naolaaustin md, clinicalinstructor,anesthesia kay ... daniels md, clinical professor, obstetrics and...

Naola Austin MD, Clinical Instructor, Anesthesia

Kay Daniels MD, Clinical Professor, Obstetrics Gynecology

Laura Harwood MS, Office of Emergency Management

Kristine Taylor MSN, Nurse Quality Manager

http://archive.boston.com/news/nation/gallery/Iowa_Missouri_flooding_061308/

Naola Austin MD, Clinical Instructor, Anesthesia

Kay Daniels MD, Clinical Professor, Obstetrics andGynecology

Laura Harwood MS, Office of Emergency Management

Kristine Taylor MSN, Nurse Quality Manager

1. Understand the unique needs of obstetric units during a disaster

2. Introduction of tools for OB disaster plan3. Implement an OB disaster plan for your unit with a

Table Top Exercise4. Describe disaster training for Staff5. Perform self assessment for your facility and test your

readiness with a Tabletop Exercise

Practice with a Disaster Simulation & Debrief

• What resources do they need for continued care?

Are they readily available?

• If needing to evacuate How do you prioritize who goes first?Where are they going?How are they getting there?

35 yo G3 P2 @ 40 weeks admitted in active labor

Pmhx: chronic htn on 200 mg labetalol tid Epidural in place x 2 hours Vitals: Temp 37, BP 120/70, HR 85, RR 20 Contractions q 2 min spontaneous Exam: 8 / 100% / +2 Fetal heart tracing stable

28 yr G2 P1 s/p repeat CS x 30 min

Pmhx: NC Surgery uncomplicated with EBL 800cc Vitals: Temp 36.6, BP 110/70, HR 72, RR 15 Preop Hct = 34 Spinal anesthesia (pt unable to move legs)

33 yr G2 P2 s/p uncomplicated vaginal delivery yesterday

Pmhx: NC Vitals: Temp 37, BP 110/65, HR 72, RR 18 Baby is rooming in

30 yr G1 P0 @ 41+5 weeks admitted for induction of labor for over the due date

OB hx: uncomplicated Vitals: Temp 36.8, BP 90/60, HR 87, RR 16 Exam: not in labor Labor Induction medications placed 6 hours ago Occasional mild contractions

Surge Shelter in Place Evacuation

www.emaze.com/@ALLICORI/Northridge-Earthquake

Image credit: Robert Gauthier/LA Times

1. Designate someone to be in charge. This may be one nurse and one doctor Decide before the disaster who this should be

2. Have staff wear vests or identifiers.

3. Use job aids to assist with roles and tasks – we do not use disaster process too frequently.

• Account for safety of all staff members.• Have staff routinely check in through a

huddle schedule.1. Safety

• Assess area for resources, problems, needs. • Think about what you need to maintain your

operations for the entire shift.2. Assessment

• Report all findings back to the Hospital Command Center.

• Use the Status Report Form.3. Reporting

Hospital Command Center

L&D Unit Leader

L&D Assistant Unit Leader

MDs Bedside RNs Techs Clerk

PP Unit Leader

PP Assistant Unit Leader

Bedside RNs Clerk

RN manager RN bedside OB Anesthesia OR techs Unit clerk

Status report form Standard assessment

by each unit Helps prioritize

response to needs Want units to have

open lines of communication so that hospital is one large response

The American College of Obstetricians and Gynecologists note:

“Providers of obstetric care and facilities that provide maternity services, offer services to a population that has many unique features warranting additional consideration”

>97% of all births in the US occur in a hospital or clinical setting…which may not be accessible or may be severely damaged during a disaster event

http://www.soc.ucsb.edu/sexinfo/article/childbirth

Pregnant women are subject to the usual risks of injury at a disaster, but with more complicated care

One size ≠ all in a disaster setting for OBWithin the same footprint of any OB unit there exists a large variety of patient acuity and needs Laboring women Intra op and post operative patients Healthy postpartum patients with their newborns

In the days after Hurricane Katrina struck Louisiana, 125 critically ill newborn babies and 154 pregnant women were evacuated to Woman's Hospital in Baton Rouge

It was at least 10 days before some of the infants and mothers were reunited

Washington Post 2006

http://www.neworleans.va.gov/images/evacuate2_lg.jpg

We always have 2 patients• Ante partum = mom and fetus

• Postpartum = mom and newborn

OB TRAIN* = Triage by Resource

Allocation for IN patient

*Based on the triage system created by Dr. Ron Cohen for the NICU at LPCH and adapted for OB

(S) Specialized = must be accompanied by MD or Transport RN* MBS 6 = Patient is able to perform a partial knee bend from standing** Epidural catheter capped off

Labor status

Mobility

Anesthesia status

Maternal risk factors / fetal risk factors

Blue = Car

Green = BLS (Basic Life Support)

Yellow = ALS (Advanced Life Support)

Red = Specialized (Critical Care or with MD)

(S) Specialized = must be accompanied by MD or Transport RN* Modified Bromage Score 6 = Patient is able to perform a partial knee bend from standing** Epidural catheter capped off

26yrs @ 40 weeks

Early labor: 4cm

Can ambulate

No epidural

Cat 1 FHR No significant maternal or fetal risk factors

32 yr @ 31 weeks with severe preeclampsia undergoing induction of labor

Early labor: 2 cm Non-ambulatory Epidural in place < 1 hr Cat 1 FHR Intermittent IV

labetalol for BP control On 2 g of IV

magnesium sulfate

How will peds know where OB is evacuating to? Is there a system in place for notification?

Who from peds has been designated to go with OB ?

To care for ‘shelter in place’ in deliveries

Delivery - NSVD versus Cesarean delivery- Time from delivery

Mobility

Anesthesia status

Maternal risk factors

Transport Car(Discharge) BLS ALS SPC

DeliveryVD > 6 hours

or CD > 48 hours

VD < 6 hours or CD < 48 hours

Complicated VD or CD Medically complicated

Mobility Ambulatory* Ambulatory or Non-ambulatory

Ambulatory or Non-ambulatory Non-ambulatory

Post Op> 2 hours

from non-CD surgery**

> 2 hours from CD< 2 hours from non-CD surgery

< 2 hours from CD Medically complicated

Maternal Risk Low Low/Moderate Moderate/High High

(S) Specialized = must be accompanied by MD or Transport RN* Modified Bromage Score 6 = Patient is able to perform a partial knee bend from standing** If adult supervision is available for 24 hours

Give them a Checklist:

1. Levels: Birthing Centers Basic Care (Level l) Specialty Care (Level ll) Subspecialty Care (Level lll) Regional Perinatal Health Care Centers (Level lV)

2. Capabilities

3. Types of providers

SENDING THE RIGHT PATIENT TO THE RIGHT HOSPTIAL

Obstet Gynecol 2015:125:502-15

Distance (mi) Hospital City Neonatal Maternal

Hospital Phone number

L&D Phone Number

0.0 LPCH Palo Alto 3 3 (650) 497-8000

18.4 Santa Clara Valley Medical Center

San Jose 3 3 (408) 885-5000

34.6 UCSF SF 3 3 (415) 476-9000

36.0 CPMC SF 3 3 (415) 600-6000

38.6 Kaiser Oakland Oakland 3 3 (510) 752-1000

17.0 Kaiser: Santa Clara Santa Clara 3 3 (408)

851-1000

19.8 Good Samaritan San Jose 3 3 (408) 559-2011

36.4 Kaiser: San Francisco

San Francisco 3 3 (415)

833-6353

53.0 John Muir Walnut Creek 3 3 (925)

939-3000

9.0 El Camino Mountain View 3 2 (650)

940-7000

32.3 SF General SF 2 2 (415) 206-8000

42.7 Alta Bates Berkeley 2 3 (510) 204-4444

45.5 Dominican Santa Cruz 2 2 (831) 462-7700

78.5 Natividad Medical Center Salinas 3 2 (831)

647-7611

81.2 Salinas Valley Memorial Salinas 2 2 (831)

757-4333

205 Sierra Vista Regional Medical Center

San Luis Obispo 2 2

(805) 546-7600

8.2 Sequoia Redwood City 2 2 (650)

369-5811

17.9 Washington Fremont 2 1 (510) 797-1111

19.9 O’Connor San Jose 2 1 (408) 947-2500

22.7 Regional Medical Center San Jose 2 1 (408)

259-5000

Give an OB train score to each of the following OB patients

Assess damage on the unit and report to Command Center

Arrange for patient care as indicated Transfer Shelter in place Discharge

Broken window with glass everywhere. Water leaking from the sink.

35 yo G3 P2 @ 40 weeks admitted in active labor

OB hx: rapid active phase, previous mild PPH Pmhx: mild chronic HTN (100 mg labetalol bid) Epidural in place x 2 hours Vitals: Temp 37, BP 120/70, HR 85, RR 20 Ctx q 2 min spontaneous SVE: 8 / 100% / +2 FHT cat 2 with mild variable ctx

One broken light fixture, no smoke or sparks

18 yo G1 P0 @ 37 weeks undergoing induction of labor for severe preeclampsia

Pmhx: NC Vitals: Temp 37, BP 150/100, HR 65, RR 18 SVE: 3 / 80% / -2 Ctx q 3-4 min, oxytocin 7 millunits/min Magnesium 2 grams an hour Labs:

4+ protein (urine protein cr ratio = 0.38)LFTs wnlCr 0.9Hct 42, Plts 150

Windowless room, light fixtures not working

30 yr G1 P0 @ 41+5 weeks admitted for induction of labor for over the due date

OB hx: A1GDM diet-controlled Pmhx: Appy (16 yr) Vitals: Temp 36.8, BP 90/60, HR 87, RR 16 SVE: l/c/h Cervidil placed 6 hours ago Occasional mild ctx

No major room damage. Medication machine locked, says “Fatal error #1000”

28 yr G2 P1 s/p repeat CS x 30 min Pmhx: NC Surgery uncomplicated with EBL 800cc Vitals: Temp 36.6, BP 110/70, HR 72, RR 15 Preop Hct = 34 Spinal anesthesia (pt unable to move legs)

Television fell and shattered glass on floor. Door to bathroom jammed.

33 yr G2 P2 s/p uncomplicated NSVD yesterday

Pmhx: NC Vitals: Temp 37, BP 110/65, HR 72, RR 18 Baby is rooming in

No major room damage

24 yr G1 P1 s/p CS for failure to progress, POD #3

OB hx: pt labored x 20 hours, progressed to 6 cm Pmhx: NC CS uncomplicated with 1000 cc EBL Vitals: Temp 37.7, BP 100/60, HR 89, RR 16 Post op Hct: 30 Baby is rooming in

No major room damage.

44 yr G1 P1 s/p CS @ 30 weeks for preterm labor/breech POD #1

OBHx: IVF pregnancy with donor ovum Pmhx: mild HTN CS complicated by PPH with EBL 1500 cc Postop Hct pending Vitals: Temp 36.6, BP 140/80, HR 100, RR 16 Baby in NICU

No major room damage

39 yo g3P2 @ 7 weeks gestation with poorly control insulin dependent diabetes. Here for blood sugar control.

Last postprandial blood sugar= 230

No major room damage

26 yo g1 @ 32 weeks here for premature rupture of membranes yesterday

Not in laborOn ampicillin and erythromicinBreech presentation

Knowledgeable about application of TRAIN NursePhysician

1/8/13 = 35 patients on Labor and Delivery and Post Partum

Grassroots effort by staff that was supported by the Executives

In house EPIC team did the technical changes to produce the daily reports

Uses certain fields in the EMR to classify their TRAIN category every day

Report can be used to estimate patients classified as "rapidly discharge" for a surge event

Daily reports Office of Emergency Management Nurse Supervisor

Updates with any change in documentation

Report is available to run at anytime Downtime report Decision making regarding personnel

Decrease impact to clinical workflows Non-biased categorization Administrative support Discreet data points from nursing chart

rather than from orders Validation to ensure that the coding is

correct

Computer 48 second

Manual 57 minutes

Command center request over 2 hours

MRN

Emer

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y C

onta

ctPh

one

Num

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64

TRAIN allows us to speak a common language for resource needs

Enable coordination between EMS and Regional EOC

Enhance state and national patient movement plans

Make training mandatory for all staff (if possible)

Have training based on the use of tools Periodically reinforce information and expand

as possible

Staff, patients and visitors

Fire extinguishers?

Gas valves turn-off switch?

Avoid a minor problem becoming major….

Disaster equipment boxes too high

Need flashlights / headlamps

Need non-rechargeable batteries

Denial exists

Home preparedness is criticalhttp://www.ready.govhttp://www.redcross.org/prepare/location/home-family/get-kit

Situational awareness

Staff responsibilitiesPhysical fitness and stamina?Family and pet housing? Commitment to patients vs. family

Institutional policies Mandatory disaster-duty requirement? Overtime / disaster pay? Disciplinary action?

Policies about trainees“In a disaster situation, licensed residents are allowed to perform tasks that are needed for patient safety”

Identify your champion Someone familiar with the unit and its unique needs

Organize disaster box with vital equipment Flashlights / batteries / head lamps can be Used in a simple electrical outage

Create a disaster binder Required, but make it useful

Assign disaster roles Use the generally accepted terms: unit leaders, assistant unit leaders Each facility will have unique disaster roles assignments

Unit leader = the role given to the staff position that is always in house

Create ‘job action sheets’ for each designated role

Create ‘grab and go bags’ Imagine you are delivering in the parking lot

Create a ‘phone tree’

Based on distance from the hospital

A list of hospital first respondersResponders who will / can come in immediately

Begin simulation disaster training for all personnel on the unit

Follow-up training and drill

L&D Disast er Plan Checklist for Unit Leaders

(Resource RN & SWC At t ending/ Chief Resident )

1. Locate Disaster Binder (tube room)

2. Send Tech to get Disaster Boxes (O R hallway supply room)

3. M eet at white board or other safe area to assign Disaster roles (fill out Disaster Roles Poster and hang it next to white board)

4. Distribute Job Action Sheets, decide on best form of communcation (runners, phones, etc), and designate regular meeting times (ie: every 20-30 minutes)

5. Locate Fire Extinguishers (Near OR A, OR C, LDR 8, and elevator)

6. Locate O 2 Supply Valves (N ear each O R, lunch/ breakroom, and L&D entrance)

7. Ensure that only life-sustaining equipment is plugged into red plugs (to avoid overloading generator)

8. Assistant Unit Leader(s) and Tech(s) team up to: 8a: Assess unit for damage and fill out Department Damage M ap (map can be used to fill out Department Status Report for hospital command center)

!

8b: Write on each door (paper sign for SIM ) with a sharpie “SAFE” or “DAN GER”

!

8c. TRAIN Triage each patient

!

9. Bedside RN s fill out Paper Patient Forms in case of computer failure or evacuation

!

10. Bedside RN s or Techs fill up Grab & Go bags to be prepared for possible evacuation

!

11. In event of evacuation/ transfer order from Hospital Command Center, assist with putting patients in M ed Sled that will be brought to L&D. (Emergency management/ transfer folks will belay patients down the stairs)

Disaster Transfer Summary L&D or AP (DRAFT 6-3-13) ROOM # _______Train Score:

Hospital level needed: Neonatal LEVEL 1 2 3 (CIRCLE ONE)

Maternal LEVEL 1 2 3 (CIRCLE ONE) Patient name: (Last, First) MRN: (MRN) DOB: Primary OB provider: (PMD) Other important outside care provider(s): Date of Admission to LPCH: A G P EGA i l l i l P i

Blue Green Yellow Red

Know what you have Think of what you need What is you plan?

Equipment Staff Practice, Practice, Practice EMS

Assess your organization Group together with others from your organization

to assess your facility using the self assessment tool

Assess your capabilities as regional partners Review the maternity hospital levels of care and

determine where you can send each of the patients you TRAINED in table top exercise #1

Let’s discuss gaps and solutions

Gaps Challenges Possible solutions

Stanford Disaster website for OB tools

obgyn.stanford.edu/community/disaster-planning.html

Want more information including peds and NICU TRAIN and to join quarterly webinars:

https://stanforduniversity.qualtrics.com/SE/?SID=SV_aeBdluNgaCcizFb

Divide into 3 groups Group 1 Group 2 Group 3

Photo by John Moore/Getty Images

It is 4 am and an 8.0 earthquake has hit your

hospital

You have had extensive damage to your unit

Please work with your group to care for the

patients on your unit

The command center is at your disposal