Telecommunications

How I Heard

Early Sunday around 3:00 am, my cell phone went off with an extra loud alert that is specifically programmed for emergency messages from the hospital operators. When these messages go off, I know it’s either a hospital drill or a critical message. I assumed given the time of day it was not a drill. But I was shocked when I read it was a Mass Casualty code due to an off-site shooting with more than 20 victims. It’s not unusual for emergency messages to be sent out, but to see one with this many known shooting victims was definitely a shock.

I immediately turned on the television and computer to see if any additional details were available, while I began contacting the hospital operators and key managers in other areas I oversee. As I began gathering information, I received a call from our chief operating officer for Orlando Health Orlando Regional Medical Center (ORMC). Although he didn’t need anything specifically from me at the time, he wanted to make sure I was there if needed. Having known him for years, I could tell from the sound of his voice this was bad.

Synopsis

The telecommunications team consists of hospital operators and leadership at two of Orlando Health’s hospitals and a corporate call center that supports ORMC, Orlando Health Arnold Palmer Hospital for Children and Orlando Health Winnie Palmer Hospital for Women & Babies.  On a typical day, the corporate call center receives more than 3,100 calls and an average of 20 codes such as Code Blues, Code Reds, Traumas and other emergency codes hospital operators regularly handle. The center is staffed with an average of 6 operators during peak times and staffing is optimized to match the normal call volumes based on the time and days. During the Pulse incident, our operators experienced a much higher call volume not only during the actual event but in the days that followed.

Preparation

The telecommunication team participates in all internal drills and community-wide exercises, which are critical to ensure they are prepared to communicate timely and accurate information to responding teams and hospital team members during emergencies. These exercises have identified several areas for improvement that were incorporated as standard operating procedures for the department. However, real-life situations such as the Pulse nightclub incident make you realize there’s so much more you have to think about and plan for.

The telecommunication team plays a vital role in emergency situations. Upon notification of an incident or drill, they are responsible for sending out the notifications via overhead announcements, paging systems and/or email. Once the notifications are sent, the hospital operator’s role is usually just waiting for instructions and additional information from the Hospital Incident Command centers or hospital leadership. The community-wide exercises are planned well in advance and typically occur during a time when our departments are fully staffed and department leadership is available. This is probably the norm for most organizations, but as we learned with the Pulse nightclub incident, tragedies don’t always happen when you have full resources available. 

The lessons learned in the drills are documented in the policies and procedures for the department, and the staff receives ongoing training about them as well as any new procedures that are implemented. The telecommunication teams use the same call system software across the areas supported, so any changes to the system are available to all hospital operators. Our telephone system also has the ability to overflow calls to the other hospitals if one site is receiving high call volumes.

Response

Early Sunday morning began like a typical day for the corporate call center. Our staffing consisted of 3 operators, including a more experienced lead operator. As the morning progressed, the lead operator was not feeling well and went home early, leaving only two operators. 

• 2:00 am -- The local fire department contacted the operators through the “Fire” phone in the call center and informed them there was an active shooting in the area. The operators transferred the call to the charge nurse in the ORMC Emergency Department, which was standard procedure.
• 2:14 am -- The emergency code line rang and the operators were instructed to send out the code “Trauma Now,” which alerts our trauma team to immediately respond to the ED.
• 3:00 am -- Operators were instructed to send out an “All Page,” which goes to approximately 3,000 pagers, and a global email with the message ”Mass Casualtywith up to 20 patients.”
• 3:20 am -- Operators were contacted by the patient care coordinator (PCC) and informed the “All Page” did not go out to all the pagers. The operators resent the message using the same process.
• 3:33 am -- The operators sent the original message using the wrong procedure. They realized there was an issue and contacted an off-site supervisor for instructions and resent the message correctly to include all the pagers.
• 3:45 am -- Operators were instructed by the PCC to send out a “Code Silver,” the code for an active shooter in the building.
• 4:00 am -- The PCC instructed the operators to send out the “Code Silver” all clear message, which means the active shooter situation was over. When the operators sent out the message, they were immediately contacted by security and informed it was not all clear and to leave it active. (The belief of an active shooter inside the building was later determined to be inaccurate.)
• 5:11 am -- Operators were instructed to send out an “All Page,” announcing ORMC was on lock-down. This was the last call the operators received requesting alerts to be sent.

After these initial actions, the hospital operators received high call volume from team members, media and concerned family members looking for information. Additional operators were brought in to help address the large volume of calls. Later on Sunday morning, the hospital set up a hotline for families who were looking for information about victims, and this enabled the operators to quickly transfer the calls to those who could help answer their questions.

Lessons Learned

Although the drills and exercises are critical to identifying ways to improve our response to these types of incident, they sometimes do not fully prepare you for real emergencies. Key lessons learned were:

• Training, Training, Training — This needs to be done for all team members and continuously tested to ensure everyone is fully trained on how to perform procedures that may occur infrequently.
• Simplified Processes — The operator’s software system is very powerful, but we had created some complicated processes that made it more difficult to quickly send out urgent “All Page” messages.
• Clear Communication for Notifications — During major incidents such as this, misinformation can easily be communicated to the operators. It’s important they have one key contact to provide all instructions on what is needed from them. The confusion over the “Code Silver” being cleared early was due to security not being aware of what notifications the operators were being instructed to send.
• Additional Staffing — With the lead operator out sick, the remaining operators did not feel empowered to reach out for additional help. The call center team needed procedures on how to escalate quickly when major incidents such as this occur.
• Ongoing Communication During Events — The hospital operators received huge volumes of calls from people wanting information. They had to continuously inform family members and the media that they did not have any information. This caused stress for the operators and frustration for the callers.
• Mass Communication System — With changes in personal technology, many team members and physicians have moved away from pagers and use their personal devices for receiving messages. Key personnel did not receive messages about the event until they awoke on Sunday and checked their email or heard it from the news outlets. A system that allows critical audible alerts to personal devices is essential.

What We Changed

It’s important to review the lessons learned from this unfortunate event and take action on them to continuously improve our processes. Key changes that have been implemented or are being developed include: 

• Training and Staffing — The training program for the operators has been improved. New processes have been developed to assess the skill levels of each operator and provide targeted training accordingly. New employees receive the necessary training before they are placed on shifts where limited support from experienced operators is available. In addition, staff has been instructed that if telecommunication’s leadership is unavailable during a major event, they are empowered to reach out to other team members for assistance. We also are exploring technology that would enable off-duty operators to connect from home and assist in handling additional call volumes.
• Improved Communication — During emergencies, instructions to the operators can come from many areas. It’s important that these are coordinated. Telecommunications and security leadership have begun working closely together to identify ways they can improve communication and avoid conflicting information. The hotline for team members that was established remains in service and can be updated quickly for events such as the Pulse nightclub incident, hurricanes, etc. Evaluations of a mass communication system are underway to see if that technology would benefit the organization.
• Simplified Processes — Since the Pulse nightclub incident, the organizational structure of the telecommunications department has been reviewed and an information systems liaison hired. One of this team member’s responsibilities is to work closely with our call system software provider to streamline the steps needed for emergency notifications and develop templates that will make it easier for the operators to easily and quickly send out accurate information.

Conclusion

Although this terrible event uncovered areas that needed to be improved in the telecommunications department, we are very proud of the way the call center team handled this extremely stressful situation. It was a tragedy that captured the world’s attention and was happening only a few hundred yards outside the call center. The operators remained calm and did their best to meet the demands they faced. As leaders, we must work with our teams so they have the necessary tools to not only handle the daily routine, but the exceptional events such as the Pulse nightclub incident. Although the department took the drills and exercises seriously in the past, they now mean so much more to those who went through this tragic event.

Key Takeaways

• Ensure your teams are receiving constant training on emergency procedures. New employees should be thoroughly trained on the procedures before putting them in a situation with limited support from other experienced staff. Existing employees also should be regularly tested on the same procedures so their skills are kept at the highest level possible.
• Evaluate your processes for emergency notifications and work with your team to make these as simple as possible. Although they may seem fine during planned drills and routine exercises, the stresses of a real-life event make you realize they are not as simple as first thought.
• Be prepared for a large influx of calls in a real emergency. Planned drills can test your procedures, but most drills do not simulate a large increase in callers reaching out to the hospital for more information. During an emergency, keep the operators updated on the current situation so they can field as many questions as possible, but quickly establish a “Hot Line” so operators can transfer a caller when additional information is needed.