This is a paper by Sheuwen Chuang, David Woods, Hsien-Wei Ting, Richard Cook, and Jiin-Chyr Hsu that examines a disaster that occurred in 2015 in Taiwan where almost 500 people were injured when a flammable colored powder was sprayed into a crowd. This paper looks at one regional hospital’s emergency room that didn’t have a burn ward or any specialized experience in dealing with incidents at this skill and yet they were able to adapt and continue to serve not only burn patients, but regular ER patients as well.
This paper not only highlights ways of responding to incidents and adapting for unpredicted events, but also what is possible to learn and surface after an incident using interviews and other available data. 11 people were interviewed that were part of this incident also medical records and emergency department logs were used to help construct these lessons. A timeline was constructed and instead of leaving it at that, it was used to help trigger recall.
Often, in post incident review, I see a timeline get treated as the main artifact or purpose of the review when, as in this study, it should just be a tool to help others remember and discuss their experience with the incident. Of course that’s not to say that everyone can devote this level of analysis to their incidents, but I don’t believe the only options are all or nothing.
Initially, the ER became aware of the incident when they were informed by the Fire Department that a fire had taken place. At that point, they had figured they’d only receive a few additional patients. This view changed when, minutes later they received a call from the hospital VP who was on a train, but could see the news and saw that reporting indicated “almost a hundred victims on scene.” The VP directed them to prepare for a surge and began to activate communication channels that would allow more physicians to be dispatched.
This ER would typically see about 70 patients total during a day shift and 40 during the night shift. Ultimately they’d treat 68 patients during the time of this event and would begin with 17 patients already in the ER. Previously the staff had practiced various scenarios for an influx of patients where they’d use their normal operating procedure, but they were very different from what they were facing now. Previous practice had included things like 15 people with food poisoning or 5 people injured in a fire. Never had they practiced something this large, where they’d see 30 patients from a single incident, nor where the number of patients they’d continue to receive would be uncertain. But their previous practice was still important, it gave them experience in working in situations that challenged them, possibly let them see the limits of the standard operating procedure, and build common ground with other responders.
At multiple points the head of the surgical department contacted the Emergency Operation Center and asked them to sop sending victims to the hospital as they were reaching capacity, but each time they received a non-committal answer on the ability to do so.
The ER went through three stages before returning to normal, where the difficulties were different in each stage:
1. Initial surge
- This is where the ER is close to using up the normal number of beds (23), physical space, and staff.
- At this point, the staff available don’t have a lot of specialized burn experience. This is challenging because burn care can differ significantly from other wound treatment, especially as severity increases.
- The staff are still unsure just how many patients they’re going to get. We can look back now and know how many they got, but in the moment as the situation was unfolding, they had no way of knowing. Every time they’d get a patient or group of them they couldn’t tell if they were the last or not.
- Some of the patients arriving needed ICU level care, but no ICU beds were available. At this point the staff isn’t even sure whether transfer to the ICU would even be possible.
Now, they’re really running out of supplies. The supplies needed to treat burn victims are fairly specialized and are in limited supply. Further, there aren’t enough staff to care for the number of patients and staff are anticipating that patient care could suffer with this overload.
3. Patient Transfer
This is where things start to deescalate, but there’s still work to do like deciding which patients need transfered and where they should. Also, care givers need informed so that they can care for the patients they get and figuring out how to follow up with the patients who were transfered out.
Overall, 14 “key functional adaptive strategies” were discovered from the response. They fall into 4 categories:
- First aid
- Mobilization and deployment of resources
- Rearranging of regular emergency services
- Public communication
While it may not map exactly to incidents your organization and team have been involved in, you can see how adaptations of similar categories are useful in software as well. The specific adaptations included things like:
- Giving staff additional authority and encouraging them to work independently.
- Reducing the workload from patients who were not critical and not part of the incident.
- Increased coordination like a Surgical Department director that acted as a local incident commander.
- Reconfiguring space, like moving burn patients out of the Emergency Department to help them with overcrowding and preserve the space for continued assessment.
- Making judgement calls and balancing risks, like deciding when to transfer patients to the ICU or the regular ward based on severity.
- Calling in additional physicians, both from home and from other departments in the hospital.
- Flexible team structure as more victims and staff arrive.
I want to highlight two of these because they are some of the most important:
Giving staff additional authority and encouraging them to work independently.
If the staff had been constrained to only normal ways of working or those that were explicitly specified by policy or procedure, then few if any of these adaptations would have been possible. Without these adaptations patients wouldn’t have been able to be cared for.
As a leader it can be tempting to try and control a situation, incident or otherwise, by attempting to advice rules and standard operating procedure, but that will never close the gap between what is predicted and the reality of uncertain, unpredicted events. Here the staff had the authority, within reason of course, to do what they needed. They understood the goals of the teams and organization as a whole. They were able to use all that to come up with creative solutions.
Flexible team structure as more victims and staff arrive.
This goes hand in hand with the previous. When I first work with teams to help them build an incident response framework that fits them, there’s often a concern that they now have to live in some very rigid structure and act like robots. The reality is that’s the last thing I want and the last thing that helps resolve incidents. They need to have some sort of norms around how they work so they can adapt from there and recognize when the norm doesn’t work and when others are not working in that way. They need to know the rules so they can know when to break them.
In this case, we know the team reorganization was “mostly spontaneous”. These front line responders were trusted to do their job and did so. They created teams where one group would provide immediate treatment before the patient reached other groups. Because most of the staff didn’t have specialized skills to handle burns, both surgeons and nurses with those skills directed others.
- Response plans need to be flexible in order to facilitate response to unexpected situations
- Front line responders need the authority to be able to adapt
- Coordination, not just communication played a large role in the teams ability to continue to treat patients
- Though the hospital staff had not practiced an incident of that scale or type, they had been practicing other incidents where their capacity was challenged.
- Flexible teams that could changed as the situation changed were critical in meetings needs.
- Those with needed experience and specialization directed those who didn’t have it, regardless of their role in the “normal” or “traditional” hierarchy.
- Many of these lessons were possible because of later interviews. Without this sort of post incident investigation, these learnings would not be available to us.