Development of the ASPR TRACIE No- Notice Incident Fact Sheets & Recommendations for Use Melissa Harvey Dr. John Hick Dr. Rick Hunt June 19, 2018
ASPR Visit to Las Vegas ASPR representatives visited with staff from Sunrise and University Hospitals on December 13-15, 2017. Purpose: Improve ASPR s understanding of the response, what went well, and what other communities from across the country would benefit from knowing. Discussions were a mix of general sharing of big issues or action the healthcare system could do to prepare for future incidents to structured questions from ASPR. 2
Mass Shooting Timing & Patient Distribution On Sunday, October 1, 2017 at 10:05 PM, a shooter opened fire on an outdoor Las Vegas concert venue with approximately 22,000 attendees Hospital shift change at 11PM allowed for double staffing; below average census in hospitals ~600 patients treated at local hospitals, only (21%) of them transported by EMS Unique Las Vegas hospital dynamics: public and for-profit systems Hospital Health System Trauma Center # Pts Treated # Mortalities University Medical Center Public Hospital Level 1 104 Sunrise Hospital HCA Level 2 214 16 (10 DOA) Dignity Health-St. Rose Dignity Health Level 3 79 Desert Springs Valley Health System 93 Spring Valley Universal Health System 52 10 DOA Valley Hospital Universal Health System 30 Henderson Hospital Valley Health System 25 Summerlin Hospital Valley Health System 10 Centennial Hills Hospital Universal Health System 5 3
Select Exemplary Practices in Las Vegas Response Planning, training, and response conducted by Rescue Task Forces (RTFs), composed of EMS and police, facilitated rapid victim retrieval 19 RTFs (7 responders/team) used EMS was well-equipped with stocked resource kits, including a large volume of tourniquets EMS and public use of Stop the Bleed UMC does not utilize a just-in-time supply chain and had an abundant supply of resources on-site; Sunrise was able to rapidly retrieve additional supplies from a nearby HCA corporate warehouse Sunrise built off their daily operations efficiencies minimized bottlenecks and rapidly discharged 167 patients, or 27 percent, within a few hours 4
Coalition and Communications Identified Needs Coalition active in planning but response interface and integration of disciplines not as well defined Communication between hospitals and EMS needs protocols and process no current system exists for hospital coordination / support Define responsibilities for patient distribution and patient information / reunification Lessons Learned Information that University was closed led to problems Information on possible secondary shooter event at another hospital was inaccurate Promote role of coalition partners in information gathering, vetting, patient information management, etc. Role definition and systems of communication that are known prior to the event are critical for success Relationships are key! Know the resources and who to call to get them 5
Role of EMS and Pre-Hospital Care Identified Needs Strengthen coordination between EMS and hospitals to facilitate patient distribution/redistribution Open lines of communication with hospitals to avoid miscommunication about facility closures and ability to accept patients Emphasize stop the bleed training and resources EMS policies for hospital support / secondary transfers Lessons Learned Recognize/promote use of EMS to redistribute patients, not just for initial transport ~80% of patients arrived by POV/Uber; used Google to determine hospital locations Self-referral may be unavoidable in MCIs; results in uneven patient distribution Continue to support partnerships between EMS and law enforcement Echo calls created chaos for responders for hours after the initial event dispatch could have cleared many of these up with the question where were you when you were shot? Triage was essentially already performed gone, not able to flee, dead 6
Patient Care Identified Needs Best practices for managing large volume of unidentified patients Tattoos, piercings, clothing Streamlined patient identification, registration, patient flow, billing, and family reunification processes; resolve HIPAA barriers Clear guidance on decedent and evidence management Lessons Learned Use senior physicians to triage and conduct the orchestra Use of pediatric ED and other spaces for contingency care Utilize pediatric surgeons for adult patient care; utilize surgical residents and physicians from other facilities Unidirectional flow of patients (e.g. ED radiology OR ICU) Beneficial impact of CONTOMS and military-style treatment Identify efficient models to reduce administrative burden of patient registration; manage patient flow and discharge Ideally have one staff accompany each patient through process 7
Medical Supplies and Equipment Identified Needs More mass casualty supplies (triage tags, tourniquets) and surgical resources (trays, chest tubes, suction containers, PPE, trauma packs) Simplified documentation methods and templates for ED and OR use during MCIs Training for staff and personnel in locating disaster supplies Lessons Learned Obvious hazards associated with just-in-time supply chain Supply needs for penetrating trauma are very different than for other conventional disasters Jazz Band: Personnel took proactive, creative actions to address resource shortfalls; emphasis should be on critical thinking/problem-solving rather than strict adherence to plans 8
Responder Safety and Health Identified Needs Notification system to manage staff response Staff orientation on facility emergency management practices Lessons Learned Establish appropriate hospital security protocols to protect staff while maintaining access to patient care 9 9 9
Mental Health Identified Needs Plan for emotional support following MCIs for health care staff and first responders Additional resources/training for peer-support Recognition of/continued support for long-term impacts (e.g. 1-year anniversary, etc.) Lessons Learned Address behavioral health needs for medical and non-clinical personnel EMS and hospital staff who worked shifts after the event, but were not called in during the night, suffered significant guilt Significant impact on ancillary staff (EVS, etc.) Use of VA mental health teams at UMC, Sunrise, and the family reunification center Use of prioritized CISM response, including peer-support teams, for Fire/EMS 10 10 10
Cost and Donations Identified Needs Approach for handling uncompensated care Managing costs differs for private, for-profit (Sunrise) and public (UMC) entities Estimated $500,000 staff costs alone at one major hospital Promote broader use of disaster billing designation Technical assistance for donation management to avoid numerous, unusable donations overwhelming facilities Lessons Learned Identify and communicate donation needs to the public, such as phone chargers and clean clothing rather than food, blood (unless necessary) Designate space and resources early in the process to manage incoming donations Consider potential community partnerships in the aftermath, e.g., many hospitals received inquiries from the private sector about donations 11 11 11
Sharing Lessons Learned ASPR TRACIE Webinar: Healthcare Response to a No- Notice Incident: Las Vegas on March 28, 2018 No-Notice Incident Tip Sheets ASPR TRACIE Exchange Issue 7: Providing healthcare after mass casualty incidents (Release end of June 2018) ASPR TRACIE Mass Violence Resource Page (asprtracie.hhs.gov/mass-violence) 12
ASPR TRACIE No-Notice Incidents Tip Sheets ASPR TRACIE developed a series of tip sheets (9) for hospitals and other healthcare facilities to consider when planning for no-notice incidents in their area. The tip sheets are based on discussions with healthcare personnel who were involved in the response to the October 2017 mass shooting in Las Vegas and supplemented with information from other recent no-notice incidents. Each tip sheet focuses on a priority response activity. While there is great variance in the scope of and healthcare needs resulting from no-notice incidents, these activities were identified as likely to require attention. 13
Community Response and Media Management No-notice incidents are often followed by an overwhelming response from the community, including the media. While generally wellintentioned, these efforts may complicate healthcare facility operations. Tip Sheet Contents: Security Implications Volunteers Media Affairs Donations 14
EMS Considerations Tip Sheet Contents: Pre-Event Considerations Initial Response Issues EMS Support for Hospitals Other Considerations 15
Expanding Traditional Roles As part of their no-notice incident planning, healthcare facilities should consider arranging for specialty providers to assume non-traditional roles to help address the surge in patients. In some cases, specialists may be available to meet their traditional roles as well as supplement other critical activities. Describes the non-traditional role some anesthesiologists assumed following the October 2017 mass shooting in Las Vegas. It also lists possible non-traditional roles other providers (e.g., pediatric) can assume in similar incidents. 16
Family Assistance Considerations for family assistance centers to include: Establish a process even if there is no information to give. Ensure interpreter services are available. Telephone support as part of surge planning. Provide on-side mental health support. Items to provide family members and friends that may arrive from the incident for support (e.g. phone chargers, clothing) Plan for longer-term family and patient assistance. 17
Fatality Management Lessons learned from Sunrise Hospital are provided: Designated the endoscopy suite as a temporary morgue Arranged decedents in rooms in the order of their arrival Recorded sex, approximate age, hair color, and eye color on a blank sheet of paper located with each victim Photographed each victim Collected descriptions and photographs from family members Cleaned stretcher, replaced bedding, and covered with a clean sheet once identified Tip Sheet Contents: Mortuary response Considerations for when responders are affected Forensic considerations 18
Hospital Triage, Intake, and Throughput Tip Sheet Contents: Prepare for large volumes of self-referred patients Conduct initial triage and intake / tagging / registration Review your trauma alias process for patients who arrive without identification Stage personnel and resources to manage initial treatment needs Initiate rapid discharge of existing patients, as appropriate Establish a process for disaster patient flow one way! Partner with hospital incident command to expand capacity Be prepared for existing ED patients to depart 19
Non-Trauma Center Considerations During the initial response to a large-scale, no-notice incident, all healthcare facilities should be prepared for unusual patient distribution patterns, misinformation, and challenging communications. Patient Arrival Patient Management Surgical Services Communications and Information Sharing Transfer coordination 20
Trauma Surgery Adaptations and Lessons Healthcare facilities should be prepared to conduct initial triage of patients at their door and continue to assess and reprioritize patients as the incident evolves. Plan for clear decision making on patient prioritization Secondary triage Consider zoning patients by injury type Plan for services to support trauma surgery Know how other spaces will be used Plan for the next shift 21
Trauma System Considerations Tip Sheet Contents: Community-wide Patient Distribution Considerations Resource Considerations Surgical Services 22
Additional Mass Violence Resource Examples Exchange Issue 3: Preparing for and Responding to No-Notice Events Post-Mass Shooting Programs and Resources Overview Tips for Retaining and Caring for Staff after a Disaster Explosives and Mass Shooting Topic Collection 23
Questions/Comments asprtracie.hhs.gov 1-844-5-TRACIE askasprtracie@hhs.gov 24