Emergencies at ambulatory surgery centers (ASCs) can take multiple forms. Several speakers at the 2024 annual meeting of the Society for Ambulatory Anesthesia focused on common crises that can arise in ASCs and how to prepare for them.
With violence in the healthcare setting on the rise, the risk for gun violence in an ASC is very real, said Michael Guertin, MD, a clinical professor of anesthesiology at The Ohio State University Wexner Medical Center, in Columbus. He noted that in a 2018 survey conducted by the ASA, 20% of the respondents reported they had experienced physical violence during their careers, mostly from patients and family members.
“We know that in a healthcare setting, the usual response of ‘run, hide and fight’ may not be possible, and we may need to consider ‘secure, preserve and fight’ instead,” Guertin said. “These are very dynamic situations, with 70% of them lasting five minutes or less. That’s why it’s very important that we talk about these things, so that we are prepared to react to the situation.”
Nationally, emergency preparedness rules from the Centers for Medicare & Medicaid Services and accreditation mandates from The Joint Commission require hospitals to have emergency response plans for “all hazards.” In June 2021, The Joint Commission included active shooter preparation as a requirement. “But drills for a gun violence scenario are very difficult to create, unlike with a code blue,” Guertin noted. “So tabletop discussions are the most effective way to prepare for these things.”
The National Institute for Occupational Safety and Health recommends a series of key strategies for violence prevention in healthcare:
Environmental Designs:
- Develop emergency signaling, alarms and monitoring systems.
- Install security devices such as metal detectors to prevent armed people from entering the hospital.
Administrative Controls
- Restrict the movement of the public by card-controlled access.
- Develop a system for alerting security personnel when violence is threatened.
Behavior Modifications
- Provide all workers with training in recognizing and managing assaults and maintaining hazard awareness.
Dealing With the Consequences of Violence
- Provide an environment that promotes open communication.
Guertin noted there are a number of unique elements to these preparation steps in ASCs. “Many facilities block overhead announcements in the OR to decrease distractions,” he said. “Work with your facility to make sure that in an emergency like this, that information is communicated to everyone in the OR. Personnel should know how they will be notified if an active shooter is present.”
To protect patients who cannot flee in the event of violence, securing the area is necessary. Guertin discussed how to reduce access and visibility: Turning off lights, turning off phones, closing and locking doors, and pulling curtains closed may save lives.
While every reasonable attempt to continue caring for patients must be made, Guertin noted that no person should be required to stay or leave. “Healthcare professionals have a responsibility to significant, but not disproportionate, risk in their efforts to benefit their patients. This is not a moral or ethical question but a very personal one,” he said. “It’s important that we, as leaders in our facilities, ensure that we provide people with the means and the training and the opportunity to think in advance about how they would deal with these kinds of situations.”
Cardiac arrest requiring CPR during ambulatory surgery is rare, with an overall incidence of 0.03% intraoperatively and 0.33% postoperatively (PLoS One 2020;15[1]:e0225939). However, with patients generally becoming sicker and the procedures becoming more complex, the incidence of cardiac arrest is likely to increase, warned Jamey Eklund, MD, an associate professor of anesthesiology at Children’s Wisconsin, in Milwaukee.
“Factors associated with increased risk for these issues include vascular surgery, emergency procedures, disseminated cancer and elevated ASA physical status,” she said. “Although the likelihood of us seeing most of these risk factors in an ambulatory surgery center is quite low, things like increasing age, frailty and ASA status are becoming more common. We need to be prepared for an extremely rapid response because brain death can occur in about four to six minutes.”
Eklund stressed the importance of a crisis management plan. This strategy begins with a facility layout that allows anesthesiologists to be prepared and to quickly locate emergency equipment. Arrest protocols should be developed, she also noted, and ASCs should have resources available to treat arrests, including emergency equipment.
Staff competencies are also an essential part of preparation for a cardiac arrest emergency. “We know that just like professional athletes, staff need to possess knowledge and skills and continuously review those to be prepared,” Eklund said. “This involves not just advanced cardiac life support, basic life support and pediatric life support, if applicable, but also continuing education for certification and licensure. Trainings should be evidence-based and frequent so that people have information at their fingertips when needed.”
All ASCs should have a code cart readily available, but there are no nationwide standards for what must be included on such a cart, according to Eklund. She recommended an automated external defibrillator or defibrillator, airway equipment, resuscitative medications and IV lipid emulsion in the event of a local anesthetic toxicity, and a written guide/checklist.
“Surgery centers should have protocols for staff to regularly look at the cart and its medication boxes to remove outdated material and replace any missing or broken equipment,” she said. “Specific staff members should be assigned to these roles, and have that responsibility reiterated during their annual review.”
Mock code drills, such as simulating a cardiac arrest, should be conducted on a regular basis. This allows staff to demonstrate and practice skills they may not use often, familiarize themselves with equipment and identify issues, allay anxiety, and debrief afterward to discuss what did well and what needs to improve, Eklund explained.
Patient selection and protocols on the day of surgery also can help mitigate a potential crisis. Patients with an ASA physical status of III and above; those with a noteworthy social history like tobacco use, alcoholism and/or drug use; and those with a recent cardiac arrest or cardiac procedure should be evaluated in a preanesthetic center and possibly referred for additional testing before surgery.
“If a patient walks in the door looking diaphoretic, mentioning chest pain or demonstrates abnormal vital signs such as high blood pressure or a new-onset arrhythmia, that should lead to an escalation,” Eklund said.
When a code is called, specific responsibilities should be taken by each member of the surgical team, including the code leader (typically an anesthesia professional or the surgeon), the surgeon, the RN circulator, the scrub person, physician and nursing assistants, and the OR manager or charge nurse. Staff not directly involved with running that code should help minimize disruption by moving other patients and their family members to a different area or putting up privacy blinds.
“Intraoperative cardiac arrest is different than pre-op or post-op cardiac arrest in the surgery center,” Eklund said. “Because you’re in an OR, you typically have an idea of what is causing the arrest, and so that issue should be treated concurrently—for example, an allergic reaction to an antibiotic, a lost airway or bronchospasm, a new arrhythmia, malignant hyperthermia. Patients that have cardiac arrest in the recovery room are more likely to have a better outcome than those that have a cardiac arrest in an OR.”
Once the code has been run, post-arrest patient management and procedures begin. The facility policies should indicate whether one may call an affiliated hospital or EMS for transfer. “Then comes the documentation, not just in the patient’s medical record but also for quality improvement processes and then reporting to the governing body of the center and potentially the American College of Surgeons,” Eklund noted. “A thorough debrief should occur with the staff in just a couple of business days while all the information is fresh in everybody’s head in order to be able to move forward, identify problems, and then create policies or protocols to mitigate those issues. And, of course, the schedule must go on.”
Natural Disasters
Weather-related and other natural disasters can cause major disruptions for healthcare facilities, including ASCs, said Justin Routman, MD, an associate vice chair for multispecialty anesthesiology at the University of Alabama at Birmingham. “It’s not just damage to buildings and facilities that is the problem, but also supply chain issues, staffing and infrastructure. Weather events can disrupt all of these things not only during the storm but for days and weeks afterward,” he said. “And if there’s a significant disaster, it’s possible that the hospitals in the area will be prioritized before your surgery center, so you may have to wait longer for relief.”
According to Routman, there are five key components to making a severe weather plan for your facility:
- Identify capabilities and vulnerabilities.
- Develop workflows and procedures.
- Create a communications plan.
- Educate staff on the plan.
- Practice and maintain it.
One of the key roles that staff should take in your disaster plan is perhaps the most basic, “weather watcher,” Routman noted. This person is designated to monitor communications channels about impending events and make decisions when certain weather-related “watch” or “warning” thresholds are reached.
Sheltering strategies should include safe zones located within three minutes of your location. “It’s important to keep in mind that when you’re moving a patient, particularly an anesthetized patient, you really can’t get that far in about three minutes,” Routman said. “You may need to bring engineers, architects in to help you find places where you can avoid debris, breaking glass, water ingress—that sort of thing. Usually that will be an interior room on the lowest floor away from windows, but keep in mind how long it takes to get there.”
An emergency plan should also include consistent guidance on when and how to decide to suspend ASC operations. “Everyone needs to know what to expect. Write it down, make sure you have it in one place and then follow it every time,” he said.
Routman concluded by recommending additional resources including NOAA (National Oceanic and Atmospheric Administration) Weather Radios: systems with backup battery that warn when weather alerts are issued for your area, powered by a nationwide system of towers. “The National Weather Service also has a program called StormReady, which bolsters communities with communication and safety skills related to extreme weather hazards,” he said. “We are all obligated to develop and maintain proper emergency response plans. At the end of the day, the only thing harder than preparing for an emergency is explaining to someone why you didn’t do it.”
—By Gina Shaw
Eklund, Guertin and Routman reported no relevant financial disclosures.
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