Making Hospital Triage Operations Safer

ER personnel have a difficult time deciphering messages regarding incoming victims. The risk of a misdiagnosis from an incorrectly heard message is real.

SINCE September 11, 2001, hospitals across the United States have invested in equipment to facilitate safe operations and communication during a crisis involving airborne infections or nuclear/biological/chemical (NBC) contaminants. The extent of this investment varies from one region of the United States to another and from one hospital to the next, but this much is clear: When personnel wear powered air-purifying respirator (PAPR) suits, most hospitals are still ill-prepared to facilitate clear communication among staff and to patients.

Most hospitals currently use portable decontamination tents to treat the victims of NBC types of events. In other instances, buildings attached to the hospital are used. It is within and adjacent to these areas where emergency communication would occur. While triage teams must prepare for events such as a Severe Acute Respiratory Syndrome (SARS) outbreak, a more likely scenario would involve some type of chemical spill. No matter the type of environment or contaminant, effective communication is critical.

During training exercises where PAPR suits were used in a triage tent or other decontamination area, doctors, nurses, security staff, and others found it difficult to communicate even while using portable radios. As a result, patient and triage team member safety was compromised.

A person wearing a PAPR suit experiences 76 decibels of air noise around the ears. Other noises that affect the wearer's ability to hear include shower sounds and radio chatter from other personnel in the tent area. Being able to clearly hear a patient is imperative. The mouth area also is covered by the suit, which further complicates communication. Injured persons in the tent often cannot hear doctors or nurses. Sometimes a patient may have a hearing impairment. In most instances today, medical personnel have to yell to be heard. "You get tired fast in a PAPR suit," says Dr. Mary Russell, a research and organizational preparedness specialist at the 400-bed Boca Raton Community Hospital in Boca Raton, Fla. "It is easy to get hoarse trying to be heard."

To communicate among themselves, hospital personnel typically use two-way radios. Unfortunately, one needs at least one hand to hold and key a radio. That easily compromises a doctor's or nurse's ability to assist a patient. Often, decontamination team members are not properly trained in the use of two-way radios. In one recent drill exercise, personnel at one hospital attempted communication while not keying the radios. Others continued to hold the Push-to-Talk (PTT) button down too long after communicating. While they were doing so, the radio frequency was unusable by others.

Radio chatter is a flaw inherent in triage environments today. Too many people talking on the same frequency makes it difficult to communicate effectively. Emergency room personnel have a more difficult time deciphering messages regarding incoming victims, and the risk of a misdiagnosis from an incorrectly heard message is real.

Triage team members' inability to communicate effectively with security personnel also is problematic at most hospitals today. In a decontamination zone, it is critical that security personnel always know exactly what is going on in the triage area and what contaminants are present. If wearing PAPR suits themselves, they also need hands-free ability to communicate with bystanders, triage team members, and victims.

In any decontamination environment, process time is critical. The more time needed to decontaminate a victim, the greater is the likelihood of injury or additional injury. Of course, the timeframe varies by contaminant, but a communication system should not compromise the speed of the decontamination process. The goal of any hospital team should be to reduce the time from point of decontamination zone entry to exit. With proper training and the proper communication equipment, this can be done.

New Technology Addresses Communication Gaps
Fortunately for hospital emergency response teams, communication systems recently have been introduced to address the challenges of effectively hearing and speaking in a decontamination zone. One such system has been implemented by Boca Raton Community Hospital. It utilizes a throat microphone, oversized push-to-talk (PTT) button, and belt-mounted voice amplifier. It works in tandem with most radios and enables hands-free communication.

Prior to donning a PAPR suit, team members assist one another with the quick communication system set-up. The routine includes connecting the radio to the PTT button, the radio to the belt, and the PTT button to the shirt. The setup also involves placing a throat microphone around the neck and an ear speaker in one ear, as well as connecting the throat microphone by cable to the PTT button. Once the PAPR suit is donned, an amplifier is attached to the belt and connected by cable to the radio/PTT/throat microphone system.

Because the radio is connected to the belt and the PTT button is attached to the shirt, doctors, nurses, and security personnel can have both hands free in the decontamination zone. To communicate to other team leaders with the radio, one need only push the oversized PTT button. When releasing the button, outgoing radio communication stops. The throat microphone and voice amplifier are used to project the voice to others in the triage area. The voice sound level can reach 82 decibels out of the amplifier, easily overcoming the PAPR suit noise level. Once the amplifier is on, it projects anything the user says unless the PTT button is pushed for radio communication. With improved communication, only key team leaders need to use radios. "The lower the number of people who are using a radio, the better," Russell says.

A reduction in radio traffic enables a triage operation to run on just one frequency and allows emergency room personnel to more effectively prepare for incoming victims. Other frequencies are available and open to call for backup, if needed. With communication issues addressed, doctors and nurses can do a much better job helping to calm the injured. "Security personnel also can do a much better job managing crowds at the perimeter of the triage zone," Russell says. "We've also trained our maintenance and engineering staff how to use the communication system."

Hospitals interested in implementing communication systems that incorporate throat microphones, PTT buttons, and voice amplifiers should consider the ruggedness of the products and whether or not they can be decontaminated after the emergency has taken place. It is also important to look for systems that are certified to be intrinsically safe. This means the products can be used in environments where explosive gases are present.

Hurricane Wilma Tests Hospital Staff
While not an NBC or airborne virus type of event, late October 2005's Hurricane Wilma tested the preparedness of the staff at the Boca Raton hospital and demonstrated the importance of having an effective communication system. After leaving a path of destruction in Mexico, the fifth-costliest storm in U.S. history made its way through southern Florida, destroyed homes and infrastructure, and left 6 million people without power. Approximately 2,200 hurricane victims visited the hospital for treatment of injuries.

Russell says patients crowded the hospital, its hallways, and reception area and were even stitched up in the parking lot. Communicating with all those people was a challenge. "We had a bullhorn, but it was not very patient-friendly," she says.

Considering its proximity to I-95 in southern Florida, the hospital's staffers often train in PAPR suits to prepare for transportation-related accidents involving some type of chemical spill. Even though PAPR suits were not needed for Wilma, throat microphone and amplifier training made a difference and simplified communication. Some hospital staff had been working more than 20 hours straight and would have strained their voices if they had to shout instructions to the crowd of patients. By using the communication system, they were able to save their voices and communicate effectively. Having both hands free also enabled hospital personnel to more easily treat victims. Russell says the system was especially helpful when trying to speak with those patients who were hearing impaired. "It was easy to use, and we did not have to charge it," she says.

Practice Prompts Progress
As emergency response to recent man-made and natural catastrophes has demonstrated, communication in a hospital decontamination zone remains an important issue, especially in regard to the ability to communicate while wearing a PAPR suit. Improper equipment, fatigue, and extraneous noise all compromise the ability of personnel to communicate among team members and to patients. Having to use one hand to operate a radio inhibits the ability to assist a patient.

Fortunately, new systems have been introduced to help overcome the communication hurdles emergency response team members face while wearing PAPR suits. The benefits of these systems are numerous: hands-free operation, less voice fatigue, the ability to amplify one's voice clearly to patients and to team members, a reduction in radio chatter and the number of frequencies used, and an overall improvement in the decontamination zone safety level.

This article appeared in the July 2006 issue of Occupational Health & Safety.

This article originally appeared in the July 2006 issue of Occupational Health & Safety.

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