Hurricane Harvey roared onto shore August 24-25, 2017. San Antonio hospitals, emergency medical service agencies, and other healthcare organizations joined with the Southwest Texas Regional Advisory Council (STRAC) in activating the Regional Medical Operations Center (RMOC). On Thursday, August 24, the RMOC team coordinated with San Antonio and Bexar County authorities at the Emergency Operations Center to prepare for evacuees from Texas coastal communities and patients from affected hospitals.
The winds, and record rainfall over the next several weeks, resulted in major damage. The prolonged flooding affected an enormous region of Southeast Texas. University Health System nursing staff was called to four locations – a reception center and three shelters – that were set up for evacuees. As the evacuee arrivals increased, nursing staff was adjusted to meet the demand. Nursing staff were scheduled to work 12-hour shifts around the clock. University Health System also was asked to staff nurses at a mega-shelter. This shelter had anticipated up to 2,500 evacuees.
More than 1,600 nursing hours and 90 nurses were dedicated to the Hurricane Harvey response. Nurse leaders and educators led the initiation of clinical operations and performed extraordinarily in helping the evacuees and their families. Nurses were emotionally and physically exhausted, but remained courteous and respectful despite working countless hours through the heavy rainfall to ensure quality care. The nurse educators set up the clinics within the first 24 hours of activation.
It was a complex, well-organized response to a stressful emergency to ensure that all evacuees received quality care. During this event, we had three pregnant women who delivered healthy babies at University Health System Women’s Health Services where our nurses assisted in the coordination of care. Nurses went to heroic lengths to secure medical supplies when there was a delay in receiving needed equipment from the city.
Nurses prepared a standard list of supplies for the evacuees, which the San Antonio Metropolitan Health District provided. Two important processes were developed in collaboration with the RMOC team for patients needing dialysis and transporting patients with VIA, San Antonio’s public transportation system. Nurses even provided emotional comfort when evacuees heard they had lost a loved one or discovered that their homes or belongings had suffered excessive damage.
The Maternal Transport team may be less than a year old, but it is a continuation of the University Health System Women’s and Children’s Services that dates back more than 100 years. The Maternal Transport Team is the newest jewel at University Health System, providing high-risk pregnant patients with specialized, safe and quality care during ground and air transport throughout South Texas.
In late 2017, the Maternal Transport team began with a training program for nurses to transport patients to University Health System by ground and air transport. The nurses simulated transport of high-risk patients inside University Health System ambulances with paramedic teams. The team worked with San Antonio AirLife to develop extensive training on procedures for transport from the helipad to referring hospitals.
The program was designed to provide patients with the highest level of care by our OB/Maternal-Fetal Medicine team on arrival at our Level IV Maternal Facility 24/7. Protocols, flight physiology, collaboration of care with the experienced labor and delivery nurse, and skilled flight personnel prepared this highly qualified, specialized team. The Maternal Transport team members participated in training in the Intensive Care Unit at University Hospital. As a result, the Labor and Delivery team is able to transition high acuity patients into the Intensive Care Unit (ICU) and co-manage complicated maternal patients alongside the ICU team.
This robust program was developed through the leadership of Pat Ramsey, MD, MSPH, and team leader Allison Moreno, BSN, RNC-OB. In September 2018, the program met and exceeded expectations of high-risk patients transported from rural southwest Texas to a higher level of care at University Health System. The Perinatal-Neonatal program at University Hospital, under the direction of Rebecca Terrazas, BSN, complements and promotes the team – providing multidisciplinary training to educate the nurses and physicians who provide care for pregnant women and neonates at maternal facilities throughout South Texas. Rural physicians contact our Maternal-Fetal Medicine providers for consults and/or transports, which then allows the University Health System Maternal-Fetal Medicine team to begin caring for patients immediately and evaluate on-site prior to transport.
Uncontrolled hemorrhage is the leading cause of preventable death in trauma patients. An individual can die in just minutes if there is no intervention. To improve survivability rates for the severely injured, the American College of Surgeons has developed Stop the Bleed, a free, hour-long class combining lecture and hands-on skills training. Participants learn the ABCs of basic bleeding control. The curriculum is designed for the general public, so no previous medical experience is needed. The goal of the campaign is to empower bystanders with the basic knowledge and skills to identify and intervene, as immediate responders, in the event of life-threating bleeding. Participants learn the use of direct pressure and tourniquet application.
University Health System held its first bleeding control training in 2017. Since the launch of the program, the trauma team has instructed approximately 4,700 individuals. Classes are offered at the main campus and throughout the community for various organizations, businesses, schools and churches. Children as young as six years of age have been successfully trained in the basics of bleeding control. In 2018, Southwest Texas Regional Advisor Council (STRAC) reported 6,577 individuals received training throughout the region. University Health System contributed to over half that number with 3,378 instructed. With support of the trauma surgeons and nurses who volunteer their time as instructors, the organization is able to meet the growing demand for this lifesaving training.
Having access to a bleeding control kit is an essential part of care of the injured patient. A basic kit includes a Combat Application Tourniquet, gloves, gauze and a marker. Individuals are instructed on how to obtain a kit for personal use. As the importance of immediate hemorrhage control in the injured patient gains attention, bleeding control kits are becoming readily available in many locations, including grocery stores and airports. Current efforts are in place to put a bleeding control kit in every classroom in the country. According to www.BleedingControl.org, the only thing more tragic than a death is a death that could have been prevented.
Two of our dedicated, highly accomplished nurses have earned international recognition for their exemplary skills and service. Congratulations to Debra Fraley and Polly Smith for winning the DAISY Award!
Debra Fraley, MSN, RN, CCRN, CCNS, nurse educator III, Adult Emergency Services, exemplifies quality through her work with the Emergency Department (ED). In addition to directing training in the ED, Debra educates our next generation of healthcare professionals. For over 36 years, Debra has ensured that all aspects of her work, from education to training nurses, emphasizes a commitment to quality and empowers nurses through educational advancement. Debra has earned the trust and respect of her staff and colleagues by continuously setting a positive example of fairness and hard work.
When her team is in need, Debra can be found working side-by-side with nurses like fellow DAISY Award winner Polly Smith, MSN, RN, CPAN, director of PACU, to assist her team or patients. Debra and Polly have earned this award for their consistent nursing care and leadership.
Debra sums up the nursing philosophy that guides their work: “The patients always come first and we must provide them with excellent care.”
Polly leads a team of nurses and is their role model for excellence in nursing in two ways: Setting high standards of service and exhibiting true enthusiasm and passion for serving others.
Debra and Polly believe that the primary goal of nursing is doing what’s best for the patient. They join nurses around the world whose extraordinary clinical skill and compassionate care single them out for the prestigious DAISY Award. Over 3,700 healthcare facilities and schools of nursing in all 50 states and 22 countries honor nurses with the DAISY Award.
University Health System joins progressive healthcare facilities across the United States in recognizing that quality healthcare extends beyond creating a safe healing environment to one that also promotes nurse job satisfaction, teamwork, pride, organizational culture and a healthy work environment.
Polly and Debra’s attitudes of service are an inspiration to other staff and departments that work alongside them.
Pediatric Transport was launched in 2013 to accommodate the growing medical ICU population and the return of the Pediatric Cardiac program to University. The team transports patients requiring specialized services or higher level of care from clinics, freestanding ERs and hospitals to University Hospital.
Pediatric specialty teams are associated with improved outcomes and fewer unplanned, adverse events during transport. Unplanned adverse events include airway-related events, cardiopulmonary arrest, sustained hypotension, and loss of essential IV access. One study showed greater mortality among children transported by a non-specialized team versus a pediatric team (23% to 9%).
Pediatric Transport is comprised of RNs and RRTs who are experienced in pediatric critical care. Since the team cares for patients from birth to young adults, all transport specialists have certification in numerous areas. To maintain skills and knowledge, transport specialists attend a Critical Care Skills Lab annually, perform at least three intubations quarterly, and participate in frequent simulations. Specialists also work shifts in the PCCU, PICU, and Pedi Emergency Department.
While not on transport, the team is available to assist in the pediatric units. They place IVs, draw labs, assist with post-ops, assist with admissions and discharges, provide respiratory treatments and other tasks. The team also responds to pediatric code blues, rapid responses, pedi priority 1s, and pediatric level 1 and alpha 1 traumas.
Continued outreach and outreach education increases referrals from local and regional facilities, and builds relationships with referring physicians and leadership at those facilities. Follow-up visits give a consistent message, answer questions, and introduce our physicians. We also offer outreach education on Sepsis in Pediatrics, Pediatric Respiratory Illnesses and Pediatric Basics. The team has taught in Eagle Pass, Laredo, Del Rio and Fredericksburg.
Marketing efforts include hosting tables at conferences, fairs, and other health events to promote Pediatric Transport and all of University Children’s Health services. At the Teddy Bear Clinic hosted by Commnuity First Health Plans (CFHP) at the DoSeum, 1,100 visitors were exposed to our message and 500 teddy bears got a free check-up.
The priority of the team is transport. Often, referring facilities that don’t offer pediatric services do not have the resources to care for critically ill or injured children, so we must reach our patients quickly. Our goal mobilization time is under 20 minutes. Critical steps must be completed to initiate and prepare for the transport. The team secures appropriate transport (ground, rotor-wing, fixed-wing), taking into consideration weather conditions, patient acuity, patient’s potential to deteriorate, distance, and the referring facility’s ability to stabilize the patient. The team sets up the stretcher or flight board for the size and acuity of the patient, and retrieves needed medications.
At the referring facility, the team acts as a mobile ICU to stabilize the patient for transport and initiates protocol-based and physician-ordered interventions. En route, patchy cellular service can prevent the team from phoning for physician guidance, thus the two specialists on each transport rely on teamwork and training.
Quality care is crucial to great patient outcomes. Goals in 2018 included zero unplanned dislodgements of essential lines/tubes, 100% follow-up phone calls to referring physicians, and less than 20 minutes of mobilization time for unscheduled ground transports. The team achieved 100% follow-up phone calls in the last 6 months of 2018. By December 2018, our mobilization time for unscheduled ground transports was 19 minutes, improved from 49 minutes in January 2018. In 2019, the focus is on improving our IV success rate and continuing a goal time of less than 20 minutes for unscheduled ground transports.