Environmental Services

How I Heard

I woke up around 7:00 on that Sunday morning after a deep sleep and realized that my phone had seven text messages and four voicemails, one of which was our hospital president.  I turned on the TV to see that every channel was inundated with “Breaking News.” The visual was of a familiar stretch of Orange Avenue surrounded by an unfamiliar addition of barricades, media trucks and first responder vehicles. I was in shock at first, then immediately went into working mode. I called to see who already was set up in the Incident Command Center at Orlando Health Orlando Regional Medical Center (ORMC) and then realized that this shift was going to need a break both mentally and physically. So, I started planning to cover the evening relief shift of the Incident Command team and arrived to the hospital early that afternoon. 

Synopsis

On a typical day, our environmental services (EVS) team is responsible for ORMC, which is an 808-bed facility.  Its average inpatient census is 540 – 590 with 140 – 170 daily cleans due to discharges and transfers. The Emergency Department turns over 240 – 300 beds/stretchers per day, including the trauma bay. We treat gunshot wounds and other penetrating injuries, which result in a significant loss of blood and bodily fluids. But the EVS team could never have imagined the volume of blood they would encounter on the floors of the trauma rooms that morning. 

Preparation

The EVS team of ORMC had just participated in a large scale, city-wide mass casualty incident (MCI) exercise a few months earlier in March.  Regardless of the scenario, EVS is always involved either as part of the Decontamination Team or by providing capacity throughout the hospital by cleaning beds with an expedient turnaround time. During these MCIs, our goal is to always tax the system, including personnel, equipment and resources.

Response

I called the EVS ops manager early in the morning to check on resources and determine if there was an escalation plan implemented. One of our EVS team leads was first on the scene at 3:00 am and went straight to work delegating duties to the Emergency Department EVS team. Our EVS house supervisor arrived at approximately 6:00 am and went to the basement to make sure the cleaning carts were stocked with supplies and equipment, and immediately sent housekeepers out to the units upstairs to take care of discharges so that inpatient rooms could be ready for the ED and surgery patients. Some team members from the 3^rd shift stayed over to help. Around 7:00 am, patients were lying out on stretchers in the halls of the ED and staff was running around the department in all directions. Patients would stop our EVS team as they walked through the ED aisles, grab a team member’s hand and ask for help or information about a friend at the club with them that night. 

Lessons Learned

The ED EVS team was working quite collaboratively that night. However, one of our EVS managers reacted to the stress by focusing the team’s efforts in unexpected places — such as dusting common walkways — instead of toward the emergent event. Reflecting on that now, we should have recognized that some team members, even leadership, can minimize the situation and use this as a defense mechanism when under intense stress. Had we realized this earlier, we would have removed this manager from the leadership role for that day and had other leaders step in earlier to direct the team.

There were assignments that should have been put on hold that morning, for example:  cleaning the MD call rooms, floor care in the other parts of the hospital and dusting the back corridor and ancillary spaces. We learned that we could have gotten tasks done faster if we had doubled up and assigned two EVS team members in the trauma room instead of one.

We took for granted that the Emergency Department EVS team members were accustomed to working five or six traumas at a time. However in hindsight, we could have brought down a team from the units to focus on the ED common areas and not relied solely on the Emergency Department EVS team members. We now refer to this as our MCI Staffing Response and Support plan.

What We Changed

During an MCI, there is a need to have additional EVS support in the ED to ensure the area is kept clean during the incident. We learned that if we had broken the tasks up into three phases to distribute the resources evenly, then our response to the incident would have gone much smoother. 

• Phase I, the ED: Focus on the ED, but not just cleaning and turning over beds. The need for additional EVS staff to perform cleaning throughout the hallways and the main corridor into the hospital from the ED to ensure that blood or blood-borne pathogen issues were continually addressed was essential.
• Phase II, the OR: Send more EVS team members to the operating rooms instead of having them focus on dusting and other non-essential tasks.
• Phase III, the ICU: Prepare the ICU rooms for intake. The MCI Staffing Response and Support plan allows us to strategically deploy resources more efficiently where needed. It also includes an opportunity to debrief with the team members.

Conclusion

This event was a disruption to our normal day-to-day operations, but not a disruption in how we care for patients. Because of the collaboration and team effort that our EVS team members contributed across the organization, the ability to provide healthcare to our community was never in jeopardy. The EVS team could not have done their part without a partnership with clinicians and the other departments in the hospital that night. I am so proud of the work they do every day, but I have never seen them work so tirelessly and focused than I did on June 12, 2016. EVS team members who had been assigned to other areas were coming together and asking, “What can I do to help?” The memories of the patients and family members they saw that night and during the months of recovery are forever etched in their minds. Some of these experiences were triggers for reliving personal experiences and losses from their own lives. It is something they would never want to experience again, but if they had to be called to action, they would undoubtedly be able to answer the call and perform.

Key Takeaways

• Don’t assume that everyone with MCI training is able to react appropriately in a stressful situation. Recognize when your team members, including those in leadership roles, are having a stress response and remove them from the immediate event.

   

• Break the cleaning tasks into phases to adequately distribute the resources:Phase I – ED, Phase II – OR, Phase III – ICU.

   

• After Phase III, debrief with the team to determine what went well/wrong, how the team is feeling emotionally and physically after the adrenaline lowers, and what resources you will need after the event is over as well as for the next shift.

   

• Prepare and train for fast cleaning and turning over rooms/beds/stretchers during MCI drills. This will minimize the temptation to cut corners in order to keep up with the demand. Thoroughly wiping down stretchers and rails will prevent the risk of finding blood and bodily fluids in the stretchers later. It is a valuable investment in time.