Capstone: running a unit emergency drill

Plans that have never been tested are hopes, not plans. Every lesson in this course has shown the same pattern: problems that nobody noticed on paper became obvious the first time a unit practiced. Stored sleds that no one could unroll, corridors full of equipment, doors that could not be locked quickly, downtime kits with old forms. Drills and exercises are how a facility finds these problems before a real emergency does. In this capstone, you will follow Sarah MacLeod and the 4 West team as they plan, run and learn from a night-shift drill, using the methods that emergency managers use for exercises of every size.

Types of exercises

Exercises range from a conversation around a table to a full-scale test involving the whole hospital, outside agencies and actors playing casualties. In the United States, the Homeland Security Exercise and Evaluation Program (HSEEP) sets out a common approach that many hospitals use, and Canadian emergency managers use very similar methods. Exercises fall into two families:

• Discussion-based exercises talk through a plan without moving people or equipment. A seminar or workshop introduces or develops a plan. A tabletop exercise presents a scenario to a group of leaders and staff, who talk through what they would do, step by step, as the facilitator adds new information. Tabletops are cheap, safe and good at finding gaps in plans, roles and decisions.
• Operations-based exercises test the plan in action. A drill tests one function or skill, such as a fire response on one unit, a decontamination set-up or a call-in of staff. A functional exercise tests coordination and command, such as running the emergency operations center during a simulated mass casualty incident, without moving real patients. A full-scale exercise involves multiple agencies and real people moving through a realistic scenario, such as a simulated bus crash with actors arriving at the emergency department.

The CMS Emergency Preparedness Rule requires hospitals to carry out two exercises each year, at least one of them a full-scale or functional exercise, and NFPA 101 requires fire drills every quarter on every shift. But the best programs choose exercises based on the hazard analysis and on what the facility most needs to learn, not only on what is required.

The exercise cycle

Every exercise, from a ten-minute unit drill to a full-scale event, follows the same cycle.

• Plan: decide what the exercise is for, write objectives, design the scenario, choose participants and roles, and set safety rules.
• Conduct: brief everyone, run the scenario, and observe what happens.
• Evaluate: collect observations, hold a hot wash, and write an after-action report.
• Improve: turn findings into an improvement plan with owners and dates, and follow up until the actions are done. Then test the fixes in a later exercise.

Step 1: planning the 4 West drill

Sarah chose a night-shift drill because the fire drill results and the evacuation model in earlier lessons both pointed to nights as the weak point. She worked with Grant Ellison, Tom Bergstrom for maintenance, the security supervisor and Amira Haddad, who would lead the drill on the unit as the safety committee member, to plan it.

The first step was writing objectives. Good objectives are specific and measurable, so that evaluators can say whether they were met. Vague objectives such as test the fire plan cannot be evaluated. The team wrote five:

• Within 60 seconds of discovering the fire, staff raise the alarm, call 5555 with the correct location, and close the door of the fire room.
• Within 3 minutes, all patient room doors and the smoke barrier doors are closed and the corridor is clear of equipment.
• Within 3 minutes, the charge nurse confirms the oxygen status of every patient on oxygen before any decision to close a zone valve.
• The fire response team arrives on 4 West within 4 minutes.
• Staff move four simulated bed-bound patients to the next compartment within 10 minutes, using beds and evacuation sleds, with every move recorded on the tracking sheet.

Next came the scenario, which needs to be realistic and to test the objectives without putting anyone at risk. The scenario was a fire in the clean linen room at 0300, discovered by a staff member responding to a call bell nearby. The team used a smoke machine with harmless theatrical smoke in the linen room and a light to simulate fire, with the agreement of the fire department and maintenance, and switched the area's smoke detectors to drill mode to avoid sending a real alarm to the fire department.

Then the roles. Every exercise has players, who respond as they would in a real event; controllers, who run the scenario and add information (injects); evaluators, who observe and record against the objectives; simulators or actors, who play patients or other people; and a safety officer, who watches for real hazards and can stop the exercise. For the 4 West drill, the players were the night staff and the fire response team; Grant was the controller; two evaluators from another unit used a checklist and a stopwatch; four volunteers from the education department played bed-bound patients; and Tom was the safety officer.

Safety rules were set in advance. No real patient would be moved; patients on the unit would stay in their rooms with doors closed and a staff member assigned to them, and would be told about the drill the evening before. Any real emergency, or a phrase agreed in advance, would stop the drill at once. All radio and phone messages would begin and end with the words this is a drill. Night staff on the unit were told that a drill would happen sometime that week, but not when, so that the drill would show how they would actually respond.

Step 2: running the drill

At 0300, Grant started the smoke machine and gave the first inject to the nurse responding to the call bell: you see smoke coming from under the door of the clean linen room and smell burning. From then on, the evaluators recorded times and observations. Grant added two more injects during the drill: at 2 minutes, a simulated patient in room 414 asks to go to the washroom and is confused; at 5 minutes, the fire response team is told the elevator they would normally use is out of service. Injects test the parts of the plan that a simple scenario might not, such as decisions under pressure and backup routes.

When the last simulated patient was moved and checked in, Grant ended the drill with the agreed announcement, and the unit returned to normal care. The whole drill took 14 minutes.

Step 3: evaluating

Right after the drill, Sarah held a hot wash: a short, informal debrief with everyone who took part, while memories were fresh. She asked three questions: what went well, what did not go as planned, and what would you change? The tone was learning, not blame. Then the evaluators compared their records with the objectives, using a short script to score the drill.

# 4 West night fire drill: results against objectives
objectives = [
    # objective, target seconds, actual seconds (None if not observed)
    ("alarm raised, 5555 called, fire door closed",  60,  48),
    ("all doors closed and corridor clear",         180, 205),
    ("oxygen status confirmed for all patients",    180, 170),
    ("fire response team on unit",                  240, 290),
    ("four bed patients moved and tracked",         600, 540),
]
met = 0
for name, target, actual in objectives:
    ok = actual is not None and actual <= target
    met += ok
    status = "met" if ok else f"missed by {actual - target} s"
    print(f"{name:45}{actual:4} s  {status}")
print(f"objectives met: {met} of {len(objectives)}")

alarm raised, 5555 called, fire door closed    48 s  met
all doors closed and corridor clear           205 s  missed by 25 s
oxygen status confirmed for all patients      170 s  met
fire response team on unit                    290 s  missed by 50 s
four bed patients moved and tracked           540 s  met
objectives met: 3 of 5

Three of the five objectives were met, and the observations explained the two that were missed:

• The corridor took 205 seconds to clear because a vital signs machine and a lift had been left outside rooms 409 and 410, and the staff member assigned to clear the corridor was also helping the confused patient in room 414.
• The fire response team arrived 50 seconds late, because two of its members were on another floor and their usual elevator was out of service, as in the inject; they did not know the alternate route through the east stairwell.
• On the positive side, the alarm and first call were fast and accurate, the oxygen check was done before anyone touched the zone valve, and the sled moves were smooth, because the unit had practiced them at the skills day.
• The tracking sheet was used for all four moves, but the time of each move was missing on two lines.

The evaluators also noted things the objectives did not cover: the overhead announcement could not be heard in two rooms at the end of the corridor, and one staff member did not know where the second evacuation sled was stored.

Step 4: improving

Within two weeks, Grant and Sarah wrote a short after-action report: the objectives, what happened, what went well, what needs to improve and why. It ended with an improvement plan, the part that matters most, because findings that are not acted on will appear again in the next drill or a real emergency.

The improvement plan went to the emergency management committee and the safety committee, which tracked each action until it was finished. Three months later, the unit ran a shorter night drill to test the fixes: the corridor cleared in 150 seconds and the response team arrived in 3 minutes 40 seconds, using the east stairwell. That repeat test closed the loop.

Lessons for any drill

Running a good drill on any unit does not need a big budget. It needs a few habits:

• Start from your own hazards and weak points, and write objectives you can measure.
• Keep it safe: never move real patients for a drill, use volunteers or mannequins, plan for real emergencies during the drill, and say this is a drill on every message.
• Test the shifts and situations that matter most, including nights and weekends, not only weekday days.
• Use evaluators who are not taking part, and give them a checklist and a stopwatch.
• Hold a hot wash right away, and keep it about learning, not blame.
• Turn every finding into an action with an owner and a date, and test the fix.
• Start small. A ten-minute tabletop discussion at a staff meeting, asking what would we do if the power failed now, is an exercise too, and often finds real gaps.

Over this course, you have seen how emergencies in healthcare are planned for, called, answered and learned from. The common thread is that preparation happens before the emergency, and that every worker, not only managers and specialists, is part of it. Knowing the codes, keeping corridors clear, charging equipment, knowing where the sleds are, reporting near misses and taking drills seriously are the everyday actions that decide how a facility performs on its worst night.