Ice-Mageddon in Fort Worth

• Involve your scheduling team in the assignment of mandatory overtime shifts to help ensure employees still maintain adequate rest periods between scheduled shifts.
• Plan ahead for non-emergency interfacility needs and attempt to do as many calls proactively as possible.
• Suspend the use of “HOT” response modes as soon as the risk-benefit analysis is tipped to the risk side of the equation.
• Continue mobilization of resources until the non-emergency volume delayed due to the incident has been successfully completed.

Two inches of frozen precipitation would be challenging for most communities, but in a community known more for its 70+ days of summer with temps over 100° F, it tested the will and innovation of MedStar and the entire Fort Worth EMS community. Winter Storm Cleon, (we prefer to use “Ice-Mageddon”) resulted in a 22% increase in typical emergency medical service calls, and a 44% increase in the time it normally takes to complete a call.

Anticipating not only the call volume increase, but also the increase in the time it would take to complete the calls, the Fort Worth Fire Department, other area first response agencies, MedStar and the EMS system control authority, the Emergency Physician’s Advisory Board (EPAB), put several innovative emergency action plans in place.

The lessons learned from this protracted event could be of use for other communities facing significant weather or other adverse operational conditions.

Lesson #1: Plan Ahead and Keep Planning

The weather predictions were ominous, but thankfully the predictions gave us time to make plans. We quickly implemented an Incident Command System (ICS) using the National Incident Management System (NIMS) to begin the planning process. We identified essential internal stakeholders who would be involved in any kind of operational planning and developed objectives for each operational period. ICS incident action plans (IAPs) were used for each 12-hour operational period and situational briefings were held at the transition of each operational period so all command staff would be briefed on the significant happenings during the previous period and the goals for the next operational period (see Figure 1).

We planned on three major impacts to the EMS system. First, an increase in non-emergency response volume prior to and immediately following the storm. Second, the volume of calls would dramatically increase during the storm due to motor vehicle crashes, falls and weather-related exposures. Third, the time it would take to complete a call would be significantly longer. MedStar’s typical December call volume is 333 calls per day, with an average task time of 65 minutes. The key to returning to normal system delivery was anticipating the impact of the increase in the non-emergency volume and staffing for it.

We started working with our internal departments to help ensure additional resources for the adverse weather.

Personnel:

Local hotel rooms were secured for employees who lived outside our immediate service area and a shuttle system was developed to bring employees to and from the local hotels to ensure they could report for work as scheduled. This also helped ensure safety for our employees by reducing the need for them to drive in the treacherous road conditions.

Knowing the field crews would be pushed to the maximum and food resources would be at a minimum, we made the decision to provide meals to all personnel working during the storm. Many restaurants were closed due to weather and so we enabled our fuel cards to be used to obtain food or drinks for personnel on duty.

A lottery system was developed to assign mandatory overtime shifts to essential employees in the field and communications to increase staffing levels in these departments.

Vehicles:

The fleet department accelerated repairs on ambulances to ensure the maximum number of ambulances were available for deployment. The fleet department also ordered additional de-icer fluid and windshield wipers to ensure visibility on the ambulances. The information technology department also worked double time to keep the on-board mobile gateways and other IT resources up and running to ensure access to critical systems as needed.

Supplies:

The logistics team made sure we had sufficient winter weather-related supplies, such as blankets, hats for crew members, buckets with sand and salt mixtures for the ambulances to carry for scene safety, and most importantly, sufficient analgesics for the large volume of patients that might need pain control. The team also monitored the level of fuel available from our usual vendors and mitigated any fuel delivery problems that may have resulted from delayed fuels deliveries due to the weather.

Interfacility Patients:

As the provider for non-emergency, interfacility transports, we wanted to ensure we reached out to the facilities in advance for two reasons. First, to advise them that there may be a time in the next few days that we will be delaying non-emergent transfers until it was safe to move patients, and second, to ask if there were any pending transfers that we might be able to do now, before the bad weather struck. This resulted in many patients being transferred prior to the storm arriving.

Lesson #2: Focus on Safety

Crew and community safety was integral to all planning and operations for the storm period. A safety officer was designated for each operational period to monitor any safety issues and keep the command staff focused on personnel safety. An ICS form 208 was developed for safety planning purposes. The safety officer also published safety cards to all field crew members focusing them on important safety reminders for ice storm operations (see Figure 2).

In addition to placing five-gallon pails of sand/salt mixture on each ambulance to be used for sprinkling on ice at scenes, we also suspended the use of red-light and siren (“HOT”) responses as soon as the road conditions deteriorated. The philosophy behind this decision was that we wanted to slow the responding units down and reinforce safety, while at the same time prevent the motoring public from having to navigate dangerous roads and yield the right of way to a responding ambulance.

Lesson #3: Engage Community Stakeholders

24 hours prior to the start of the ice storm, MedStar’s executive director and the medical director of the Emergency Physician’s Advisory Board, the medical control authority for MedStar and all first response organizations (FRO) in the service area, held a conference call with all the FROs to brainstorm innovative ideas to help weather the storm. This action yielded several operational changes for the duration of the event:

1. The FROs offered to respond to low-priority medical calls to ensure patients remained stable during a potentially delayed ambulance response due to weather and call volume. Typically, the medical director-approved response protocol for low-acuity medical calls would not result in a FRO response, saving the FRO resources for the more serious medical, law enforcement, fire or rescue calls.
2. In some cases, if the patient did not want to go to the hospital, the FRO personnel would complete the patient assessment, consult by phone with the on-call medical director, initiate the ambulance transport refusal process and cancel MedStar’s response so the ambulance could be reassigned to another response.
3. Knowing that vehicles involved in weather-related crashes may remain on the side of the road or in a ditch for an extended period of time, we all agreed to tie caution tape, the kind you may see at crime scenes, to the side of the car visible to the street. That way, if another person called 9-1-1 reporting the same crash with a car off the road, the MedStar 9-1-1 call taker would ask if the car had caution tape on it. If the caller said yes, we knew the crash had already been mitigated, thus preventing another response to a previously handled incident. This helped conserve valuable response resources.
4. Finally, there were times when the FRO would arrive on a scene knowing there was no chance that the MedStar unit would be able to navigate the treacherous road. They would communicate this to MedStar so the ambulance would stop in a safe location, limiting the potential for the ambulance to get stuck on the ice. In some cases, the FRO personnel brought the patient to the ambulance, situated in the safe location.

Lesson #4: Think Outside the Box

Facing unprecedented system demand, we also implemented a few other truly out-of-the-box ideas brought to us by internal and external stakeholders:

1. If a MedStar crew was transporting a low-acuity patient to the hospital and they were the closest unit to another low-acuity call, the ambulance transporting would actually respond to the second call and double load the patients, taking them both to the hospital. This process was utilized 16 times with no adverse patient outcomes. In fact, a few crews reported that the patients fully understood the reasons and in several occasions, the patients would dialog with each other—“My wife told me not to go outside, but I didn’t listen, what’s your story?” It also helped ensure efficient use of available resources.
2. For low-acuity 9-1-1 responses with a delayed arrival, our EMD staff made repeat calls to the caller to ensure them they were still in the cue and did a secondary EMD process to ensure nothing had changed with the patient’s condition, potentially warranting an upgraded response priority.

Lesson #5: Keep the Community Informed

Our public affairs team published community and media briefings every 8 hours. This was done for several key reasons (see Figure 3):

1. Educate the community on risk reduction strategies they should engage in to prevent crashes, falls and exposure to mitigate the need for EMS responses.
2. Let the community know how well their EMS system was working to meet unprecedented call demand.

Lesson #6: Demobilization and Debriefing

There is a residual effect the event has on operations. For example, non-emergency interfacility calls were suspended during the height of the storm. This created a backlog of these calls that would need to be mitigated as soon as the road conditions were safe to do so. We continued the mandatory overtime for one operational period after the roads were clear to effectively manage the volume of interfacility transfers. There was also a formal debriefing and after action report meeting held and everyone involved in the incident were invited to attend, including field, communications and logistics staff members. Their insight into the effectiveness of the storm operations were an invaluable component of the debriefing.

All of the lessons learned from the event have been incorporated into a living planning guide, which will be used as a template for future events to ensure they run even smoother.

Lesson #7: Fill the ICS Organizational Chart

We learned early on that ICS was providing a benefit in organizing our efforts but we were not utilizing our staff as efficiently as we could have. Our operations supervisors became taxed with organizing food, transportation, lodging and scheduling while other positions could have shared that workload. Here are some examples of key ICS positions that were identified as a priority to fill:

• Service and support branch to be responsible for food, transportation and lodging;
• Finance to be responsible for tracking expenses and claims compensation;
• Documentation unit to ensure we are completing and receiving proper documentation;
• Resources unit leader (scheduler) to manage all scheduling needs during an incident or event.

Lesson #8: Remember the Employee’s Family

When employees are deployed for mandatory overtime, there will invariably be hardship on the employee’s family—child care, transportation, food, even minor home maintenance issues. Build into your emergency plans mechanisms for caring for their family to help ease the logistical and emotional burden placed on the employee.

Lesson #9: Thank Everyone!

Internally, we thanked the staff working extra duty under extreme conditions by providing meals and other logistics support to the personnel working in the field. Executive level leadership went into the field to deliver meals and hot beverages, and to assist with crews at hospitals. A manager was assigned to be on-site during every operational period to resolve any issues that came up during the operational period. Successfully mitigating large-scale events is a team effort. It involves multiple departments within your organization working in close collaboration with other external agencies. As soon as reasonably possible, once the after action reports (AARs) are completed and the dust has settled, arrange for a formal thank you to internal and external stakeholders who contributed to the success. In this event, we commissioned the printing of T-shirts for all MedStar employees, issued framed certificates for all the FRO agencies, which we presented to them at the city council meetings for each agency, and co-wrote an op-ed article with the chief of the Fort Worth Fire Department that was published in the Fort Worth Star-Telegram.

Summary

Large scale incidents can tax any emergency response system. Plan ahead by forging strong relationships with your co-response agencies, and get everyone trained in the National Incident Management System, the National Response Framework and Incident Command System to better coordinate resources. Don’t be afraid to think outside the box, but always keep the patients’ best interests at the center of what you do.

For more information on NIMS, NRF and ICS, visit https://www.fema.gov/national-incident-management-system.

Matt Zavadsky, MS-HSA, EMT, is the public affairs director at MedStar Mobile Healthcare. He has 34 years’ experience in EMS and holds a master’s degree in Health Service Administration with a Graduate Certificate in Health Care Data Management. Matt is a frequent speaker at national conferences and has done consulting in numerous EMS issues, specializing in mobile integrated healthcare, high performance EMS system operations, public/media relations, public policy, health informatics, costing strategies and EMS research. He is also adjunct faculty for the University of Central Florida’s College of Health and Public Affairs and Adjunct Faculty for the University of North Texas Health Science Center teaching courses in Healthcare Economics and Policy, Healthcare Finance, Managed Care and U.S. Healthcare Systems.