Care Management

How I Heard

I first heard about the Pulse shooting from my husband. We woke up that morning and he saw a news alert on his cell phone saying there was a shooting in downtown Orlando with victims being taken to Orlando Health Orlando Regional Medical Center (ORMC). I remember being surprised that there was another shooting, as the night before Christina Grimmie was shot and killed outside an Orlando concert venue.

I immediately got my laptop and saw the email stating “mass casualty incident is in effect with 20 victims.” My stomach dropped.

We quickly got up and turned on the news. A short time later, we saw the press conference announcing 49 deceased victims and both of us audibly gasped. It took me almost an hour to process what I was seeing come across my work email and what I saw on the news. Soon enough the phone calls from friends, family and coworkers began. That afternoon I got the call that one of our team members was trying to get in touch with me because he was injured in the shooting. He was about to have his first of many surgeries.

At the time, I was acting lead for my department while my manager and administrator were on medical leave. Knowing I had to lead the department through the incident was very nerve-wracking. That Monday, I had no idea what I was walking into or if I would be prepared. I just wanted to make sure my team had everything they needed to support the victims and their families as well as the other patients in the hospital.

Synopsis

The Care Management department consists of utilization review nurses, social work discharge planners, registered nurse discharge planners, mental health therapists and case management technicians. Our team is responsible for making sure the patient's status (observation, short stay or inpatient) is correct on admission, a safe discharge plan is in place for all patients, emotional support is available for patients and families, and patients are provided with state and federal notices.

Our day-to-day activities vary greatly based on a multitude of factors. However, I never expected that our team would have to coordinate the safe discharge and provide emotional support for so many victims at once.  

With the help of the care management leadership from our sister hospitals, Orlando Health South Seminole and Orlando Health Dr. P. Phillips, I coordinated staffing so we could provide extra mental health team members at ORMC to support the families in the waiting rooms. Our discharge planning team focused on coordinating as many discharges as possible with the medical staff to make sure there were open beds for the victims.

Preparation

Because our days vary so greatly based on the patients’ needs, our team is composed of professionals who are able to rise to any challenge. Our mental health therapists are trained in crisis intervention. Our social workers are patient advocates who make sure they have the best resources available for all of their patients. The nurses in our department understand the complex medical needs that follow a mass shooting. With so many diverse backgrounds and skill sets, we are able to come together as a team to ensure patients receive the care they need to safely transition from the hospital to the next level of care.

During the mass casualty drills at ORMC, our team staffs the emergency room to see if any inpatient admissions can be diverted to outpatient services. Meanwhile, our inpatient care management teams work quickly to arrange a safe discharge plan for as many patients as possible, knowing many victims are waiting for an inpatient bed.

Like many departments, there is always opportunity to improve. Because discharge planning for patients often depends on many outside factors, it is important to communicate with vendors, insurance companies and providers to ensure everyone can quickly assist when patients need to transfer to the next level of care.

Response

Our mental health therapists reported to the family room where parents, siblings and friends anxiously waited to hear if their loved ones were in fact in the hospital or as many feared, among the casualties at Pulse. The therapists as well as guest services, chaplain and patient experience teams provided support as the families waited for updates from the administrators and medical staff. Our discharge planning team made sure as many patients as possible were discharged from the inpatient units. As the teams walked around, there was a sense of shock across our hospital.

I live near Pulse and all roads were blocked on Sunday, so the first day I could physically get to the hospital was Monday. I checked in with our nursing supervisors for a list of the victims and their locations. Our department's main focus was making sure the emotional support was available for the victims and the families, and enough discharges were taking place across the hospital to accommodate the large number of patients who came in Sunday morning. Many of my team members told me how other patients in the hospital asked to be discharged to make sure the staff could care for the victims. This was the first sign of the support we would receive from the Central Florida community and across the world.

Community providers began to reach out to offer emotional support and donate whatever services were needed. Because we were still in the assessment phase, we were uncertain what would be needed. When we learned many of the victims and their families were primarily Spanish speaking, we asked our sister hospitals to send counselors who were bilingual. Our teams began to email each other to offer assistance and share resources as they were identified. Many of the community outpatient mental health services offered their support and educational material for the victims and families.

Soon after the incident, the City of Orlando arranged a service fair so the families and victims could learn about the services available to them, including victim services, FBI advocates, Medicaid application assistance, airline companies, emotional support and country consulate connections. Once we heard about the fair, I reached out to our Community Relations and Government Relations departments to confirm I could attend the fair and gather information for the victims who were still in the hospital. At the fair, I met with the FBI victim advocates, who later became the best resource for the victims. Later in the week, I met with the assigned hospital FBI victims services advocates and we rounded on each victim to make sure they received the packet of information and any additional resources that were available.

Our hospital also received a generous donation of durable medical equipment from a local company to offer the victims. Rehab centers and home health companies also offered pro bono services to the victims.

The FBI advocates connected with the Orange County victim services to complete the application for financial assistance for medical coverage for victims. The FBI advocates then offered additional services such as cleaning of clothes, jewelry, shoes, assistance with having family members from out of the country come to the United States to provide care for the victims, and any other request from the victims.

Soon after the event, online financial donations began to pour in to support the victims. The City of Orlando did an amazing job of organizing the One Orlando Fund. Victims and families began to ask our team about the fund. With the assistance of our Government Relations department, a phone call was arranged so we could learn more about the process of applying for the fund and tell the victims and families. Once the contact information was identified, we created a document to share with the victims and families. Any new resource that became available through the generosity of the community also was shared.

Lessons Learned

The first lesson our team learned was to ask what federal or county resources were available rather than trying to identify them ourselves. If we had connected earlier with the FBI advocates, the first few days could have been spent understanding what resources they had available. This would have provided a streamlined resource for the victims and families instead of piecemeal plan of services from various agencies and providers.

The second lesson learned was be ready for a large influx of calls and emails from community partners asking how they can help. I was not prepared to receive the amount of incoming communication from the community partners. Looking back, I wish I would have connected with our community relations and patient experience teams sooner so we could have streamlined these calls to a single area.

The final lesson learned was that we needed to develop a disaster plan specifically for our department. If we’d had one, it could have helped us streamline communications, identify who would be doing what and eliminate duplication of work. During disaster situations, each minute is critical and there are not enough resources to waste time.

What We Changed

Ensuring effective and precise communication is important on a daily basis, but essential during a mass casualty. After the event, we met with the Spiritual Care department to make sure we had a valid list of patients. The two departments also discussed a plan to check in every few hours in case we needed to reallocate resources to meet all of the emotional needs of victims and families. Our department also decided to create a disaster protocol.

Conclusion

We were able to ensure the victims and families had the resources available to them through the amazing community donations and federal and county services. These smoothed the way for patients to transfer to their next level of care. Our team found a new appreciation for collaborating not only among ourselves but with our sister hospitals and other departments across the organization.

Our team also worked together to ensure our teammate injured at Pulse felt the love and support of our department. Never once that I checked on him was he alone in his hospital room.

Conclusion

Duplicating effort is time consuming and wastes resources. Making sure leaders have a direct line to key stakeholders with the ability to support and assist the victims and families is essential. At the beginning of the incident, a lot of time and effort could have been saved if we had started working with the FBI victim advocates rather than trying to find resources on our own.

No one thinks an incident like the Pulse shooting can happen to them, their hospital or their community. Thankfully, our mass casualty drills, discussions and plans made it possible for our organization and department to treat and safely discharge all of the victims with the proper care and resources they needed.