Worst-Case Scenario
By Kathy Hardy
Radiology Today
Vol. 22 No. 5 P. 10

Planning Imaging Workflow for Mass Casualty Events

Increased speed doesn’t always result in better efficiency. Nowhere is that more the case than in a hospital’s emergency department (ED), where multidisciplinary teams work side by side to assess and triage patients with urgent medical needs. When dealing with a mass casualty incident (MCI), an event that results in a surge of patients that overloads the standard response process, proactive planning for radiology workflow is a good first step in ensuring successful outcomes.

“A common misstep in planning for mass casualties is the assumption that ‘we’re a trauma center, we handle events like this all the time, we’ll just work faster in the event of a large-scale disaster,’” says Ronald M. Bilow, MD, assistant chief of emergency radiology at UTHealth McGovern Medical School in Houston. “All facilities need a separate operations plan that takes all reasonable contingencies into consideration. You can’t just follow standard operating procedures. You need to switch to emergency operating procedures.”

Whether the facility is a Level 1 trauma center or a community hospital, no medical facility is too small when it comes to proactive preparedness for an MCI. There’s no substitute for having a plan to address issues such as how to mobilize staff, how equipment should be utilized, how reports will be structured and delivered, and whether any protocols can be adjusted to save time.

“Every type of incident needs some kind of plan, and all hospitals need a plan,” says Siobhan B. O’Neill, MD, PhD, FRCPC, an emergency trauma and chest radiologist in the department of emergency radiology at the University of British Columbia/Vancouver General Hospital. “A trauma center might get the most seriously injured patients, but small hospitals will most likely see the ‘walking wounded’ and can quickly become overwhelmed.”

A challenge in planning is how to plan without knowing details of the disaster. Bilow says that while no one can plan for every possible scenario, he recommends that medical facility personnel run a hazard vulnerability analysis to evaluate the most likely threats in their area, identifying risks in their vicinity. Is the hospital located near an airport or factory, where MCIs could occur from plane crashes or explosions? Or is the facility in a disastrous weather zone, such as “tornado alley” or along a fault line? Planners need to take all reasonable scenarios into consideration when making decisions about staffing and equipment resource needs. And, of course, all the best plans can “blow up” in any given situation.

“You need to be nimble and prioritize on the fly,” Bilow says.

Types of MCIs
The nature of an MCI is that the people who are affected don’t know what it will be or when it will hit. O’Neill describes two different categories: natural and man made. Natural catastrophes include pandemics, earthquakes, hurricanes, and tornados. Man-made events can be intentional, such as mass shootings, or unintentional, such as hazardous waste spills. Some MCIs can be predicted to a certain extent, such as those that are weather related. Each comes with its own type of injuries.

Given the surge of patients that occurs immediately following an MCI, hospital resources are used quickly and can become overwhelmed. While man-made MCIs are more likely to result in a sudden burst of patients, natural MCIs, such as the current COVID-19 pandemic, see a steady increase in patients over a longer period of time, which can still overwhelm a hospital.

“With a building collapse or a bus crash, there’s an immediate need for lots of imaging,” Bilow says. “With a mass casualty event like COVID, there’s still a surge, but the patients don’t need as much imaging. And with COVID, you also have to balance the infection control issues, such as limiting exposure and social distancing.”

Hospitals also need to plan for what happens if the facility falls in the path of the emergency situation, such as flooding that hit hospitals in New Orleans during Hurricane Katrina or the tornado that destroyed the only hospital in Joplin, Missouri. As O’Neill notes, radiology departments and server rooms are often located on the ground floor or basement areas of hospitals, where floodwaters can take a toll on medical technology.

“You need to prepare for system failures,” she says. “You can have the best plan, but if you have system failures due to water damage or power outages, or if staff cannot get to the hospital due to closed roads, plans will need to be adjusted.”

One way to mitigate issues caused when the MCI also damages a hospital is to prioritize core needs.

“When preparing for power outages, consider that air conditioning is important for keeping servers cool. Oftentimes, air conditioning isn’t considered a priority, but, without it, servers will overheat,” O’Neill says.

Steps Toward a Plan
According to O’Neill, “planning to plan is the most important first step.” Just knowing that the hospital needs to have some sort of script to follow for an MCI gets everyone thinking about emergency scenarios and how each department would need to mobilize and navigate through a situation, regardless of its cause.

“You need to get buy-in from the entire team—clinical staff and tech support,” she says. “Each department has its own needs, so you need multidisciplinary team representation in the planning process.”

Preparations should include a workflow map showing patient transfer from image acquisition, processing, and interpretation. Using unique patient identifiers can help avoid any confusion as patients are moved through the process, thereby reducing delays in workflow.

Preparations for managing workflow through an MCI event require input from all disciplines that regularly work in the ED. A lead from each area—emergency physician, trauma surgeon, anesthesiologist, and radiologist—should be involved in determining how best to utilize resources and determine roles for all clinicians in the response process. O’Neill says radiologists are on the front line of emergency care, using imaging to help quickly identify injuries and assist in prioritizing patients.

“Radiologists need to speak up,” she says. “If radiologists aren’t involved in the planning of the mass casualty incident response, they risk having assumptions made about their role in the event. Those assumptions can lead to mistakes in estimating capacity and misunderstandings regarding capabilities.”

O’Neill’s first experience in MCI planning was as an observer. She and other radiologists heard “through the grapevine” that the hospital where she was working at the time was holding a “code orange drill,” an exercise where personnel simulate how they would respond in the event of an external MCI. There were representatives from trauma surgery, the blood bank, and other specialties, but no radiologists were invited to participate.

“They didn’t wonder if we were ready to handle a scenario like this,” she says. “They genuinely had no idea if we would have a capacity issue or need different workflows. It surprised me how many people outside of radiology didn’t think to include us. Handling patients with the types of injuries suffered in a mass casualty event is a core part of our job.”

Regardless of who starts, it’s important that radiology departments coordinate planning with the entire hospital.

“The planning process can start with any department,” Bilow says. “What’s important is, as you work on the planning process, you continually identify areas you may not have addressed in previous drills. Always look for things to add to or modify the process.”

Response Criteria
Bilow says it’s important to know the criteria for what constitutes an MCI response, as well as understand that the definition can differ from place to place.

“At our facility, we could handle 10 casualty patients, but a small hospital would not have the capacity for that many patients,” he says. “It’s a matter of supply and demand. You need to look at the number of resources available, the number of casualties, and the size of the facility.”

Once it’s been announced that an MCI has occurred and casualties are on the way, emergency planners should look at the department’s surge capacity and number of resources available. As initial victims arrive in the ED, an assessment of capacity should include how much staff is available plus how to ensure that there is back-up staff and that they are rested and able to relieve those on shift. Bilow suggests trying to increase imaging department staff on hand, from techs to transporters to radiologists, to process and read images and provide reports to trauma surgeons.

“You might need an extra person to clean the room between patients and maybe an extra tech to set up IV contrast on a patient while another patient is being scanned,” he says.

Then there’s the matter of equipment capacity, including how many workstations are available, where imaging equipment is located in proximity to the ED, and how many CTs can be utilized. The capacity of a radiology department is determined by manpower, equipment, and PACS support. Roles and duties should be assigned. Scanners and workstations should be accounted for and worked into the predetermined layout. Workflow optimization includes the logistics of transferring patients to the scanner as well as calculating waiting area capacity, scan time, and transfer time.

“You need to maximize capacity,” O’Neill says. “We can normally move four patients per hour through the CT, but, during an MCI, with the right process, we can scan six to eight patients per hour.”

As Bilow notes, all of that work takes place on one side of the imaging process, but there are two sides to radiology throughput.

“You need enough radiologists to read the images created by this increased workload,” he says. “We’re focused on CT, but there could also be X-rays, which aren’t as important but can still be useful in this situation. You might want more than one radiologist or teams of radiologists assigned to one patient at a time.”

Other Considerations
With a need to view images quickly, radiologists must determine the best process for communicating findings with physicians in the ED. As radiologists try to improve efficiency, they often look to adding a rapid reporting system, but a computer-based system may not be the best solution in the event of an MCI.

“You can’t rely on an electronic system,” Bilow says. “It’s best to use a paper triplicate form, with redundancy in recording findings. You can have a runner deliver one copy to the doctor, keep a copy to have scanned to the patient’s electronic medical record, and retain a copy at the modality location.”

Initially, radiologists are reviewing images for major injuries for triage, but, by saving paper copies, they can be reviewed later for additional findings, he says.

The standard of care in an MCI is to assess and treat the largest number of victims possible in order to minimize serious long-term injuries and death. MCIs change the workflow dynamics and immediate standard of care for patients, shifting the threshold of care from the best possible care for a single patient to the minimum acceptable care for the maximum number of patients.

“There’s definitely a mind shift,” O’Neill says. “You have to look at the greater good for the most patients.”

Simulation drills are a good way to see how a plan will work. Participants can then conduct a debrief after the event and make adjustments as needed.

“People will get used to what their role is and see the importance of what they’re doing by conducting emergency drills,” O’Neill says. “When working under pressure, it’s amazing where time gets lost.”

Practice should also include a plan for returning to normal once the MCI victims have been treated and moved to other departments within the hospital. As Bilow explains, it’s not just a matter of stopping the mass casualty mode and getting back to business as usual. A plan should include maintaining a fresh shift of staff to relieve those who worked during the surge of patients.

Part of the planning process includes an organized postmortem of how the event was handled, analyzing the department’s performance after the MCI. This is an opportunity for everyone involved to review what processes worked and where improvements could make workflow more efficient.

“Lessons learned during the response to a mass casualty event can also benefit regular day-to-day operations within the multidisciplinary emergency departments,” O’Neill says. “We can get leaner at all times.”

— Kathy Hardy is a freelance writer based in Pottstown, Pennsylvania. She is a frequent contributor to Radiology Today.