Utilization of

Information Systems for ED Disaster

Registration and Tracking

C L I N I C A L

Authors: Robert Powers, BS, RN, EMT-P, and Julie Phipps,

RN, MSN, Raleigh, NC

Robert Powers, NC ENA: Heart of Carolina Chapter, is EmergencyPreparedness Coordinator, Emergency Services Institute, WakeMedHealth and Hospitals, Raleigh, NC.

Julie Phipps is Systems Analyst II for Emergency Services, WakeMedHealth and Hospitals, Raleigh, NC.

For correspondence, write: Robert Powers, BS, RN, EMT-P, 9200Dawnshire Road, Raleigh, NC 27615; E-mail: rpowers@wakemed.org.

J Emerg Nurs 2006;32:497-501.

0099-1767/$32.00

Copyright n 2006 by the Emergency Nurses Association.

doi: 10.1016/j.jen.2006.09.005

December 2006 32:6

uring a disaster event, the rapid inf lux of pa-

Dtients into the emergency department coupled

with the paper documentation that emergency

departments standardly revert to in mass casualty incidents,

makes it challenging to quickly locate patients, to register

them, or to have real-time information available to guide

operations response. By utilizing existing information sys-

tems, WakeMed Health and Hospitals was able to develop

a process to facilitate the whole registration procedure and

to capture needed information quickly and accurately.

WakeMed Health and Hospitals has 4 emergency

departments in its system. The Main Campus emergency

department in Raleigh, NC, is a 60-bed Level I emer-

gency department coupled with a 22-bed children’s emer-

gency department (CED). Additionally there is a 25-bed

emergency department at WakeMed-Cary and a 14-bed

freestanding emergency department at WakeMed-North

Healthplex. Combined volume at the Main Campus emer-

gency department and CED for 2005 was 122,812 pa-

tient visits.

Difficulties With Paper System

Before implementation of the new system, WakeMed used

a paper-based process for tracking patients during a di-

saster or mass casualty incident. A gas leak at a local mid-

dle school brought a large number of patients to the CED.

The CED used WakeMed’s paper-based process for track-

ing and registering patients during a mass casualty incident.

With this procedure, arriving patients were logged onto

a paper log upon arrival to disaster triage and assigned a

pre-assembled disaster packet. Patients were later regis-

tered into the hospital information system at discharge or

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FIGURE 1

Sample disaster HMED chart.

C L I N I C A L / P o w e r s a n d P h i p p s

as time allowed during the event. Copies were made of

the current disaster log to distribute among charge nurses

and ED administration; knowing which or how many

patients had arrived was dependent on having a current

copy of the disaster log. Patients were logged into

the emergency department’s electronic tracking system,

but that was dependent on a nurse or registrar being free to

do it and, as a result, that information was incomplete and

lagged behind current conditions in the CED. Addition-

ally, patients were relocated within the department after

initial placement, furthering the difficulty of keeping up-

to-date information on the current location of patients.

Hospital administration also came to the CED to ob-

tain the most up-to-date information and tended to stay

in the CED to ensure they kept abreast of the latest con-

ditions. Parents of patients were also arriving, some very

early in the process, having received calls directly from their

children via cell phone, and time was required to pinpoint

the current location of the patient because of the lag-

time and incompleteness of the paper records and the

tracking board.

System Change

The emergency department had recently begun a process

of updating their existing pre-made disaster packets, and

discussions began about improvements that could be made

in the system. These packets contain all the paperwork nec-

essary to process a patient through the emergency depart-

ment and are pre-assigned with a disaster patient number.

Arriving disaster patients were assigned one of these packets

and a disaster patient number. However, the numbers were

kept on paper tracking logs and registration staff were

registering the patients into the system when they had spare

time during the disaster event. This registration process was

the same as everyday arriving patient registration, and time

was required to do it. With the arriving inf lux of mass

casualty patients, spare time sufficient for a full patient

registration is rarely found. Thus the information system

rarely had current information, and paper logs were the

ultimate authority for current conditions.

WakeMed emergency departments use Healthmatics

ED (HMED) for their emergency department information

system (EDIS). HMED is used for a patient tracking board,

498 J

for documentation, and for order entry (Figure 1). Beyond

replacing the whiteboards of years past for patient tracking,

HMED allows for nursing and physician documentation.

HMED is interfaced to the hospital information system,

Siemens Medical Solutions (SMS) Invision. HMED

receives an account number and inbound demographic

information from Invision. Once this information updates,

HMED orders can be sent to and from HMED and SMS,

the laboratory, radiology, and patient placement systems.

Results of laboratory and radiology tests can also be sent

directly back to the HMED electronic patient chart.

With staff already used to electronic documentation

and order entry, it seemed like the perfect vehicle for uti-

lizing in disasters. Because it was already in everyday prac-

tice, there would be no double standard; what was done

for the everyday patient would also be done for the disas-

ter patient.

A registration process was developed that ties the

disaster packets to the electronic system (Figure 2). The

process was also streamlined with a quick disaster registra-

tion process and by pre-loading all the disaster patient

packet numbers into the information systems. Through

this combination of improvements, an arriving disaster

patient could be registered with 5 key-strokes and in less

than 10 seconds. This new disaster registration process was

then incorporated into the existing disaster plan.

OURNAL OF EMERGENCY NURSING 32:6 December 2006

FIGURE 2

HMED disaster activity/chief complaint. FIGURE 3

ED disaster triage registration. Photo credit: Robert Powers.

C L I N I C A L / P o w e r s a n d P h i p p s

Information System Disaster Process

When a disaster event occurs, there may or may not be

early notification from the scene before the arrival of pa-

tients. If there is early notification from the scene, ED

registrars can begin the quick registration process for these

patients using their disaster patient number. For instance,

EMS notifies the emergency department that 50 patients

are coming from a bus accident. Before the first patient

arrives, the registrars will take the first 25 male and the

first 25 female packets (unless field information indicates

different male/female ratios) and pull up these pre-loaded

patient numbers on HMED. The disaster patients will be

indicated as ‘‘pending arrival’’ on the tracking board. Then,

with the ‘‘quick reg’’ process, the patients will be entered in

the hospital, emergency department, laboratory, and

radiology IS systems. In this way, when the patients arrive

all that would be required would be snapping on the

armband from the disaster packet that has the patient’s

registration number on it and updating their location

in the emergency department. Patient names would then

be updated in both HMED and SMS as soon as they

became known.

ED Registrars or ED IS staff are assigned to disaster

triage, which is set up near the ambulance bay to receive

the inf lux of disaster patients. At this location the armband

is placed on the patient if they have been pre-registered

before their arrival. If not, the ‘‘quick reg’’ process is done

at triage while the physician/nurse team carries out triage of

December 2006 32:6

the patient. Registration is done at this point through the

utilization of a wireless computer or ‘‘COW,’’ that is, a

‘‘computer on wheels’’ (Figure 3).

Patients that are triaged as green tag patients by

EMS or by ED disaster triage personnel are diverted from

the emergency department and go to the Andrews Center,

which is immediately adjacent to the emergency depart-

ment. WakeMed Faculty Physicians run clinic offices in

the upper f loors of the Andrews Center. In a disaster event,

clinic staff organizes the ground f loor conference room

area of the Andrews Center to receive green tag patients.

They also stockpile disaster packets that are brought to

their triage area. The HMED software has been loaded

onto their wireless computers and WakeMed Faculty

Physicians’ staff begins registering their patients using the

same process followed at the ED disaster triage area.

HMED allows for patients to be assigned rooms and

tracked by that assignment. For instance, ‘‘A Bay’’ of the

adult emergency department has three trauma rooms and

nine acute patient care rooms; scrolling through the A Bay

listings on HMED shows those patients by location, name

and chief complaint. Registered disaster patients would be

updated on the HMED tracking board by ED staff to their

specific location as they arrive from disaster triage.

Also, the emergency department uses hallway space

surrounding the adult emergency department for surge

expansion in a disaster event. These 2 hallways are iden-

tified as Area 51 and Area 52. These expansion area beds

JOURNAL OF EMERGENCY NURSING 499

FIGURE 4

Hospital Emergency Operations Center. Photo credit: Dr. William

K. Atkinsen, II.

C L I N I C A L / P o w e r s a n d P h i p p s

are already in the HMED system like regular bay beds;

however, they are de-selected from view so that they only

appear when they are being used. During a disaster event,

RN hall monitors oversee the expansion area and, through

the use of portable wireless computers, ensure that arriv-

ing patients are entered in the proper hallway space, eg,

Area 51-12. Use of the portable computers in the expan-

sion areas also allows nurses and physicians to process

orders at bedside, and returning lab work can be viewed

electronically rather than having staff tied up returning

paper lab results throughout the department.

Additionally, the green tag patients are seen in

WakeMed Faculty Physicians’ clinic offices after being

triaged and quickly registered in the downstairs conference

area. These individual clinic rooms are also pre-established

in the HMED system so that a patient can be placed in

the specific clinic room in HMED and tracked to their

exact location throughout their time in the hospital.

Sustainability

Sustainability during an event is addressed by long life

batteries on the wireless computers with verified 12-hour

lives, back-up batteries, and the inclusion of IS systems on

emergency power. Additionally, paper back-up systems are

in place to handle documentation and tracking should

there be unforeseen difficulties with the system or signifi-

cant hospital infrastructure damage.

Advantages

By utilizing the IS system, charge nurses are not depen-

dent on having a current paper copy of the disaster log in

hand to know how many patients are in the department

and where they need to send more resources. They can

view any computer screen in the department for a real-time

view of patients being triaged and of their exact location

within the department. As patients are shuff led to accom-

modate additional incoming waves of patients, there is

no need for runners to update master boards because in-

formation is immediately updated electronically by hall-

way monitors in the expansion areas or by bedside nurses.

Nor are runners required to track down patients to return

lab results because the system electronically returns results.

Also, by using a chief complaint of ‘‘disaster’’ in HMED

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for the disaster patients, the charge nurse or ED admin-

istration can readily differentiate between patients involved

with the disaster event and ‘‘regular’’ patients. Additionally,

with green tag patients located in a separate building, the

HMED system allows for patient tracking throughout

both areas. No phone calls or runners are required in the

search for a patient as the green-tagged patients in the

Andrews Center can easily be viewed by the charge nurse

in the emergency department.

The hospital emergency operations center (HEOC)

is located away from the emergency department. Distance

has been problematic in the past because of lack of real-

time information available for guiding the administrative

response to the disaster event. Now, however, HMED is

displayed for the HEOC on a wall screen where they can

view real-time information about the situation (Figure 4).

They can quickly assess the number of arriving patients and

view chief complaints so early estimates can be made on the

likely services impacted and the number of admissions

from the event. Informed decisions regarding hospital re-

sponse can be made as they’re happening, with a complete

view of the event, rather than from information pieced

together from different team leaders with only partial views

of what is transpiring. This also serves the emergency de-

partment because it eliminates the clutter of administrative

personnel in the emergency department trying to gather in-

formation while the emergency department is receiving

large numbers of patients.

OURNAL OF EMERGENCY NURSING 32:6 December 2006

C L I N I C A L / P o w e r s a n d P h i p p s

Previously, registrars used the paper log at disaster

triage and then were expected to free up after the inf lux

to register patients before they were discharged or admitted

out of the department. In an on-going event, registrars have

difficulty completing this 2-stage process. The removal of 1

step plus the creation of the disaster ‘‘quick reg’’ process has

allowed the registrars to keep pace with the swift processing

of patients by the MD/RN triage team.

The information captured on the HMED system also

allows for a better post-event critique because the details of

patient arrival and movement are better captured through the

computer system. Also, this capture of information helps

disaster research by detailing vital information such as exact

arrival times and exact impacts on the hospital response.

System Test

The system was tested during a countywide drill. WakeMed

was to receive patients from a city disaster drill involving

the release of nerve agents. Registration was established at

disaster triage and at the Andrews Center, for the green tags,

and registrars quickly entered the arriving patients. The sys-

tem worked as expected, easily keeping up with arriving

patients and keeping everyone abreast of the current situa-

tion. Laboratory and radiology order entry and results re-

porting was also tested and both departments reported

positively on their ability to keep up with a high volume

of requests.

In the HEOC, ED staff or ED IS staff assisted hospi-

tal administration in properly interpreting the data being

displayed on HMED. HMED, displayed on a wall screen,

greatly enhanced hospital administration’s ability to gauge

the current conditions of the emergency department.

Conclusion

Implementation of a disaster registration and tracking pro-

cess utilizing existing information systems has significantly

lessened the difficulties of keeping pace with the rapid ar-

rival of large numbers of patients to the emergency de-

partment. Not only is registration completed promptly,

which facilitates order entry and documentation, but real-

time information is also readily available to guide emer-

gency department and hospital decision makers through

the disaster response.

December 2006 32:6 JOURNAL OF EMERGENCY NURSING 501