Almost every facility has an emergency response protocol, but until you actually experience a crisis, you may not know where the weaknesses of that protocol lie. Like others our surgery center has routine drills to rehearse protocols for emergency evacuations. But when the emergency alarm sounded in our building on September 13th, two days after the terrorist attacks in New York and Washington, DC, we all thought that it was the real thing. It was later discovered that the alarm was set off by dust particles from building construction that had reached some of the system's sensors. But our somewhat haphazard responses to this crisis made us realize that it was time to re-evaluate and update our emergency policies and procedures.

The next work day, we gathered the staff to discuss areas of concern, acknowledging that our initial response and the issues raised were greatly affected by the recent events of September 11th. Following the staff meeting, the department heads met and drafted a new evacuation policy, which was presented to the staff during a mandatory in-service session the following week. Here are some of the lessons we learned that day and the steps we took to ensure that if a real incident were to occur, we would be better prepared.

Establish better communication.
During the evacuation, some members of our OR staff elected to remain in the facility to finish a cataract procedure that had just gotten underway. We lost contact with them for more than twenty minutes.

We had never realized that this could happen when we were first setting up our emergency procedures. During that time, the fire marshall told us that if staff members were left behind, a liaison from the fire department would report to the center and facilitate communication with those outside. He assured us that the local firehouses were aware of the location of our center. However, on the day of our evacuation, a fire department from another area was the first to respond. Because they were not in the immediate vicinity, their arrival took longer than we anticipated, leaving our OR staff to assume the worst. When the fire department arrived, they were unaware that there was even an ASC in the building, let alone that there was a surgical procedure in progress.

We decided it was important to have a better communication system to keep our OR informed during an emergency. To that end, we purchased a pair of two-way radios. One radio remains in the OR hallway, the other at the reception desk. During an emergency, it's my job to take the walkie-talkie at the reception desk. The clinical coordinator or designee remains in the OR hallway and maintains contact using the other radio. We also contacted 911 to make sure our location and the fact that we were an ASC would be programmed on the 911 computer system.

Be prepared to give up control.
The most difficult decision during the evacuation fell to the surgeon who was performing the cataract procedure. He ultimately decided to stay and finish the case, but he had no idea if he was placing the staff and the patient at risk. Following the evacuation, the staff raised concerns about who should make the decision to stop a procedure prematurely in the event of an emergency. Some concern focused specifically around retina procedures, which, if interrupted, could result in the patient losing his or her eyesight.

Ultimately we decided that, upon the emergency team's arrival, a spokesperson for the facility would inform them of what was happening in the ORs. The head of the emergency response team, not the operating surgeon, would then be the best judge of whether a procedure could continue without jeopardizing the safety of those involved. More than anyone in the OR, this person would know whether the emergency could be contained and for how long.

The week following the evacuation, the chairman of our risk management committee sent a letter to all the surgeons explaining the reasons that this life-or-death decision would be taken out of their hands. The surgeons were not necessarily happy with our decision. However, they realized that the fire department did have a better handle on the safety of the environment and the people in the building.

Keep a stock of emergency supplies.
Because the fire department was delayed, several of us scrambled to our cars to retrieve folding chairs for elderly patients to sit on while we waited for help to arrive. Our experience made us realize that we needed a better way to accommodate these patients, as well as some basic emergency equipment to treat injuries. During our in-service, our staff came up with the following list of critical supplies:

• blood pressure cuffs,
• stethoscopes,
• sterile water,
• blankets,
• foam scrub,
• a portable oxygen tank,
• emergency drugs (nitroglycerine, glucose, and IV fluids),
• basic first aid items, and,
• several fold-up chairs. These chairs fold up into their own storage bags. They are inexpensive and can be found at many local discount or sporting goods stores.

We purchased these supplies along with two carts for storage. The emergency items are stored in a supply closet.

Assign staff emergency roles.
One practice we found to be successful during the evacuation was having three coordinator positions, each with specific roles in the event of an emergency.

The business office coordinator assigns office staff to lead patients and visitors in the waiting room out of the building to the designated meeting area. The remaining office staff reports to the PACU for directions. The business office coordinator is also responsible for taking the back-up tape from our server, the evacuation cart, the OR schedule, and a clipboard to record the names of all the visitors and patients once they are safely outside.

The PACU clinical coordinator directs the staff in evacuating patients, gathering their medical charts, and the employee sign-in sheet. (One problem immediately identified during the evacuation was accounting for the staff present at work that day).

The OR clinical coordinator's responsibilities include turning off the emergency shut-off valve for the medical gases located in our OR hallway and maintaining contact via the two-way radio.

Find additional help.
You can never have enough hands in the event of an emergency. We made arrangements with the practice administrators of two physician practices on our floor to direct some of their staff to the ASC during an evacuation to aid in transporting patients and supplies.

While we have a very favorable set-up, I would recommend you talk to your property manager to find out if there may be tenants in your building who could be of help to you. Even non-medical personnel may be willing to help take out supplies and patient charts, freeing up all of your staff to focus on the patients.

Our ordeal, while harrowing, was a valuable wake-up call for our facility. While it's impossible to predict everything that can go awry in a medical facility, we now feel we are as prepared as we can be to handle another emergency evacuation.

Andrea Hyatt is the administrator of Dulaney Eye Institute, a single specialty facility in Towson, Md.