Six staff members from Orlando Health delivered an emotional keynote presentation on Wednesday as part of the IHI 28th Annual National Forum on Quality Improvement in Health Care. The team, including surgeons, a nurse, and administrators, spoke about the difficult lessons they learned when they responded to the worst mass shooting in US history.
Orlando Regional Medical Center (ORMC), part of Orlando Health and Central Florida’s only Level 1 trauma center, is just three blocks from the Pulse Nightclub. There, starting around 2 AM on June 12, an armed shooter killed 49 people and wounded 53 more. Soon after, ambulances, police cars, and the beds of several pickup trucks brought dozens of victims to the emergency room.
“If [organizations] don’t have a plan, you need to make one,” said Dr. Michael Cheatham, Chief Surgical Officer at Orlando Health. "It is not a question of if you will be faced with any event like this. It’s a question of when.”
WATCH: Orlando Health staff speak about their response to the Pulse nightclub shooting
That night and the next morning, the emergency department treated 44 patients and performed 28 surgeries. Every patient who reached the operating room survived.
That was one of the many statements that drew resounding applause from the audience of some 5,000 health care professionals and students. The lessons the Orlando Health team shared ranged from practical to emotional, and the story left a lasting impression on Forum attendees.
Here are seven lessons that stood out:
- Teamwork, trust, and leadership are critical to your frontline staff’s success. Elisabeth Brown, RN, was an emergency department nurse on duty the night of the shooting. When the first patient came in, she got to work — as ER staff members always do, she said. But when the patients kept coming, one after another, minutes apart, some with wounds she had never seen before, she started to get scared. She kept calm by following the directions of Dr. Chad Smith, the trauma surgeon and team leader. “Dr. Smith was going to tell us what to do, and it was going to be right,” Brown said she told herself that night to keep collected. “He leads our team, and I trust him.”
- Times of crisis require difficult decisions about where to focus resources, but those decisions can save lives. Smith, the trauma surgeon who issued directions to Brown that night, also did the difficult work of triage. The battlefield concept has been around in health care since Napoleonic times — it instructs that the sickest patients receive care first. But it also suggests that care must cease for patients who are unable to be saved. “We study this. We train for this,” Dr. Smith said. “But making those decisions in real life is very different.” Dr. Cheatham said the team had to switch their mentality from delivering the standard of care to delivering sufficient care. He recalled the painful, but correct, decision to stop CPR on a patient who wasn't responding and record the time of death as another patient came in without a surgeon attending at all.
- Practice can (and will) save lives. As the only Level 1 trauma center in the area, ORMC has a responsibility to the community to be ready for a crisis. Mark Jones, President of the ORMC, said the hospital participated in a community-wide mass casualty drill focused on an active shooter just three months before the Pulse shooting. Fifty-six organizations participated. “There’s no question that the work that was done that day helped to save lives,” Jones said. “Hospitals, we would really urge you to practice incident command. Drill often. Drill when you’re busy. Practice on the weekend. What comes out of that is lessons and learnings and gaps that are identified to help you prepare.”
- Patient-centered care means doing more than providing creature comforts in the family waiting room. Holly Stuart, director of service and hospitality at Orlando Health, described the support the hospital offered victims and their families and friends. They handed out dozens of phone chargers and put blankets and pillows in the waiting room, and they also offered chaplain services, medical care, and Spanish translation — it was Latin night at the Pulse nightclub. As the injured and deceased were identified, Orlando Health partnered with the FBI to deliver the worst news to friends and families with the experience and compassion of health care professionals. “We are sadly very adept at giving bad news to patients,” Stuart said. “But the resignation on the faces in that room. ... I never will forget.” And over the coming months, they offered care coordinators to help victims manage the many services they received inside and outside the health care system.
- Caregivers need care, too. Jones, the hospital president, said Orlando Health offered counseling sessions for caregivers every two hours, day and night, for three days following the shooting. They continue to offer counseling, especially in moments when providers are likely to re-live the trauma of that night. “That was a huge part of our responsibility,” he said, “to care for our team.”
- A culture of improvement can help you be prepared for tragedy. Jamal Hakim, Orlando Health Chief Operating Officer, said he believed that the performance of the staff that night resulted from years of investment in improvement culture, teamwork, and empowering the front line at Orlando Health. “Are you prepared? Are you prepared for the worst to show up on your doorstep unannounced?” Hakim asked. “The Pulse tragedy brought out the best of us in the worst of times.”
- Love can overcome hate. After the tragedy, Orlando Health staff received an outpouring of love and support from the community — endless pizzas, handmade cards from kindergartners, and banners of support signed by health care staff in other cities affected by mass violence, including Boston; Aurora, Colorado; and Blacksburg, Virginia. Brown, the ER nurse, said that love helped the community heal — including the love that Orlando Health staff showed for their patients, their work, and one another. “The only thing that helps me get through this is thinking that in the face of such hate, the only thing that can ever change it is love,” said Brown, the ER nurse. “And I know love because I was there that night.”
Editor’s note: IHI would like to thank the leaders and frontline staff at Orlando Health for their commitment to excellence and for sharing their experience so that others might be better prepared for tragedy.