Hospital Preparedness and the Boston Marathon Bombing

In the last eight years, Brigham and Women’s Hospital in Boston has conducted 78 large scale emergency drills.  On the afternoon of April 15, immediately following the two bombs set off during the Boston marathon, it was time to put their well-practiced plans into action.

Brigham and Women’s Hospital had prepared for a variety of events, both natural and man-made.  Casting a wide net and taking an all-hazards approach, they ran drills for oil spills, chemical attacks, active shooters, blizzards, train crashes, hurricanes and building evacuations. The hospital ran exercises and responded to real-life events at a division, departmental, hospital, city-wide and state-wide level.  No doubt, the drills helped to establish routines and relationships across departments and across systems.

On Monday, April 15, there was a short turnaround between finding out about the event and implementing a plan.  At 2:54 p.m., when  the call came in about two explosions at the race, the already busy 55-bed emergency department had 66 patients. 

Brigham and Women’s Hospital implemented what they call a Code Amber, activating the hospital disaster response system.  The hospital-wide response plan that they practiced regularly started with building capacity and capability in the emergency department, in the operating rooms, and throughout the hospital.  Where possible, patients were discharged or transitioned to other departments to disperse the crowded area.  Multiple operating rooms were rapidly opened and staffed for potential emergency surgeries.

The hospital cared for 39 patients from the bombing, 23 in the first 45 minutes. Staff set up a primary triage team to assess immediate need before a secondary triage team identified patients that needed emergent surgery.   Patients requiring surgery went directly to the operating room from the Emergency Department, just as they had drilled in prior exercises.   Patients were rapidly cared for throughout the hospital.

In the end, the drills and training clearly contributed to the success of the hospital’s response.  The Incident Command System followed protocols and organized logistics and communications to ensure an effective, rapid hospital wide response. Even with all the advanced training, there was still room for improvement.

The first lesson learned was the importance of establishing crowd control in the emergency department.  With plenty of hands jumping in to help it was almost overwhelming.  Brigham knew they needed to establish a labor pool and work on how they assigned roles to doctors, nurses, and volunteers in order to maximize contributions and response. 

The second lesson was to improve and streamline communication between the various teams in the emergency department and the emergency operations center.  With the available resources in an emergency, Brigham and Women’s Hospital discovered that they could enhance communications more readily assigning available staff in leadership and support roles.

The third lesson was overall situational awareness regarding communications, patient and staff location.  With multiple events occurring, clear, frequent information flow was critical.

In the months following the bombing event, Brigham and Women’s Hospital instituted a mandate to focus on July 4 as a milestone date to show improvement.  With a half a million spectators coming to the Boston waterfront to celebrate the holiday, the hospital wanted to be ready in advance.

They conducted more spontaneous drills to focus on role clarity, reviewed job action sheets with providers and refined their information systems based on the marathon bombings experience.

“We have to be fluid, flexible, and able to adapt to the scenario,” said Dr. Eric Goralnick, Medical Director of Emergency Preparedness.  “We are a 793 bed academic medical center that is running at capacity a majority of the time. With competing priorities, getting everyone on the same page and operating cohesively in an emergency requires constant vigilance. A commitment to preparation and training is an institutional imperative. ”