'Freak occurrences are hard to predict': How hospitals plan for unpredictable events

Emergency departments engage in advance planning for many scenarios, writes Colette Sheridan

Dr. Kanti Dusari, Consultant Emergency Department (centre) shows Dr David O'Donnell, intern (left) and Faruk Alagic, Medical Student UCC (right), equipment. Picture: Jim Coughlan.

CUH's emergency department (ED) has had its share of major emergencies over the decades and in anticipation of anything from an aeroplane crash to an explosion in a chemical plant or an extreme weather event, the ED has to be on the alert.

Major emergency planning is vital to prepare a hospital to be ready for the challenges of a major emergency, says CUH consultant in emergency medicine with a special interest in major incident management, Dr Kanti Dasari.

He has been working in the hospital's ED since 2015 and is the lead clinician involved in the multi-disciplinary major emergency planning team that meets every month to prepare for catastrophes. The response required from staff is far in excess of a routine day's work at the hospital. While a strategy to enhance the capability of the emergency systems to respond to multiple casualties is necessary, there is also the need to postpone hospital work that is not crucial. Part of managing the incident is to keep disruption to the minimum.

On May 14 of this year, a new type of cataclysmic event, presenting massive challenges occurred when there was a cyber-attack on the HSE online systems. How prepared was CUH for this unprecedented event?

"We have systems that work when the IT system malfunctions," says Dr Dasari. "With our paper based system, we handwrite request forms for blood tests and x-rays. The IT system is also our patient tracking system so we have multiple ID systems. As well as patient tracking, the main ones access pathology and radiology."

As Dr Dasari says, IT systems were designed "to create efficiency so without those systems, we become inefficient."

Could the cyber attack have been avoided with better investment in IT security? "We have security systems in the hospital. But the perpetrators are very clever. All the systems have back doors and loop holes. It's not just the HSE that has been affected. Loads of places around the world have been affected. 

IT cyber security is certainly not something I'd be an expert in. But you'd like to think that there could be ways to mitigate the impact rather than see the whole HSE system being taken down.

The main systems "are functionally back but I wouldn't say we have the complete IT system that we had beforehand. I'm not sure when remote access to my PC will come back. That was set up due to Covid, to maximise working from home, when necessary."

Dr Dasari says that despite the cyber attack, the numbers attending ED have increased to similar amounts that were turning up prior to Covid-19. "We found that unusual. I can only postulate that there may be limited access to the kind of primary care that patients would normally experience before Covid happened. Things built up (and people started attending again.)"

The monthly major emergency planning meetings are multi-disciplinary. They're attended by clinical, nursing, administrative, engineering, social work and pathology staff as well as switch board operators.

"If a major emergency is declared, a lot of infrastructure access has to be changed. We go to a paper-based system for registering patients. They're also registered on the IT system . But to speed things up, we will not use patients' normal details. They will be allocated major emergency details. We will open up major emergency boxes that contain pseudonyms. For example, we use the names of countries. A patient might be registered as 'Angola'. They'll be given a unique number that operates during the major emergency. A wrist band will be put on the patient, with all the details on it. The problem with a major emergency is that we receive a lot of work in a small period of time. Normally, we receive twenty to thirty patients an hour, during our busiest hours. In a major emergency, we still have to anticipate that non-major emergency patients will present at ED. So for several hours, we might have to double the number of hourly attendances. We don't have systems in place to address that using the normal registration systems. What we do in a major emergency event is what is done internationally."

A mass fatalities plan is all part of the major emergency planning at CUH's ED. It also has a severe weather plan. The floods in Germany, resulting in scores deaths, is a terrible example of how we are all subject to climate change and extraordinary weather events.

"Germany is obviously a very well developed country. This must have caught them off guard. Freak occurrences are hard to predict. Hospitals in the areas where (the floods happened) would have initiated their emergency plans."

Dr Dasari recalls the severe snow in Ireland in March 2018. Transport became a problem with many roads dangerous for driving. Just trying to get staff into the hospital posed a challenge. "We tried to arrange for staff to stay locally. I was able to take a colleague home because I have a four wheel drive."

No major emergency was declared when Covid first hit, says Dr Dasari. Hospital attendances were reduced with the deferral of non-emergency consultations and treatment. "I think we dealt with the first wave very well. We were reaching capacity when we managed to head it off. We had the knowledge then to manage the second wave so it didn't impact the hospital too significantly." But we could be looking at a fourth wave. Unpredictable events, unfortunately, are what hospitals have to factor in when planning ahead.