The Day the Lights Went Out: One Charge Nurse's Nightmare

Critical Care Nurse, Vol 19, No 3, June 1999

Beverly Small, 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.

Exemplar


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 become unstable.

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 trust.

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.

Unit Needs


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 of patients.

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.

Nurse Characteristics


The Synergy Model comprehensively and universally describes contemporary nursing practice through 8 concepts. Here is how it applies to the exemplar.

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.

Summary


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.

Reference


1. Curley, MA. Patient-nurse synergy: optimizing patients' outcomes. Am J Crit Care. 1998;7(1):64-72.