Code Triage - Disaster Plan
Code Yellow - Bomb Threat
Environment of Care-Designing for the Management of Hazardous
Materials & Waste
Environment of Care-Security Management Plan
Environment of Care - Fire Safety/Life Safety Management Plan
Environment of Care - Medical Equipment Management Plan
Environment of Care - Safety Management Plan
Environment of Care-Utilities Management Plan
Emergency Operations Plan
Inclement Weather Policy
Radiation Plan
Reporting of Fatality or Multiple Hospitalization Injuries
Workplace Violence Prevention Policy
FirstHealth of the Carolinas Emergency Operations Plan
PRINCIPLES OF THE FIRSTHEALTH OF THE CAROLINAS EMERGENCY OPERATIONS PLAN
FirstHealth of the Carolinas (FHC) emergency operations plan is conceived and designed to respond to a single and multiple emergencies for an extended length of time without reliance on community support when an extended emergency should occur.
FHC uses the information from assessments (HVA, and the six critical areas of emergency management) to develop our Emergency Operations Plan, which are tested regularly, and uses the lessons learned to improve.
FHC can not predict the nature of a future emergency that may occur, nor can it predict the date of its arrival. Therefore, FHC has planned for managing the six critical areas of emergency response so that it can assess needs and prepare staff to respond to events most likely to occur, regardless of causes of emergency situations. The six critical areas of managing an emergency that FHC plans for are as follows;
Communication (EM.02.02.01) FHC has developed a plan to maintain communication pathways both within the hospital and to critical community resources.
Resources and assets (EM.02.02.03) FHC has established access to in times of crisis in order to ensure patient safety and sustain care, treatment, and services.
Safety and security (EM.02.02.05) As emergency situations develop and parameters of operability shift, FHC provides a safe and secure environment for their patients, visitors and staff.
Staff responsibilities (EM.02.02.07) FHC has developed alternate roles from the Emergency Management Staffing Risk Assessment (See Appendix C for matrix) to ensure that staff can adapt to their new roles and responsibilities during an emergency and as an emergency situation escalates.
Utilities management (EM.02.02.09) FHC has inventoried all of its essential utilities based on calculated demand loads that may be imposed in an emergency condition and is prepared to maintain effective operations of the hospital and strive for 96 hours without reliance for replenishment of supplies associated with utilities at FHC from external sources.
Patient clinical and support activities (EM.02.02.11) FHC has a clear and reasonable plan in place to address the needs of patients during extreme conditions when FHC infrastructure and resources are taxed.
This emergency operations and management plan is supported by additional documentation contained in the plan as an appendix as follows:
Appendix A: Hazard Vulnerability Analysis
Appendix B: Emergency Operations Plan – Four Phase Planning Activities
Appendix C: Emergency Operations Plan – Assets and Resource Inventories
Appendix D: Alternative Sites for patients care, treatment and services during emergencies
Appendix E: Coordination Matrix for the 6 critical areas of emergency management
Appendix F: Incident Command Structure
1.0: PROGRAM OBJECTIVES
It is the intent of the Emergency Operations Plan to describe FHC's emergency preparedness program and ensure an effective response to a variety of natural, human and technological disasters that could cause harm and/or disrupt the environment of care. The plan provides distinct policy direction, describes the roles and responsibilities of personnel and contains information and references to corresponding departmental mitigation, preparedness, response, and recovery procedures.
2.0: SCOPE
The Emergency Operations Plan applies to natural, human and technological events that significantly disrupt the environment of care and treatment (i.e. hurricane, loss of utilities, civil disturbance, act of terrorism, etc.); or that results in sudden, significantly changed, or increased demands for the organization's services (i.e., bioterrorist attach, building collapse, plane crash, etc.).
3.0: PROGRAM ORGANIZATION AND RESPONSIBILITIES
1. FHC's Board of Directors and Administrative teams provide the program vision, leadership, support and appropriate resources, which are embodied within and conveyed through the development and institutionalizing of business fundamentals relative to emergency management.
2. FHC Safety Committee
The Board of Directors and Administrative Teams have given the FHC Safety Committee the authority to ensure that the emergency operations plan is formulated, appropriately set forth and carried out. The FHC Safety Committee monitors the ongoing program and provides a forum for consensus building, approvals, recommendations for improvements and exercise planning to the Corporate Disaster Committee. The FHC Safety Committee serves as the central hub of the information collection and evaluation and furnishes a forum to ensure pertinent action items, issues, and risks are controlled in a timely fashion. The FHC Safety Committee receives reports from the Disaster and examines the actions taken relative to the emergency operations plan. Recommendations are given to and received by the Disaster Committee.
3. Corporate Disaster Committee
The FHC Safety Committee has delegated the management of the emergency management program's policies and procedures to the Corporate Disaster Committee. The Corporate Disaster Committee is multi-disciplinary in nature, integrating key functional areas, including Human Resources, Facilities/Engineering, Medical Staff, Quality/Clinical Performance, Clinical Operations, Emergency Medical Services, Security and Leadership. Functions of the Corporate Disaster Committee include designing, conducting and evaluating disaster drills and exercises; proposing and reviewing policies and operational procedures; reviewing and recommending revisions to the emergency operations plan; and annual evaluation of the overall emergency preparedness program. Corporate Disaster Committee reports are given to the Corporate Safety Committee for Quality/Clinical Performance review.
4. Safety Officers
The Director of Safety is the Corporate Disaster Committee Leader and has the authority and responsibility for strategic design and the operational oversight of the Emergency Operations Plan with input from each entity's Safety Officer. The Safety Officer's responsibilities include:
A. Providing overall coordination as appropriate of the emergency operations plan
B. Developing the facility disaster plan
C. Providing guidance and technical assistance to departments for department specific planning
D. Responding to disasters and coordinating drills
E. Reporting and evaluating incidents, drills and exercises
F. Coordinating specialized emergency preparedness training.
The Safety Officer also works in concert with Administration, the Corporate Disaster Committee, and the FHC Safety Committee to ensure the Emergency Management program is in alignment with the direction of the comprehensive Environment of Care program. The Safety Officer compiles relevant information to form the basis of periodic reports to the FHC Safety Committee and to the Quality/ Clinical Performance Committee.
5. Quality/Clinical Performance Committee
FHC's Quality/ Clinical Performance Committee is primarily focused on patient safety initiatives and oversees the hospital's “Plan for Patient Safety”. The Safety Officer as appropriate meets with the Quality/ Clinical Performance Committee and participates in initiatives to provide a safe environment of care to patients, including but not limited to issues pertaining to disaster preparedness. Efforts to minimize the risk to patients in the event of a disaster are communicated to the Quality/ Clinical Performance Committee through disaster drill critiques, HVA review, and periodic performance reports.
6. Department Director
Each Department Director, or designee, is responsible for the provision of a safe work environment for his/her staff and safe, suitable provisions for the care of patients, through full implementation of established emergency management programs. Directors are also responsible for the development and management of specific department disaster policies and procedures (as applicable), ensuring that they are evaluated and revised (as appropriate), verifying all staff are trained on their individual roles and responsibilities. The Department Director is responsible for ensuring the department specific disaster policies are consistent with the emergency operations plan; and staff participates in the implementation of the plan.
7. Employees
Employees are responsible to participate in emergency management training and exercises, as well as to demonstrate core competencies in the given subject matter. Employees must ensure their behaviors, work practices and operations are safe, and in accordance with departmental procedures, the provisions of the disaster plan, and clinical judgment.
4.0: PROGRAM IMPLEMENTATION AND PROCESSES
FHC PLANS FOR MANAGING THE CONSEQUENCES OF EMERGENCIES (EM.01.01.01)
1. Active Participation in Emergency Planning
Representation from leadership and the medical staff at FHC actively participate in emergency management planning by attending disaster committee meetings and reviewing strategies set forth by the organization in response to emergencies.
2. Hazard Vulnerability Analysis (HVA)
The risk to the hospital of naturally occurring events, technological events, human related events as well as events involving hazardous materials has been calculated as part of the HVA to indicate the potential emergencies that could have either a direct or indirect effect on FHC operations and demand for services. Risks associated with large scale emergency events are periodically reviewed and analyzed by the Safety Officer in concert with Administration and the local geographic area (i.e. Moore, Montgomery and Richmond Counties). When conducting the risk assessment of the hospital the probability of the event happening, as well as the severity of the impact of a potential event was taken into consideration. Each FHC hospital has consulted with local emergency management planners for the purpose of prioritizing disaster preparedness efforts. The staff and our community are continually reminded of response procedures for prioritized events through education, drills, and training.
Each entity's HVA is evaluated annually relative to its objectives, scope, performance, and effectiveness. This evaluation process is coordinated through the Safety Officers, in conjunction with each entity's Safety Committee, as appropriate.
3. Coordination with Community
A. FHC Hospitals Role in Community Emergency Management Program: FHC hospitals participate in several community wide emergency management programs, such as the local emergency planning committee (LEPC) of Moore, Montgomery and Richmond Counties, the Mid Carolina RAC (MCRAC), Disaster Preparedness Personnel Response (DPPR) and National Disaster Medical System (NDMS). FHC's role in relation to these entities in the event of a disaster is discussed, planned, and exercised accordingly.
B. An “All-Hazards” Command Structure that Links with the Community's Command Structure: The Hospital Incident Command System (HICS) model is in direct correlation with Moore, Montgomery and Richmond Counties EOC, Fire Department ICS, Police Department ICS, as well as neighboring hospital HICS structures.
C. Communicating the Hospital's needs and Vulnerabilities: FHC has met with the local emergency planning committee (LEPC) of Moore, Montgomery and Richmond Counties, the Mid Carolina RAC (MCRAC), Disaster Preparedness Personnel Response (DPPR) and National Disaster Medical System (NDMS) and communicated the hospital's needs and vulnerabilities based on analysis conducted as part of the FHC's emergency operations plan and established expectations that the hospital will have from local response agencies in a disaster in terms of the local response agencies meeting the needs of the hospital.
4. The disaster policies and procedures are developed through the Safety Officers in concert with the appropriate committees.
The Code Triage - Disaster Plan outlines the following levels of an emergency:
Normal Operations – Involves a moderate incident that may or may not warrant Code Triage activation, as local resources are available and adequate.
Code Triage Stand By (Alert) - Defined as an extraordinary situation managed within the Emergency Department (ED) with pre-existing manpower and supplies. Emergency response levels are determined by the Emergency Physician and Clinical Director/designee.
Code Triage – (Emergency Operations Plan Activated) – Defined as a situation that necessitates hospital-wide involvement and resources. Plan of activation and deactivation is performed by the Emergency Department Physician and Clinical Director/designee
CODE TRIAGE DECON TEAM – (Emergency Operations Plan activated) Defined as a event of a chemical or biological situation managed within the Emergency Department (ED) with pre-existing manpower and supplies or necessitates hospital-wide involvement and resources. Plan of activation and deactivation is performed by the Emergency Department Physician and Clinical Director/designee. (Refer to departmental procedures in the Decontamination Plan).
All Clear – Operations of the area or hospital have returned to normal or near normal status. Implement recovery processes, as necessary.
Full implementation and training on department specific procedures are assured at the department level by the Department Director.
5. Development of Emergency Operations Plan
FHC Emergency Operations Plan is based upon the industry standard of HICS as a coordinated organizational response to a disaster. In addition to utilizing this industry standard, FHC disaster planning involves the incorporation of the principles of the plan into all levels of the organization. Specific policies and procedures are developed in collaboration with FHC Administration, physicians, and front-line staff.
6. Mitigation, Preparedness, Response, and Recovery Emergencies will occur. Effective assessment and planning reduces the impact of emergencies on the quality of patient care. The FHC EOP is based on, and addresses the four phases of the plan
A. Mitigation
This phase of emergency management involves proactive efforts to minimize the severity and impact of a potential disaster and reduce the potential for an event to occur. Pursuant to the results of risk assessments, the Safety Officers will assist with the identification and implementation of appropriate mitigation efforts.
B. Preparedness
This aspect of the emergency management planning process refers to activities and plans designed to increase readiness, should disaster response become necessary. The Safety Officers, in conjunction with the Disaster and Safety Committees, coordinates preparedness efforts to identify resources that may be used if an emergency occurs. All departments are responsible to actively participate in preparedness efforts, to the extent that the unique departmental risks are addressed and program continuity is maintained throughout the facility.
C. Response
This phase focuses on tactical activities and actions taken to address a disaster event, to include the implementation of one or more component of the emergency operations plan. The IC/ACC guides and directs the overall response, forecasting and strategic planning at the time of an incident. As indicated or directed, all departments are expected to implement appropriate aspect of the plan.
D. Recovery
This phase entails those efforts to quickly and effectively re-establish business, resume critical support functions, continue the provision of care, and ensure financial integrity. The Recovery aspects of the plan take the form of risk and vulnerability analysis that include contingency plans and interim measures that are predicated on relative risks, resources and systems operations; efforts to identify and quantify shortfall of damages and outlay for the purposes of reimbursements and governmental interventions, as indicated.
9. FHC maintains a documented inventory of assets and resources on-hand, that is available on site for use in an emergency. This inventory is updated on an on-going basis, and full inventory assessment and review is completed at least annually. Through this assessment the organization can identify its capabilities to be self-sustaining in the event that FHC cannot be supported by our local community for 96 hours. Once the plan is activated, supplies and equipment availability is closely monitored for depletion and replenishment. Supply conservation activities may be required, and this will be done at the direction of the Logistics Chief in collaboration with other members of the General and Command Staff. This inventory includes but is not strictly limited to PPE'S, water, fuel, staffing, medical / surgical supplies, pharmaceuticals and other back-up supplies listed in appendix C.
10. FHC has established a method for monitoring quantities of assets and resources during an emergency and keeps control of depletions of supplies in order to assess duration of sustainability for an extended emergency (see appendix C for asset and resources monitoring).
11. Annual Evaluation of Emergency Management Planning
On an annual basis, Emergency Management Planning will be evaluated relative to its objectives, scope, performance, and effectiveness.
A report will be given to each entity's Safety Committee and then reported to Quality/ Clinical Performance and then to the Board of Trustees/ Directors for review. In addition, the HVA will be reviewed annually to determine whether it needs to be changed or altered due to
disaster drill findings, staff knowledge, and change in current events.
FHC DEVELOPED AND MAINTAINS A WRITTEN EMERGENCY OPERATIONS PLAN (EOP) THAT DESCRIBES AN “ALL- HAZARD” COMMAND STRUCTURE (EM.02.02.01)
The EOP provides processes for initiating the response and recovery phases of identified emergency situations. Based on the damage assessment and evaluation of operational needs, an incident recovery plan will be developed and implemented immediately. The Incident Commander/Designee is responsible for initiating this activity. The EOP is based on an “all-hazard” command structure for coordinating the six critical areas of operations as follows;
FHC ESTABLISHES EMERGENCY COMMUNICATIONS STRATEGIES (EM.02.02.01)
1. Notification and reporting (Personnel, Medical Staff, Agencies) when emergency measures are initiated:
The Department Director's or designee's responsibility is to continually assess and adjust staffing patterns so as not to exceed the individual capability of the staff utilized during a disaster.
A. MEDICAL STAFF
Notification:
The Medical/Technical Specialist, in collaboration with the Emergency Department Physician (if not Unit Leader), will notify the Medical Staff.
The Medical Staff office will also respond to requests for telephone numbers and specialties of physicians.
Exception:
On call Emergency Department Medical Staff
shall be notified by the Emergency Department
Charge Nurse/Designee as requested by the Emergency Department Physician.
NOTE: In the event of significant road closures, a designated physician staging area will be arranged and located at the site or where designated if needed.
Reporting:
With or without notification and after family and home are secured, all physicians are to report to the Medical Staff Personnel Pool, in the Medical Staff Office, or where designated, for assignment. Physicians will be assigned, as needed, by the Medical Staff Director Unit Leader or designee.
Exception:
On-Call Emergency Department Medical Staff shall report directly to the Emergency Department.
B. PERSONNEL
Notification:
When the hospital activates its Emergency Operations Plan (EOP), Department Directors or Designees will be notified by telephone or runner or overhead page. They will be informed of the type of disaster and an estimate of the number and type of patients to be expected. Each Department Director, or designee, will activate their Departmental Disaster Plan to the degree that is necessary. If a department is closed, the appropriate Department Director or Designee will be instructed to implement their telephone tree, if necessary.
Reporting:
All off duty employees should report initially to the Personnel Pool.
Moore Regional Hospital – Cafeteria
Richmond Memorial Hospital- Cafeteria
Montgomery Memorial Hospital- 2nd Floor Nursing Station
C. VOLUNTEERS
Notification:
The Director of Volunteer Services, or designee, will be notified by the Planning Section Chief/Designee and will then initiate their departmental plan to provide staff.
Reporting:
Volunteers will report to the Volunteer Services Office or other designated location and sign in.
D. CHILDREN OF EMPLOYEES
If employees do not have care facilities for their children they may bring them to the designated child care location if needed. The need for a Child Care Center will be reassessed every eight (8) hours by the Director, Child Development Center/designee.
E. FIRE AND POLICE DEPARTMENT
The Fire Department is contacted automatically through the fire alarm system for fire situations.
For non-fire situations, the Incident Commander/ Designee as appropriate will contact Fire and/or Police Departments.
F. FAMILY, VISITORS, CLERGY
Will be routed to the hospital's family waiting area. All entrance doors to the hospital will be secured by security as needed except the main entrance and the Emergency Department entrance if lockdown procedures are initiated by the IC/ACC.
G. PRESS AND MEDIA
Staff members should contact the IC/ACC when approached by a member of the press or media. Staff members should not give information to the press or media. All information will be provided by the Public Information Officer (PIO).
In a major event members of the press/media will be escorted to the designated area where a Public Information Center will be established.
2. On going communication of information and instruction to staff once emergency measures are initiated:
On going communication and dissemination of information to staff is of vital importance during a disaster it enables better utilization of assets and resources. During a disaster all information and communications will be funneled through the section leaders to the incident commander then disseminated back to the section leaders for communicating to the individual department directors.
3. Processes and Plans for communicating with external authorities once emergency response measures are initiated:
FHC participates in community wide emergency management planning groups. This group of hospital and community emergency management planners has agreed to provide mutual aid to one another in the event of a disaster. Also included in the disaster planning is the sharing of the following information to improve communication and resource management when responding to a disaster:
A. Essential elements of command structures and control centers for emergency response
B. Names, roles, and telephone numbers of individuals in their command structures
C. Resources and assets that could potentially be shared or pooled in an emergency response
D. Names of patients and deceased individuals brought to their organizations to facilitate identification and location of victims of the emergency.
Several local agencies may play a role in managing an emergency. Some of the key contacts include police, fire, EMS, local emergency management offices, department of Health, CDC and the Red Cross. Agencies are notified by the Incident Commander or a designee as soon as possible after an emergency response is initiated.
Communication with external agencies will depend on the given emergency situation. For example, as outlined in the Bioterrorism Plan, evidence of a possible biological attack will be reported to the Moore, Richmond, or Montgomery Public Health Care Agency, Emergency Medical Services (EMS), local police department, and if verified, to the State of North Carolina Department of Health & Human Services, FBI Field Office, and CDC.
When all normal communication channels (telephone, cell phones and emails) are operative, the normal means of voice / electronic communications is the first to be sought. When normal communication channels are not operative (due to internal or external infrastructure damage, loss of power or loss of communications links; wiring, satellite, microwave transmissions), the hospital will use all available means to communicate with external authorities including employment of walkie-talkie radios, ham radios, and runners.
5. Communication with patients and their families during emergencies and notification of patient relocation to alternate care sites:
FHC staff will communicate with patients during disaster response and Code Triage activities in order to allay their anxieties. It is essential that the patients understand the reasons for the accelerated activities they notice, and be reassured. For patients whose family was not able to arrive at the hospital prior to an emergency in the community or the hospital, designated staff will contact family members to inform them of the conditions of their loved ones and the emergency response activities. If the hospital can no longer sustain operations and relocation of patients becomes necessary; designated staff will notify family members (those present at the hospital and those unable to get to the hospital due to the nature of the emergency in the community) that their loved ones are being relocated and provide the name of the facility where the patient is being relocated and provide name and telephone number of contact individual at the facility.
6. FHC defines the circumstances and plans for communicating with the community and the media during emergencies:
When the emergency operations plan is initiated at the hospital, the hospitals will communicate with external agencies depending on the given emergency situation. Reporting requirements are included in the specific disaster response policy and procedure. For example, as outlined in the Bioterrorism Plan, evidence of a possible biological attack will be reported to the Moore, Richmond, or Montgomery Public Health Care Agency, Emergency Medical Services (EMS), local police department, and if verified, to the State of North Carolina Department of Health Services, FBI Field Office, and CDC. In a major event members of the press/media will be escorted to the designated area where a Public Information Center will be established.
The circumstances for communicating with the community and the media will be defined for any disaster event (of an internal or external nature) that impacts the community health and safety within the hospital campus.
7. FHC plans for communicating with purveyors of essential supplies, services, and equipment once emergency measures are initiated.
Once emergency measures are initiated, the hospital utilizes its vendors list for essential supplies, services and equipment and notifies each vendor by telephone (or other means if the telephone system is not operational) to be on standby to respond to the hospital's needs should they arise.
8. FHC plans to communicate with other healthcare organizations regarding essential elements of their command structures and control centers for emergency response;
FHC has communicated with other health care organizations essential elements of our command structures and control center for emergency response as indicated in the EOP above, in the IC/ACC section.
9. FHC plans to communicate with other healthcare organizations regarding names and roles of individuals in their command structures and command center telephone numbers;
FHC has communicated with other health care organizations the names and roles of individuals in our command structures and control center for emergency response as indicated in the EOP above, in the IC/ACC section.
10. FHC plans to communicate with other healthcare organizations regarding resources and assets that potentially could be shared in an emergency response;
The logistics leader is responsible for assessing what resources and assets (such as personnel, beds, transportation, linens, fuel, personal protective equipment, medical equipment and supplies) can potentially be shared with other local health care organizations; or with non-local health care organizations in the event of a regional or prolonged disaster. The decision to transfer resources and assets will be made by the incident commander or designee predicated on FHC current and potential impact by a disaster or its escalating potential within the community.
11. FHC plans to communicate with other healthcare organizations regarding names of patients and deceased individuals brought to their hospitals in accordance with applicable law and regulation, when requested;
In a disaster all patients brought to FHC are entered into a master patient triage roster that will be located in the triage area and continually be submitted to the incident commander for updates to other health care organizations in accordance with applicable law and regulation, when requested. The roster will include patient's names and deceased individuals brought to FHC.
12. FHC defines the circumstances and plans for communicating information about patients to third parties (such as other health care organizations, state health dept. police, FBI, etc.);
The circumstances for communicating information about patients with community third parties will be defined for any disaster event (of an internal or external nature) that impacts the community health and safety within the hospital campus and as required by laws and regulations.
13. FHC plans to communicate with identified alternative care sites;
In the unlikely event the facility is deemed unsuitable for continued occupancy or cannot support adequate patient care, communication will be coordinated through a collaborative effort between the IC/ACC, Operations, Planning, and Logistics sections. The management of necessary patient materials, the transfer of medications, medical records, medical equipment, as well as transportation arrangements and tracking patients to and from the alternative care site(s) is also a collaborative effort. Communications to county agencies and other healthcare facilities to find potential adequate outside facilities may be obtained through the SMART system, cell phones, or the UHF Communications (NCMCN).
14. FHC established back-up communication systems and technologies;
FHC alternative communication systems include runners, hand-held disaster radios, two-way radios, cellular phones, amateur radios, email, etc. It is the responsibility of the IC/ACC to ensure as many means of communication are utilized appropriately and when needed.
FHC ESTABLISHES STRATEGIES FOR MANAGING RESOURCES AND ASSETS DURING EMERGENCIES (EM.02.02.03)
1. FHC has planned for obtaining supplies that will be required at the onset of an emergency response (medical, pharmaceutical, and non medical supplies);
FHC maintains on hand supplies that may be required for an extended emergency at all times (see appendix - assets and resource inventory list) for those supplies with short shelf life and those that require continual replenishment, FHC will contact supplier immediately upon suspecting the onset of an emergency and stock up for a minimum of 96 hours.
2. FHC has planned for replenishing medical supplies and equipment that will be required throughout response and recovery, including personal protective equipment.
The plan consists of continually monitoring inventories required for an extended emergency and the aftermath of an emergency during the recovery phase. FHC has memorandum of understanding with suppliers to replenish medical supplies and equipment.
3. FHC has planned for replenishing pharmaceutical supplies that will be required throughout response and recovery, including access to and distribution of caches (stockpiled by the hospital or its affiliates, local, state, or federal resource) to which the hospital has access:
The plan consists of continually monitoring inventories required for an extended emergency and the aftermath of an emergency during the recovery phase. FHC has memorandum of understanding with Pharmaceutical suppliers to replenish pharmaceutical supplies and equipment. FHC also has access to local, state and federal stockpiles.
4. FHC has planned for replenishing non-medical supplies that will be required throughout response and recovery such as food, linen, water, fuel for generators and transportation vehicles, etc.:
FHC maintains on hand supplies that may be required for an extended emergency at all times (see appendix “C” assets and resource inventory list) for those supplies with short shelf life and those that require continual replenishment, FHC will contact supplier immediately upon suspecting the onset of an emergency and will strive to stock for a minimum of 96 hours.
The plan also consists of continually monitoring inventories required for an extended emergency and the aftermath of an emergency during the recovery phase. FHC has memorandum of understanding with suppliers to replenish non-medical supplies.
5. FHC has planned for managing staff support activities (such as housing, transportation, stress debriefing, etc):
During an emergency, it may be necessary for the FHC to provide for various support activities to ensure continuity over a period of time depending on the length of the response phase of an emergency. Below are some of the activities the IC/ACC may plan for during an emergency:
Housing for Staff- If call in procedures for off-duty staff are activated, the IC/ACC will identify areas where staff members can relax and sleep when not working.
6. FHC has planned for managing staff family support needs such as childcare, elder care, communications, etc.:
Housing/Childcare for Staff Family Members- It may be necessary for staff members to bring in family members or their children because they do not feel comfortable leaving them during an emergency or because they have no one to care for them in their absence. It is preferred that those staff members be the last resource during call-in procedures. If the emergency creates a demand that would require these staff members to be necessary, the IC/ACC will identify areas and personnel to assist in caring for these individuals. The Personnel Pool Area will be contacted to determine availability of staff members to be assigned to staff these areas.
7. FHC has planned for potential sharing of resources and assets (such as personnel, beds, transportation, linen, fuel, PPE, medical equipment and supplies, etc.) with other health care organizations within the FHC community that could potentially be shared in an emergency response:
FHC has processes for cooperative planning among organizations that together provide services to the contiguous geographic area of the FHC service area to facilitate the timely sharing of resources and assets. During community emergency planning meetings, resources and assets that may be available from the member organizations is communicated.
8. FHC has planned for potential sharing of resources and assets with health care organizations outside the immediate community of the FHC service area in the event of a regional or prolonged disaster:
FHC has processes for cooperative planning among organizations that together provide services to the contiguous geographic area outside of the immediate community to facilitate the timely sharing of resources and assets. During community emergency planning meetings, resources and assets that may be available from the member organizations is communicated.
9. FHC has planned for evacuating (both horizontally and when required by circumstances, vertically) when the environment cannot support care, treatment, and services:
FHC has established an emergency procedure when evacuation of the hospital or unit is required. In the unlikely event the hospital or a unit is deemed unsuitable for continued occupancy or cannot support adequate patient care these procedures will be initiated. Staff is educated on evacuating both horizontally and vertically. Staff is also trained to request assistance in evacuating non-ambulatory patients.
The FHC Fire Response Plan (Code Red) dictates that in the event of a fire emergency, the initial preferred evacuation method will be horizontal evacuation to an area of safe refuge / an adjoining smoke compartment. If evacuation from the facility becomes necessary due to a disaster situation where defending in place is not feasible and when the facility cannot continue to support care, treatment and services, the incident commander and the fire dept. may initiate vertical evacuation of the facility. If vertical evacuation becomes necessary, the following protocol, as outlined in the Evacuation Plan, will be followed:
Vertical Evacuations
1. If a vertical evacuation is required, the patients should be moved vertically down and horizontally away from the affected area(s).
2. Elevators may be used for evacuation if authorized by the IC/ACC. The elevators used must not service the affected area and must be controlled by trained personnel. Trained personnel include Engineering staff, Security staff, or a member of the Fire Department.
3. Once evacuation priorities have been established, the safest route to vertically evacuate patients should be chosen and communicated by the IC/ACC. It may be necessary to move patients vertically up and horizontally across then vertically down depending on the location of the affected areas.
4. Holding areas for the patients shall be identified by the IC/ACC. These areas should be chosen to keep all the patients from a specific unit together. Units can be mixed but units should not be split between holding areas if at all possible.
5. Staff from evacuated units should stay with the patients from their respective floor/unit. Once all patients have been evacuated to the holding area, the staff shall do a patient count and check armbands against the census for their unit to ensure all patients have been evacuated. Once the patient count and verification is complete, the IC/ACC shall be advised that all patients have been evacuated.
E. Facility Evacuation
Once the notification is made, the IC/ACC shall begin planning for complete facility evacuation. Evacuation of the facility shall be addressed in four parts:
1. Visitors
Because the facility does not have a way to track visitors coming and going from the facility there is not a mechanism in place to account for all visitors. The hospital operator should announce for all visitors to leave the facility immediately. If a destination for the patients has been identified, the location may also be paged overhead or otherwise communicated to the visitors.
2. Ambulatory Patients
Ambulatory patients and their medications, equipment, and pertinent information, including essential clinical and medication-related information shall be moved as directed above to transportation as coordinated between the IC/ACC and EMS.
Admitting staff shall track each patient as they leave the facility based on the current computer census. Patient disposition shall be determined based on the destination. If FHC will be staffing an alternate care site, the disposition will be different than if being discharged home or to another facility. The disposition determination shall be made by the IC/ACC.
The HICS 260- Patient Evacuation Tracking Form shall be utilized for patient tracking. When more than two patients are being evacuated, the HICS 255- Master Patient Evacuation Tracking Form shall be completed to gain a master copy of all patients that were evacuated.
3. Non-Ambulatory Patients
Non-ambulatory patients and their medications, equipment, and pertinent information, including essential clinical and medication-related information shall be transported by ambulance or other vehicle designed for patient transport as coordinated between the IC/ACC and EMS.
Admitting staff shall track each patient as they leave the facility based on the current computer census. Patient disposition shall be determined based on the destination. If FHC will be staffing an alternate care site, the disposition will be different than if being discharged home or to another facility. The disposition determination shall be made by the IC/ACC.
The HICS 260- Patient Evacuation Tracking Form shall be utilized for patient tracking. When more than two patients are being evacuated, the HICS 255- Master Patient Evacuation Tracking Form shall be completed to gain a master copy of all patients that were evacuated.
4. Staff
FHC staff shall be evacuated based on facility needs. Staff members may be needed to staff an alternate care site or to assist with the transfer of patients from FHC to another facility.
All staff shall be tracked through the Personnel Pool Area using the emergency list and other resources available through Human Resources. As staff members are allowed to go home, the Personnel Pool Area can track them through their clocking status on the Kronos system and or paper roster.
10. FHC has planned for transporting patients, their medications and equipment, and staff to an alternative care site or sites when the environment cannot support care, treatment, and services:
Formal agreements and arrangements are in place so that patients may be transferred to a facility that can provide adequate patient care. The Liaison Officer will be responsible for inter-facility communication between the hospital and the designated alternative care site, and for retaining records of which patients were transferred to and/or from an alternative care site. The patient care unit transferring the patient is responsible for obtaining copies of the patient's medical records, gathering personal belongings and ensuring the patient's medications are continued throughout the transfer. If any hospital equipment is transferred with the patient, the patient care unit is responsible for documenting what equipment was transferred with the patient so that the equipment may be retrieved during the recovery phase post emergency. The following arrangements and agreements are in place for transporting patients to alternate care sites:
Ambulance contract agreements for transfer of patient between facilities.
Licensed vendors are contracted for providing van / bus transportation.
FHC owned vehicles are utilized.
FHC is provided with transportation vehicles arranged by the appropriate County Emergency Medical Services (EMS).
11. FHC has planned for transporting pertinent information, including essential clinical and medication related information, for patients to an alternative care site or sites when the environment cannot support care, treatment and services:
When the environment cannot support care, treatment and services, and the IC/ACC has ordered evacuation of the hospital to an alternate care site, it will be necessary to transfer equipment, medications, essential clinical and medication-related information, and supplies to the alternate care site. This shall be coordinated through the IC/ACC in conjunction with Materials Management and Facility Services. See the section below regarding Alternate Care Sites. The transfer of these components is made utilizing transportation agreements and arrangements (indicated in 10 above) and all transferred equipment, and records are entered into a transfer log for record keeping.
FHC ESTABLISHES STRATEGIES FOR MANAGING SAFETY AND SECURITY DURING EMERGENCIES (EM.02.02.05)
1. The hospital establishes internal security and safety operations that will be required once emergency measures are initiated:
Safety and security measures and monitoring activities when emergency measures are initiated play a vital role during response and recovery phases of emergencies. When emergency measures are initiated, FHC mode of operations for safety and security shifts to operating under emergency conditions and are covered in the appropriate policies and procedures. The designated safety and security officers conduct staff education sessions and monitor activities during emergency exercises and when emergency measures are initiated.
2. The hospital identifies the roles of community security agencies (law enforcement, national guard, etc.) and defines how the hospital will coordinate security activities with these agencies:
FHC has identified that the roles of community security agencies external to the hospital's buildings will be under the command of the highest-ranking law enforcement personnel on site. Command of security inside the hospital's buildings will be under the hospital's Incident Commander unless the incident commander deems that law enforcement intervention is required inside the buildings, the police in conjunction with the Security Supervisor/designee will assume command jointly.
3. The hospital identifies a process that will be required for managing hazardous materials and waste once emergency measures are initiated:
It is recognized that once emergency measures are implemented, contracted hazardous waste haulers may not be able to get to the hospital to haul hazardous materials and medical wastes for days thus the hospital has set up a temporary secured storage area during emergencies.
The hospital's normal spill response policy will continue to be followed in addition, storage of hazardous materials and waste management will be temporarily placed in the designated overflow areas until the emergency conditions have been lifted and vendors contracted for hauling are able to get to the hospital and remove materials from the overflow areas.
4. The plan identifies means for radioactive, biological, and chemical isolation and decontamination:
Facilities for decontamination are maintained and coordinated through the Facilities/ Engineering Department, Security, Safety, Administration, Disaster and Safety Committees. The effectiveness of this equipment and materials is periodically tested and evaluated.
FHC is equipped to manage decontamination with specified chemical agents, provided the agent and concentration is known. FHC staff can utilize the primary decontamination shower outside of the Emergency Department ambulance entrance and/or set up portable decontamination showers if the incident warrants. Radiological emergencies are responded to in concert with the Radiation Safety Officer. Biological emergencies are responded to in concert with Infection Control or physician. Chemical decontamination situations are responded to in concert with the Safety Officers.
The hospital has designated a decontamination area with a separate ventilation system or ventilation shutoff available for radioactive or chemical isolation and decontamination. Personnel are trained in the response to radiation or hazardous material contamination.
A separate Bioterrorism Preparedness Plan has been developed, reviewed, and approved by hospital and is included in the hospital's disaster manual.
Hazmat events including radioactive, chemical & biological events are handled based on FHC IC/ACC & Operations Section Hazmat / Decontamination procedures for emergency departments and support departments. The organization's biological response plan will be supplemented with the city and/or county Emergency Services & Hazmat team expertise.
Pursuant to exposure conditions, FHC may establish a chemical hazmat decontamination triage setting external to Emergency Department when appropriate and in unknown exposures defer to the local fire department Hazmat team who has authority to command all emergency HAZMAT events.
Upon identification of a radiological hazmat events, FHC will establish an external hazmat decon triage setting per the radiological plan. The facility Radiation Safety Officer will act as Liaison and coordinate activities with external hazmat/ NRC entities.
Upon identification of a biological event as confirmed by the public health epidemiologist, FHC will follow all aspects of the Bioterrorism Response Plan.
FHC has limited number of isolation rooms and is not equipped to deal with mass isolation that may be required under emergency conditions. Once it is determined that isolation of an area is required, security personnel, or designee, will be posted at all point of entry and exits from the area to ensure that the area remains confined as directed by the incident commander. The department of facilities/ engineering will respond to isolate recirculation of ventilation systems from the isolated area wherever possible or may initiate a fan shutdown in the area.
6. The hospital establishes processes for controlling entrance into and out of the health care facility during emergencies:
At the time the Emergency Operations Plan is activated, the Security Department personnel on duty will be responsible for securing all exits and entrances with the exception of the ambulance entrance. Personnel of the hospital are required to wear nametags or carry cards identifying them as personnel. Only persons with proper identification will be admitted to the hospital during an emergency.
7. The hospital establishes processes for controlling the movement of individuals within the health care facility during emergencies:
During emergency conditions, when it becomes necessary to control the movement of visitors and staff horizontally and vertically in order to facilitate an effective environment during emergencies; movement within the hospital will be controlled by security designee through security check points, control of elevators, control of doors, control of staff that does not have a need to perform essential functions, controls to ensure that necessary logistics receive preference for reaching their intended destinations. Movement within the hospital during emergencies will be controlled based on the following priorities:
Priority 1; only those personnel that are properly identified, assets and logistics that are necessary in response to the particular emergency at hand will be permitted.
Priority 2; only those personnel that are properly identified, assets and logistics that are necessary for the clinical needs of patients will be permitted.
Priority 3: only those personnel that are properly identified, assets and logistics that are needed for other than emergency purposes will be permitted.
8. The hospital establishes processes for controlling traffic accessing the health care facility during emergencies:
Signs will be posted on the hospital campus directing overflow emergency vehicle in terms of locations for decontamination facilities and parking for emergency vehicles.
Traffic flow on the campus will be controlled by security and law enforcement personnel only allowing authorized vehicles to enter the campus during emergencies.
Efficient traffic flow is also established as follows:
Traffic control signs to show external and internal routing of casualties and other traffic are used.
The IC/ACC will assign appropriate staff to perform traffic control and security functions during emergencies.
FHC DEFINES AND MANAGES STAFF ROLES AND RESPONSIBILITIES (EM.02.02.07)
1. Staff roles and responsibilities are defined in the EOP for all critical areas (communications, resources and assets, safety and security, utilities, and clinical activities):
See the Emergency Operations Plan (EOP) section (EM.02.02.01) for a complete description of staff roles and responsibilities for all the six critical areas.
2. Staff is trained for their assigned roles during emergencies:
FHC discusses roles and responsibilities during Safety or Disaster Committee meetings and provides training (through NIMS, and in-house training) for the specific roles assigned to staff during emergencies. The staff roles and responsibilities are also assessed during exercises conducted and opportunities for staff improvement in their roles are then implemented.
3. The hospital communicates to licensed independent practitioners their roles in emergency response and to whom they report during an emergency:
FHC discusses roles and responsibilities of licensed independent practitioners (LIP) during Disaster Committee meetings and provides training (through NIMS, and in-house training) for the specific roles assigned to independent practitioners during emergencies. The roles and responsibilities are also assessed during exercises conducted and opportunities for LIP improvement in their roles are then implemented.
4. The hospital establishes a process for identifying care providers and other personnel assigned to particular areas during emergencies:
FHC personnel are identified during emergencies by means of donning their staff identification badges. If an employee does not have his/her badge or it cannot be located, temporary badges can be obtained through the Human Resources Department, upon verification.
During a disaster “Code Triage”, FHC staff members are expected to return to their units and provide support to the needs of their departments. Departments are to report their staff and bed availability to the IC/ACC. Selected staff members are responsible for carrying out a function on the HICS organizational chart. These staff are to report to the IC/ACC and then to their pre-designated section meeting location to coordinate response activities. These staff will wear their appropriate HICS Section or Unit Leader vest indicating their title to inform others they are responsible for that function. In addition, supervisors are to send any extra staff to the Personnel Pool to help the organization respond to the needs of the disaster.
The assignment of staff response activities during other emergency situations are described within the specific disaster response policy and procedure (i.e. Code Pink, Code Yellow, etc.) and included in department specific trainings.
FHC MAY GRANT DISASTER PRIVILEDGES TO VOLUNTEER LICENSED INDEPENDANT PRACTITIONERS (EM.02.02.13)
The Personnel Pool will assign roles as requests for manpower are received. In the event volunteers from the community come to the hospital, their credentials will be verified through the Medical/Technical Specialist.
CREDENTIALING OF VOLUNTEERS
During disaster situations, members of the community may report to the facility wishing to provide volunteer assistance. Some volunteers may have specific medical licenses and skills that can be valuable to patient care. These could be physicians or other medical professionals. These volunteers will be directed to the Personnel Pool and their names provided to the Human Resources Department or in their absence, Nursing Staff Office to verify licensure. If licensure can be verified, the volunteers will be used as necessary in conjunction with hospital staff. If licensure cannot be verified, the volunteers can be used in roles that are not directly related to patient care. See the Medical Staff Bylaws for more detail regarding Emergency Credentialing of Physicians or the Human Resources policy for the procedure for assigning emergency responsibilities to volunteer practitioners.
FHC ESTABLISHES STRATEGIES FOR MANAGING UTILITIES DURING EMERGENCIES (EM.02.02.09)
1. The hospital identifies an alternative means of providing electricity in the event that their supply is compromised or disrupted:
Alternative means of meeting essential building utility needs such as power, medical gases, water, ventilation, and fuel sources are coordinated in advance and tested through the Facilities/ Engineering Department as part of the Utility Systems Management plan to ensure, to the extent practicable, uninterrupted services. If necessary, external arrangements and contracts for essential services are coordinated through the HICS Logistics Section.
FHC has a reliable, adequately sized and fueled emergency generation system consisting of multiple generators capable of providing for effective operations under emergency conditions.
2. The hospital identifies an alternative means of providing water needed for consumption and essential care activity in the event that their supply is compromised or disrupted:
Alternative means of meeting essential building utility needs such as power, medical gases, water, ventilation, and fuel sources are coordinated in advance and tested through the Facilities/ Engineering Department as part of the Utility Systems Management plan to ensure, to the extent practicable, uninterrupted services. If necessary, external arrangements and contracts for essential services are coordinated through the HICS Logistics Section.
Water needed for consumption and essential care activities have been calculated based on need and is stored on premises at the hospital. During emergencies the hospital will implement conservation measures.
3. The hospital identifies an alternative means of providing water needed for equipment and sanitary purposes in the event that their supply is compromised or disrupted:
Alternative means of meeting essential building utility needs such as power, medical gases, and water, ventilation, and fuel sources are coordinated in advance and tested through the Engineering Department as part of the Utility Systems Management plan to ensure, to the extent practicable, uninterrupted services. If necessary, external arrangements and contracts for essential services are coordinated through the HICS Logistics Section.
Water needed for dialysis equipment, dish washing, instrument washing, hand washing and for other equipment and sanitary purposes, has been calculated based on need to strive for an extended period of 96 hours and is stored on premises at the hospital. During emergencies the hospital will implement conservation measures.
4. The hospital identifies an alternative means of providing fuel required for building operations or essential transport activities in the event that their supply is compromised or disrupted:
Alternative means of meeting essential building utility needs such as power, medical gases, and water, ventilation, and fuel sources are coordinated in advance and tested through the Facilities/ Engineering Department as part of the Utility Systems Management plan to ensure, to the extent practicable, uninterrupted services. If necessary, external arrangements and contracts for essential services are coordinated through the HICS Logistics Section.
Diesel fuel required for operation of the emergency generators and other fuels required for operations of vehicles have been calculated and are stored on site at the hospital to support an extended period of 96 hours.
5. The hospital identifies an alternative means of providing other essential utility needs (ventilation, medical gas/vacuum systems, etc.) in the event that their supply is compromised or disrupted:
Alternative means of meeting essential building utility needs such as power, medical gases, and water, ventilation, and fuel sources are coordinated in advance and tested through the Facilities/ Engineering Department as part of the Utility Systems Management plan to ensure, to the extent practicable, uninterrupted services. If necessary, external arrangements and contracts for essential services are coordinated through the HICS Logistics Section.
These essential utilities have been calculated based on needs for an extended period of 96 hours and are provided as follows:
Ventilation; all critical care areas in the hospitals have their HVAC systems connected to the emergency generators power source so that they will continue to operate during commercial power interruptions.
Other areas that may desire ventilation during emergencies; will be provided by spot coolers on an as needed basis. The spot coolers will be connected to emergency power receptacles. FHC maintains a supply of spot coolers at the hospital.
Medical Gases; the medical air compressor and control circuits for other types of piped medical gas systems are connected to emergency power. Provisions have been made for portable air cylinders and appropriate regulators to enable stand-alone operations where medical air may be required (ventilators, etc.). The oxygen manifold is adequately sized with main and reserve cylinders and additional back up cylinders to enable functioning for 96 hours. The medical vacuum system is connected to an emergency power source and as a backup, all critical care units in the hospital are provided with battery operated suction pumps located on crash carts and in the unit storage rooms.
FHC ESTABLISHES STRATEGIES FOR MANAGING PATIENT CLINICAL AND SUPPORT ACTIVITIES DURING EMERGENCIES (EM.02.02.11)
1. The hospital manages the clinical activities required as part of patient scheduling, triage, assessment, treatment, admission, transfer, discharge, and evacuation during emergencies:
Upon activation of the Emergency Operations Plan, normal admission requirements will be abolished. Initially, admissions to the hospital will be limited to those whose survival depends upon services obtainable only through hospital bed care.
Outpatient care will be restricted to those whose lives may ultimately depend upon the present expenditure of medical supplies and health manpower time.
All elective admissions and procedures may be canceled or postponed, including elective surgery, non-emergency outpatient procedures and transferring patients who are stable to be discharged.
Patients may be transferred to other facilities so those emergency victims may be accommodated.
Individuals may be redirected or relocated for a Medical Screening Exam in the event that the hospital's Emergency Operations plan is activated. (Section 1135(b) of the Social Security Act §489.24(a)(2).
In the event that the hospital's Emergency Operations Plan is activated, persons may be transferred prior to being stabilized if, based upon the circumstances of the emergency the hospital is unable to provide proper care, treatment or services. (Section 1135(b) of the Social Security Act §489.24(a)(2).
2. The hospital manages clinical services for vulnerable populations served by the hospital, including patients who are pediatric, geriatric, disabled, or have serious chronic conditions or addictions during emergencies:
Clinical activities for vulnerable patient populations including pediatric, geriatric, disabled, and psychiatric and addiction patients will be provided in the custom.
