UVA Health System was on the front lines responding to the violence that erupted in Charlottesville on August 12. Advisory Board's Jennifer Stewart and Josh Zeitlin spoke with UVA Health leaders about their lifesaving strategies—including their decision in advance of the protest to free up hospital beds, their coordination with other local providers on how best to respond to casualties, and their monitoring of social media to learn about a terrorist attack in real time. This interview was conducted prior to the Oct. 1 mass shooting in Las Vegas.
Question: How did UVA approach its preparations for the Charlottesville rally and counter-protest?
Tom Berry, Director of Emergency Management, UVA Health System: I'd break our preparations into four categories: 1) Intelligence analysis; 2) Small working groups; 3) The large incident management team; and 4) Coordination with local, regional, and state entities.
On intelligence analysis, in advance of August 12, we were getting information through unclassified and classified sources that people were coming to Charlottesville to protest and that things might get violent.
I received some of that information from the local police departments, the university, and regional stakeholders. I also did a lot of data mining myself through social media and the websites of various groups, while keeping our information security team in the loop. That gave us situational awareness, and it made our heightened readiness more credible.
As a result, we knew about two and a half weeks out when we began our planning process that we were going to stand up our command center first thing Saturday morning. We also made the decision to decompress the hospital.
Jody Reyes, Cancer Services Administrator at UVA Cancer Center and UVA Medical Center's incident commander on August 12: As you can imagine, decompression of the hospital was not a popular decision, but leadership recognized that limiting elective admissions toward the end of the week would ensure we would have plenty of acute beds and ICU beds available. We wanted to make sure we were well postured to absorb a large volume of patients if called upon.
Small working groups
Tom: Our small working groups, the second preparedness category mentioned above, helped with those efforts. We had eight or so small groups that worked on everything from clinical operations to logistics to communications plans. These small working groups are where the real work and coordination occurred.
The large incident management team for information sharing
Intel collection and small working groups for planning were supplemented by a third preparedness category, convening the large incident management team to share information, to just make sure everyone understood what others were working on. We formed this large group of 100 or so people twice in 90-minute sessions before August 12 , which included leaders from our health system, local fire/rescue representatives, Virginia Department of Health leaders at the regional level, and officials from Sentara Martha Jefferson Hospital, our sister hospital across town. These efforts were not for coordination, but for information sharing; there were simply too many people involved to conduct detailed planning.
Finally, the fourth planning category was sharing information with our local, regional, state planners.
In short, throughout the preparedness phase, we reminded people that it was not necessarily the plan that we developed but the planning process that was most important. These four key categories broke down barriers, eliminated misunderstandings, created buy-in, established accountability, and empowered experts to do what they do best—so on Saturday morning, the left hand knew what the right hand was doing. There weren't any misunderstandings to be had; those had already occurred and been addressed in the small working groups and large information sharing sessions.
Q: How did you work with the nearby hospital, Sentara Martha Jefferson?
Jody: Coordination with the local community hospital, Sentara Martha Jefferson, was critical, as we all needed to be prepared to support our community. It was refreshing to see the teamwork and planning that occurred between our two organizations. Together we planned for UVA, as a Level I trauma center, to take the more acute and emergent patients if something were to happen, while Sentara Martha Jefferson would be better situated to care for the other patients. That plan worked out very well that day. Ultimately 28 patients came to UVA from the incident, including a few pediatric patients, and another dozen or so received care at Sentara Martha Jefferson.
Q: So after those weeks of preparation, you get to August 12. Can you discuss how you approached handling the unexpected and staff anxiety on what must have been a stressful day?
Tom: There was a lot of activity in downtown Charlottesville early on Saturday, and we sensed that the anxiety level within our hospital team members was pretty high. Even though we were a mile down the road, some staff members felt unsafe at first.
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We had our employee assistance program on call, and we made a decision to pull them in to start doing rotations to make sure team members were aware of the security plans we had in place. Our CNO also gathered all the managers, directors, and administrators who were on-site to do rounds to reinforce and familiarize team members with our security and clinical operations plans. That reassured team members that they were safe to do what they were going to be asked to do later in the day.
Our three-tiered security plan was really key for us. Phase one was controlling access to our buildings by having all but two exterior doors locked, phase two was controlling access to our units if necessary, and phase three was controlling access to the primary road in front of our hospital if necessary by shutting down the main road, so if we had massive surge of ambulances and patients we would have room.
Jody: There were a few hiccups for us early that morning, and while they were pretty minor issues, they could have become something more significant if our team hadn't been so prepared.
Once the violence broke out at the event, we made the decision to close off the main road in front of our medical center, to ensure that ambulances and other emergency vehicle could easily get to our front doors. Unfortunately, we had a few physicians called in emergently who couldn't get to the medical center through our blockades, so we had to work through that in real time.
We also didn't anticipate the level of communication that would be needed between the incident command center and our inpatient teams. For example, when patients started arriving to the emergency department, we made the decision to restrict access on our inpatient units. Because we didn't communicate this prior to locking the doors, our inpatient teams got very nervous, and we needed to quickly draft a communication that there was no immediate threat, but this was precautionary, as we were concerned that visitors of injured patients could become violent in their spaces.
One last important lesson learned: Words matter. Both our ED team and security team were incredibly prepared. The ED had developed an escalation plan based upon four tiers that correlated with patient flow, while our security team had an escalation plan based upon four phases that correlated with risk and safety. Quickly we identified that as one team might need to escalate their readiness, there would be the need for the other team to escalate their readiness as well. The confusion between "tiers" and "phases" were cleared up, clearly written down in the command center, and didn't become an issue at all.
Q: While you all were responding to the expected and unexpected, what was it like in your home base for the day, the command center?
Jody: Both Tom and I were on active duty in the military and saw combat action during deployments, so while this was stressful, it was the kind of work we were comfortable with. Tom was so calm and collected, and that set the tone for the entire command center. After all the preparation that had taken place, it was like a choreographed dance in there.
The protests occurred about a mile down the street from our medical center, so we knew that once an injury occurred we would have little time to prepare and respond, so relying on traditional radio communications would have put us behind the curve.
If you would have walked into the command center you would have seen two huge screens projecting information that gave us 'real-time' situational awareness. We had a specialist in room monitoring and projecting social media channels on the big screen. We knew, for example, that the car accident had happened almost immediately because we had Periscope video on the downtown mall that we were watching in real time. A software application we use to facilitate communication across the University, the city, and the county known as VEOCI was leveraged to facilitate in-the-moment communication, collaboration, and coordination, which was extremely helpful.
Q: Could you speak more to who was in the command center and what roles they played?
Jody: The incident command center was divided into four hubs: The administrative team, which included Tom and me, our PIO (Public Information Officer), communications team, and our health system's executives, including the Executive VP for Health Affairs, Dr. Rick Shannon, our Chief Nursing Officer, Chief Medical Officer, Chief Operating Officer, and Strategic Planning and Marketing Chief. Each one of our senior leaders was highly engaged and available throughout the day. While me, Tom, and the rest of the Incident Management Team (IMT) were managing the incident ("what's now" and "what's next"), they were considering the strategic environment ("what else").
The next hub was our logistics team, which included leaders from security, supply management, patient transport, facilities, pharmacy, and the traditional service support teams. We also had the planning team, which was our lifeline into the day's activities, maintaining situational awareness, communicating decisions, deploying and reallocating resources, and coordinating our priorities. They were plugged into Charlottesville and University Police and were on top of what conversations were taking place on social media.
The 4th hub was our clinical operations team, which monitored the bed board up on the big screen, tracking, in real time, inpatient/ED/OR capacity. This team also managed face-to-face communications via telemedicine with our ED, hazmat area, and family assistance center. It was really something impressive to be part of.
Tom: We decided to stand up our family assistance center early on. In the end they processed 35 family members, connecting them with their loved ones through telemedicine, and with social workers and chaplains. Often in these situations, you tend to focus more on your clinical operations, your logistics, but setting up a family assistance center alongside all of that is really key. Providing support to others and connecting them with their loved ones in times of crisis is the difference between an average-performing organization and a high-performing one.
UVA Medical Center main entrance, catastrophic MCI staging and receiving area, morning of Aug. 12
In addition, once we got notice that a mass casualty incident (MCI) occurred in downtown Charlottesville after a vehicle was used as a weapon, we quickly flipped the switch from receiving patients into the normal ambulance receiving area by our ED to receiving ambulances and patients through the hospital's front doors and into our front lobby. That gave us more room to receive ambulances. Some patients would go straight to the ED while others would go directly to the OR from the front door. We've spent a lot of time planning how that would work, going back about two years. We drew a lot from other MCIs in Paris, Aurora, and Orlando.
Q: You mentioned Periscope and social media. Could you speak more to how you used technology in your preparation and response?
Jody: In terms of technology, we utilized a web-based application called VEOCI, which stands for Virtual Emergency Operations Center, to aid in immediate communication with all members of the clinical and command center teams. Whether using an iPhone, iPad, or work station, we all were able to know what was happening from a logistics, planning, and clinical standpoint.
Tom: VEOCI can be used to share information similarly to Facebook and things like that.
Jody: On August 12, we quickly learned how important a tool like VEOCI was, and that it should be used only if you had something important to contribute. As Incident Commander, I spent a significant amount of time on VEOCI monitoring each component of our operation simultaneously. For example, we used it to determine capacity across the medical center; our physician lead in the OR reported that they had two rooms going, three rooms available, and two on-call teams in route to the hospital. Everyone logged into VEOCI could see this critical status instantaneously.
Tom: In addition, we also used more traditional communication methods like 800 megahertz radios and a basic paging system, along with telephone, cellphone, and email. To me, the more redundancies that you can create in terms of technologies and communications to share information and communicate directives, the better.
Q: After August 12, what steps have UVA leaders taken to address the events that occurred and to surface lessons learned?
Gov. Terry McAuliffe visits Hospital Command Center team, Aug. 13
Jody: The following week, we conducted a two-hour debrief with all who participated in the August 12th event, reflecting on what went well, and also what we had learned. Recognizing we had time to plan and prepare for the August 12th event, we challenged ourselves to consider how we might respond to a mass-casualty event with no warning. We also considered how we might stand up a comprehensive command center and pivot our focus on a dime from routine clinical care to a preparedness stance. There is a heightened awareness that we have more work to do there.
As our Director of Emergency Management, I think the hardest part of Tom's role is that no one want to interrupt their day-to-day patient care activities to 'drill' for a mass casualty event. I think that after August 12, we recognized how important it would be to find the time to drill in the future.
Tom: People across the system, whether or not they had a role day-of—our executive vice president, Dr. Shannon, and other senior leaders, including the CEO, CNO, COO, CMO, and head of strategic relations and marketing—took it upon themselves to have a town hall meeting. They live streamed it so that any of the 13,000 system employees, wherever they might be, could hear about what had happened and our takeaways. I thought that had huge impact in making sure that team members knew that things were transparent, that even though we felt like we rose to the occasion that there's always room for improvement. That to me set the tone for moving forward. We also did an after-action review and came up with corrective actions that we want to take away and improve on.
More on how hospitals can prepare for disasters
Hospitals must be prepared for myriad disasters that can stress health care systems to the breaking point and disrupt delivery of vital health care services.
Advisory Board has compiled step-by-step procedures for various threats your facility may encounter—though we hope you'll never need to use them.
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