cars, several private vehicles, and one ambulance arrived at ED doors
– Many patrol cars had 3 victims slumped inside
– One and only ambulance had 3 victims – Patients arrived as “war casualties” instead of
usual ambulance condition
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Organized Chaos
Three video files embedded here
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MCI preparation begins:-Call for blood-Prep STARR rooms-Call by Dr. Kim to general surgery of possible MCI-Dr. Kim (R2) to STARR B-Dr. Mackenzie (R1) to STARR A-Dr. Johnson (R3) to doorway of STARR rooms
Emergency Department Course
0100 0110 01300120
20’sF, private vehicle, GSW
ext, hall 1
4mM, private vehicle,
dropped, hall 1
Teenage M, police, GSW to head, STARR A
30’sM, police, GSW to torso ext, STARR B
Teenage F, police, GSW head, hall 2
20’s F, police, eviscerated abdomen, STARR A2
20’s F, police, GSW bil ext and face, hall 6
18F, police, GSW LLE, hall 3b
20’s F, ran, GSW ext triage
Unknown Age F, police, GSW head
20’sM, police, GSW to head, disaster area
Teenage F, police, GSW to neck, disaster area
Teenage M, police, GSW torso/ abdomen, STARR B1
14 M, EMS, GSW lumbar back, hall at room 15
40’s F, police, GSW upper and low ext, no pulse ext, hall room 4
Teenage F, police, triage, mult abrasions
20’s M, EMS, GSW upper and lower ext, hall 3a
30’s M, EMS, GSW R chest, hall 6
New Patient
Patient Course
Radiology
Intervention
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Emergency Department Organization
18 Head
33 L Chest
25 LLE/ 4 mo 17 Face
27 abdomen
23 bilateral legs, face
18 LLE
19 Ribs
18 Head
23 Head
19 Neck
44
LL
E28 LUE
14
Lu
mb
ar
39 R chest
17 abd
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Incident Timeline01:05 Administrator on-call, CNO and CEO
notified and en route to hospital
01:25 Hospital incident commander position filled; initial coordination done from the ED
01:30 House manager alerted OR and PACU
01:31 Internal call-down lists activated in OR, PACU, inpatient units and support departments
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Emergency Department Course
0130 0140 02000150
18 y/o M GSW to head, CT
Plan-D initiated-internal disaster command center-departmental call downs begin-additional nurses called in-ICU and floor nurses to ED-initiation of admitted patients transported to PACA, floors, hallways
New Patient
Patient Course
Radiology
Intervention
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Emergency Department Course
0130 0140 02000150
Teen M GSW to head, CT
30’s M, private vehicle, with GSW
hand, hip pain, triage
Plan-D initiated-internal disaster command center-departmental call downs begin-additional nurses called in-ICU and floor nurses to ED-initiation of admitted patients transported to PACA, floors, hallways
Teen M GSW to chest/ abd, CXR
Teen M, chest tube to L chest
30’s F, private vehicle, GSW to lower ext and lac R foot
30’s M GSW to R chest/ abdomen, CXR
New Patient
Patient Course
Radiology
Intervention
20’s M GSW to head, CT
20’s M, GSW head, intubated by anesthesia
20’s M, GSW head, R femoral line, Dr. Kim and Dr. Johnson
30’s M, GSW chest, chest tube to chest,
MICU attending
20’s F, evisceration, intubated Dr Johnson
30’s M, GSW chest, obtunded, decreased BP and
70% NRB, to STARR A
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Emergency Department Course
0130 0140 02000150
Teen M GSW to head, CT
30’s M, private vehicle, with GSW
hand, hip pain, triage
Plan-D initiated-internal disaster command center-departmental call downs begin-additional nurses called in-ICU and floor nurses to ED-initiation of admitted patients transported to PACA, floors, hallways
Teen M GSW to chest/ abd, CXR
Teen M, chest tube to L chest
30’s F, private vehicle, GSW to lower ext and lac R foot
30’s M GSW to R chest/ abdomen, CXR
New Patient
Patient Course
Radiology
Intervention
20’s M GSW to head, CT
20’s M, GSW head, intubated by anesthesia
20’s M, GSW head, R femoral line, Dr. Kim and Dr. Johnson
30’s M, GSW chest, chest tube to chest,
MICU attending
20’s F, evisceration, intubated Dr Johnson
30’s M, GSW R chest, obtunded, decreased BP and 70% NRB, to STARR A, CT
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Emergency Department Course
0130 0140 02000150
Teen M GSW head, CT
30’s M, private vehicle, GSW hand,
hip pain, triage
Plan-D initiated-internal disaster command center-departmental call downs begin-additional nurses called in-ICU and floor nurses to ED-initiation of admitted patients transported to PACA, floors, hallways
Teen M GSW to chest/ abd, CXR
Teen M, chest tube to chest
30’s F, private vehicle, GSW to lower ext and lac foot
20’s M, GSW head, intubated by anesthesia
20’s M, GSW head, R femoral line, Dr. Kim and Dr. Johnson
30’s M, GSW chest, chest tube to chest,
MICU attending
30’s M GSW to R chest/ abdomen, CXR
20’s F, evisceration, intubated Dr Johnson
30’s M, GSW chest, obtunded, decreased BP and
intubated STARR A23M GSW to
head, CT
New Patient
Patient Course
Radiology
Intervention
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Emergency Department Course
0130 0140 02000150
Teen M GSW head, CT
30’s M, private vehicle, GSW hand,
hip pain, triage
Plan-D initiated-internal disaster command center-departmental call downs begin-additional nurses called in-ICU and floor nurses to ED-initiation of admitted patients transported to PACA, floors, hallways
Teen M GSW to chest/ abd, CXR
Teen M, chest tube to chest
30’s F, private vehicle, GSW to lower ext and lac foot
20’s M, GSW head, intubated by anesthesia
20’s M, GSW head, R femoral line, Dr. Kim and Dr. Johnson
30’s M, GSW chest, chest tube to chest,
MICU attending
30’s M GSW to R chest/ abdomen, CXR
20’s F, evisceration, intubated Dr Johnson
30’s M, GSW chest, obtunded, decreased BP and
intubated STARR A23M GSW to
head, CT
New Patient
Patient Course
Radiology
Intervention
Teen F, expanding neck hematoma
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Emergency Department Course
0130 0140 02000150
Teen M GSW head, CT
30’s M, private vehicle, GSW hand,
hip pain, triage
Plan-D initiated-internal disaster command center-departmental call downs begin-additional nurses called in-ICU and floor nurses to ED-initiation of admitted patients transported to PACA, floors, hallways
Teen M GSW to chest/ abd, CXR
Teen M, chest tube to chest
30’s F, private vehicle, GSW to lower ext and lac foot
20’s M, GSW head, intubated by anesthesia
20’s M, GSW head, R femoral line, Dr. Kim and Dr. Johnson
30’s M, GSW chest, chest tube to chest,
MICU attending
30’s M GSW to R chest/ abdomen, CXR
20’s F, evisceration, intubated Dr Johnson
30’s M, GSW chest, obtunded, decreased BP and
intubated STARR A23M GSW to
head, CT
New Patient
Patient Course
Radiology
Intervention
Teen F, expanding neck hematoma, intubated by MICU
attending fiberoptic scope
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Incident Timeline
02:00 Plan-D announced overhead and operations move to the hospital command center
02:10 Managers and directors from all departments begin arriving
02:30 Arrangements made to stand up PACU as inpatient unit; open as many ICU beds as possible
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Hospital Priorities
• Initial Priorities– OR/PACU/ICU/ED Staffing– Off-load ED to PACU– Augment ED Staffing– Medical supplies– Patient families– Behavioral Health– Security– Hot Line
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Emergency Department Course
0200 0220 03000240
40’s F, GSW upper and lower ext, to CT scanner for run off
40’s M, private vehicle, R eye
pain, hall 1
New Patient
Patient Course
Radiology
Intervention30’s M, intubated, Dr Johnson
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Emergency Department Course
0200 0220 03000240
30’s M, intubated, by Dr Johnson
40’s F, GSW upper and lower ext, to CT scanner for run off
Teen M, GSW lower back to CT scanner for abdomen/ pelvis
Teen F, GSW to neck and chest, chest tube placed by Dr Vandivier
60’s M, EMS, hypoglycemic and
altered mental status, hall 5
30’s M, chest, CT scanner for chest
40’s M, private vehicle, R eye
pain, hall 1
20’s F, private vehicle, abrasions to
ribs, triage
New Patient
Patient Course
Radiology
Intervention
30’s M, GSW chest, CT C/A/P
20’s M, private vehicle, 11 seizures throughout day, not clearing, room 3.
20’s M, seizures, 6 mg of ativan with continued seizure activity.
20’s M, status epilepticus, intubated, Dr Johnson
30’s M, GSW chest, 2nd chest tube placed by Dr Kim and Dr
Johnson
20’s M, GSW head, OR
Teen M, GSW chest/ abd
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Emergency Department Course
0200 0220 03000240
30’s M, intubated, by Dr Johnson
40’s F, GSW upper and lower ext, to CT scanner for run off
Teen M, GSW lower back to CT scanner for abdomen/ pelvis
Teen F, GSW to neck and chest, chest tube placed by Dr Vandivier
60’s M, EMS, hypoglycemic and
altered mental status, hall 5
30’s M, chest, CT scanner for chest
40’s M, private vehicle, R eye
pain, hall 1
20’s F, private vehicle, abrasions to
ribs, triage
New Patient
Patient Course
Radiology
Intervention
30’s M, GSW chest, CT C/A/P
20’s M, private vehicle, 11 seizures throughout day, not clearing, room 3.
20’s M, seizures, 6 mg of ativan with continued seizure activity.
20’s M, status epilepticus, intubated, Dr Johnson
30’s M, GSW chest, 2nd chest tube placed by Dr Kim and Dr
Johnson
20’s M, GSW head, OR
Teen M, GSW chest/ abd, OR
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Casualties Treated
• Total Citywide– 58 victims treated in local hospitals– 11 dead at scene
• UCH– 23 patients would arrive– 22 treated (38% of total alive); 1 DOA
• Of the 22 patients treated:– 10 were “treat and release”– 12 were hospitalized– 8 ICU including 6 trauma surgery– 4 Med/Surg
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Emergency Department Response
• Staff cooperation was extraordinary• Many people performed duties that were
outside of their normal roles– Security, Facilities
• Best term that can be used is “focused chaos”
• Everyone was assigned a role
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Hospital Response• Nurses came from inpatient units floors to
assist in decompressing ED– Many inpatient units doubled RN-to-patient
ratios• Clinical and support departments called in
extra personnel– Coordinated delivery of 150+ units of blood– Supported OR lab
• The words “that is not my job” were never heard
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Hospital Response
• Medical Staff– Within 20 minutes, many surgeons and
anesthesiologists reported from home– All available house staff came to assist ED– ED attendings assigned groups of patients to
house staff after triage• Within 1 hour, more than 50 directors,
managers, staff and physicians physically responded to the hospital
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Hospital Response
• Radiology– Patients going to OR required scans; staff
stayed over; radiologists called in to read– Teamwork between ED and Radiology never
better– 150 scans performed in under 1 hour
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Hospital Response• Hospital switchboard handled all incoming
calls until hotline could be set up• The hotline had been in planning stages
– Went “live” this night (Over 1,000 calls)• Purpose of hotline: Answer calls from
families and friends searching for victims– Hospital Command Center coordinated with
APD in getting the names of all the victims at all local hospitals
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Hospital Response
• Operating Room– Difficult pump case in progress at the time of
the event– Activated internal call-down list very rapidly– 9 operating rooms stood up in <2 hours
• 4 ORs ready within 30 minutes• 6 cases that night
• PACU– Off-loaded entire ED yellow zone and ICU
patients (14 beds) within 45 minutes
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Hospital Response
• Radiology– Patients going to OR required scans; staff
stayed over; radiologists called in to read– Teamwork between ED and Radiology never
better– 150 scans performed in under 1 hour
• Lab– Staff stayed over; others called in to ensure
STAT labs performed and reported expeditiously
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Hospital Response
• Security– Secured entire hospital and maintained
control throughout the event– Integrated with the numerous law
enforcement agencies very effectively– Provided a great deal of assistance in
managing the news media– Got great assistance from Campus Police
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Hospital Response
• Media Team– Once initial patient care was being handled,
quickly became the eye of the storm– Were dealing with both the UCH and UCD
aspects of the incident throughout– Brought in some outside PIO assistance
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Hospital Response• Food and Nutrition
– Contacted very early on to provide support for staff and victim families
• Supply Chain– Contacted early on to backfill medical
supplies– Ordered disaster caches from Owens-Minor
and had them delivered to the dock
• EVS– Were anywhere at anytime
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Hospital Response• Spiritual Care and Social Workers
– Provided assistance to staff, victims and families
– Conducted initial debrief for ED staff at shift change
• Engineering Services– On-duty staff assisted in bringing up
stretchers, unloading patients and moving patients
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Command Center Structure
Command and General Staff
• Incident Commander• Operations Section Chief• Planning Section Chief• Logistics Section Chief• Public Information Officer• Liaison Officer• Medical/Technical Specialist –
Hospital Administration• Medical/Technical Specialist –
Privacy Officer
Planning Section
• Patient/Bed Tracking Unit Leader• Personnel Tracking Unit Leader
Logistics Section
• Supply Unit Leader• Food and Water Unit Leader
The following standard HICS roles/functions were staffed either formally or informally during the incident
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Command Center Structure
Operations Section
• Hospital Care Branch Director• OR/PACU Unit Leader• OR Team Leader• PACU Team Leader• ED Branch Director• ED Triage Unit Leader• ED Registration Team Leader• ED Treatment Area Supervisor
Operations Section
• Security Branch Director• Radiology Unit Leader• Pharmacy Unit Leader• Respiratory Therapy Unit Leader• Clinical Lab Unit Leader• EVS Unit Leader• Mental Health Unit Leader
The following standard HICS roles/functions were staffed either formally or informally during the incident
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The Aftermath• The President• The press• The investigation• Ongoing emotional support for staff
including debriefings• Written communications to faculty and
staff to keep all informed• Rumor control – social media
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Suspect Residence
Suspect Office
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Lessons Learned
• Communications• Resources and Assets• Staff Roles and Responsibilities• Patient Care• Safety and Security• Utilities
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Our New ED!
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Implications For Health Care and Emergency Management
• You cannot train, exercise and drill too much• Successful patient outcome is dependant on a
complex system of direct clinical, clinical support, and non-clinical support activities
• Unless your medical staff is fully integrated into all of your planning and preparedness efforts you will not succeed
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Implications for Health Care and Emergency Management
• Unified Command is a reality and must be incorporated into Hospital Emergency Operations Plans
• ESF 8 (Medical Care) support and coordination is often times lacking in local communities
• Assumption is that hospitals can take care of themselves
• This is generally true but only to a point• This has been demonstrated in Joplin, Hurricane
Irene, and others
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Implications for Health Care and Emergency Management
• Hospitals will quickly become a major focus of media related activities
• This may require Public Information Officer and Joint Information Center support depending on capabilities
• Patient names/location information is not as easy as you may think – HIPPA
• Law Enforcement interface is critical – patient care/HIPPA issues are tricky
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Implications For Health Care and Emergency Management
• Integrated and interoperable communications means with everyone
• Public Health and Health Care are identified as two of the ten first responder disciplines by Homeland Security for a reason
• A modern medical campus provides much more than just inpatient medical care
• Interruptions in service delivery can have significant ripple effects within the community
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Moving Forward:Consistent Message
We will be our own worst critics. While we will identify lessons learned but
understand that we, as a team, performed extraordinary feats under
extraordinary circumstances.
Link to embedded video here
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Thank You
22/22