Clinical Emergency: Are You Ready in Any Setting?
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Pennsylvania Patient Safety Advisory Clinical Emergency: Are You Ready in Any Setting? ABSTRACT and trained staff to manage the clinical emergency; Emergency equipment and supplies often are not and (3) once systems are in place, monitoring those readily available when a patient experiences a life- systems to ensure that clinical staff maintain a state of threatening emergency. The location of these clinical readiness to manage clinical emergencies. emergencies varies, but there is a common theme: lack of the correct equipment and supplies to opti- This article describes means to assess and evaluate mally manage the emergency. There are three distinct the ability of a clinical setting or facility to manage a factors of rapid response preparedness that must rapid response or a clinical emergency and offers spe- be addressed in virtually every clinical point of care cific strategies to improve preparedness. While much area: (1) rapid access to functioning equipment and of the literature written about managing clinical up-to-date supplies; (2) knowledgeable and trained emergencies deals with the office setting, many of the staff to manage the clinical emergency; and (3) after concepts are appropriate for a clinical emergency in systems are in place, maintaining a state of readi- any setting (e.g., inpatient unit, outpatient unit, other ness to manage a clinical emergency at any time. ambulatory setting in a hospital). The Pennsylvania Patient Safety Authority identified Evaluating Needs and Risk 56 reports over the course of a 12-month reporting period specifically related to emergency equipment; The first step in assessing preparedness for a clinical 35 reports referenced issues with emergency carts and emergency is convening an interdisciplinary team 21 reports referenced issues with missing supplies or within the clinical area or department to review spe- malfunctioning equipment during an emergency situ- cific needs. This is important because there may be ation. Strategies for facilities to achieve preparedness specific logistics, space, or staffing issues that need to include convening a team to evaluate the needs of be considered when planning for an emergency situa- the floor or unit, establishing a written plan, selecting tion in a given clinical setting. appropriate equipment and supplies (e.g., automated While published data may help identify areas of focus external defibrillators, rapid response teams), training within an identified clinical area, physicians should and educating staff, and maintaining a state of readi- be prepared to treat the emergencies most likely to ness (e.g., through mock drills). (Pa Patient Saf Advis occur within the patient population of the clinical 2010 Jun;7[2]:52-60.) area or department. For example, a clinical unit with many patients with epilepsy must be more prepared to treat seizures. Units with children or adolescents should have a wider range of equipment sizes as well Introduction as specific medications which may be more appropri- The Pennsylvania Patient Safety Authority conducted ate for this age group. Physicians should also prepare a data review encompassing a 12-month reporting for any possible adverse reactions resulting from com- period (2008) to determine whether or not there may mon procedures.1 be an issue with event reports related to crash carts The following questions can help evaluate the facil- and missing or unavailable equipment, specifically ity’s ability to manage a clinical emergency . during a clinical emergent or rapid response situation. The review identified 56 reports that highlighted 1. What is the patient population and age range of emergency or rapid response situations in which sup- the unit? 2 plies or equipment were missing or outdated. The 2. What types of procedures are performed in the locations of these incidents varied as did the types of clinical area (e.g., invasive procedures, cardiac medical emergencies (see Table 1), but the common testing)?2 theme was lack of the appropriate equipment and supplies to successfully manage the emergency in a timely manner. 3. Are injectable drugs administered?2 Reports identified issues such as incorrect size sup- 4. How comfortable and skilled in emergency care plies, missing items, empty oxygen tanks, drained are the physicians?2 batteries on equipment, or unstocked or unlocked crash carts. 5. Is staff trained in and competent to assist with emergency care?2 Analysis of the event reports submitted to the Author- 6. What equipment, drugs, and supplies are avail- ity and review of the literature identifies three factors able? What additional equipment, drugs, and of clinical emergency preparedness that warrant atten- supplies might be required?2 tion in virtually every clinical point of care area: (1) having rapid access to functioning equipment 7. Where are the supplies kept? How often are they and up-to-date supplies; (2) having knowledgeable inventoried and updated?2 Page 52 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Vol. 7, No. 2—June 2010 Pennsylvania Patient Safety Advisory 8. What is the location of the clinical area in rela- breathing, circulation” model of emergency care tion to emergency care at a hospital, and what is taught in formal life support classes. 9 Additionally, the typical response time for those attending the protocols should account for the emergency skills of emergency?2 each employee and the assignment of each employee to specific responsibilities. Designating a location 9. If the facility is located outside of a hospital, how for the delivery of emergency care and for storing all long does it take the emergency medical services emergency equipment is a good start to the planning (EMS) in the area to respond?3,4 process. If the layout of the clinical area makes this While the probability may be low of a life-threatening difficult, emergency equipment should be portable clinical emergency occurring in certain clinical set- (e.g., on a rolling cart, within carrying cases) and tings, the possibility remains. For example, behavioral stored in a common location.9 health and psychiatric units may be vulnerable to cardiac or respiratory arrest through coexisting physi- At a minimum, a written plan addresses equipment, cal illness, self-harm, and the effects of medication, supplies, medications, ordering and maintenance, including rapid tranquilization. These patients are emergency protocols, training and competency of also vulnerable to choking or aspiration associated staff, emergency drills, and assignment of responsibil- 2 with illnesses like dementia, food bolting, substance ity for continued oversight of the process. Consider 10 abuse, or intentional self-harm.5 As clinical teams the following aspects of a written plan: convene in these seemingly low-risk areas, having ■ How will staff notify others in the clinical area to a plans in place to manage the infrequent emergency life-threatening emergency? may be a wise patient safety strategy. For hospitals in the United States, the Joint Commission states that ■ Who will contact the code team, the rapid “Resuscitation services [must be] available throughout response team (RRT), or EMS? the hospital.” The phrase “throughout the hospital” ■ Who will bring the emergency supplies to the scene? is crucial. It implies that equipment, supplies, oxygen, and medical personnel must all be present and ready ■ If the patient requires a backboard, is staff trained to respond to cardiac arrest—not just in emergency and competent in how to position the patient? departments (EDs), intensive care units (ICUs), and ■ Who will initiate cardiopulmonary resuscitation wards but also in less acute areas, such as inpatient (CPR)? Who will assist? mental health facilities.6 In many cases, facilities also must be prepared for clinical emergencies that may ■ Who will document the emergency? In what for- happen with family members or visitors. mat is documentation supposed to occur? Establishing a Written Plan ■ Who will take vital signs? After evaluating the potential needs of a clinical ■ What information should be provided to EMS, area, the next step is developing or adopting a writ- the code team, or the RRT? Who will assemble ten emergency response plan .7 Questions to consider that information? about existing plans include the following: ■ Who will start an intravenous line, if necessary? ■ When was the last time the clinical emergency or Who will help set it up? rapid response plan had been reviewed? ■ Who will administer medications? ■ Do staff know that a plan exists; if so, do they adhere to it? Is it included as part of new employee ■ Who will assist family members during an orientation? emergency? ■ Is the plan still current and appropriate for the ■ How will staff be educated about the emergency plan? clinical services and procedures that are performed ■ How often will practice drills be conducted? on the unit? ■ For facilities accredited by the Joint Commission, Who is responsible for the supplies (e.g., inventory there are requirements that speak directly to the provi- and maintenance)? sion of emergency services and the need for a written ■ Who will manage other patient needs on the floor plan. When emergency services are provided at the during the emergency? hospital or one or more off-campus locations, the medical staff must have written policies and proce- Since the written plan should include specific details dures for appraisal of emergencies, initial treatment, about supplies, equipment, and medications to be and referral of patients at the off-campus locations.8 used, the next step is to outline items that are needed for the specific clinical area and who needs to be The written plan should include clinical protocols, involved in the selection process (e.g., hospital admin- specific employee responsibilities during the emer- istration, pharmacy, central supply). gency, and details on where and how the emergency care should be delivered. Written clinical protocols for clinical emergencies typically follow the “airway, (continued on page 56) Vol. 7, No. 2—June 2010 REPRINTED ARTICLE - ©2010 Pennsylvania Patient Safety Authority Page 53 Pennsylvania Patient Safety Advisory Table 1.