The Day the Lights Went Out: One Charge Nurse's Nightmare
Critical Care Nurse, Vol 19,
No 3, June 1999
RN and Paula Moynihan,
RN, BSN, CCRN
During a designated shift, charge nurses constantly assess,
plan, delegate, and evaluate all unit activities. Charge nurses also forecast patient
care needs while supporting the philosophy of patient- and family-centered care.
Proficient clinical decision-making, problem solving, and collaboration skills are
all essential. In addition, charge nurses must be ready to provide leadership for
any problem, anticipated or not.
The following exemplar highlights the collaborative efforts
of a multidisciplinary team during a real environmental disaster. The Synergy Model
is used to frame the unit's needs and the nursing competencies that were critically
important during the event.
Wednesday was a typical day in the pediatric cardiovascular
intensive care unit (CICU). At 5pm, the unit census was 22 patients. As day charge
nurse, I started to do my mental overview of patients in preparation for shift report
and to make the necessary adjustments in nursing assignments for the following shift.
5:15pm: Lights go out
Alarms began to sound and then fade to silence. This is a sound
I hope to never hear again. Also, daylight was fading, and I hadn't even realized
that it was raining outside. The unit was in twilight and several bedspaces - those
without windows - were in total darkness. It was now apparent that there was no
power or backup power.
My first actions were to evaluate personnel levels to determine
if they were adequate to care for the patients and reassure families and to remain
calm and supportive for the staff.
5:16pm: Hospital disaster plan put into effect
I did not yet know the systemwide effects of the power outage.
There was a sense of isolation. I started making decisions that would maintain the
stability of all patients. Without immediate intervention, stable patients would
Fourteen of the unit's 22 patients were mechanically ventilated;
2 were fresh postops (one had an "open chest"); and one infant was receiving
nitric oxide. The unit is geographically divided into a north and south side with
additional beds connecting the CICU to the main building. Beginning at the north
side podium, I instructed all available medical personnel to hand ventilate the
patients on respirators.
I ran to the south side and repeated the same instructions.
When I checked the connector rooms, I discovered that these
rooms had power. Four less acute patients in these spaces were being cared for by
two nurse, one of whom was able to come inside the unit to help.
I was still unsure of the extent of the power outage, but I
now knew that there were some areas that did have power. This would be important
when making long-term plans that may have included triage.
Once inside the unit, it was clear that more help was needed.
I instructed the secretary to call the inpatient cardiac floor for help. It was
then we realized that the public address system and the phones were also out of
service. Isolation was now very real. Communication within the hospital and to the
outside world was impossible.
5:18pm: CICU medical director arrives
We made our rounds together quickly. We moved from patient
to patient, assessing and prioritizing each's needs. Pulse oximeters became our
status monitors because they are battery operated and provide both heart rate and
oxygen saturation. I instructed nurses to document vital signs every 10 minutes.
Together we assessed each patient, family member and staff
member. While making rounds, I noticed that I was also assessing each nurse's response
to the crisis. The importance of offering advice and quiet words of encouragement
could not be minimized. The medical director and I continue to exchange suggestions
as we assess patients.
5:25pm: Cell phone arrives
When the cell phones arrived, communication was established
with the Internal Disaster Control Group. We found out that 2 intensive care units
were affected and efforts to restore power were in progress. The medical director
and I discussed with the group the potential need for triage and/or evacuation.
I was able to reach the nurse director and the administrator
on duty and notify them of the crisis. The batteries on the intravenous infusion
pumps, which deliver essential medications to patients, began to fail. Alarms were
heard throughout the unit. I dispatched a clinical assistant to other patient care
areas in the hospital in search of available intravenous pumps. The trip was hampered
by darkened stairways.
The hospital as a community provides backup for failing equipment.
Potential harm to vulnerable patients was averted.
Additionally, the Pyxis machine, which dispenses all our medications,
was out of service. Fortunately, having been involved in the Pyxis implementation
and as a member of the Pharmacy Nursing Committee, I knew that the Pyxis can be
manually unlocked from the back, allowing us access to the medications. Physicians,
nurses, respiratory therapists, and others began to arrive in the CICU to lend a
hand. As they sought me out I triaged them to patients. Soon, each patient had a
doctor and a nurse. The flexibility of all personnel was outstanding.
Everyone wanted to help. Ideas on how to manage the situation
flowed freely. I acknowledged and carefully filtered ideas and took the responsibility
for making final decisions.
5:30pm: Helping the families
From experience and the literature, I knew the importance of
providing families with information. The medical director and I went to the family
waiting area to update and reassure families. They were encouraged to visit with
their children and to speak with their child's physician and nurse.
5:40pm: Coordinator's role expands
As it got darker, I began to address the potential needs if
the power outage was not resolved. Flashlights were issued at each bedside. I began
to anticipate the potential for patient evacuation.
5:45pm: Unstable patient
One patient became unstable, his oxygen saturation and heart
rate dropping. A portable chest x-ray was obtained, although darkened stairways
continued to hamper personnel and messengers. The x-ray was read by flashlight.
This was not related to the power outage, but results could be greatly affected
by it. Utilizing available resources and avoiding panic was essential. I needed
to be creative.
5:50pm: Updating families
We visited the waiting room again, providing parents with updates
and addressing individual needs and concerns. Most families remained at their child's
bedside. It was clear that including and informing the parents had gained their
5:55pm: Power returns
As we began to triage four patients from the CICU, the power
was restored. Monitors came back on with their alarms - music to my ears! Parents
and staff cheered. It was at this point that I realized the level of my own anxiety.
Synergy occurs when individuals work together in mutually enhancing
ways toward a common goal. The Synergy Model focuses on the unique contributions
of nursing to patient care and emphasizes the professional nurse's role. The fundamental
premise of the Synergy Model is that patients' characteristics drive nurses' competencies.
The model can be applied to individual patients or, as in this case, to a group
Stability. Unit census was
22 patients. On this afternoon, all beds were filled. The acuity level was high
and approximately 40% of the patients required one-to-one nursing care. A moderately
stable unit became a minimally stable unit.
Complexity. The charge nurse
evaluated the needs of all the patients to determine which were most at risk. Approximately
two-thirds of the patients were dependent on mechanical ventilation and had cardiac
problems. Many were receiving vasopressor support. Without effective ventilation,
many of the patients would have the potential for acidosis, which would then adversely
affect their cardiac output. The majority of the patients were considered highly
complex, some moderately complex, and four minimally complex, allowing 1 nurse to
be freed up to help with other patients.
Vulnerability. Every patient
in the unit was susceptible to potential harm if there was not a rapid response
to the event. Within 1 minute of the power failure, the hospital disaster plan was
in effect. Approximately 70% of the patients were newborns and infants, unable to
help themselves. All mechanically ventilated patients were manually ventilated while
additional help was arriving. Battery-operated pulse oximeters were used on all
patients, providing continual monitoring of heart rate and oxygen saturation. All
patients were highly vulnerable.
Resiliency. As previously noted,
approximately 70% of the patients were infants. The majority of these were neonates.
Although neonates are more labile than older children, they are usually more resilient
to metabolic or ischemic injury. This characteristic does not remove the neonates
from potential harm. Many of the patients were recovering from complex, open-heart
surgery, and the stress of cardiopulmonary bypass. Taken as a group, the patients
were moderately resilient.
Predictability. Overall, with
perhaps 4 to 5 exceptions, the patients in the unit had highly predictable courses
of illness. In contrast, the course of the disaster was highly unpredictable.
Resource Availability. Very
early into this event, it was apparent that more personnel, equipment, and avenues
of communication would be needed. The hospital, as a community, helped with these
resources. Within 10 minutes, each patient had a doctor and a nurse at their bedside
and backup equipment and cell phones were available.
Participation in Care. Admission
of a critically ill infant or child to an intensive care unit is stressful for any
family. Numerous studies show the importance of providing information to help relieve
anxiety. Recognizing this, families were kept up-to-date and were encouraged to
be at their child's bedside. Families were provided with what they needed most -
information - and were invited to fully participate in their child's care.
Participation in Decision-making.
Families are an integral part of the team and are included in decisions about their
child. During this event, trust was the key factor. Decisions in managing the disaster
required someone to be in charge. This was the charge nurse, working in collaboration
with the medical director. Families were comfortable with this.
The Synergy Model comprehensively and universally describes
contemporary nursing practice through 8 concepts. Here is how it applies to the
Clinical Judgement. The seriousness
of the situation necessitated a rapid response based on an immediate grasp of the
whole picture. The charge nurse intuitively used her formal and experiential knowledge
in assuming the coordinator role. She immediately made short-term decisions, which
were essential because of the immediate vulnerability and instability of the patients.
Advocacy/Moral Agency . Advocating
on behalf of patients, family, and staff, the charge nurse identified clinical concerns,
prioritized these concerns, and responded rapidly.
Caring Practices. The charge
nurse was responsive to everyone affected by the disaster: patients, families, staff
and people offering help. She remained outwardly calm, and provided reassurance,
support and encouragement throughout the disaster. Only afterward did she realize
her own anxiety.
Collaboration. When the lights
first went out, the charge nurse took the lead. Within minutes, the medical director
arrived. They worked side-by-side, assessing each patient, family member, and staff
member. They began planning for potential long-term needs such as triage and evacuation.
Systems Thinking. When the
disaster first began there was no way of knowing how much of the hospital was involved.
One positive indication was that the connector rooms to the main building had power.
Because phone lines were down and communication was cut off within the hospital
and to the outside, there was a pervasive sense of isolation. Prior to the arrival
of the safety officer, the charge nurse initiated the hospital disaster plan. When
cell phones arrived, communication with the internal disaster control group was
established. We soon found out that 2 intensive care units were affected and that
efforts to restore power were in progress. Tentative plans for triage and evacuation
for both units were made in collaboration with the disaster control group.
Response to Diversity. Incorporating
differences in strategies to best manage an event of this magnitude was challenging.
The charge nurse acknowledged, then carefully evaluated, each idea and assumed responsibility
for the decisions.
Clinical Inquiry. Evidence-based
practice was evident in how the charge nurse helped manage the families in crises.
Continually providing them with information and involving them in the care of their
child minimized the potential anxiety and fear that families may have experienced.
Facilitator of Learning. Much
is learned form an event such as this. After the disaster the charge nurse formally
shared her experience with colleagues at a unit nursing leadership meeting.
The Synergy Model can be applied to many clinical situations.
As nursing leaders evolve, competencies required to effectively respond to unexpected
events saliently develop. Applying the Synergy Model to this exemplar helped to
articulate the charge nursing's leadership in ensuring a safe practice environment.
The model provides a framework to more fully describe the multiple dimensions of
a charge nurse's role, and acknowledges the richness of knowledge and competence
that charge nurses often contribute to complex clinical situations.
1. Curley, MA. Patient-nurse synergy: optimizing patients'
outcomes. Am J Crit Care.