Patient Emergencies: Are You Prepared?

November 17, 1999: Lori Marie Rose, a 25-year old mother of four, enters Crittenton Hospital in Detroit for minor outpatient elbow surgery. On the operating table, her heart unexpectedly fails, and despite frantic efforts to save her, she dies. That same year, in Florida Hospital in Orlando, Orlando Magic basketball player Derek Strong also undergoes minor outpatient surgery, to repair a broken nose. During the procedure, he suffers an onset of malignant hyperthermia. Fortunately, the staff is able to respond quickly, turning about Strong's 107-degree temperature and narrowly averting tragedy.

These stories highlight a chilling reality: incidences of malignant hyperthermia, respiratory distress, cardiac arrest, and other patient emergencies, while rare in ambulatory surgery, can and do occur. If they happen in your facility, would you be prepared to respond? The answer could mean the difference between life and death. We asked several experts how they ensure that their facility and staff are prepared in case disaster strikes. Here's what they had to say.

Maintain an Inventory of Emergency Drugs and Equipment
Mike Lipomi, CEO of Stanislaus Surgery Center in Modesto, Calif., stresses the importance of having life-sustaining equipment in every OR and a complete supply of emergency drugs in storage. A quick rundown:
- Fully stocked crash carts with all of the drugs recommended by the American Heart Association.
- Narcotic reversal agents.
- Topical coagulants.
- A portable ventilator that can conveniently go into an ambulance with a patient.
- A dedicated malignant hyperthermia cart to supplement your crash carts. According to Nancy Burden, RN, director of the Morton Plant Mease Health Care Outpatient Surgery Centers, the cart should contain at least 36 vials of dantrolene (normally packaged in boxes of 12), and sterile, preservative-free water to reconstitute the medication.
- At least two defibrillators. Although this may seem like overkill, Ms. Burden says it's better to be safe than sorry in case one of them fails.

Ask the Right Questions
Ms. Burden recommends working with your surgeons to establish patient appropriateness guidelines. When taking patient histories, keep these guidelines in mind; if your facility is far from a local hospital, you may elect to not admit a patient who is even a medium risk, says James Yates, MD, president of The Center for Cosmetic Surgery in Camp Hill, Pa.

Our experts recommend focusing on the following areas while taking a patient history to determine his or her risk level:
- Previous Response to Anesthetics: You can identify patients at risk for adverse drug reactions and malignant hyperthermia, the sudden anesthestic and/or muscle relaxant-induced onset of uncontrollable fever, by making sure they haven't had any previous negative reactions to anesthetics.
- Family Medical History: Certain conditions that predispose patients to risk, such as malignant hyperthermia, are genetically inherited. Therefore, our experts say, take a thorough family history-you might decide that a prospective patient with a parent who has had episodes of malignant hyperthermia or other potentially inherited conditions might not be appropriate for your facility. Other conditions that may be associated with malignant hyperthermia include such muscular diseases as muscular dystrophy and central core disease.
- Medications, vitamins and herbs: Always let your patients know what medications they should and should not take before a procedure, and on the day of the surgery, verify that they followed your instructions, advises Ms. Burden. Also, ask patients what vitamins and herbs they are taking, recommends Dr. Yates. These can impact a patient's body chemistry as significantly as medications do (for example, vitamin E thins the blood).
- Food allergies: Nathan Schwartz, MD, chief of the anesthesia and pain management departments at Coordinated Health Systems in Lehigh Valley, Pa., recommends asking patients to supplement their list of allergies to medications with a list of any known allergies to food. Allergies to tropical fruits such as bananas and kiwis, for instance, may suggest a sensitivity to latex. You can also ask patients whether their mouths get irritated when inflating balloons, or if they are able to wear rubber gloves when doing housework. Be creative in your questioning; often patients can be sensitized to latex without even knowing.

Keep your crash cart stocked with all of the drugs recommended by the American Heart Association.

Establish Protocol
To respond effectively to an emergency, it's critical to establish protocols for every possible scenario; this is one instance where learning on the job is not appropriate. Some suggestions:

Establish and draft protocols for adverse drug reactions: Adam Dorin, MD, the Medical Director and Chief of Anesthesia for the Surgery Center of Chevy Chase in Chevy Chase, Md., believes this may be one of the more common patient emergencies. A good protocol for how to deal with these incidents would include how to provide IV access, fluid, oxygen, and how to stop the suspected triggering agent.

Establish and draft protocols for malignant hyperthermia: These protocols must include detailed information on how and where to get ice. If there is an ice machine in your facility, know what to do if its supply becomes depleted; make sure all members of your staff know how to make the machine immediately produce more ice. It may also be wise to keep an extra bag of ice for emergency use in a freezer.

Ms. Burden once tried to ensure a ready supply of ice by striking up a deal at a nearby convenience store. The agreement was that if anyone from the facility came for bags of ice, he or she would be allowed to rush out with them and repay the store later. Unfortunately, Ms. Burden discovered that the manager of the store changed so frequently that the deal wasn't viable; unless the facility kept constant tabs on the store's employee turnover, there was no easy way to make the deal work.

The Malignant Hyperthermia Association of the United States (www.mhaus.org) can help you develop MH protocols. The Association also offers the MH Hotline, (800) MH-HYPER, which provides 24-hour a day access to physicians who specialize in malignant hyperthermia crisis treatment and can respond to any pre-, post-, or intra-operative anesthesia questions.

If your facility handles pediatric cases, develop guidelines concerning child emergency policy. The question of whether a parent should be called in during an emergency is quite controversial. Some experts believe that a parent can provide comfort to a child in duress. Others argue that a parent's presence would create a disruption in care and could jeopardize the child's outcome. Discuss the subject in a multidisciplinary meeting before drafting the policy.

Consider making it policy that an anesthesiologist always be present in the facility until the very last patient has been discharged, advises Ms. Burden. She explains that in many reported cases of emergencies, the anesthesiologist had left the facility after the patient was taken to the PACU. Remember, even recovering patients can suddenly and unexpectedly deteriorate.

Pre-determine as many duties as you can. If an emergency occurs in the recovery room, most staff members may automatically drop what they're doing to respond to the coding patient, leaving the other patients in the PACU unattended. To avoid this, have a system in place to quickly assign responsibilities. Ms. Burden suggests that the head PACU nurse distribute color-coded, laminated cards that spell out each responsibility for non-critical personnel (i.e. the staff members who aren't immediately tending the patient). One card, for example, should immediately designate a staffer as the family liaison, so families know what's happening as soon as possible.

Developing policies and educating your staff about them is key, but even the best plans may fall through if you don't keep daily tabs on your facility and emergency equipment. Three suggestions:

Check for medication outdates. Mr. Lipomi recommends looking for outdates as often as once a week, while Ms. Burden feels that checking on a monthly basis is sufficient. Keep all drugs current and their labels clear, with all of the dosage information listed.

Test and document defibrillators daily. In addition, every month test their ability to work on their batteries, since wall outlets may not always be immediately accessible. Unplug the device from the wall and fire it at full power two to three times.

Check your oxygen supply daily. Should the individual normally responsible for checking the supply be away, there must be a contingency person responsible for this duty, says Dr. Dor.

Test your Staff
R. David Bean, president of the Georgia Association of Emergency Medical Technicians and a commander for the DeKalb County EMS with 27 years of emergency care experience, believes that poor staff preparation is the most serious problem that his paramedics encounter when they are called to an outpatient surgery facility. "Staff members often run around in circles and scream and shout without doing anything practical," he says. It would help tremendously if the staff could effectively stabilize the patient before the paramedics arrive on the scene. Unfortunately, staff members at outpatient surgery centers seem ill prepared for emergencies and they generally just wait until help arrives. They also seem ignorant of how, or reluctant to, perform CPR."

Mr. Bean's experiences show that establishing emergency protocols are not enough-it's crucial to make sure your staff know them by heart and practice them from time to time. Here are some suggestions on how to ensure staff readiness:
- Run quarterly mock drills testing your staff's response to the full gamut of possible emergencies.
- Schedule an in-service education session every other month. Ms. Burden recommends crash cart identification as a potential in-service. Since emergencies are so rare, staff members may often go years without seeing the inside of a crash cart. Therefore, it may be a good refresher to periodically open the cart and have all members of your staff demonstrate their ability to identify the items and state the uses of the cart's contents.
- At monthly staff meetings, consider asking your staff five questions relating to emergency protocols. Let your staff know ahead of time what general area the questions will cover, and consider making the sessions fun by offering small prizes when they answer correctly (Ms. Burden presents her staff with silver dollars). This will stimulate a periodic mental review of emergency protocols.
- Consider mandating Advanced Cardiac Life Support (ACLS) certification as a condition of employment, Dr. Schwartz suggests. The American Heart Association gives ACLS courses. Recertification is necessary every two years.
- If your facility does pediatric cases, your staff should also be certified in Pediatric Advanced Life Support (PALS), opines Ms. Burden.
- Conduct annual clinical competency reviews for high-risk, low-volume procedures.

Schedule EMT Site Visits
If your facility is freestanding, it's critical to have foolproof arrangement with a patient transportation company, either an ambulance or an airlift, and an agreement with a hospital to admit your patients for emergency treatment. Here are a few useful tips:
- Mr. Bean recommends that you ask ETS companies whether they are staffing Advanced Life Support (ALS) EMS units or Basic Life Support (BLS) EMS units. Try to contract with a company that provides ALS units. These units will always be able to provide advanced airway support and manually defibrillate patients instead of using an automatic defibrillator. They will also always be able to deliver medications. BLS units will occasionally be able to provide advanced airway support and manually defibrillate patients, but they will almost never be able to administer medications. Additionally, some states prohibit BLS units from starting IVs. Unfortunately, the majority of EMTs in most states are not ALS but BLS providers.
- Almost all of our experts recommend that you have your EMTs take a tour of your facility a couple of times each year. Danny Bercher, an assistant professor in the EMS department at the University of Arkansas and a member of the Arkansas EMT Association, points out that site visits will enable the paramedics to always be familiar with your facility layout, which can be critical when responding to an emergency call. "The ability to assess driving patterns and a facility's parking situation, in particular, is an important element in efficiency," Mr. Bercher says. During the site visit discuss such matters as response time (Has the EMT station changed locations? Is the response time still the same?) and access (Which entrance should they use?). Whenever possible, avoid having paramedics rush past waiting patients and families.

Hopefully, your facility will never have to respond to a serious emergency. But by following our experts' advice and using some common-sense preventive measures, you can ensure that should disaster threaten, your facility will be well equipped to avoid tragedy.