Health IT lessons from the Boston marathon bombings

BOSTON--Emergency preparedness drills meant the difference between life and death when Boston was in the throes of the marathon bombings last year. “These drills have taught us trust, taught us about collaboration, and on April 15 they saved lives,” said Adam Landman, MD, MS, MIS, MHS, CMIO for health information innovation and integration at Brigham and Women’s Hospital (BWH), speaking at the Medical Informatics World Conference on April 29.               

When the bombs struck at 2:49pm on April 15, 2013, prepositioned support teams were ready. EMS, fire, police and hundreds of volunteers did their part to help, including bystanders that applied homemade tourniquets. A triage site received 118 patients within 28 minutes, hastening their route to care. “Every patient that made it to a hospital lived,” said Landman.

BWH activated a hospital-wide alert that enabled it to focus on building up capacity in the emergency room to accommodate the rush of new patients by discharging low-risk patients and completing surgeries.

After the 3:08pm alert, the hospital saw 23 patients in the first hour. In all, 40 patients were seen at BWH. All patients were rapidly triaged and assessed by a team, and designated into one of three categories: life threatening; limb threatening or requiring surgery. The first patient entered surgery at 3:26pm.

Despite these successes, information system challenges created a bottleneck for hospitals during the Boston Marathon bombings. When asked the biggest barrier to providing care after the bombing, “they all said information systems,” said Landman.

Eric Goralnick, MD, medical director of emergency preparedness at BWH, shared three challenges that since have been addressed in the case another disaster strikes.

One issue was emergency department tracking. BWH’s core electronic system tracking board provides a geographic representation of patients—including their name, chief complaint and tracking team—for clinician use. To put a patient in a room, usually a nurse drags an icon that establishes that person's location.

During the Boston Marathon crisis, staff struggled with limited situational awareness, specifically of patient location, as nurses were too busy to drag the icons. Locating patients and their core care teams was challenging for all involved, including specialists.

The hospital has since charged a leader in each unit with the responsibility of ensuring that the tracking board is updated, said Goralnick.

A second challenge involved distinguishing unidentified patient names, which were difficult to read as only a few elements separated one from the other. “It was very difficult for the human eye to separate patients. It works well for computers, but clinicians had a tough time distinguishing patients,” said Goralnick. To remedy this issue, BWH has since put in more identifiable elements and uses a unique term—currently color but they plan to use names of cities, states and lakes in the future—to more easily distinguish patients.

A third challenge revolved around the lack of real-time documentation of orders, assessments and procedures, which stemmed from the fact that clinicians were too busy to keep them updated. BWH created the role of provider scribe, authorized to use CPOE, to keep these systems up-to-date. During a time of crisis, typically physician volunteers step forward to help. “This could be an excellent use of their skills and time,” he said.

Making these adjustments was essential to prepare BWH for future crises, but more improvements are forthcoming. The hospital is looking into RFIG technology to better pin down patient location and also is looking to help develop national recommendations for best practices during emergency scenarios.