utilization of information systems for ed disaster registration and tracking
TRANSCRIPT
Utilization of
Information Systems for ED Disaster
Registration and Tracking
C L I N I C A L
Authors: Robert Powers, BS, RN, EMT-P, and Julie Phipps,
RN, MSN, Raleigh, NCRobert Powers, NC ENA: Heart of Carolina Chapter, is EmergencyPreparedness Coordinator, Emergency Services Institute, WakeMedHealth and Hospitals, Raleigh, NC.
Julie Phipps is Systems Analyst II for Emergency Services, WakeMedHealth and Hospitals, Raleigh, NC.
For correspondence, write: Robert Powers, BS, RN, EMT-P, 9200Dawnshire Road, Raleigh, NC 27615; E-mail: [email protected].
J Emerg Nurs 2006;32:497-501.
0099-1767/$32.00
Copyright n 2006 by the Emergency Nurses Association.
doi: 10.1016/j.jen.2006.09.005
December 2006 32:6
uring a disaster event, the rapid inf lux of pa-
Dtients into the emergency department coupled
with the paper documentation that emergency
departments standardly revert to in mass casualty incidents,
makes it challenging to quickly locate patients, to register
them, or to have real-time information available to guide
operations response. By utilizing existing information sys-
tems, WakeMed Health and Hospitals was able to develop
a process to facilitate the whole registration procedure and
to capture needed information quickly and accurately.
WakeMed Health and Hospitals has 4 emergency
departments in its system. The Main Campus emergency
department in Raleigh, NC, is a 60-bed Level I emer-
gency department coupled with a 22-bed children’s emer-
gency department (CED). Additionally there is a 25-bed
emergency department at WakeMed-Cary and a 14-bed
freestanding emergency department at WakeMed-North
Healthplex. Combined volume at the Main Campus emer-
gency department and CED for 2005 was 122,812 pa-
tient visits.
Difficulties With Paper System
Before implementation of the new system, WakeMed used
a paper-based process for tracking patients during a di-
saster or mass casualty incident. A gas leak at a local mid-
dle school brought a large number of patients to the CED.
The CED used WakeMed’s paper-based process for track-
ing and registering patients during a mass casualty incident.
With this procedure, arriving patients were logged onto
a paper log upon arrival to disaster triage and assigned a
pre-assembled disaster packet. Patients were later regis-
tered into the hospital information system at discharge or
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FIGURE 1
Sample disaster HMED chart.
C L I N I C A L / P o w e r s a n d P h i p p s
as time allowed during the event. Copies were made of
the current disaster log to distribute among charge nurses
and ED administration; knowing which or how many
patients had arrived was dependent on having a current
copy of the disaster log. Patients were logged into
the emergency department’s electronic tracking system,
but that was dependent on a nurse or registrar being free to
do it and, as a result, that information was incomplete and
lagged behind current conditions in the CED. Addition-
ally, patients were relocated within the department after
initial placement, furthering the difficulty of keeping up-
to-date information on the current location of patients.
Hospital administration also came to the CED to ob-
tain the most up-to-date information and tended to stay
in the CED to ensure they kept abreast of the latest con-
ditions. Parents of patients were also arriving, some very
early in the process, having received calls directly from their
children via cell phone, and time was required to pinpoint
the current location of the patient because of the lag-
time and incompleteness of the paper records and the
tracking board.
System Change
The emergency department had recently begun a process
of updating their existing pre-made disaster packets, and
discussions began about improvements that could be made
in the system. These packets contain all the paperwork nec-
essary to process a patient through the emergency depart-
ment and are pre-assigned with a disaster patient number.
Arriving disaster patients were assigned one of these packets
and a disaster patient number. However, the numbers were
kept on paper tracking logs and registration staff were
registering the patients into the system when they had spare
time during the disaster event. This registration process was
the same as everyday arriving patient registration, and time
was required to do it. With the arriving inf lux of mass
casualty patients, spare time sufficient for a full patient
registration is rarely found. Thus the information system
rarely had current information, and paper logs were the
ultimate authority for current conditions.
WakeMed emergency departments use Healthmatics
ED (HMED) for their emergency department information
system (EDIS). HMED is used for a patient tracking board,
498 J
for documentation, and for order entry (Figure 1). Beyond
replacing the whiteboards of years past for patient tracking,
HMED allows for nursing and physician documentation.
HMED is interfaced to the hospital information system,
Siemens Medical Solutions (SMS) Invision. HMED
receives an account number and inbound demographic
information from Invision. Once this information updates,
HMED orders can be sent to and from HMED and SMS,
the laboratory, radiology, and patient placement systems.
Results of laboratory and radiology tests can also be sent
directly back to the HMED electronic patient chart.
With staff already used to electronic documentation
and order entry, it seemed like the perfect vehicle for uti-
lizing in disasters. Because it was already in everyday prac-
tice, there would be no double standard; what was done
for the everyday patient would also be done for the disas-
ter patient.
A registration process was developed that ties the
disaster packets to the electronic system (Figure 2). The
process was also streamlined with a quick disaster registra-
tion process and by pre-loading all the disaster patient
packet numbers into the information systems. Through
this combination of improvements, an arriving disaster
patient could be registered with 5 key-strokes and in less
than 10 seconds. This new disaster registration process was
then incorporated into the existing disaster plan.
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FIGURE 2
HMED disaster activity/chief complaint. FIGURE 3
ED disaster triage registration. Photo credit: Robert Powers.
C L I N I C A L / P o w e r s a n d P h i p p s
Information System Disaster Process
When a disaster event occurs, there may or may not be
early notification from the scene before the arrival of pa-
tients. If there is early notification from the scene, ED
registrars can begin the quick registration process for these
patients using their disaster patient number. For instance,
EMS notifies the emergency department that 50 patients
are coming from a bus accident. Before the first patient
arrives, the registrars will take the first 25 male and the
first 25 female packets (unless field information indicates
different male/female ratios) and pull up these pre-loaded
patient numbers on HMED. The disaster patients will be
indicated as ‘‘pending arrival’’ on the tracking board. Then,
with the ‘‘quick reg’’ process, the patients will be entered in
the hospital, emergency department, laboratory, and
radiology IS systems. In this way, when the patients arrive
all that would be required would be snapping on the
armband from the disaster packet that has the patient’s
registration number on it and updating their location
in the emergency department. Patient names would then
be updated in both HMED and SMS as soon as they
became known.
ED Registrars or ED IS staff are assigned to disaster
triage, which is set up near the ambulance bay to receive
the inf lux of disaster patients. At this location the armband
is placed on the patient if they have been pre-registered
before their arrival. If not, the ‘‘quick reg’’ process is done
at triage while the physician/nurse team carries out triage of
December 2006 32:6
the patient. Registration is done at this point through the
utilization of a wireless computer or ‘‘COW,’’ that is, a
‘‘computer on wheels’’ (Figure 3).
Patients that are triaged as green tag patients by
EMS or by ED disaster triage personnel are diverted from
the emergency department and go to the Andrews Center,
which is immediately adjacent to the emergency depart-
ment. WakeMed Faculty Physicians run clinic offices in
the upper f loors of the Andrews Center. In a disaster event,
clinic staff organizes the ground f loor conference room
area of the Andrews Center to receive green tag patients.
They also stockpile disaster packets that are brought to
their triage area. The HMED software has been loaded
onto their wireless computers and WakeMed Faculty
Physicians’ staff begins registering their patients using the
same process followed at the ED disaster triage area.
HMED allows for patients to be assigned rooms and
tracked by that assignment. For instance, ‘‘A Bay’’ of the
adult emergency department has three trauma rooms and
nine acute patient care rooms; scrolling through the A Bay
listings on HMED shows those patients by location, name
and chief complaint. Registered disaster patients would be
updated on the HMED tracking board by ED staff to their
specific location as they arrive from disaster triage.
Also, the emergency department uses hallway space
surrounding the adult emergency department for surge
expansion in a disaster event. These 2 hallways are iden-
tified as Area 51 and Area 52. These expansion area beds
JOURNAL OF EMERGENCY NURSING 499
FIGURE 4
Hospital Emergency Operations Center. Photo credit: Dr. William
K. Atkinsen, II.
C L I N I C A L / P o w e r s a n d P h i p p s
are already in the HMED system like regular bay beds;
however, they are de-selected from view so that they only
appear when they are being used. During a disaster event,
RN hall monitors oversee the expansion area and, through
the use of portable wireless computers, ensure that arriv-
ing patients are entered in the proper hallway space, eg,
Area 51-12. Use of the portable computers in the expan-
sion areas also allows nurses and physicians to process
orders at bedside, and returning lab work can be viewed
electronically rather than having staff tied up returning
paper lab results throughout the department.
Additionally, the green tag patients are seen in
WakeMed Faculty Physicians’ clinic offices after being
triaged and quickly registered in the downstairs conference
area. These individual clinic rooms are also pre-established
in the HMED system so that a patient can be placed in
the specific clinic room in HMED and tracked to their
exact location throughout their time in the hospital.
Sustainability
Sustainability during an event is addressed by long life
batteries on the wireless computers with verified 12-hour
lives, back-up batteries, and the inclusion of IS systems on
emergency power. Additionally, paper back-up systems are
in place to handle documentation and tracking should
there be unforeseen difficulties with the system or signifi-
cant hospital infrastructure damage.
Advantages
By utilizing the IS system, charge nurses are not depen-
dent on having a current paper copy of the disaster log in
hand to know how many patients are in the department
and where they need to send more resources. They can
view any computer screen in the department for a real-time
view of patients being triaged and of their exact location
within the department. As patients are shuff led to accom-
modate additional incoming waves of patients, there is
no need for runners to update master boards because in-
formation is immediately updated electronically by hall-
way monitors in the expansion areas or by bedside nurses.
Nor are runners required to track down patients to return
lab results because the system electronically returns results.
Also, by using a chief complaint of ‘‘disaster’’ in HMED
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for the disaster patients, the charge nurse or ED admin-
istration can readily differentiate between patients involved
with the disaster event and ‘‘regular’’ patients. Additionally,
with green tag patients located in a separate building, the
HMED system allows for patient tracking throughout
both areas. No phone calls or runners are required in the
search for a patient as the green-tagged patients in the
Andrews Center can easily be viewed by the charge nurse
in the emergency department.
The hospital emergency operations center (HEOC)
is located away from the emergency department. Distance
has been problematic in the past because of lack of real-
time information available for guiding the administrative
response to the disaster event. Now, however, HMED is
displayed for the HEOC on a wall screen where they can
view real-time information about the situation (Figure 4).
They can quickly assess the number of arriving patients and
view chief complaints so early estimates can be made on the
likely services impacted and the number of admissions
from the event. Informed decisions regarding hospital re-
sponse can be made as they’re happening, with a complete
view of the event, rather than from information pieced
together from different team leaders with only partial views
of what is transpiring. This also serves the emergency de-
partment because it eliminates the clutter of administrative
personnel in the emergency department trying to gather in-
formation while the emergency department is receiving
large numbers of patients.
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C L I N I C A L / P o w e r s a n d P h i p p s
Previously, registrars used the paper log at disaster
triage and then were expected to free up after the inf lux
to register patients before they were discharged or admitted
out of the department. In an on-going event, registrars have
difficulty completing this 2-stage process. The removal of 1
step plus the creation of the disaster ‘‘quick reg’’ process has
allowed the registrars to keep pace with the swift processing
of patients by the MD/RN triage team.
The information captured on the HMED system also
allows for a better post-event critique because the details of
patient arrival and movement are better captured through the
computer system. Also, this capture of information helps
disaster research by detailing vital information such as exact
arrival times and exact impacts on the hospital response.
System Test
The system was tested during a countywide drill. WakeMed
was to receive patients from a city disaster drill involving
the release of nerve agents. Registration was established at
disaster triage and at the Andrews Center, for the green tags,
and registrars quickly entered the arriving patients. The sys-
tem worked as expected, easily keeping up with arriving
patients and keeping everyone abreast of the current situa-
tion. Laboratory and radiology order entry and results re-
porting was also tested and both departments reported
positively on their ability to keep up with a high volume
of requests.
In the HEOC, ED staff or ED IS staff assisted hospi-
tal administration in properly interpreting the data being
displayed on HMED. HMED, displayed on a wall screen,
greatly enhanced hospital administration’s ability to gauge
the current conditions of the emergency department.
Conclusion
Implementation of a disaster registration and tracking pro-
cess utilizing existing information systems has significantly
lessened the difficulties of keeping pace with the rapid ar-
rival of large numbers of patients to the emergency de-
partment. Not only is registration completed promptly,
which facilitates order entry and documentation, but real-
time information is also readily available to guide emer-
gency department and hospital decision makers through
the disaster response.
December 2006 32:6 JOURNAL OF EMERGENCY NURSING 501