American College of Physicians: Internal Medicine — Doctors for Adults ®


Minneapolis bridge collapse tested local hospitals' emergency plans

Having a common command system in place was key to their swift response

From the November ACP Hospitalist, copyright © 2007 by the American College of Physicians

By Sheila Dyan

During evening rush hour last Aug. 1, the Interstate 35 bridge over the Mississippi River in Minneapolis collapsed, plunging at least 50 vehicles into the water more than 60 feet below. Thirteen people died and dozens were injured, but the tragedy could have been worse if local hospitals had not been prepared to respond.

Within 15 minutes of the collapse, Hennepin County Medical Center (HCMC), six blocks away, called an orange alert—a disaster code. By 7:00 p.m., 25 ICU beds, 10 operating rooms and three computed tomography (CT) scanners were available, and the Hospital Incident Command System (HICS) center was fully functional.

Hennepin County Medical Center, six blocks from the bridge, received most of the critically injured patients.

Hennepin County Medical Center, six blocks from the bridge, received most of the critically injured patients.

"We didn't hesitate declaring a disaster," said William Heegaard, MD, emergency medicine assistant chief. "We had about 20 to 25 minutes before critical patients showed up, enough time to get fairly organized." Because of its location, HCMC received most of the critically injured patients. Twenty-eight patients arrived in the space of two hours.


Command system kicks in

The University of Minnesota Medical Center, Fairview, about a mile from the collapse, saw 25 patients. "First came the walking wounded," said Jeffrey Chipman, MD, assistant professor of surgery. Fairview freed up four CT scanners and eight operating rooms, assembled four trauma teams and got ready to triage hospital patients out to make room for victims. Dr. Chipman, the director of trauma services by his side, concentrated on moving patients through the emergency department. An anesthesiologist was also available in the ED in case airway help was needed, Dr. Chipman said.

Like HCMC, Fairview has adopted an HICS, a system based on the national Incident Command System long used by fire departments and other public safety organizations. The effectiveness of HICS lies in the use of a common management structure with standard naming conventions and reporting channels that help unify hospitals with each other and other emergency responders during a disaster.

In the Twin Cities, all 29 metropolitan hospitals, fire, police and Minnesota Homeland Security formed a compact to help solidify working relationships among these organizations "to establish communication and emergency preparedness within hospitals and in the community," said Daniel O'Laughlin, MD, medical director for emergency preparedness at Abbott Northwestern Hospital. Located about two miles from the scene, Abbott was prepared to take overflow of less-injured patients to free up trauma center resources for major cases, and saw about nine patients.

"We'd been planning for years," said Dr. O'Laughlin. "We initiated [an orange alert], activating the [HICS] hospital command center. Leadership on call picked up their roles and coordinated as to plan. It all went very well, with clear lines of communication."


How HICS works

"The goal of incident management is to get the right resources to the right place at the right time," said John Hick, MD, medical director for emergency preparedness at HCMC.

At Fairview, for example, when a disaster becomes evident, the hospital administrator on call or the charge nurse in the emergency department calls code orange. A member of hospital leadership is designated the site commander, and an Incidence Command Center is opened, furnished with communication equipment and job description sheets dictating what is to be done in the first few hours of a disaster. The center is where decisions regarding staffing, supplies and disposition of patients are made.

The site commander assigns other hospital leaders (e.g., vice presidents, managers and directors) roles, such as liaison, public information, operations, logistics and finance. These leaders in turn work with public organizations, such as police, fire and ambulances. Setting up these processes and communication channels in advance pays off when disaster strikes, Minnesota health care providers said.

"The EMS response at the scene was exceptional," said Dr. Heegaard, "and our work with the fire personnel and police was well-coordinated."

"I can't say enough about HICS. Train it, practice it, use it," said Denzil Mellors, emergency management specialist at Fairview.


Adapting on the fly

Although the Minneapolis hospitals had drilled and planned thoroughly before the bridge collapse, going through a real disaster required some tweaks to their existing plans.

"We'd gone through four drills, but a bridge collapse was not one of the scenarios we'd developed," said Dr. Heegaard.

At Fairview, one of the biggest challenges was patient identification, according to Dr. Chipman. The disaster plan called for incoming patients to be assigned ID packets using medical record numbers that were already in the system and didn't require registration. When the number of patients exceeded the number of packets, patients were identified by room and casualty number, and finally by using regular registration processes.

At HCMC, staff tracked patients the old-fashioned way. "[It] was a challenge, even though we were set up to do it," said Dr. Heegaard. "Our electronic medical record system was too slow and had to be abandoned. We went to pen-to-paper, with someone writing everything down."

Dr. O'Laughlin noted that his facility needed to improve its overall knowledge of the HICS, as well as training on every level. This was also true at HCMC. For example, when HCMC's external phone system jammed, it wasn't clear to employees how to access the internal system. "They hadn't been educated on which lines to use," said Dr. Hick.

Communication mainly worked well at Abbott Northwestern, Dr. O'Laughlin reported, although a few of the staff's two-way radios didn't function. "And it's difficult to use a voice-activated communications system during a disaster because of background noise," he added.


Lessons learned

The Minneapolis bridge collapse reinforced several principles that can be applied to other cities' disaster planning, those involved said.

Don't be afraid to activate the emergency response system. "Call a disaster, and call it early," said Dr. Heegaard.

Practice so the system runs smoothly when it needs to. "We don't look forward to drills; they're disruptive. But after something like this happens, we realize how important they are," said Joseph Clinton, MD, HCMC's chief of emergency medicine.

Make sure staff knows the drill. "People should wait to be called in [to work]," said Mr. Mellors, rather than just showing up when they hear about the disaster.

Don't forget family members and the media. HCMC set up a support center staffed with social workers and chaplains to inform and aid victims' family members and organized a plan to handle the press.

Offer support. Dr. Clinton recommended holding debriefing sessions for everyone involved in the disaster, including victims, rescuers and hospital staff. "Events like this have more impact on people than you may think," he said.

Although good planning was essential, it was people—those on the scene, EMS members and hospital personnel—who were the hospitals' best resource, the Minneapolis health care providers said.

"The response was successful because of the hundreds of people doing their small part," Dr. Hick said. "We learned we have a great capacity to respond to these incidents. The community is well prepared, and the HICS framework works well."

Sheila Dyan is a freelance writer in Cherry Hill, N.J.


Keys to successful hospital incident management

  • Hospital Incident Command System (HICS)
  • Drills
  • Education and training
  • Hospital and community teamwork
  • Coherent communication
  • Fast, reliable patient identification and tracking


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