sv mercy emergency management plan st. vincent · pdf file3. man-made hazards; events such as...

Current Status: Active PolicyStat ID: 3302639

Origination: 02/2017Last Approved: 02/2017Last Revised: 02/2017Owner: Michael Jones: Safety OfficerDepartment: Environment of Care_Life SafetyReferences:Applicability: St.Vincent Mercy Hospital

SV Mercy Emergency Management Plan

ST. VINCENT MERCY HOSPITAL EMERGENCYOPERATIONS PLAN

I. INTRODUCTION

A. MISSION, VISION AND VALUESIn concert with, and in support of the hospital's mission, values and vision, the purpose of the Emergency Operations Plan(EOP) is to establish and provide the facility with a high quality, comprehensive emergency response plan wherein staff willdemonstrate knowledge and skill in response to a variety of disasters. The Emergency Operations Plan is designed todemonstrate how the facility coordinates its communications, resources and assets, safety and security, staff responsibilities,utilities, and patient clinical and support activities during an emergency.

B. ORGANIZATIONThe following represents how emergency operations reporting occurs:Board of TrusteesExecutive AdministrationRegulatory Readiness CommitteeEOC Committee

C. RESPONSIBILITESBoard of Trustees (Governing Board): The Governing Board accepts ultimate responsibility for the emergencyoperations program, and reviews reports from the Safety Committee, providing feedback if applicable.Medical Executive Committee: This committee reviews quarterly reports from the Safety Committee, which has anemergency management component.Patient Safety Committee: Requests Safety Committee review, as applicable, of issues relating to emergencymanagement that may have an impact on the safety of our patients.EOC Committee: Monitors and evaluates the Emergency Operations Plan and ensures implementation of theprogram's components.Environment of Care: This committee implements operational aspects of the Emergency Operations Plan (e.g., drillplanning, developing the inventory of organizational assets, equipment purchases, etc.).Safety Officer: Gathers all information that relates to emergency management and preparedness and reportsinformation to executive management, and presents information for the EOC committee to review. This individualmay assume the Safety Officer role in the event the Emergency Operations Plan is activated, and acts as a resourcefor the hospital for emergency planning.Managers: Are responsible for the development of unit-specific disaster plans, and for implementing them in theevent a disaster situation warrants activation.Staff: Are responsible for the care of patients in a disaster situation, and for enacting disaster functions asidentified in his/her unit-specific disaster plan.

D. OBJECTIVES

The primary objective of the Emergency Operations Plan is to reduce harm to life and property due to unforeseen circumstances.The EOP provides a concise, pre-established plan to be implemented during a disaster or other emergency to ensure the

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• Mitigation: These activities eliminate or reduce the effects of hazards. Mitigation begins with identifying hazards that mayaffect the facility and analyzing how vulnerable patients, personnel and information resources may be to those hazards.

• Procedures to respond to a variety of disasters based on a Hazardous Vulnerability Analysis (HVA) performed by theorganization. The HVA will be reviewed periodically to ensure consistency with hospital and/or community changes.

• Priorities of the potential emergencies are identified in the HVA.• The organizations role in relation to a community-wide emergency operations program.• An "all-hazards" command structures within the organization that links with the community's command structure.

• Preparedness: These activities build individual and organizational ability to manage the effects of hazards that activelyimpact a facility. Some of the important preparedness steps include creating an inventory of resources that may be neededin an emergency.

◦ Pre-arranged agreement with vendors and healthcare networks.◦ Maintaining an ongoing planning process.◦ Holding staff orientation on basic response actions.◦ Implementing facility wide rehearsals.◦ Staff and family well-being.◦ Integrating into local and state emergency operations plans, as appropriate, to support local and statewide operations.◦ Defining and establishing procedures for the preparation, staffing, organization, activation, and operation of the

hospital's role in the event of a community wide disaster.• Response: These activities control the negative effects of emergency situations and are divided into actions that all staff

must take when confronted by an emergency such as:◦ Initiation of plan.◦ Assessing the situation.◦ Issuing warning and notification announcements.◦ Setting objectives and priorities.◦ Serving as a liaison with external groups.◦ Minimizing suffering, loss of life, personal injury, and damage to property.◦ Effective utilization of available resources to prevent or minimize the consequences of a hazardous or emergency

condition.◦ Notification to staff of plan implementation defining their alternate roles and responsibilities.◦ Management of physical plant, space, supplies, and security both on campus and alternative sites as appropriate.◦ Providing internal and external communications systems.◦ Procedures for partial and total facility evacuation.◦ Identification, where appropriate, of available facilities for chemical, radiological, or biological isolation and

decontamination.◦ Management of patients during disasters or emergencies, including the scheduling, modification, or discontinuation of

services.◦ Control of patient information and admission, transfer and discharge of patients.

• Recovery: These actions begin almost concurrently with the response activities and are directed at restoring essentialservices and resuming normal operations.

◦ Resuming normal operations and schedules.◦ Dispersing of "Employee Pool".◦ Disassembling of decontamination area and alternate care sites (ACS).◦ Restoring normal traffic flow.

A. DEFINITIONS OF EVENTS

1. Natural Hazards: Natural events that threaten lives, property, or other assets such as hurricanes, tornados, floods, andepidemics.

2. Technological Hazards: Events such as failure of utilities, communication systems, medical gases, or internal floods,fires, structural damage, or supply shortages.

continuity of patient care. Additionally, at the beginning of each calendar year, specific goals may be identified, and these areevaluated during the annual evaluation process. The EOP comprehensively describes the organization's approach to respondingto emergencies within the organization or in its community that would suddenly and significantly affect the need for theorganization's services, or its ability to provide those services. The EOP provides processes in the following 4 phases:


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3. Man-Made Hazards; Events such as mass causality incidents, bioterrorism, bomb threats, civil disturbances, infantabduction, or other security related issues.

4. Hazardous Materials: Events involving chemical or radiological releases, both internal and external.

I. PLANNING ACTIVITIES

ELEMENTS OF PERFORMANCEA. PLANNING PARTICIPATION AND HAZARD VULNERABILITY ANALYSIS

EM. 01.01.01EP-1THE HOSPITAL'S LEADERS, INCLUDING LEADERS OF THE MEDICAL STAFF, PARTICIPATE IN PLANNINGACTIVITIES PRIOR TO DEVELOPING AN EMERGENCY OPERATIONS PLAN.The hospital's leaders and medical staff participate in planning activities at the EOC committee. It is at this committee levelthat the Hazard Vulnerability Analysis is conducted, drill exercises are designed and planned, education relating to drillimplementation is prepared, the inventory of organizational assets is developed and monitored, and activities relating to thefacility's Hospital Command Center are developed. All activities that emanate from the EOC committee are integrated intothe Emergency Operations Plan, and are brought forth to the EOC Committee.

B. COMMUNITY INVOLVEMENTEM. 01.01.01EP-2 through 4THE HOSPITAL CONDUCTS A HAZARD VULNERABILITY ANALYSIS (HVA) TO IDENTIFY POTENTIALEMERGENCIES THAT COULD AFFECT DEMAND FOR THE HOSPITAL'S SERVICES OR ITS ABILITY TO PROVIDETHOSE SERVICES, THE LIKELIHOOD OF THOSE EVENTS OCCURRING, AND THE CONSEQUENCES OF THOSEEVENTS. THE FINDINGS OF THIS ANALYSIS ARE DOCUMENTED. THE HOSPITAL, TOGETHER WITH ITSCOMMUNITY PARTNERS, PRIORITIZES THE POTENTIAL EMERGENCIES IDENTIFIED IN ITS HVA AND DOCUMENTSTHESE PRIORITIES. THE HOSPITAL COMMUNICATES ITS NEEDS AND VULNERABILITIES TO COMMUNITYEMERGENCY RESPONSE AGENCIES AND IDENTIFIES THE COMMUNITY'S CAPABILITIES TO MEET ITS NEEDS.THIS COMMUNICATION AND IDENTIFICATION OCCUR AT THE TIME OF THE HOSPITAL'S ANNUAL REVIEW OF ITSEOP AND WHENEVER IT'S NEEDS OR VULNERABILITIES CHANGE.At the EOC committee, in a multidisciplinary forum, the HVA is analyzed at least on an annual basis, or wheneverexperiences warrant additional review. Historical experience, geographical location, weather and climate conditions, localhazards, political conditions and populations served are factored into the analysis, and balanced against the facility'smitigation strategies and preparedness activities. When the HVA is completed, collaboration with local governmental ormunicipal agencies occurs to assist in defining priorities within the HVA and to ascertain capacities to support the needs ofunexpected events. Medical staff review additionally occurs. The HVA process is documented, and kept on file in the EOCCommittee minutes. A copy of the local HVA is kept on file.

C. MITIGATION AND PREPAREDNESSEM. 01.01.01-EP5THE HOSPITAL USES ITS HVA AS A BASIS FOR DEFINING MITIGATION ACTIVITIES (THAT IS, ACTIVITIESDESIGNED TO REDUCE THE RISK OF AND POTENTIAL DAMAGE FROM AN EMERGENCY).See ATTACHMENT A - HAZARD VULNERABILITY ANALYSIS. The top five hazards have been identified as follows:HVA - 2015 – Top 5 RisksEvent RationaleBlizzard HVA Typical Indiana Weather – Past experiences

Winter Storm Typical Indiana weather – Past occurrences

Tornado Typical Indiana weather – Past occurrences

Cyber Attack Recent activities worldwide

Communication Failure Radio turnover / reprogramming

EM. 01.01.01-EP6THE HOSPITAL USES ITS HVA AS A BASIS FOR DEFINING THE PREPAREDNESS ACTIVITIES THAT WILLORGANIZE AND MOBILIZE ESSENTIAL RESOURCES.The HVA is used as a planning tool in defining preparedness activities that will organize and mobilize essential resources. Itis also used to determine what assets may be needed to augment emergency preparedness at the facility, and what


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community partnerships may be invoked to strengthen response and/or mitigation. Key members of the EOC Committeemeet on an annual basis to review risks to determine if changes in operational practices, mitigation strategies, and changesin local and/or global conditions warrant changes in our risks.

D. HOSPITAL INCIDENT COMMAND SYSTEM (HICS)EM. 01.01.01-EP7THE HOSPITAL'S INCIDENT COMMAND STRUCTURE IS INTEGRATED INTO AND CONSISTENT WITH ITSCOMMUNITY'S COMMAND STRUCTURE.The facility uses the Hospital Incident Command System (HICS) as a scalable response to different types of emergencies.The facility has adopted NIMS (National Incident Management System), and has integrated NIMS into pre-planning fordisasters. Key personnel with the facility are expected to respond to the Hospital Command Center if activated, and toassume functional responsibilities within the HICS command structure. HICS and NIMS training are required for staff thatassume leadership roles in the management of emergencies. HICS is compatible with an "all hazards approach" to themanagement of disasters, and is consistent with our local agencies having jurisdiction, such as police, fire, and emergencymedical services. HICS appointees are appointed based upon parallel functions within their day-to-day job activities, andanticipated HICS response for a variety of scenarios. However, it is possible that one employee can equally assume morethan one HICS role due to the nature of standardized responses and a reduction in staffing resources. For example, on theevening or night shifts, the employee who assumes the Incident Commander role, may also assume Operations andPlanning functions until relief can occur from incoming employees. At least annually HICS participants receive education/training relative to their role and anticipated responses during a drill or actual event. This may occur formally, through aneducation class, or through rehearsal during planned disaster drills. The chart below identifies how HICS is organized at thefacility:Hospital Incident Command Structure St. Vincent Mercy Hospital


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*

E. INVENTORY OF ASSETS & RESOURCES

EM. 01.01.01-EP8

I. EMERGENCY OPERATIONS PLAN

THE HOSPITAL KEEPS A DOCUMENTED INVENTORY OF THE RESOURCES AND ASSETS IT HAS ON SITE THAT MAYBE NEEDED DURING AN EMERGENCY, INCLUDING, BUT NOT LIMITED TO, PERSONAL PROTECTIVE EQUIPMENT,WATER, FUEL, AND MEDICAL, SURGICAL AND MEDICATION-RELATED RESOURCES AND ASSETS.

The facility maintains an inventory of assets and resources that are maintained on-site that could be used in the event of anemergency.

The inventory is assessed by EOC Committee members on an ongoing basis. During an emergency, the facility will monitor thequantities of assets and resources by using the inventory as a planning tool. The inventory will be updated by the LogisticsSection as needed, and the updated inventory communicated to the Hospital Command Center. See SUPPLEMENTALMATERIALS-RESOURCES ON PAGE 170.


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ELEMENTS OF PERFORMANCEA. PLANNING PARTICIPATION AND LEVELS OF RESPONSE

EM. 02.01.01-EP1 and 2THE HOSPITAL'S LEADERS, INCLUDING LEADERS OF THE MEDICAL STAFF, PARTICIPATE IN THEDEVELOPMENT OF THE EMERGENCY OPERATIONS PLAN. THE HOSPITAL DEVELOPS AND MAINTAINS AWRITTEN EOP THAT DESCRIBES THE RESPONSE PROCEDURES TO FOLLOW WHEN EMERGENCIES OCCUR.The Emergency Operations Plan is developed in pre-planning meetings by key EOC members. Medical staff leadershipprovides review and input in the development of the Emergency Operations Plan. Decisions in an emergency will be madeby leadership within the Hospital Command Center. The EOP requires the Hospital Command Center (HCC) to determinewhat specific response procedures are needed during an emergency, including the decision to continue operations ifinventory supplies are used, and it is not imminent that re-stocking will occur. Response options may include minimizingoperations or closure of operations. Relocation of patients and staff to an alternate care site may be another option. TheHospital Command Center may initiate collaboration with local emergency operations as needed when planning involves aloss or diminishing supplies, or when patients may need to be moved to an alternate care site. Other response options thatwill be determined at the Hospital Command Center may include staged or total evacuation.Levels or ResponseNormal Normal operations

Level1

Minor incident affecting the hospital, the situation can be handled with the normal staff on duty at the time.The hospital command center may or may not be open at the discretion of the hospital leadership.

Level2

Major incident in the community surrounding the hospital or within the hospital itself. Additional staff may beneeded in specific areas of the hospital. The hospital needs limited support from division resources (e.g.,supply chain, staffing, patient transfer center).This level also includes significant event warnings for the community (e.g., Severe weather, ice or winterstorm warnings).The hospital command center is activated at a level determined by the hospital leadership.

Level3

Event of such a significant impact to the hospital that additional resources are required from corporate orcommunity partners.The hospital command center is fully activated. The division command center is operational in support ofthe facility.

B. SUSTAINABILITYEM.02.01.01EP-3THE EMERGENCY OPERATIONS PLAN IDENTIFIES THE HOSPITAL'S CAPABILITIES AND ESTABLISHESRESPONSE PROCEDURES FOR WHEN THE HOSPITAL CANNOT BE SUPPORTED BY THE LOCAL COMMUNITY INTHE HOSPITAL'S EFFORTS TO PROVIDE COMMUNICATIONS, RESOURCES AND ASSETS, SECURITY ANDSAFETY, STAFF, UTILITIES OR PATIENT CARE FOR AT LEAST 96 HOURS.In the event of a disaster, and it is known that the facility cannot be supported by the local community, an immediateassessment of the six critical areas will be initiated by the Hospital Command Center (communications, resources andassets, staff roles and responsibilities, safety and security, utilities, and clinical activities). The safety and security of patientswill be assessed by managers and/or lead personnel on every unit, and the security of the buildings will be assessed by theSecurity Branch Director and their appointed officers. The Infrastructure Branch Director will assess utilities, including power,HVAC, potable water and fuel. Patient clinical and support activities will be assessed when the facility's infrastructure andresources are taxed. All managers will conduct bed availability and staffing needs for current patients, as well as forexpected incoming patients if known. Hospital Command personnel will use Supplemental Materials-Resources as aplanning guide in determining resource needs and allocation, and whether or not conservation strategies will be needed.

C. RECOVERY

EM.02.01.01EP-4THE HOSPITAL DEVELOPS AND MAINTAINS A WRITTEN EMERGENCY OPERATIONS PLAN THAT DESCRIBES THERECOVERY STRATEGIES AND ACTIONS DESIGNED TO HELP RESTORE THE SYSTEMS THAT ARE CRITICAL TOPROVIDING CARE, TREATMENT, AND SERVICES AFTER AN EMERGENCY.


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• Activating the Demobilization Unit Leader to begin the gradual demobilization of the Hospital Command Center, andemergency operations according to the progression of the incident and facility/hospital status.

• Return of HICS personnel to their normal job.• Briefings for staff, administration and the Board of Trustees.• Approval of the "ALL CLEAR" when the incident is no longer a critical safety threat, or can be managed during normal

operations.• Ensuring outside agencies are aware of the status change.• Declaring the hospital and facility is safe.• Return of borrowed equipment, replacement of broken or lost items, cleaning of the HCC and facility, and restocking

supplies and equipment.• Ensuring that after-action activities are coordinated and completed, including the collection of all HCC documentation.• Coordination and submission of response and recovery costs, and reimbursement documentation.• Conducting a debriefing, and identifying areas requiring improvement.• Conducting staff debriefings to identify accomplishments.• Assessing the need to change the Emergency Operations Plan.• Participating in external (community and governmental) meetings, and other post-incident discussion and after action

activities.• Participating in media debriefings.• Providing stress management and services for staff as needed.

A. PLAN INITIATION AND TERMINATIONEM.02.01.01-EP5 and 6THE EMERGENCY OPERATIONS PLAN DESCRIBES THE PROCESSES FOR INITIATING AND TERMINATING THEHOSPITAL'S RESPONSE AND RECOVERY PHASES OF THE EMERGENCY, INCLUDING UNDER WHATCIRCUMSTANCES THESE PHASES ARE ACTIVATED. THE EOP IDENTIFIES THE INDIVIDUAL(S) WHO HAS THEAUTHORITY TO ACTIVATE THE RESPONSE AND RECOVERY PHASES OF THE EMERGENCY RESPONSE.The individual who assumes the Incident Commander role at the facility has the authority to initiate and terminate thehospital's response and recovery phases of the emergency. The Emergency Operations Plan is activated when anunexpected or sudden event significantly disrupts the facility's ability to provide care, or that results in a sudden andincreased demand for services. Activation includes notification of the Division Emergency Operations Center.

B. ALTERNATE CARE SITESEM.02.01.01-EP7THE EMERGENCY OPERATIONS PLAN IDENTIFIES ALTERNATIVE CARE SITES FOR CARE, TREATMENT ANDSERVICES THAT MEET THE NEEDS OF ITS PATIENTS DURING EMERGENCIES.Alternate Care Sites - Acute Care Location: In the event evacuated patients require transfer to an acute care facility, aprocedure to coordinate with other hospitals are in place for mutual reciprocity in the event an alternate site is needed.Individuals who would direct this effort would begin with the employee assigned to the safety officer role at each facility, inconjunction with executive and administrative personnel, and the Security and Transportation Officers. The Patient TrackingCoordinator in the HICS system would be responsible for tracking all patients transported to and from the alternate care site,in conjunction with the Transportation Officer, Security Officer and Safety Officer. Inter-facility communication between thehospital and the alternate care site is the responsibility of each affected manager at the site, and the Patient TrackingCoordinator.Alternate Care Sites - Lower Acuity Patients: Lower acuity patients may be transferred to off-campus locations owned oroperated by businesses other than the hospital. These may be churches, schools, hotels/motels, etc. In this plan, ACSs areconsidered to be relatively small private sites staffed by the hospital and treating only hospital patients, not large regionalcommunity-wide alternate care sites established by the county. HICS appointees will oversee the management of patienttransfers, which include communication, equipment, supplies, security and staffing issues.The Division Emergency Operations Center may assist with coordination of patient transfers and use of alternate care sites.Communication with the Division EOC is outlined above in the Plan Initiation and Termination section of this plan. For eventsthat exceed the capacity of the St. Vincent Health EOC, the Medxcel Facilities Management EOC will be activated by theDivision to provide additional assistance and resources.

Recovery strategies are included for every HICS participant in their Job Action Sheets, which focus on demobilization andrecovery activities. These activities are designed to assist the facility and management in the resumption of normal operationsafter a disaster event. Demobilization strategies include, but are not limited to the following:


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C. AUTHORITY AND INCIDENT PHASES

EM.02.01.01EP8

I. COMMUNICATION MANAGEMENT

ELEMENTS OF PERFORMANCEA. STAFF AND LICENSED INDEPENDENT PRACTITIONER NOTIFICATIONS

YOUR ATTENTION PLEASESEVERE WEATHER ALERT

YOUR ATTENTION PLEASE

• By overhead page• By telephone and/or FAX if operating• By email• By mass notification system• By runner• By hand-held radios• By combination of the above

IF THE HOSPITAL EXPERIENCES AN ACTUAL EMERGENCY, THE HOSPITAL IMPLEMENTS ITS RESPONSEPROCEDURES RELATED TO CARE, TREATMENT AND SERVICES FOR ITS PATIENTS.

In the event of an actual emergency, the facility is prepared to respond using HICS to manage the event, which includes oversightof activities relating to the care, treatment and services for our patients. Activities relating to emergency management may includethe establishment of a triage and/or decontamination area, deployment of staff, allocation of resources and equipment, monitoringof supplies and actions taken, and documentation of the event, if possible. Through an all hazards planning process, the facility ispoised to respond to emergencies, utilizing HICS, which is scalable to the event.

EM.02.02.01-EP1 through 17

AS PART OF ITS EMERGENCY OPERATIONS PLAN, THE ORGANIZATION PREPARES FOR HOW IT WILL

COMMUNICATE DURING EMERGENCIES.

HOW STAFF WILL BE NOTIFIED THAT EMERGENCY RESPONSE PROCEDURES HAVE BEEN INITIATED

Upon activation of the EOP, the Command Center will communicate with staff in the following ways: overhead page (PBX),telephone and cellular phone, house wide email, mass notification system, verbally through the chain of command, and runner ifnormal communications are disrupted. The specific mechanism(s) used for communicating will depend upon the scope andduration of the emergency as well as its impact on communication mediums. More than one type of communication may benecessary to assure that effective communication occurs. A plain-language emergency notification system is in effect thatdescribes types of disasters, such as a Internal/External. New hire and ongoing orientation programs teach or reorient staff to thetypes of codes and the response required for each code. When emergency response procedures have been initiated, staff will benotified by PBX that emergency response procedures have been activated as follows:

All staff please return to your departments

The Hospital Incident Commander or his/her designee has the authority to terminate emergency response procedures. Upontermination of the event, the Hospital Incident Commander will instruct the PBX to page overhead:

The Severe Weather Alert is now canceled

HOW THE HOSPITAL WILL COMMUNICATE INFORMATION AND INSTRUCTION TO ITS STAFF AND LICENSEDINDEPENDENT PRACTITIONERS DURING AN EMERGENCY

Staff in various departments and care areas on duty at the time of the emergency will be notified as follows, depending uponcapability:


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• Notify staff through public service announcements on local television and radio through the Public Information Officer)• Notify staff through announcements placed on the facility's website, or Send Word Now (mass notification system).

A. COMMUNICATION WITH EXTERNAL AUTHORITIESWhen the emergency response measures have been initiated, external authorities will be notified by the Liaison Officerthrough the COMMUNICATION SYSTEM, or through HAM Radio operators designated to respond to our premises.In the HICS system, a position is designated for communications with external authorities during a disaster. This HICSposition is the Liaison Officer. The Liaison Officer will communicate with external authorities during an emergency using theCOMMUNICATION SYSTEM or in coordination with HAM Radio operators if normal communications fail. The Liaison Officerwill report updates to the Hospital Command Center when contact has been made with external authorities. Externalauthorities may include local, regional, and/or state Incident Command Posts, 911 Centers, Emergency Operations Centers,and others as applicable..

B. COMMUNICATION WITH PATIENTS AND FAMILY

• Verification that the patient is at the organization.

• The general condition of the patient.• If the patient is going to be moved to an alternate care site, then the name, address, and specific care area of that site, as

well as the anticipated timeframe for relocation.

A. COMMUNICATION WITH MEDIA AND COMMUNITY

• Media and public inquiries.• Emergency public information.• Rumor monitoring and response.• Media monitoring.

A. COMMUNICATION WITH SUPPLIERS

Licensed Independent Practitioners who are within the facility premises will be notified as above. Staff not on duty at the time ofthe emergency are notified (if necessary) through activation of department / unit call- back procedures. If phone service isdisrupted, the following will be considered:

See ATTACHMENT D – CODE SYSTEM.

Patient Care providers will communicate with patients using routine methods, such as verbal, and through call light response. Ifthe call light system is inoperable, more frequent rounds will be required to determine the needs of the patient (until power isrestored to the call light system). The Public Information Officer (PIO) will establish processes to communicate pertinentinformation to patients and their families – including when patients are relocated to an alternative care site. Consistent with TheHealth Insurance Portability and Accountability Act (HIPAA), as well as local laws and regulations and surrounding confidentialityof patient information, families may be apprised of the following:

If patients must be relocated to an alternate care site, the Planning Section will develop a complete list of patients who will requiretransfer to the alternate care site, and the name/phone number of a family member to be contacted. Information regarding theaddress of the alternate care site, the location within the alternate care site, and the estimated time of relocation will bedetermined. The clinical care team will determine what type of transfer will be needed, and the primary care nurse will notify thepatient of the plan for relocation to an alternate care site once a physician has ordered the relocation. The PIO or designee willcontact the family member and notify them of the relocation information.

The Command Center will establish a Public Information Center for the PIO for the purpose of providing timely and accurateinformation to the public during a crisis or emergency situation. During an event, the Public Information Officer will handle:

The PIO will also perform other functions required for coordinating, clearing with appropriate authorities, and disseminatingaccurate and timely information related to the incident, particularly regarding information on public health, safety and protection,and patient care and management issues. All media and community inquiries will be managed through the PIO. The effective useof the media to convey information during and following an incident is critical. The information provided to the public must includedirection on what actions should and should not be taken, along with appropriate details about the incident and the actions beingtaken by the hospital. The PIO will work closely with the PIO at other community response agencies, or with a Joint InformationCenter (JIC), if established, so that any contradictory or confusing messages coming from different sources can be avoided.


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• Vendor contact information.• The type of critical supplies, equipment, and/or service that will be provided during an emergency.

A. COMMUNICATION WITH OTHER HEALTHCARE ORGANIZATIONS

• Essential elements of the command structures and control centers for emergency response.• Names and roles of individual(s) in their command structures and the telephone number of their command center.• Resources and assets that could potentially be shared in an emergency response, such as beds, transportation, linen, fuel,

personal protective wear, medical equipment and supplies.• If requested, and if in accordance with law and regulation, the names of patients and deceased individuals brought to the

organization will be shared in order to facilitate re-unification (i.e., for religious and ceremonial reasons, and to facilitateclosure issues with the deceased).

• Verification that the patient is at the facility.

• The general condition of the patient.• If the patient is going to be moved to an alternate care site, include the name, address, and specific care area of that site, as

well as the anticipated timeframe for relocation.

A. COMMUNICATION WITH ALTERNATE CARE SITES

• Apprise alternate care sites as to the status of the organization, its operational capability, and the anticipated need forassistance.

The Logistics Section Chief and Operations Section Chief of HICS will work collaboratively to assure that there is appropriatecommunication with vendors that may provide essential supplies, services, and equipment once emergency measures areinitiated. Memorandums of understanding (MOU) may be invoked with key vendors to assure priority delivery and service to theorganization during an emergency. For each vendor, the facility has defined:

The Hospital Command Center will use normal methods of communication, e.g., phones (landline and cellular), and email andtext messages to communicate with other healthcare organizations, providing these services have not been interrupted. Ifcommunications have been interrupted, the Hospital Command Center will communicate via redundant systems listed inSupplemental Materials-Communications

. At a minimum the following may be communicated to and from these healthcare organizations:

HOW THE HOSPITAL WILL COMMUNICATE THE NAMES OF PATIENTS AND THE DECEASED WITH OTHER HEALTHCARE ORGANIZATIONS IN ITS CONTIGUOUS GEOGRAPHIC AREA.

Consistent with The Health Insurance Portability and Accountability Act (HIPAA), as well as local laws and regulations andsurrounding confidentiality of patient information the facility will communicate the names of the patients and the deceased withother healthcare organizations in its contiguous geographic area through normal communication channels if operational, only withan individual designated to be the Public Information Officer. If normal communications are not operating, the Liaison Officer, incoordination with the PIO, will transfer information to the local EOC through backup communications equipment or HAM radio(including agencies having jurisdiction, such as the police and fire). Please note: Deceased names will not be transmitted viaHAM radio. This type of sensitive information will only be shared by the Public Information Officer; however, if a mass influx ofdeceased patients occurs, the Public Information Officer may appoint deputy PIO's to assist in the communication process.

HOW AND UNDER WHAT CIRCUMSTANCES, THE HOSPITAL WILL COMMUNICATE INFORMATION ABOUT PATIENTS TOTHIRD PARTIES (SUCH AS OTHER HEALTH CARE ORGANIZATIONS, THE STATE HEALTH DEPARTMENT, POLICE ANDTHE FBI).

Consistent with The Health Insurance Portability and Accountability Act (HIPAA), as well as local laws and regulations andsurrounding confidentiality of patient information, the Public Information Officer will establish a plan to communicate pertinentpatient information to third parties – including when patients are relocated to an alternative care site. Every attempt will be madeto remain consistent with law and regulation surrounding patient confidentiality. The plan to communicate patient information willinclude minimally the following:

Depending on the nature, scope, and duration of the emergency, the Hospital Command Center will establish periodiccommunication with designated alternate care sites. The first choice of communication will be landline, fax, cellular phone and e-mail. If these forms of communication are disrupted, runners will be dispatched from the Labor Pool to send and retrieveinformation if it is safe to do so. The purpose of communication will be to:


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• Determine the status of the alternate care site(s), their operational capability, and their ability to receive patients should itbecome necessary.

A. BACKUP COMMUNICATION

• Maintenance of communication equipment (e.g., hand-held radios, HAM radio.)• Practice with alternate communications during drill exercises (e.g., hand-held radios, HAM radio, and activation of runners.)• Practice with downtime procedures relative to email and internet capabilities (e.g., during routine service repairs and/or

equipment maintenance, electrical shut-downs.)

I. RESOURCE AND ASSET MANAGEMENT

ELEMENTS OF PERFORMANCEA. OBTAINING AND REPLENISHING SUPPLIES

• Food• Water• Linen• Fuel for Emergency Power Generators

Backup communication technologies include use of the following: overhead page, HAM radio, VoIP systems, two-way radio, cellphones, satellite phones and runners. One or more types of communications may be used during a disaster depending upon thenature and scope of the disaster, and depending upon what is operational. Through various activities, the facility participates inadvance preparation to support communications during an emergency. These include, but are not limited to:

EM.02.02.03-EP1 through 12

AS PART OF ITS EMERGENCY OPERATIONS PLAN, THE HOSPITAL PREPARES FOR HOW IT WILL MANAGERESOURCES AND ASSETS DURING EMERGENCIES.

THE EMERGENCY OPERATIONS PLAN DESCRIBES HOW THE HOSPITAL WILL OBTAIN AND REPLENISH MEDICATIONS,MEDICAL SUPPLIES, AND NON-MEDICAL RELATED SUPPLIES THAT WILL BE REQUIRED THROUGHOUT THERESPONSE AND RECOVERY PHASES OF AN EMERGENCY, INCLUDING ACCESS TO AND DISTRIBUTION OFMEDICATION CACHES THAT MAY BE STOCKPILED BY THE HOSPITAL, ITS AFFILIATES, OR LOCAL, STATE ORFEDERAL SOURCES.

The Operations Chief and Staging Manager will coordinate with Pharmacy and Materials Management the initial delivery ofsupplies, equipment and pharmaceuticals upon activation of the disaster plan. Prioritization will be given to those areas eitherimmediately impacted by the emergency, or are likely to be so.

Carts containing pre-positioned pharmaceuticals, supplies, and equipment, will be sent to designated staging areas. The contentsof the carts will be rotated out on a regular basis to assure that inventory does not expire. Equipment designated for pre-positioning is included in the organization's medical equipment inventory and is maintained in accordance with pre-establishedpreventive maintenance requirements.

ONGOING REPLENISHMENT OF SUPPLIES, EQUIPMENT, AND PHARMACEUTICALS

For the duration of the emergency – including response and recovery phases – the Operations Section Chief and StagingManager are responsible for monitoring the inventory of supplies (including personal protective equipment), equipment, andpharmaceuticals in the various care areas. Replenishment from storage areas (Central Supply) will occur on an as needed basis.

A general inventory of supplies (including personal protective equipment), equipment and pharmaceuticals will be taken in theirrespective storage areas on at least a daily basis (or more frequently if necessary) for the duration of the emergency. Remaininginventory shall be measured against the rate of consumption that is occurring as a result of the emergency. When existinginventory of critical supplies (including personal protective equipment), equipment, and/or pharmaceuticals are in danger ofreaching insufficient levels, then contingency plans with outside vendors will be implemented.

ONGOING REPLENSIHMENT OF NON-MEDICAL SUPPLIES

For the duration of the emergency – including response and recovery phases – the Logistics Section Chief and the InfrastructureBranch Director in coordination with Central Supply are responsible for monitoring the non-medical supply inventory. Thesesupplies include, but are not necessarily limited to:


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• Fuel for Vehicles

• The average amount of resource or asset within the organization at any given time.• The estimated consumption of the resource based on maximum capacity of patients and staff.

Resource or Asset Hours Self Sufficient

1. Potable Water 96 with water conservation plan

1. Food 96 with food rationing and dry food plan

1. Fuel for Emergency Generators 96+ with Cache supplies from the local EOC

1. Pharmaceuticals – Analgesics / Narcotics 96+ with Cache supplies from the local EOC

1. Pharmaceuticals – Broad Spectrum Antibiotics 96+ with Cache supplies from the local EOC

WATER CONSERVATION PLANSurgeries Finish up what is currently in progress

ER Patients On divert

Dialysis Patients Diverted to other facilities

In Patients Sponge bath with "wipettes"Hand washing with alcohol gel

All Staff Hand washing with alcohol gel

All Staff/Patients Consume bottled drinks-try to limit quantities

Toilets If able to flush, flush after usage.

Sinks Affix signs: "Do Not Use"

Chillers This is only affected if boilers can no longer run.

Boilers Season will determine heating and/or chilling needs.

Generators Can run for approximately 7 days depending upon load usage.

HVAC System The HVAC system is on generator power.

FOOD CONSERVATION PLANFood Supply – Patients,Employees, MD's, Other

Emergency back-up foodsupplies are maintained,

Meets 96-Hour sustainability; if food supplies begin todiminish, food rationing plan will go into effect

A general inventory of non-medical supplies will be taken in their respective storage areas on at least a daily basis (or morefrequently if necessary) for the duration of the emergency. Remaining inventory shall be measured against the rate ofconsumption that is occurring as a result of the emergency. When existing inventory of critical non-medical supplies are in dangerof reaching insufficient levels, then contingency plans with outside vendors will be implemented.

SUSTAINABILITY OF OPERATIONS WITHOUT EXTERNAL SUPPORT

It is possible that the nature, scope, and duration of the emergency may preclude outside agencies, vendors, authorities, or othervital entities from assisting the organization in a timely manner. Outside assistance may not be available for up to 96 hoursfollowing initiation of the Emergency Operations Plan.

The facility has designed its operations so that it can be self-sufficient for a designated time frame depending on resources andassets being affected. The table below summarizes the organization's ability to be self-sufficient in key areas. Hours of self-sufficiency is based on the following:


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• Continuing current operational capability based on anticipated assistance from external sources• Curtailing or modifying selected operational capability• Closing and evacuating the facility(s)

A. SHARING OF RESOURCESThe facility will share resources and assets with other healthcare organizations within the community by communicatingneeds to other hospital command centers, and/or by working in conjunction with the local EOC.

B. MONITORING RESOURCES AND ASSESTSPharmacy, Food/Nutritional Services, and Central Service, at the onset of any emergency, will determine the currentquantities of medications, food/water, supplies, and linens. Daily usage will be measured against the current availablequantities. If it is determined that the rate of usage/consumption is greater than expected replenishment, local resources willbe accessed. If necessary, conservation measures will go into effect as stated above. If it is determined that the facility canno longer support the care, treatment and services for the patients, a decision will be made by the Incident Commander totransfer and/or evacuate patients.

C. TRANSPORTING AND TRANSFERRING PATIENTS, INFORMATION, MEDICATIONS AND SUPPLIES

• The patient's name.• The patient's medical record or other identification number.• The disposition of the patient (where the patient was sent to.)• Whether or not family was notified (attempts should be made to notify family prior to transfer.)• Whether or not the patient's medical record was sent. At least copies of the H&P, operative reports, current medications

(including last dose given), and most recent care records should be sent.• When the patient was transferred.• When the patient arrived at the receiving facility and where the patient was placed.• When report was given on the patient to the receiving facility, and to whom the report on the patient was given.

I. SECURITY AND SAFETY MANAGEMENT

ELEMENTS OF PERFORMANCEA. SECURITY WITH COMMUNITY

If critical assets and resources have neared depletion levels, and there is no anticipated assistance from external sources in thenear future, then the Command Center will need to make a determination as to whether or not operational capability can besustained. Possible actions include:

Decisions involving curtailment, modification, or halting of operational capability will be made by the highest ranking administrator(Incident Commander) in conjunction with the local EOC.

The Planning Section Chief, Security Branch Director, and the Patient Tracking Manager are responsible for coordinating thetransfer and transporting of patients to alternate care sites should the facility need to be evacuated. This would includetransporting the patient's medication, necessary equipment and supplies, as well as pertinent clinical and medication-relatedinformation.

A tracking system will be implemented that notes at least the following:

Patients will be assessed to determine if they need to be transported by BLS or ALS as appropriate to their clinical condition. Ifnecessary, qualified hospital staff will accompany the patient.

THE HOSPITAL IMPLEMENTS THE COMPONENTS OF ITS EMERGENCY OPERATIONS PLAN THAT REQUIRE ADVANCEPREPARATION TO PROVIDE FOR RESOURCES AND ASSETS DURING EMERGENCIES.

One function of the EOC is to plan in advance, and in an ongoing fashion, an inventory of organizational assets and resourcesrelating to emergency preparedness. This effort is a multi-disciplinary process, with monthly meetings that are driven by astandard agenda. The inventory is modified as new assets and resources are accumulated, and revised as quantities may beused during drills and/or actual events.


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EM.02.02.05EP-1-10

• Incident Command• Integration of Law Enforcement into Organization Operations• Decision Making• Rules of Engagement for Crowd Control• Chain of Custody

A. MANAGING HAZARDOUS WASTEDuring an emergency, when the structural integrity of the building may be impacted, for example, due to an earthquake orinternal flood, the Safety Officer, in conjunction with hospital staff, will assess all areas that contain hazardous materials, i.e.,the laboratory, where diesel fuel is stored, environmental services storage areas, central sterile, radiology, and the kitchen todetermine if there are any spillages. If any spills are found, the area will be evacuated and secured. The SDS for the spilledmaterial will be obtained. If a spill kit can be safely used, this will be the procedural response. If the nature of the spilledmaterial poses risk to the employees or the building, an outside hazardous materials response team will be called. In theinterim, the areas will be cordoned, with staff evacuated. Any staff member that has experienced signs and symptomsrelating to an exposure will be escorted to the Emergency Department for treatment. The Safety Officer will work incoordination with the outside hazardous materials response team for clean-up and appropriate disposal.Should a vendor or contractor has been unable to collect the hazardous waste and the accumulation has exceeded thenormal storage areas, the waste will be placed in holding until pick up of those materials. This may include trash, linens, orbiohazardous waste. These temporary locations should be made as secure as possible to avoid runoff into storm drains orwaterway, and to prevent unauthorized entry.

B. BIOLOGICAL, RADIOLOGICAL, CHEMICAL ISOLATION AND DECONTAMINATIONThe facility has staff members that are trained for decontamination response, including the use of decontaminationequipment. The Emergency Room has procedures for decontamination, which includes the care of the patient whileminimizing risk to employees. Primary goals for emergency department personnel in handling a contaminated patient includetermination of exposure to the patient, patient stabilization, and patient treatment, while not jeopardizing the safety ofemergency room personnel. Termination of exposure can best be accomplished by removing the patient from the area ofexposure and by removing contaminants from the patient.Personnel must first address life-threatening issues and then decontamination and supportive measures if a radioactiveexposure occurs. Priority is given to life threatening emergencies with simultaneous contamination reduction. Once life-threatening injuries have been stabilized, emergency department personnel can then direct attention to thoroughdecontamination, secondary patient assessment, and identification of materials involved. In cases of extreme contamination,it may be necessary to perform decontamination before life threatening injuries can be addressed.

AS PART OF ITS EMERGENCY OPERATIONS PLAN, THE FACILITY PREPARES FOR HOW IT WILL MANAGE SECURITYAND SAFETY DURING AN EMERGENCY

The facility works with Security for day-to-day operations, with oversight by in-house management. There is an expectation thatSecurity will remain operational in the event of a disaster situation that occurs at the facility. Upon the activation of the disasterplan, the Hospital Command Center will determine the need to activate the Security Branch Director position of HICS. Thisdecision is based on the nature, scope, anticipated duration, and likely impact of the emergency on the safety of persons and thesecurity of the facility. The Job Action Sheet for the Security Branch Director provides guidelines for the individual who assumesthe role. Access control and hospital shut-down will be of primary importance.

COORDINATION OF SECURITY ACTIVITIES WITH COMMUNITY AGENCIES

It may become necessary to supplement internal security efforts with assistance from external law enforcement agencies (APD &MCSD).based upon the nature of the incident. The decision to request assistance from such agencies will be made by theIncident Commander based on incoming information and the scope of the event. The Security Branch Director will work incoordination with the Operations Section Chief when coordinating with outside community agencies.

Once a decision is made to integrate with external law enforcement agencies, the Security Branch Director will coordinate with adesignated lead officer of the agency having jurisdiction, and agree on the following issues:

Law enforcement will prevail, with consideration given to specific facility concerns that may arise.


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Personal Protective Equipment: Any staff member providing care to a contaminated patient must wear the appropriatepersonal protective wear. Decontamination must occur outside of the Emergency Room by staff that are trained specificallyfor decontamination response within the facility. Should large-scale decontamination be required, HICS will be activated, withspecific response guidelines implemented by staff who assume HICS positions.

C. ACCESS AND EGRESS CONTROL (FACILITY LOCKDOWN)

• Incoming patients, who will receive an identification wrist band.• Staff and current hospital volunteers with ID badges.• Authorized vendors with proper identification necessary for hospital operations.• Physicians with hospital ID badges.• Voluntary medical personnel who have been authorized by the Labor Pool and received a disaster ID badge.• Members of local, state, or federal response teams with proper identification.

A. TRAFFIC CONTROL

• Entrances to the facility will be staffed by security or designated personnel through the Labor Pool. Visitors and other non-hospital personnel will be instructed to proceed to designated areas. If necessary, entrances and exits will be locked down toprevent ingress or egress as warranted.

• Movement by visitors and other non-hospital personnel will be restricted to a minimum. If visitors need to move beyonddesignated areas, they will be identified and their intended location within the facility will be determined.

• Vehicular access to the facility will be monitored by security including access to the Emergency Department and otherdesignated staging areas.

I. STAFF MANAGEMENT

ELEMENTS OF PERFORMANCEA. HOSPITAL INCIDENT COMMAND SYSTEM, NIMS, AND ICS

EM.02.02.07EP-2-10

Control of entrance into and out of the facility is managed with access control points, for example, key access, magnetic/electronic door locks, and proximity card readers. If necessary, security staff will implement a lock-down procedure, which willlimit the areas for entry and exit, and security staff will be posted at critical access locations. All staff members are required towear ID badges, which will facilitate entry into and out of the facility during emergencies. The following will be allowed into thefacility during emergencies, providing the hospital is operational:

It is likely that access to the facility, and movement within the facility, will need to be monitored and controlled for the duration ofthe emergency. Upon activation of the disaster plan, the following may occur, and will be under the responsibility of the SecurityBranch Director:

ADVANCE PREPARATION FOR SECURITY AND SAFETY DURING AN EMERGENCY

Security and safety issues are regularly addressed at the EOC and various aspects are periodically rehearsed during pre-planneddrills, which are designed and implemented through the EOC.

THE FACILITY PREPARES FOR THE MANAGEMENT OF STAFF DURING AN EMERGENCY.

Roles and Responsibilities of staff for communications, resources and assets, safety and security, utilities and patientmanagement begin at the EOC through HICS structure appointments, through the careful monitoring of the facility's inventory oforganizational assets, and through ongoing assessment of risk and mitigation strategies when assessing hazard vulnerabilities.Drills are designed with specific objectives relating to functional responsibilities of staff during exercises based upon risk to thefacility. Integrated into drill planning are resource and asset allocation and utilization. These activities are preplanned duringongoing EOC meetings. These activities additionally support ongoing training for staff that may include other types of learning,such as new hire orientation, annual re-training, and pre-drill training. Staff roles and responsibilities in an emergency are largelydetermined by the priority emergencies identified as a result of the HVA, as well as the reporting relationships in the commandand control operations of the organization.

Depending on the nature, scope, and durations of the emergency, staff may be asked to assume specific duties andresponsibilities other than those normally noted in their position description. This most likely will involve assuming a HICS job


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• Communications• Resources and Assets• Safety and Security• Utilities• Clinical Activities

• To communicate situational needs, observations, operational status, and issues in a clear, concise, and timely manner to theappropriate individual(s) or entity(s).

• To conserve resources and assets and utilize said resources and assets appropriately.• To be aware of, and maintain, the safety and security of themselves, their patients and the environment in which care,

treatment, and service are rendered.• To appropriately utilize and conserve utilities, and to report disruption or failure of utilities to the appropriate individual(s) or

entity(s) in a timely manner.• To assure that clinical activities are carried out in accordance with accepted standards of care, and in a safe and efficacious

manner.

A. MANAGING STAFF SUPPORT

• Housing• Transportation• Communication• Food and Water• Stress Debriefing• Child/Elder Care• Pets

A. MANAGING FAMILY SUPPORT

function. In this case, the Job Action Sheet for that specific job function defines the staff person's role and responsibilities. Staffroles and responsibilities are identified in at least the following key areas with respect to the Job Action Sheet:

In addition, staff roles and responsibilities may be further identified as it relates to unit-specific planning, policies and proceduresand specific competencies.

All staff have – at a minimum – the following responsibilities relative to the above mentioned areas:

Depending on the nature, scope, and duration of the emergency, the Hospital Command Center will establish mechanisms tomeet the needs of staff. Such mechanisms include, but are not necessarily limited to;

If possible, unoccupied inpatient care areas of the facility will be converted into sleep rooms for staff and their family, includingelder care. If unoccupied patient care areas are not available, unoccupied general areas may be converted into dormitory stylehousing with cots, blankets, etc. Staff are responsible for managing personal items such as eyewear, personal hygiene items, andmedications.

It may be necessary to transport staff to the facility from a remote location. If so, a collection point will be determined, and staffreporting to the facility will be instructed to meet there. Coordination with local transportation companies (bus, taxis, etc) will beused to transport staff to the facility as needed. The Employee Assistance Program (EAP) shall be made available to staff on anas needed basis to cope with the stress of the emergency. The EAP can provide practical solutions, information, support andreferrals for a wide range of issues, including anxiety, depression, relational challenges, alcohol and other substance abuse, griefand loss, financial or legal concerns and work/life balance. The EAP is coordinated through the Human Resources department, orby request to the Division office.

The Logistics Section Chief and the Support Branch Director are responsible for implementing processes necessary to meet theneeds of staff as noted above. The Service Branch Director will coordinate with the Infrastructure Branch Director to assure thatadequate amounts of food and water are supplied to staff. Communications will include landlines, cell phones, email, or runnersand public address systems if normal communications are not operating.

Depending on the nature, scope, and duration of the emergency, it may be possible to share resources and assets with otherhealthcare organizations both within and outside the community. These assets and resources include, but are not necessarilylimited to:


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• Personnel• Beds• Transportation• Linen• Fuel• Personal Protective Equipment• Medical Equipment and Supplies

• The location and type of facility that they are being sent.• The type of care, treatment, and service they are being asked to provide.• The expected duration of the assignment.• The contact information at the receiving organization.

A. TRAINING AND IDENTIFICATION OF STAFF

Staff Role NIMS Based Training

Personnel likely to be involved as initial responders • ICS-100: Introduction to ICS or equivalent• FEMA IS-700: NIMS, An Introduction

Personnel likely to function as Unit / Care Area Supervisors orSpecialists in HICS

• ICS-100: Introduction to ICS or equivalent• ICS-200: Basic ICS or equivalent• FEMA IS-700: NIMS, An Introduction

Personnel likely to function as Managers, Unit Leaders, andBranch Directors in HICS

• ICS-100: Introduction to ICS or equivalent• ICS-200: Basic ICS or equivalent• FEMA IS-700: NIMS, An Introduction

Personnel likely to function as the Incident Commander, PIO,Safety Officer, Liaison Officer or Section Chief in HICS

• ICS-100: Introduction to ICS or equivalent• ICS-200: Basic ICS or equivalent• FEMA IS-700: NIMS, An Introduction• FEMA IS-800: National Response Plan (NRP), An

Introduction*

All licensed staff coming to work at the facility will need competencies assessed by Human Resources and Nursing. If personnelfrom the facility are going to be shared with another facility, staff will be apprised of the following information:

Staff will be instructed to wear their identification badges. If possible, copies of pertinent documents such as licensure,competencies, etc. will be made and given to staff to take with them. An accurate record will be maintained of who went whereand how long they stayed.

For equipment and supplies, an accurate inventory will be maintained of what was sent to other facilities and when, so thatappropriate reimbursement can occur.

If resources and assets are to be shared outside of the organization's geographic service area, then the Liaison Officer willcoordinate efforts from the facility with the local Emergency Operations Center and the Division office. See ANNEX H: STAFFAND FAMILY SUPPORT.

Staff members are minimally trained relative to the codes for activation of the Emergency Operations Plan, and where to reportfor assignment. In addition, specific training is required for staff in accordance with the National Incident Management System(NIMS) as follows:

* NOTE: Personnel whose primary responsibility isemergency management must complete this training.

The role of licensed independent practitioners (LIP) as well as designated allied health practitioners (AHP) is to render medicalevaluation and care during the emergency within the scope of their competence and privileges granted unto them by the medicalstaff. LIP's and AHP's are responsible for reporting to the Labor Pool. Staff and physicians are responsible for wearing their namebadges at all times. Staff assigned to specific roles and responsibilities during the emergency (e.g. HICS positions) will beidentified with color-coded vests.


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I. MANAGING UTILITIES

ELEMENTS OF PERFORMANCEA. UTILITIES: ELECTRICITY, WATER, FUEL, MEDICAL GASES, HVAC AND STEAM

EM.02.02.09 EP2-8

EssentialUtility

Alternate Means of Provision

Electricity-power andlighting

Generator power will allow us up to 6.6 days of potential run time, depending upon load usage. Loadwould be shed for the most critical functions.

Water forConsumption

Water Conservation Plan will be implemented (page 13) if quantities begin to diminish before waterdeliveries can occur.

WaterNeeded forEquipment &SanitaryPurposes

Water for Equipment: If water supplies diminish and equipment is no longer able to be supported, adecision will be made by the Incident Commander to divert patients, evacuate patients and/or closeoperations.Water for Sanitary Purposes: If water supplies diminish before replenishment can occur, waterconservation will be implemented (page 13).

MedicalGases/Air

On hand at any time are 12 e-tanks. Duration of supply would depend upon Fi02 and LFM or PSI, whichvaries per delivery device. Bulk oxygen could be accessed if extra oxygen needed.

Fuel requiredfor BuildingOperations,Generatorsand EssentialTransportServices

Agreements are in place with a company to provide diesel fuel and gasoline during an emergency.Portable gasoline dispensing tanks are available from them.

Heating,Ventilation &AirConditioning

Loss of HVAC will be dependent upon seasonal requirements. Windows will be opened if we areexperiencing high heat, with cooling measures instituted (extra water consumption, cold trays, noblankets). If it is winter, extra blankets will be obtained, and warm tray menu will go into effect. In bothcases, if the HVAC loss is sustained for greater than four hours, patients will go on divert until the HVACissue is resolved. If the HVAC loss results in adverse effects for patient and staff, a decision to closeoperations and evacuate patients will be made by the Incident Commander.

Steam forSterilization

Instruments to be sent to outside company if steam fails, if we are able to transport across roads; smallportable generator could be used to power sterilizers for emergency surgeries.

The hospital communicates, in writing or by e-mail, with each of LIP's regarding their role(s) in emergency response. A record ofthis communication will be kept on file.

PREPARATION /MANAGEMENT OF UTILITIES DURING AN EMERGENCY

Complementing the efforts to meet the medical care needs of the patients and protecting the staff will be the maintenance ofoverall facility operations. This responsibility primarily rests with the Infrastructure Branch Director in the Operations Section. Theresponsibilities include maintaining the normal operational capability of the facility including power and lighting, water, HVAC,medical gases, and building/grounds, increasing capacities when patient surge requirements dictate; and identifying and fixingutility service-delivery failures. The acquisition of equipment parts or outside contractors will be coordinated with the SupportBranch.

The Infrastructure Branch Director is also responsible for assuring that there is an alternate means of meeting essential utilitieswhen normal supply mechanisms are compromised or disrupted. At a minimum, this means identifying alternate providers bothwithin and outside the local community, and invoking memoranda of understanding for priority delivery and supply during anemergency. A summary of the key utility and alternate means of provision is:


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I. PATIENT MANAGEMENT

ELEMENTS OF PERFORMANCEA. CLINICAL ACTIVITIES

EM.02.02.11 EP2-11

• Triage of patients.• Scheduling of patients.• Assessment and treatment of patients.• Admission, transfer, discharge, and if necessary, evacuation of patients.

TRIAGE OF PATIENTS

• Immediate Treatment - Red• Delayed Treatment - Yellow• Minor Treatment - Green• Deceased/Expectant – Gray or Black

SCHEDULING OF PATIENTS

ADMITTING PATIENTS

• Emergency Department Patients• Disaster Victims• Pregnant Patients in Labor• Critically Ill Persons

The facility, through the inventory of organizational assets planning process, prepares alternate means for the provisioning ofutilities. Part of advance preparation may include testing utility failure scenarios during drills, and identifying improvement actionsas applicable.

MANAGEMENT OF PATIENTS DURING EMERGENCIES

When the Emergency Operations Plan is initiated, and for the duration of the emergency event, the

Hospital Command Center will implement processes relating to the following:

Within HICS, there are job action sheets that outline the specific duties and responsibilities of the Section Chiefs, BranchDirectors and Unit Leaders relative to the above. In addition, the following general guidelines will apply:

During an emergency, victims of an internal or external disaster will be triaged to determine their necessary level of care. Patientswill be assigned to one of the following triage categories:

Patients whose clinical needs fall outside of the scope of services or ability of the facility to care for them will be promptlyidentified, stabilized, and transferred to a healthcare facility equipped to provide appropriate care.

Depending on the nature, scope, and duration of the emergency, non-urgent tests, procedures, diagnostic studies, and careappointments may need to be delayed or canceled. When possible, patients will be notified of any delay or cancellation and whenroutine service is expected to resume. A record will be maintained of any cancellations so that patients can be contacted at theconclusion of the emergency to have their medical care needs met.

Admissions during an emergency will be limited to the following:

Non-disaster and/or emergency admissions will be screened to determine their necessity for admission. Routine admissions maybe resumed if authorized by the Hospital Command Center. Patient admissions will follow normal procedure as much as possible.

Potential Discharge & Transfer of Patients


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• Patients that can be safely discharged to the care of relatives or friends.• Patients that can be safely transferred to another medical care facility. (NOTE: Critical Care Units will identify patients who

can be transferred to a nursing floor.)

A. EVACUATIONIf the nature, scope, and/or duration of the emergency is such that the facility can no longer support care, treatment, orservice, then it may become necessary to evacuate part or all of the facility. The decision to evacuate shall be made by theIncident Commander in collaboration with the Section Chiefs within the Hospital Command Center. If necessary,communication will also occur with the local or state Emergency Operations Center. The order to evacuate a given area isbased on the safety of remaining in that area as compared to the risk of moving the patient population in question. Familiaritywith several types of evacuation is necessary for all hospital personnel. Specific plans must be worked out within individualdepartments. Evacuation must take into consideration the number and types of patients, as well as alternative means of lifesupport and cessation of invasive procedures when possible and considering the available resources at the disposal of thestaff at the time the evacuation is to take place. There are generally three types of evacuation. Each may be a separate andcomplete operation or all may have to be used in successive stages if circumstances dictate.Partial Evacuation: Partial evacuation is removing the patient(s) and staff from a dangerous area to one of safety within thehospital. The area being vacated will be marked as unsafe by Security. Once the area has been cleared of patients and staff,the area will remain off limits until repaired or cleared of the danger by the local agency having jurisdiction.Areas deemed unsafe by Security will be marked by the use of Cones or Caution Tape.Horizontal Evacuation: Horizontal evacuation is the removal of all patients laterally by bed, wheelchair, stretcher or othertype of transport, to an adjacent protected area. The patients in immediate danger are removed first, including those thatmight be separated from safety if fire or other danger enters the corridor. Ambulatory patients are moved next. Contrary tosome opinions, panic is rarely caused by helpless people. Ambulatory patients are to be instructed to line up outside of theirrooms forming a chain by holding hands and following the lead staff member. All rooms are to be carefully checked forstragglers, looking particularly in all closets, under the bed and in the bathrooms. Each room door, after it is checked, shallbe closed. Once in the protected area, patients must be rechecked to see that no one is missing.Total (Vertical) Evacuation: In the hospital, patients will be evacuated to the nearest evacuation collection point outside ofthe hospital. Patients requiring support equipment such as ventilators, incubators, intra-aortic balloon pumps, etc., will needspecial assistance during evacuation and must be moved with caution. In the event of total failure, including electricalsystems and building integrity, ventilator dependent patients will be maintained with battery operated devices or with manualsupport using a manual resuscitator. The order to evacuate is made by the person in the highest authority at the time of thedisaster.

B. SPECIAL NEEDS PATIENTS

• Infant patients• Pediatric patients• Geriatric patients• Bariatric patients• Cognitively impaired patients• Visually impaired patients• Emotionally/psychologically impaired patients• Patients with chronic conditions• Patients with addictions

A. PATIENT HYGIENE AND SANITATION

Patients housed on the various care units will be evaluated for possible transfer or discharge in the event that it becomesnecessary to release selected existing patients in order to make room for more seriously injured patients. Patients will beclassified for transfer or discharge as follows:

Special consideration will be given to vulnerable patient populations, including but not necessarily limited to, the following:

Staff, within their scope of practice, in the various care areas will be required to identify vulnerable patients and their specific careneeds. These will be noted in their plan of care and communicated to other care providers as warranted by the patient's conditionand circumstances. If necessary, staff will be obtained from the Labor Pool to assist with the care of these special needs patients,especially if relocation to an alternate care site becomes necessary.


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• All non-essential environmental cleaning services will be discontinued and resources reallocated to patient care andtreatment areas, as well as staff mobilization areas.

• Central Supply will re-supply personal hygiene articles such as toothbrushes, toothpaste, shaving articles, feminine hygienearticles, soap, and alcohol based hand gel or foam.

• If necessary, arrangements will be made to bring in additional portable restrooms to handle increases in patient, visitor, andstaff volumes.

• Baths and showers may be discontinued, or sanitary wipes may be used in lieu of water.

A. MENTAL HEALTH SERVICESThe mental and emotional needs of patients will be monitored by chaplains and social workers within the facility. If it isfeasible during the event, psychiatrists and clinical psychologists will be requested to assist as needed. Nurses will berequested to provide psycho-social support as needed, within their scope of practice, to patients exhibiting emotional ormental duress during the emergency.

B. MORTUARY SERVICES

• The local Emergency Operations Center will be contacted to assess temporary morgue services such as an environmentallycontrolled trailer.

• Local mortuaries will be contacted to arrange for direct transport of deceased individuals to the mortuary.• Refrigerated rental trucks will be used. These may be requested through St. Vincent Health System, in coordination with the

Medxcel Facilities Management Emergency Management EOC.

A. PATIENT TRACKING: INTERNAL AND EXTERNAL

I. DISASTER PRIVILEGES

ELEMENTS OF PERFORMANCEA. VOLUNTEER LICENSED INDEPENDENT PRACTITIONERS

EM.02.02.13 EP1-9

• Physicians (M.D, or D.O.), podiatrist (DPM), dentist or oral maxillofacial surgeon (DDS, DMD).• Physician Assistants and Advanced Practice Registered Nurses (NP and PA)

Technical specialists (e.g., Infection Prevention & Control) will be appointed by the Incident Commander to assuring that patientand staff hygiene and sanitation needs are met during the emergency. The following will be considered:

If morgue services become unable to accommodate increasing fatalities, the following actions will be taken:

Documentation will occur per normal protocol throughout the emergency. Each patient is provided with a unique clinical recordidentifier (i.e., a medical record number or account number). All clinical information about the patient will be noted on forms orother documentation tools with the patient's name and assigned number. If normal documentation procedures have beendisrupted because of the emergency, then downtime or designated alternate procedures will be used.

Part of advance preparation for the above components includes the mobilization and treatment of patients, either volunteer or"paper victims" during disaster drills, to test plan elements such as triage, assessment, treatment, admission, transfer anddischarge of patients.

DURING DISASTERS, THE FACILITY MAY GRANT DISASTER PRIVILEGES TO VOLUNTEER LICENSED INDEPENDENTPRACTITIONERS.

Definitions: Licensed Independent Practitioners Include:

Authority for Granting Privileges: Upon activation of the Hospital's Emergency Operations Plan and in a situation in which theHospital is not able to meet immediate patient needs, temporary disaster privileges may be granted to an appropriately qualifiedPractitioner, based upon the needs of the Hospital to augment staffing due to the disaster situation. Privileges shall be approvedby the Hospital Emergency Incident Commander (Chief Executive Officer/designee) or the Operations Chief, if that position isactivated as part of the Hospital Emergency Operations Plan (EOP), upon recommendation by the Chief of Staff or the EOPdesignated Medical Staff Director. All decisions to grant temporary disaster privileges are at the discretion of the HospitalEmergency Incident Commander or designees, and shall be evaluated on a case-by-case basis in accordance with Hospital andpatient care needs. Approvals shall be documented in writing.


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• A current identification card from a healthcare organization that clearly identifies professional designation

• A current license to practice in the State of Indiana• Primary source verification of the license• Identification indicating that the individual is a Member of a Disaster Medical Assistance Team (DMAT), or MRC, ESAR-

VHP, or other recognized state or federal organization or group• Identification indicating that the individual has been granted authority to render patient care in emergency circumstances,

such authority having been granted by a federal, state or municipal entity• Confirmation by a licensed independent practitioner currently privileged by the hospital or by a staff member with personal

knowledge of the volunteer practitioner's ability to act as a licensed independent practitioner during a disaster

• Expert Practitioners from government agencies and medical staff members from other St. Vincent Health hospitals• Volunteer Practitioners sent from known agencies (e.g., American Red Cross)• Presentation by a current hospital or medical staff Member(s) with personal knowledge regarding the practitioner's identity• Volunteers from the community or surrounding areas

A. OTHER LICENSED VOLUNTEERS

EM.02.02.15EP1-9

Temporary disaster privileges may be granted upon presentation of government-issued photo identification and any of thefollowing:

If possible, photocopies of the above-listed credentials should be made and retained as part of a credentials file.

Qualifications shall be verified as soon as the immediate disaster situation is under control, using a process identical to grantingtemporary privileges for an immediate patient care need, and verification shall be completed within 72 hours from the time thevolunteer Practitioner presents to the organization, or as soon as possible in an extraordinary situation that prevents verificationswithin 72 hours. In extraordinary circumstances when primary source verification cannot be completed, the following must bedocumented: Why primary source verification could not be performed in the required timeframe; Evidence of a demonstratedability to continue to provide adequate care, treatment and services, and; an attempt to rectify the situation as soon as possible.

The following order of preference should be used in granting temporary disaster privileges:

Identification: Upon approval, practitioners granted disaster privileges shall be issued a temporary badge or sticker to allow staffto readily identify these individuals. Badges should contain the practitioners name, specialty, and a notation stating, "Practicingwith disaster privileges". The practitioner should be assigned to a Medical Staff Member if possible, with whom to collaborate inthe care of disaster victims.

Oversight: The Medical Staff shall oversee the professional practice of volunteer Practitioners either by the direct observation ormentoring provided by the Medical Staff Member assigned to the volunteer Practitioner; or when a Medical Staff Member is notavailable to be assigned, then by medical record review to be performed as designated by the Chief of Staff or MEC.

Federal Agency Practitioners: Practitioners who are employees of any Federal agency, and Practitioners acting on behalf of aFederal agency in an official capacity, temporarily or permanently in the service of the United States government, whether with orwithout compensation, are immune from professional liability for malpractice committed within the scope of employment under theprovisions of the Federal Tort Claims Act, and are therefore exempt from the requirement to have professional liability insurancecoverage. Temporary privileges granted to Practitioners who are acting as agents of the Federal government shall be limited intheir privileges at this Hospital to the scope of their Federal employment.

Term of Disaster Privileges: The hospital shall make a decision, based on information obtained regarding the credentials andprofessional practice of the Practitioner, within 72 hours of the volunteer Practitioner presenting to the hospital regarding whetherto continue the disaster privileges initially granted. Continuing privileges shall be approved by the Hospital Emergency IncidentCommander (Chief Executive Officer/designee) or the Operations Chief, if that position is activated as part of the EOP, uponrecommendation by the Chief of Staff or the EOP designated Medical Staff Director. In the event that verification of informationresults in negative or unsubstantiated information about qualifications of the Practitioner, privileges should be immediatelyterminated. Termination of disaster privileges shall not afford hearing rights under the Medical Staff Bylaws or any other authority.Temporary privileges granted to anyone under a disaster situation shall not exceed the disaster response and recover period orone hundred and twenty (120) consecutive days, whichever is less.

Definitions: Other licensed volunteers include:


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• Registered Nurse (RN) or Licensed Practical Nurse (LPN).• Allied Health Professional or AHP: all healthcare professionals, other than those defined above whom are required by law

and regulation to have a license, certificate or registration to practice their profession.

• A current identification card from a healthcare organization that clearly identifies professional designation

• A current license to practice in the State of Indiana.• Primary source verification of the license• Identification indicating that the individual is a Member of a Disaster Medical Assistance Team (DMAT), or MRC, ESAR-

VHP, or other recognized state or federal organization or group• Identification indicating that the individual has been granted authority to render patient care in emergency circumstances,

such authority having been granted by a federal, state or municipal entity• Confirmation by a similarly licensed employee or staff member with personal knowledge of the volunteer practitioner's ability

to act as a licensed practitioner during a disaster

• Expert Practitioners from government agencies and medical staff members from other St. Vincent Health hospitals.• Volunteer Practitioners sent from known agencies (e.g., American Red Cross.)• Presentation by a current hospital or medical staff member with personal knowledge regarding the practitioner's identity.• Volunteers from the community or surrounding areas.

If AHP's are employed by another hospital, they will be sent to Human Resources for appropriate processing. If AHP's are notemployed by another hospital, they will be credentialed per the facility's policy for Disaster Privileges.

Authority for Granting Privileges: The HICS Labor Pool and Credentialing Unit Leader will implement the facility's disastercredentialing procedure for other licensed volunteers. A Volunteer Practitioner Credentials Verification Form will be completed foreach volunteer, which includes unique identifying information about the volunteer, such as specialty, work address, phonenumber license/certification/registration number and expiration date, driver's license or passport number, date of birth, socialsecurity number, name of professional liability insurance carrier and limits of liability, etc.

Temporary disaster privileges may be granted upon presentation of government-issued photo identification and any of thefollowing:

If possible, photocopies of the above-listed credentials should be made and retained as part of a credentials file.

Qualifications shall be verified as soon as the immediate disaster situation is under control, using a process identical to grantingtemporary privileges for an immediate patient care need, and verification shall be completed within 72 hours from the time thevolunteer Practitioner presents to the organization, or as soon as possible in an extraordinary situation that prevents verificationswithin 72 hours.

The following order of preference should be used in granting temporary disaster privileges:

Identification: Volunteers granted disaster privileges shall be issued a temporary badge or sticker to allow staff to readily identifythese individuals. Badges should contain the volunteer's name, specialty or AHP category, and a notation stating, "Practicing withdisaster privileges".

Oversight: If possible, the practitioner should be paired with an employee with similar training, and should act only under thedirect supervision of a medical staff, AHP, or hospital employee, as appropriate, to observe or mentor the volunteer. If partneringis not possible, oversight will be conducted by medical record review.

Federal Agency Licensees: Licensees who are employees of any Federal agency, and licensed volunteers acting on behalf of aFederal agency in an official capacity, temporarily or permanently in the service of the United States government, whether with orwithout compensation, are immune from professional liability for malpractice committed within the scope of employment under theprovisions of the Federal Tort Claims Act, and are therefore exempt from the requirement to have professional liability insurancecoverage. Temporary privileges granted to licensed volunteers who are acting as agents of the Federal government shall belimited in their privileges at this Hospital to the scope of their Federal employment.

Term of Disaster Privileges: The hospital shall make a decision, based on information obtained regarding the credentials andprofessional practice of the licensed volunteer, within 72 hours of the volunteer presenting to the hospital regarding whether tocontinue the disaster privileges initially granted. Continuing privileges shall be approved by the HICS Labor Pool andCredentialing Unit Leader or their designee, if that position is activated as part of the EOP. In the event that verification ofinformation results in negative or unsubstantiated information about qualifications of the Practitioner, privileges should beimmediately terminated. Termination of disaster privileges shall not afford hearing rights under the Medical Staff Bylaws or any


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A. INDIVIDUALS TASKED TO RESTORE LOST DATA

• Qualified staff members from other St. Vincent Health hospitals and Division IT&S offices• Necessary application or system vendor staff

I. ANNUAL AND PERIODIC REVIEW

ELEMENTS OF PERFORMANCEA. HAZARD VULNERABILITY ANALYSIS, EMERGENCY OPERATIONS PLAN AND INVENTORY

EM.03.01.01EP1-3

• The Objectives of the Emergency Operations Plan will be evaluated as follows: The intent of the objectives will be reviewedto determine if still relevant and applicable, and if change or modification is required.

• The Scope of the Emergency Operations Plan will be evaluated as follows: Planning activities will be reviewed to determineif modifications are required due to changes within the facility, its structure, the patient population served, communityplanning partners or other factors that may have an impact on disaster response to emergencies.

• The Hazard Vulnerability Analysis will be reviewed to determine if risks, preparedness and mitigation strategies havechanged or altered to lower or increase overall probability of defined risks.

• The Inventory of Organizational Assets will be reviewed to determine if resources and assets relating to emergencypreparedness have been changed based on usage experience, new purchases, expiration of products, etc. The annualreview above will be documented.

I. PLAN TESTING AND EXERCISES

other authority. Temporary privileges granted to anyone under a disaster situation shall not exceed the disaster response andrecover period.

Authority for Granting Privileges: The HICS Labor Pool and Credentialing Unit Leader will implement the facility's disastercredentialing procedure to allow facility access for individuals tasked with restoring lost data. A Disaster Privileges VerificationForm will be completed for each individual, which includes unique identifying information about the individual, such as specialty,work address, phone number, driver's license or passport number, date of birth, social security number, etc. SEESUPPLEMENTAL MATERIALS-STAFFING ON PAGE 156.

Temporary disaster privileges and facility access may be granted upon presentation of government-issued photo identificationand if individual is listed on the Authorized IT Emergency Support Team or can provide evidence indicating that the individual hasbeen granted authority to perform IT duties in disaster circumstances by Corporate or Division-level IT&S leadership.

The following types of individuals may be placed on the Authorized IT Emergency Support Team and granted temporary disasterprivileges for the restoration of lost data:

Identification: Individuals granted disaster privileges shall be issued a temporary badge or sticker to allow staff to readily identifythese individuals. Badges should contain the individual's name, specialty or purpose, and a notation stating, "Acting with disasterprivileges". If possible, photocopies of the government-issued photo identification should be made and retained as part of theindividual's local file.

Oversight: If possible, the individual should be paired with an employee with similar training, and should act only under the directsupervision of a medical staff, AHP, hospital employee, or IT&S staff, as appropriate.

Term of Disaster Privileges: The hospital shall make a decision, based on information obtained regarding the credentials andprofessional practice of the individual, within 72 hours of the individual presenting to the hospital regarding whether to continuethe disaster privileges initially granted. Continuing privileges shall be approved by the HICS Labor Pool and Credentialing UnitLeader or their designee, if that position is activated as part of the EOP. In the event that verification of information results innegative or unsubstantiated information about qualifications of the individual, privileges should be immediately terminated.Temporary privileges granted to anyone under a disaster situation shall not exceed the disaster response and recover period.

EVALUATION OF THE EFFECTIVENESS OF EMERGENCY MANAGEMENT PLANNING ACTIVITIES

On an annual basis, or after an actual event, the facility through EOC will conduct a review of the effectiveness of emergencymanagement planning activities. The annual review will be forwarded to senior leadership and include the following processes:


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ELEMENTS OF PERFORMANCEA. EXERCISES AND SCENARIOS

EM.03.01.03 EP1-17EVALUATION OF THE EFFECTIVENESS OF THE EMERGENCY OPERATIONS PLANThe facility conducts exercises to assess the effectiveness of the Emergency Operations Plan at least twice a year, stressingthe limits of the plan to support assessment of preparedness and performance. The design of exercises will reflect likelydisasters, and will test the facility's ability to respond to emergencies, and to provide care, treatment and services understressed situations. Off-site areas classified as business occupancy (as defined by the Life Safety Code) will conduct onedrill a year.At least one drill a year conducted by the facility will include an influx of simulated patients, and one drill will simulate anescalating event in which the surrounding community is unable to support the hospital. This portion of the drill may beconducted separately or in conjunction with a community wide drill, or tabletop exercise. One exercise will be conducted inparticipation with local or state emergency management agencies.

B. LEADERSHIP AND MONITORING OF EXERCISE COMPONENTSExercises will incorporate likely scenarios as identified on the facility's Hazard Vulnerability Analysis, with an evaluation toolused that monitors and assesses staff response to handling of communications, resources and assets, safety, security, staff(roles & responsibilities), utilities and patients (clinical and support care). An individual(s) will be selected whose soleresponsibility during exercises is to monitor performance.

C. EVALUATION AND MODIFICATIONS

I. STATE REQUIREMENTS

EMERGENCY OPERATIONS PLANPART 2FORMS AND RESPONSE PLANS

Type (acute, medical, triage, etc.) Location Contact Information Comments

Deficiencies and Opportunities for improvement will be addressed during debriefing by a multidisciplinary process which includesindependent practitioners, and documented, with a final evaluation completed at the Emergency Management Subcommittee. Itwill be the responsibility of the Emergency Management Subcommittee members to follow-through with documented deficiencies,with information provided to the Safety Committee and senior leadership. Identified deficiencies are expected to be resolved priorto the next planned exercise, with interim measures put in place until final modifications are made. Subsequent exercises reflectmodifications made and/or interim measures identified.

Attachment A: Local HVA

Attachment B: Local HVA

Attachment C: Alternate Care Sites


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ATTACHMENT D: CODE SYSTEMCODE DEFINITION

Code Blue Medical Emergency

Balance of codes will be called in plain language

ATTACHMENT E: FORMSHICS 204 - BRANCH ASSIGNMENT LIST

4. OPERATIONAL PERIOD1. INCIDENTNAME

2.SECTION

3. BRANCH

DATE: TIME:

5.PERSONNEL

SECTION CHIEF BRANCH DIRECTOR

6. UNITS ASSIGNED THIS PERIOD

Name Name Name Name Name Name

Leader Leader Leader Leader Leader Leader

Location Location Location Location Location Location

Members Members Members Members Members Members


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7. KEY OBJECTIVES

8. SPECIAL INFORMATION / CONSIDERATION

9. PREPARED BY (BRANCHDIRECTOR)

10. APPROVED BY (PLANNINGSECTION CHIEF)

11.DATE

12. TIME

13. FACILITY NAME

HICS 253 - Volunteer Staff Registration

1. FROM DATE/TIME

2. TO DATE/TIME 3. SECTION 4. TEAM LEADER

5. REGISTRATION

Name(Last Name,First Name)

AddressCity,Sate, Zip

Social SecurityNumber

TelephoneNumber

Certification/Licensureand Number

TimeIN

TimeOUT

Signature

6. CERTIFYING OFFICER 7. Date/Time Submitted:

8. Facility Name

Unit AvailableBeds

PotentialCOTBeds

TotalSurgeCapacityBeds

# ofNegativeAirRooms

NegativeAirRoom#

O2/Vac/SuctionAvailable

Sink/RestroomShowerAvailable

EmergencyPower

COMMENTS

Consider all available space a bed can be placed for additional NON CRITICAL patient care

Appendix F : Surge Capability and ACC Availability


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RESPONSE ALGORITHMSFIRE

#1 General Response to Smoke or Fire

You see smoke or fire.

R

Rescue anyone in immediate danger.

A

Call 106-7777.

Pull Fire Alarm.

Tell the Operator:

Your name

Telephone number you are calling from

Location of fire

Extent of fire

Type of fire (electrical, wastebasket)

Your Emergency Assembly Point

Calmly give complete information

C

Close doors and windows to contain the fire.

e


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E

Extinguish the fire with

a fire extinguisher if safe

to do so.

How to use a fire extinguisher

PASS

Pull the pin.

Aim nozzle at base of fire.

Squeeze handle.

Sweep nozzle back and forth.

Responding to a Fire Alarm in the Hospital

A Fire Alert overhead page

will say:

"Attention, Attention, Fire Alert, Fire Alert…" and a location is given, such as floor and room.

Escort patients to their rooms and visitors to public waiting areas.

Post one person at a fire extinguisher

and one at an exit.

Be ready to evacuate patients

or implement other emergency

response actions.

Fire Marshal, Security Services,

or Fire Dept. gives evacuation order.

The Nurse Manager, CNS, or person in charge directs the evacuation of their unit.

Hospital staff should perform the above procedure if the alarm originates anywhere in their area of the hospital.

(TRIGGER EVENT)

You hear the fire alarm, or see flashing lights in the hallway, and/or hear a FIRE overhead page.

Close all doors and clear corridors

of all equipment.

Watch for signs of fire.

Wait for instructions.

Responding to a Fire Alarm

in Non-Hospital Buildings

(TRIGGER EVENT)

The fire alarm is activated

in your non-hospital building.

Evacuate all staff, patients, and visitors from

your building to your assigned Emergency Assembly Point.


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If patients or staff cannot be evacuated,

move them to the nearest stairwell for protection.

Notify the Fire Dept. to rescue them.

Only Security or the Fire Dept. can authorize you to go back into your building.

First Responders to Fire Alarm

Security is the Primary Responder and the Incident Commander for all fire alarms.

Fire Alarm in the facility

Security physically responds to location of fire and determines extent of fire.

Security interacts with building occupants and decides evacuation needs.

Engineering & Maintenance sends emergency response team to the site (fire alarm technician, plumber, electrician) to assistfire fighters in isolating utilities, electrical, water, medical gas.

If fire sprinkler system is involved, the Damage Control Officer or Engineering Supervisor appoints:

Fire Pump

Operator

to monitor the fire pump

Sprinkler Control Valve

Operator

to keep all fire sprinkler valves open

Hospital Operator makes overhead and electronic pages.

to staff

The Adm. Director on-duty

is the Incident Commander.

Security notifies emergency response personnel via radio of location and type of alarm device (smoke, pull station, water flow).

Boiler Room receives Fire Alarm and calls 911.

Security notifies hospital operator of Fire Alert.

Fire Dept. and Police maintain their own command and operate Joint Command with the Facility.

Preserve evidence

for the Fire Dept. and Police.

Evacuating Patients during a Fire

(TRIGGER EVENT)

Fire in the hospital.

Evacuate patients.

R -Rescue anyone in immediate danger

A -Alarm, call 106-7777,

pull Fire Alarm

C -Contain, close doors and windows

E -Extinguish, use fire extinguisher


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Evacuate to where?

Evacuate patients

Security goes to scene of the fire, assesses situation.

Security or Fire Dept. gives evacuation order. They confer with Nursing Admin or Clinical Nursing Supvr. (CNS), if time allows.

Security, or Fire Marshall, or designee orders a general fire alarm,

or evacuation order.

Evacuate patients with their medical records to your external Emergency Assembly Point.

Overhead page:

"General Fire Alarm is now in effect. All non-essential personnel evacuate to your designated external Emergency AssemblyPoint."

Account for all patients and staff after arriving at Assembly Point.

Notify Security646-8200

and tell them

Evacuation completed

Where your Dept. evacuated to

All your group is safe

Nurse Manager, CNS, or person-in-charge

of evacuation unit directs evacuation.

Each nursing unit

gets evacuation procedures from the Nursing Services Dept.

Evacuate patients with their medical records in this order:

Closest to fire

Ambulatory

Impaired mobility

With entire bed

Look at evacuation maps posted at entrances, elevators, stairs, exits, and stations.

When cleared to do so by Security or Fire Dept., reenter building.

Shutting Off Medical Gases i.e.: Oxygen and Nitrous Oxide

During a Fire

Pull or turn Zone oxygen valve.

(TRIGGER EVENT)

Fire in a patient's room

and oxygen is on.

(TRIGGER EVENT)

Fire in the hospital

but NOT in your area.

Fire Marshall or Security notifies these managers if MAIN gas valve will be shut off


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Nursing Supervisor

Unit Manager

Department Manager

Secure oxygen and gas cylinders.

Turn off oxygen and

nitrous oxide cylinders.

THE FIRE MARSHALL AND/OR SECURITY/FACILITIES decides

to shut off a MAIN gas valve.

Engineering & Maintenance shuts off the MAIN gas valve.

Only TRAINED individuals

are authorized to shut off medical gas ZONE valves in your area.

Responding to a Fire in the Kitchen

(TRIGGER EVENT)

Fire in a cooking area in the kitchen

Activate the Discharge Hood System at the fire location

Use a Class K fire extiguisher to put out fire if needed


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FLOODINGEVACUATIONINFANT/CHILD ADBUCTIONCHEMICAL SPILLBOMB THREATHOSTAGEVIOLENT PERSONTHUNDERSTORMSEXTREME TEMPERATURECOLDTORNADODAM INUDATIONBLIZZARD IMPENDINGSNOWFALL-HEAVYICE STORMDROUGHTEARTHQUAKEWILDFIRETIDAL WAVEVOLCANIC ERUPTIONLANDSLIDEELECTRICAL POWER FAILUREGENERATOR FAILUREHVAC FAILURETELECOMMUNICATIONS FAILUREINFORMATION TECHNOLOGY FAILURE


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ELEVATOR FAILURESTEAM FAILUREDRINKING WATERSYSTEM FAILURESEWAGE FAILUREMEDICAL GAS ANDVACUUM FAILUREINFECTIOUS DISEASE OUTBREAKEPIDEMICSUPPLEMENTAL MATERIALS-UTILITY FAILUREUTILITIESLOCAL UTILITY INFORMATION1. Electric Transmission Provider

IMP24-Hour Emergency Contact: 1-800-311-4634

2. TelephoneSt. Vincent Telephones Communications24-Hour Emergency Contact: 1-877-338-2345

3. WaterElwood Water24-Hour Emergency Contact: 1-765-552-9844

4. WastewaterElwood Water24-Hour Emergency Contact: 1-765-552-9844

5. Natural Gas

UTILITIES

Vectran

24-Hour Emergency Contact: 1-800-777-5526

UTILITY RESTORATION PRIORITIES FOR CRITICAL FACILITIES & DEPARTMENTS

Utility Service Restoration Priorities: 1 = Highest, 5 = Lowest

Emer. Gen.: Yes = Emergency Generator on site.

Ltd = Generator available, but powers only a limited portion of the facility

LS = Load Shed


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Facility Name, Address and Departments Emer.Gen.

Elec. Phone Water WW Gas

EMERGENCY GENERATOR FORMS1. The emergency generator forms which follow are provided to facilitate pre-planning for emergency generator requirements,

to replace an existing generator which has failed.

2. A separate form is provided for each existing generator. The Facilities Management Director and the EmergencyManagement Coordinator will maintain completed forms for use during emergencies. A copy will be placed in the EOCReference Book and attached to this annex

3. In completing these forms, keep the following in mind:

A. If in doubt about what type of capability is needed, consult a qualified electrician.

B. Generators are often quite heavy and should be emplaced on a firm, level site, and preferably a paved area.

C. In considering emergency generator sites, remember that generators are often noisy and produce exhaust fumes thatmay be sucked into nearby ventilation intakes. Vehicle access will be needed to refuel.

1 Facility Name: SVmH

2 Facility Address: 1331 S A Street Elwood Indiana

3 Facility Type: Hospital

4 Facility Point of Contact: Mark Boyer Phone: 1-765-438-8528

5 Generator number and load, with location at facility:Caterpillar 700KW / SW corner of building

6 Electrical Requirements; Kilowatt: 700 Volts: 480 Amperes:Single 3-Phase Delta 3-Phase Wye Other:

7 Fuel: Gas Diesel Propane Other:

8 Fuel Tank Size: Gallons: 900 underground storage tank plus belly tank

9 Fuel Tank Type: Attached to generator Separate tank UST AST

10 Generator Type: Stand Alone Parallel Other:

11 Generator Support: Pad/Permanent Installation Skid Trailer

12 Generator location is: Inside Outside

13 Electrician On-site or Available: Yes No

EMERGENCY GENERATOR # 1 INFORMATION

EMERGENCY GENERATOR # 2INFORMATION


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1 Facility Name:

2 Facility Address:

3 Facility Type

4 Facility Point of Contact: Phone:

5 Generator number and load, with location at facility:

6 Electrical Requirements; Kilowatt: : Volts: Amperes:Single 3-Phase Delta 3-Phase Wye Other:


8 Fuel Tank Size: Gallons:






1 Facility Name:

2 Facility Address:

3 Facility Type:

4 Facility Point of Contact: Phone:

5 Generator number and load, with location at facility:

6 Electrical Requirements; Kilowatt: Volts: Amperes:Single 3-Phase Delta 3-Phase Wye Other:


8 Fuel Tank Size: Gallons:






14

15

Pre-Storm Checklist for Emergency Generator Preparations Notes:

Once the generator is on site and connected to the Quick connect, run the generator andrun for at least 1 hour.

Once winds reach significant magnitude (using your best judgment) start the generatorprior to anticipated outage. [as applicable]

CompletedYes/No

Setup Instructions Notes:

On Asphalt or Ground - Make sure that front support legs are placed on landscape timber, or 2layers of 3/4 inch plywood to distribute load. Support legs come in each unit for the FRONT of thegenset to sit on.

NOTE: This does not need to be done if setting on concrete.

EMERGENCY GENERATOR #3 INFORMATION


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Provide Power Source for onboard battery chargers and water jacket heaters.

Check battery gauges on the lower starting cabinet

CompletedYes/No

2000 kW Emergency Generator Notes:

1. Turn Battery Switch to On

2. Check battery voltage

3. Push Alarm Silence

4. Check warning lights

5. Turn start swith to "Run" Or Press Run on control panel.

6. Check speed of Engine -( will be on the top display) should be 60 Hz

7. Close Breaker

8. You should have Power to your disconnect.

CompletedYes/No

Quick Connect Procedure Notes:

Ensure the electrician checks the settings on the breakers forthe quick connect. The trip setting may need to be turned UPdepending on actual building load.

Ensure Hubbel locks are not laying directly on the ground

Ensure you have "pigtails" on site. Some generators will comewith the "pigtails" some will not.

CompletedYes/No

Fueling Logistics Notes:

Contact Fuel company to top the fuel off.

Investigate alternate means to provide fuel to generator via onsite storage tanks.

Make sure the fuel cap is replaced after fueling

CompletedYes/No

Document Generator Problems Notes:

Emergency Contact Numbers for Thompson: If you experience any problems,PLEASE contact one of the ThompsonCat Representatives below.

Greg Moore 615-417-7777

Donna Stallings 901-344-5602

Johnny O'Daniel 901-346-5149

Tom Williams 901-229-1129

UTILITY CONSERVATION MEASURESUtilities

The utility conservation measures outlined in this appendix are suggested measures. The specific measures to be implementedshould be agreed upon by local government and the utilities concerned.


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1. Conservation Measures for Natural Gas

A. Step 1. Discontinue:

1. Single or dual autoclaving except for one vacuum and one flash

2. Dishwashing, go to paper plates and cups

B. Step 2. Reduce:

1. HVAC hot deck supply air temperature settings

2. Conservation Measures for Electric Power

A. Step 1. Discontinue:

1. All advertising, decorative, or display lighting.

2. Use of all residential electric appliances, except those needed for patient care and radios.

B. Step 2. Reduce:

1. Digital ballast retrofitting of fluorescent lights

2. Reduce outdoor lighting.

3. Reduce lighting by 50 percent in offices and public spaces.

C. Step 3. Cut off electricity to:

1. Non-essential facilities.

2. Offices, except those providing essential services.

3. Water Conservation Measures

A. Step 1.

1. Stop outdoor watering

2. Steam Condensate return system in place

B. Step 2

1. Place limits on non patient care water use.

C. Step 3

1. Restrict or cut off water service to offices and departments except those that provide essential services.

Failure of What to Expect Who to Contact Responsibility of User

Airconditioning

System down FacilitiesManagement

Use portable fans

Computersystems

System down InformationSystems

Use backup manual paper systems

ElectricalpowerFailure-emergencyGeneratorswork

Many lights are outOnly RED plugoutlets work

FacilitiesManagement

Ensure that life-support systems are on emergency power (redoutlets). Ventilate patients by hand as necessary. Completecases in progress ASAP. Use flashlights.Flashlights in admin offices attached with Velcro under right sideof desk top

ElectricalpowerFailure –total

Failure of allelectrical systems

FacilitiesManagement andRespiratoryServices

Utilize flashlights and lanterns, hand ventilate patients, manuallyregulate IVs, and don't start new cases.Flashlights in admin offices attached with Velcro under right sideof desk top

Utilities

System Failure and Basic Staff Response


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Elevator outof service

All verticalmovement willhave to be bystairwells

FacilitiesManagement andall directors

Review fire and evacuation plans, establish services on first orsecond floor, use carry teams to move critical patients andequipment to another floor.

Elevatorstoppedbetweenfloors

Elevator alarm bellsounding

FacilitiesManagement andSecurity

Keep verbal contact with personnel still in elevator and let themknow help is on the way


Fire alarmsystem

No fire alarms or sprinklers Facilities Management Institute Fire Watch; minimize fire hazards, usephone or runners to report fire.

Medicalgasses

Gas alarms, no O2 ormedical air or nitrous oxide(NO2)

Facilities Management,Storeroom, andRespiratory Services

Hand ventilate patients, transfer patients ifnecessary, use portable oxygen and other gases,and call for additional portable cylinders.

Medicalvacuum

No vacuum; vacuumsystems fail and in alarm

Facilities Management,Respiratory Services,Central Service

Call Central Service for portable vacuum, obtainportable vacuum from crash cart, finish cases inprogress, and don't start new cases.

Naturalgas; failureor leak

Odor – no flames onburners, etc.

Facilities Management Open windows to ventilate, turn off gas equipment,don't use any spark producing devices, electricmotors, switches, etc.

Nurse callsystem

No patient contact Facilities Management Use bedside patient telephone if available; movepatients; use bells; detail a rover to check patients.

Patientcareequipment/systems

Equipment/system notfunction properly

BiomedicalEngineering

Replace and tag all defective equipment.

Sewerstoppage

Drains backing up Facilities Management Do not flush toilets, use red bags in toilets, do notuse water.

Steamfailure

No building heat, hot water,laundry, sterilizersinoperative, limited cooking

Facilities Management,Dietary

Conserve sterile materials and all linens, provideextra blankets, and prepare cold meals.

Telephones No phone service Information Systems Use overhead paging, white phones, and userunners as needed.


Water Sinks and toiletsinoperative

Facilities Management Institute Fire Watch, conserve water, use bottled water fordrinking, be sure to turn off water in sinks, use Red bagsin toilet,

Water(non-potable)

Tap waterunsafe to drink

Facilities Management, Foodand Nutrition Services, alldirectors

Place "non-potable water – do not drink" signs at alldrinking fountains and washbasins.

Ventilation No ventilation;no heating orcooling

Facilities Management Open windows (institute Fire Watch) or obtain blankets ifneeded, restrict use of odorous/hazardous materials.

SUPPLEMENTAL MATERIALS -BIOTERRORISM PLAN1.0Description of the Threat/Event.


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1. Response to release of a biological agent in the community can quickly overwhelm individual mission critical systems in aMedical Center. Examples include staffing and operational space required for patient care or quarantine, staff shortagesfrom community quarantine, or family concerns leading to family-driven work absence.

2. Breaks in procedure or unanticipated exposures may overwhelm a whole Medical Center, for example, by exposingpersonnel and requiring quarantine of the Medical Center. Targeted releases of agent or HVAC cross-contamination maydefine areas of the Medical Center, patients, and staff as contacts.

• Administrator / Administrator-on-call• VP Operations• VP Nursing• VP Ancillary Services• Infection Control Personnel and Physicians• Director, Environmental Health & Safety• Director, Security• Director, Emergency Department• Director, Corporate Communications

1. Mitigation/Preparedness Activities of the Threat/Event.The following guidelines are in place to assist with mitigating exposure and preparing for biological threats

1. Infection Control Practices for Patient Management:

1. Isolation precautions: Agents of bio-terrorism are generally not transmitted from person to person; re-aerosolization of these agents is unlikely.

2. Standard Precautions: Standard precautions are designed to reduce transmission from both recognized andunrecognized sources of infection in healthcare facilities, and are recommended for all patients receiving care,regardless of their diagnosis or presumed infected status.

3. Additional Precautions: For certain diseases or syndromes (e.g., Smallpox and Pneumonic Plague), additionalprecautions may be needed to reduce the likelihood for transmission. See Addendum A for specific diseases(Anthrax, Botulism, Plague, and Smallpox) and requirements for additional isolation precautions.

4. Hand washing: Hands are washed immediately after gloves are removed, between patient contacts, and asappropriate to avoid transfer of microorganisms to other patients and the environment.

5. Gloves: Clean, non-sterile gloves are worn when touching blood, body fluids, excretions, secretions, or itemscontaminated with such body fluids. Gloves are changed between tasks and between procedures on the samepatient if contact occurs with contaminated material.

6. Masks / Eye Protection or Face Shields: A mask and eye protection (or face shield) are worn to protect mucousmembranes of the eyes, nose and the mouth while performing procedures and patient care activities, that maycause splashes of blood, body fluids, excretions or secretions.

7. Gowns: A gown is to be worn to protect skin and prevent soiling of clothing during procedures and patient-careactivities that are likely to generate splashes or sprays of blood, body fluids, excretions, or secretions.

2. Patient Placement:

1. In small-scale events, routine facility patient placement and infection control practices should be followed.

2. In large scale events when the number of patients presenting to The facility is too large to allow routine triage andisolations strategies (if required), the Administrator will activate the Medxcel Facilities Management EOC andprepare to transport patients to designated metro hospitals.

Hospitals and clinics may have the first opportunity to recognize and initiate a response to a bio-terrorism-related outbreak. Thispolicy is to serve as a guideline in the event of any suspected bio-terrorism event originating in the community or the hospital. Inthe event that the suspected bio-terrorism event originates within the facility, the hospital would proceed with the Bio-terrorismReadiness Plan under the direction of the State Department of Health.

2.0Impact on Mission Critical Systems.

3.0Operating Units and Key Personnel with Responsibility to Manage this Threat.


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3. The Internal Disaster plan should be initiated and the personnel pool established which would provide the neededescorts for patients being relocated to other hospitals.

4. In some cases, an internal Quarantine may be necessary as directed by the local health department and/or otherhealth authorities.

3. Patient Transport:

1. Most infections associated with bio-terrorism agents cannot be transmitted from patient to patient.

2. In general, the transport and movement of patients with bio-terrorism-related infections, as for patients with anyepidemiological important infections (e.g., pulmonary tuberculosis, chickenpox, and measles) should be limited tomovement that is essential to provide patient care, thus reducing the opportunities for transmission ofmicroorganisms within healthcare facilities.

4. Cleaning, disinfecting, and sterilization of equipment and environment:Principles of Standard Precaution and existing policies and procedures of the hospital should generally be applied forthe management of patient-care equipment and environmental control. If special procedures are required the staff willbe informed.

5. Discharge management:Ideally, patients with bio-terrorism-related infections will not be discharged from the facility until they are deemednoninfectious. However, in the event that large numbers of persons exposed present to the hospital precludingadmission of all infected patients, home-care instructions will be provided (See Addendum A).

6. Post-mortem care:

1. The Laboratory will be informed of a potentially infectious outbreak prior to submitting any specimens forexamination or disposal.

2. The Lab staff should inform the pathologist in charge of the potentially infectious outbreak prior to submitting anyspecimen or bodies.

3. In conjunction with the State Department of Health, funeral home directors will be informed of the potentiallyinfectious outbreak and will be provided information about precautions specific to the organism.

7. Post Exposure Management:

1. Decontamination of Patients and Environment:Considerations: Take into consideration the following prior to initiating decontamination:

a. The need for decontamination depends on the suspected exposure and in most cases will not be necessary.

b. The goal of decontamination is to reduce the extent of external contamination of the patient and contain the contamination toprevent further spread.

c. Consult with local state and health departments prior to initiating decontamination efforts.

d. Decontamination should only be considered in instances of gross contamination.

e. Coordinate all decontamination efforts with the FBI. The FBI may require collection of exposed clothing and other potentialevidence for submission to FBI or Department of Defense labs to assist in exposure investigations.

f. If decontamination capability is not adequate to meet the needs of the situation, local HAZMAT teams will be contacted forassistance.

a. Recommendations for prophylaxis are subject to change. Consult with the local and state health department and the CDCfor up to date recommendations.

b. See local Mass Immunization and Prophylaxis System Plan for more information.

a. Minimize panic at the time of the incident by clearly explaining risks, offering careful but rapid medical evaluations /treatment, and avoiding unnecessary isolation or quarantine.

4.7.2Prophylaxis and post-exposure immunization:

4.7.3Psychological aspects of bio-terrorism:

4.7.3.1Following a bio-terrorism-related event, fear and panic can be expected from both patients and healthcare providers.When dealing with patients, staff should remember to:


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b. Treat anxiety in unexposed persons who are experiencing somatic symptoms with reassurance and medical attention asnecessary.

a. Their usual sources of social support, or by being asked to fulfill a useful role (via the personnel pool). See local CriticalIncident Stress Management Plan for more information..

1. Laboratory Support and Confirmation: The Lab will work with local, state and federal public health services to tailordiagnostic strategies to specific events.

1. Obtaining diagnostic samples:Sampling should be performed in accordance with Standard Precautions. In all cases of suspected bio-terrorism, collectan acute phase serum sample to be analyzed, aliquoted, and saved for comparison to a later convalescent serumsample.

2. Laboratory criteria for processing potential bio-terrorism agents:The processing of bio-terrorism agents will be done according to CDC requirements.

3. Transport requirements:

1. All staff shall immediately report any potential biological threat or biohazard release to the Administrator or Administrator onCall.

2. The Administrator / Administrator-on-call shall establish an Emergency Operations Center and call together the HospitalIncident Command Team. The HIC Team shall consist of Administrator, VPs of Operations, Nursing and Ancillary Services,Infection Control Practitioners and the Directors of Safety, Security, Emergency Department and Corporate Communications

3. Upon review by the Hospital Incident Command a _______________be paged to summons necessary resources and tocover response needs.

4. Security shall immediately set up a controlled perimeter around the affected area. If an external response they shall firstsecure the Emergency Department and then place the facility in a complete lock down. Clear all unnecessary patients andemployees from immediate "at-risk" area.

5. The HIC shall ensure that someone is assigned to document details of the incident and names of all persons within theimmediate "at risk" area.

6. If it is a bioterrorism act the criminal investigation process will be managed by the FBI and all clothing and materials obtainedduring the incident should be secured with the understanding that FBI will need those items for investigation.

7. Contact the state health department or CDC for sample collection and shipping instructions and patient managementprotocols.

8. Activate Infection Control Team for initiation of patient/exposed employee tracking system, and patient/employee educationalinformation.

9. Initiate prophylaxis protocols as outlined by the state Public Health Department and/or local plan.

10. Notify internal personnel, as appropriate, including Chief of Staff, Health Care Providers, Nursing Service, Pharmacy,Microbiology Laboratory, Materials Management and Engineering for immediate inventory of critical resources.

11. Immediately assess potential impact of actual event on mission-critical systems to include staffing, critical supplies,operational space, potential for patient and staff exposures and HVAC system.

12. Release in the community – Notification of a release within the community may come from any number of outside sources,and the primary function of the Medical Center in this setting will be to treat concerned asymptomatic or symptomaticpatients. Treat all reports of a community release as "real" until proven otherwise.

13. Resource Issues.

a. Staffing needs will be monitored and addressed by the Incident Command Staff

4.7.3.2Fearful or anxious healthcare workers may benefit from:

Specimen packaging and transport must be coordinated with local and state health departments and the FBI. A chain of custodydocument should accompany the specimen from the moment of collection.

5.0Response/Recovery from the Event/Threat.


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b. Critical Supplies – This will be coordinated with the Logistics coordinator of the Hospital Incident Command Team.

c. Space Management – Assess isolation room and cohorting bed and space availability. This will be managed by IncidentCommand Staff.

d. Emergency Room capabilities, acute care clinic capabilities, and current/projected bed availability should be immediatelyassessed by the OPERATIONS CHIEF and reported to the local EOC.

e. If release has occurred within the Medical Center, patients and employees may be quarantined on site or relocated toalternate care sites or alternate health care facilities.

a. Triage and initial patient assessment for those exposed should include removal of clothes with collection of clothes aspotential evidence (double-bagged and labeled), self-shower and provision of clean clothes. Exposure to clinical casesrequires no decontamination activities. Privacy and containment are important.

b. Treatment Protocols will be based upon confirmed clinical evidence and CDC guidelines.

c. All quarantine decisions will be made by the Administrator or Administrator on Call based upon recommendations of theInfection Control Team, state health department, and the CDC.

d. The Infection Control Team will monitor all potential cases and make appropriate reports to the Administrator orAdministrator on Call and the local public health department. The local public health department will notify the CDC of allsuspected and confirmed cases.

a. Periodically inventory critical supplies with re-supply or supplementation from outside facilities, as needed. Outside supplyneeds should be managed through the Medxcel Facilites Management Command Center or District 6.

b. Periodically assess staffing census with workload redistribution, as needed.

c. Close monitoring of patient census and bed status.

d. Decontamination.

6.0EXTERNAL NOTIFICATION PROCEDURES.a. Other local facilities.

b. Other State and Federal Agencies. Public Health Service, CDC, FBI, FEMA, DoD, EPA, OSHA.

c. OSHA – Notify within eight (8) hours of one (1) employee fatality, or three (3) employee hospitalizations resulting from asingle incident.

d. Community Entities. Neighboring hospitals, emergency response systems (police, firefighters, EMS, 911 operators).

7.0SPECIALIZED STAFF TRAINING.a. Health Care Provider Training – Recognition of clinical syndromes associated biological threats, treatment protocols, CDC

guidelines.

b. Infection Control Team Training – Passive and active surveillance systems for monitoring reportable infectious diseasepathogens as outlined by the CDC.

c. Safety Specialist/Industrial Hygienist – respirator usage.

BIO-TERRORISM READINESS PLANHome Care Instructions

5.13.Clinical Response.

5.14Recovery Strategies.

ADDENDUM A

Home Care Instructions

Your health care provider has determined that you may have a contagious disease or may have been exposed to a contagiousdisease. In order to decrease the chances that you will spread the disease to others, please follow these instructions:


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ADDENDUM CBIO-TERRORISM READINESS PLAN

• Excessive postage• Handwritten or poorly typed address• Incorrect titles• Title, but no name• Misspellings of common words• Oily stains, discoloration or odor• No return address• Excessive weight• Lopsided or uneven envelope• Protruding wires or aluminum foil• Excessive security material such as masking tape, string, etc.• Visual distractions• Ticking sound• Marked with restrictive endorsements such as "personal" or "confidential"• Shows a city or state in the postmark that does not match that of the return address

Suspicious UNOPENED letter or package marked with a threatening messagesuch as "ANTHRAX":

1. Do not shake or empty the contents of any suspicious envelope or package.

2. PLACE the envelope or package in a plastic bag or some other type of container to prevent leakage of contents.

3. If you do not have any container, then COVER the envelope or package with anything (e.g., clothing, paper, trashcan,etc.) and do not remove this cover.

4. Then LEAVE the room and CLOSE the door, or section off the area to prevent others from entering. KEEP OTHERSAWAY!

5. WASH your hands with soap and water to prevent spreading any powder to your face.

1.Limit contact with other people.

2.Wash your hands often. It is very important to wash your hands after using the toilet, before preparing food and before eating.

3.Cover your mouth with a tissue when you cough or sneeze.

4.Do not let others touch your body fluids. (Urine, blood, saliva, etc.)

5.Do not share eating utensils.

In addition to the general instructions listed above, your health care provider would like you to follow these specific instructions:

If you have additional questions, please contact your health care provider.

Information released from CDC on 10-12-2001

Below is a list of recommendations distributed October 12, 2001 from the Centers for Disease Control.

DO NOT PANIC!

1.Anthrax organisms can cause infection in the skin, gastrointestinal system, or the lungs. To do so, the organism must be rubbedinto abraded skin, swallowed, or inhaled as a fine aerosolized mist. Disease can be prevented after exposure to anthrax sporesby early treatment with the appropriate antibiotics. Anthrax is not spread from one person to another person.

2.For anthrax to be effective as a covert agent, it must be aerosolized into very small particles. This is difficult to do, and requiresa great deal of technical skill and special equipment. If these small particles are inhaled, life-threatening lung infection can occur,but prompt recognition and treatment are effective.

HOW TO IDENTIFY SUSPICIOUS PACKAGES AND LETTERS:

Some of the characteristics of suspicious packages and letters include:


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6. What to do next….If you are AT HOME, report the incident to the local police.If you are AT WORK, report the incident to Safety and Security.

7. LIST all people who were in the room or areas when this item was recognized. Give this list to the local public healthauthorities and low enforcement officials for follow-up investigations and advice.

1. DO NOT try to CLEAN UP the powder. COVER the spilled contents immediately with anything (e.g., clothing, paper,trashcan, etc.) and do not remove the cover!

2. Then LEAVE the room and CLOSE the door, or section off the area to prevent others from entering. KEEP OTHERS AWAY!

1. Turn off local fans or ventilation units in the area.

2. LEAVE the area immediately.

3. Then LEAVE THE ROOM and CLOSE THE DOOR, or section off the area to prevent others from entering. KEEP OTHERSAWAY!

4. WASH your hands with soap and water to prevent spreading any powder to your face.

5. What to do next…..If you are AT HOME, report the incident to the local police.If you are AT WORK, report the incident to Safety and Security.

6. Shut down air handling systems in the building if possible.

7. LIST all people who were in the room or area when this item was recognized. Give this list to the local public healthauthorities and law enforcement officials for follow-up investigations and advice8.0References and Further Assistance.

a. Public Health Service/Local, County, State Health Departments

b. Centers for Disease Control

c. Local FBI representatives

1. Multiple Web Sites.

• CDC Bio-terrorism web site:www.bt.cdc.gov .

• Association for Infection Control Practitionerswww.apic.org/bioterror/

• US Army Medical Research Institute of Infectious Diseases. Physician Handbook. for Management of Biologic Casualties:www.usamrid.army.mil/education/bluebook.html

• Smallpox Recommendations from CDC (Advisory Committee on Immunization Practices)http://www.cdc.gov/mmwr/preview/mmwrhtml/00050577.htm

Opened envelope or package with a powder that spills out onto the surface:

3WASH your hands with soap and water to prevent spreading any powder to your face.

4.What to do next….

If you are AT HOME, report the incident to the local police.

If you are AT WORK, report the incident to Safety and Security.

5.REMOVE the heavily contaminated clothing as soon as possible and place in a plastic bag, or some other container that can besealed. This clothing bag should be given to the emergency responders for proper handling.

6. SHOWER with soap and water as soon as possible. DO NOT USE BLEACH OR OTHER DISINFECTANT ON YOUR SKIN.

7.List all people who were in the room or area when this item was recognized, especially those that had any actual contact withthe powder. Give this list to the local public health authorities and law enforcement officials for follow-up investigations andadvice.

Contamination by Aerosolization: (For example: A small device triggered warning that an air handling system is contaminated;or warning that a biological agent has been released in a public space.


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http://www.bt.cdc.gov

http://www.apic.org/bioterror/

http://www.usamrid.army.mil/education/bluebook.html

http://www.cdc.gov/mmwr/preview/mmwrhtml/00050577.htm

• CDC Interim Smallpox Response Plan and Guidelines, Executive Summarywww.bt.cdc.gov/DocumentsApp/Smallpox/RPG/index.asp

• CDC Bio-terrorism Response Planhttp://www.bt.cdc.gov/Documents/Planning/PlanningGuidance.PDF2)Phone Numbers.

• USAMRIID1-301-619-2833• US Public Health Service1-800-872-6367• Domestic Preparedness Information Line1-800-368-6498• National Response Center1-800-424-8802

SUPPLEMENTAL MATERIALS – STAFFINGSTAFFING

• A current picture identification card from a healthcare organization that clearly identifies professional designation.• A current license, certification or registration.• Primary source verification of licensure, certification or registration.• Identification indicating that the individual is a member of a Disaster Medical Assistance Team (DMAT), MRC, ESAR-VHP or

other recognized state or federal organizations or groups.• Identification indicating that the individual has been granted authority to render patient care, treatment and services in

disaster circumstances (such authority having been granted by federal, state or municipal entity).• Identification of the individual by current SVARH employees or Medical Staff who possesses personal knowledge regarding

the volunteer practitioner's qualifications.

Below is the text of HR Policy- Excerpt provided here for reference only.

PURPOSE:

When the SVMH Disaster Plan has been implemented and the immediate needs of the patients cannot be met by SVMH staffmembers, the hospital may implement a modified process for determining qualifications and competence of volunteerpractitioners who are required by law and regulation to have a license, certification or registration to practice their profession.

This policy allows for a method to streamline the process for determining qualifications and competence to provide safe andadequate care, treatment and services.

POLICY STATEMENT:

This policy is intended for those individuals that would normally be processed through Human Resources, and excludesindependent practitioners that would be processed through Medical Staff. Disaster responsibilities are assigned only when theDisaster Plan (Emergency Management Plan) has been activated and SVMH is unable to meet immediate patient needs. ThePersonnel Pool Coordinator is defined in the Disaster Plan.

PROCEDURE:

I. Volunteer practitioners who arrive at SVMH in the event of a disaster must present 2 forms of identification. The first formestablishes the volunteer's identity and must be a government issued photo identification issued by a state or federal agency,such as a driver's license or passport. The second form establishes the volunteer's credentials and must be one of the following:

Once identity and credentials have been established, the Personnel Pool Coordinator will give the disaster volunteer adistinguishing "Disaster Volunteer" name badge and assign the volunteer to an area of the hospital suited to the hospital needsand the volunteer's credentials. A designee of the assigned department will oversee the professional practice of the volunteer.Verification of credentials and performance will be completed and documented within 72 hours or as soon as the immediatesituation is under control.

II. The Personnel Pool Coordinator or Designee will complete a Disaster Volunteer Information Sheet on each volunteer prior toassigning the volunteer to an area of the hospital. The Personnel Pool Coordinator will validate identity and credentials (listedabove) at that time. The Disaster Volunteer Information Sheets will be forwarded to the Human Resource Department, who will inturn begin to complete primary source verification of credentials as soon as the immediate situation is under control. This processshould be completed within 72 hours. In the event of no means of communication or lack of resources, verification of credentialswill begin as soon as possible.


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http://www.bt.cdc.gov/DocumentsApp/Smallpox/RPG/index.asp

http://www.bt.cdc.gov/Documents/Planning/PlanningGuidance.PDF

POLICY STATEMENT:

DEFINITIONS:SCOPE:

ACTION STEPS:A. The reappointment application will be presented to Credentials Committee for review and/or approval seven (7) months prior

to the end of the calendar year. The approved application will be presented to the Medical Executive Committee for review,revisions, and approval prior to being sent to individuals with privileges.

B. A current Delineation of Privileges Form will be sent with the reappointment application to be completed or updated, etc. byall individuals.

C. A separate reappointment file will be created for each individual.

D. A checklist will be placed in each file to document date of return and/or confirmation of all required reappointmentdocuments.

E. Direct confirmation by primary source is required and will be completed for:

1. Indiana State License (computer access)

2. Indiana Controlled Substance Registration (computer access)

3. AMA (computer access)

4. National Data Bank (computer access)

5. Physician Alternates

6. Hospital Affiliation/Peer Review

F. When the files are complete with all required documents and primary source documentation, the Clinical Service Chief willbe contacted to arrange a date and time for review of each clinical service member's file.

G. The Clinical Services Chief will present the list of completed files for review and approval at the scheduled Clinical Servicesmeeting.

H. The Clinical Service Chief will review and make appropriate recommendation regarding privileges to the CredentialsCommittee. Special attention will be paid to new/additional privileges requested, with supporting documentation, whenapplicable, required.

III. The Personnel Pool Coordinator or Designee will assign the volunteer to a department/role that best suits the hospital's needsand the volunteer's credentialed skill set. A St. Vincent Health employee in the assigned department will oversee the volunteer'sprofessional practice and report back to the Personnel Pool Coordinator.

IV. Within 72 hours or as soon as the situation is under control, the hospital will make a decision based upon the informationobtained regarding the professional practice of the volunteer practitioner related to the continuation of the disaster responsibilitiesinitially assigned.

V. The Disaster Volunteer Information Sheet, along with any other documentation regarding the volunteer's duties andperformance and any primary source verification that was obtained, will be sent to Human Resources and stored according to theRecords Retention Schedule for Personnel records.

Staffing

Below is the text of Medical Staff Policy . See the Medical Staff Office for the latest definitive copy of the policy. Excerpt providedhere for reference only.

Reappointment of all individuals granted privileges as stated in the Medical Staff Bylaws shall be completed no less than everytwo (2) years. Reappointments will be completed on a calendar-year basis.

Medical Staff Office


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I. Credentials Committee will review reappointment files (including quality data) and make appropriate recommendationregarding privileges to the Medical Executive Committee.

J. The Medical Executive Committee will review and make appropriate recommendation to the Board of Trustees.

K. The Board of Trustees will receive and act upon a report from the President of the Medical Staff regarding the physiciansrequesting reappointment to the medical staff.

L. Applicant will be notified in writing of Board's action and, if necessary, follow the Medical Staff Bylaws to resolve anydisputes regarding privileges that were approved.

IT&S STAFFING

Date: ___________ Time Time Time Time Time

Bed StatusRecord the following per unit:# beds available# staff available

Beds Staff Beds Staff Beds Staff Beds Staff Beds Staff

[Unit name]Phone Ext:














Record all of the following: Time # Avail Time # Avail Time # Avail Time # Avail Time # Avail

Security:Staff present

This section will need to have information added from the medical by-laws for disaster credentialing and LIP privileges

Staffing Assessment Worksheet


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Facilities:Staff present

Medical Records/HIM:Staff present

Transport:Staff present

EVS:Staff present

FNS:Staff present

Volunteers:Staff present

Staffing Status Time Time Time Time Time

Record all of thefollowing:

OnTask

Needed OnTask

Needed OnTask

Needed OnTask

Needed OnTask

Needed

Triage

Doctors

RNs

Med records

RT

Transporters

Runners

# of Patients Seen

Immediate treatment (Triage Red)

Doctors

RNs

Med records

RT

Lab Techs needed

EVS Needed

Transporters

Runners

# of Patients Seen

Delayed treatment (Triage Yellow)

Doctors

RNs

Med records

RT

Lab Techs needed

EVS Needed

Transporters

Runners

# of Patients Seen


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Staffing Status Time Time Time Time Time

Record all of thefollowing:

OnTask

Needed OnTask

Needed OnTask

Needed OnTask

Needed OnTask

Needed

Minor treatment (Triage Green)

Doctors

RNs

Med records

RT

Transporters

Runners

# of Patients Seen

Expectant (Triage Black)

RNs

Pastoral Care

# of Patients Seen

Morgue

Med records

Lab Techs needed

# of Patients Seen

Record all of the following: Time # Avail Time # Avail Time # Avail Time # Avail Time # Avail

Personnel PoolEmployees unassigned by type

Operating RoomStaff present

Operating RoomsReady to go

Child Care CenterStaff present

Children here

Staff Family needsStaff present

SUPPLEMENTAL MATERIAL-RESOURCESRESOURCESESSENTIAL SUPPLIES PLANNING FACTORS1. Planning Factors

A. Drinking Water

1. The planning factor for drinking water is 1 gallon per person per day for staff and visitors, and 3 gallons per day forpatients.

2. Emergency drinking water is usually provided in the form of bottled water. Bottled water is available from a varietyof sources already palletized and ready to ship.

This Page Intentionally Left Blank


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B. Ice

1. Ice is needed to preserve food and medicines.

2. The planning factor for ice is one 8 to 10 pound bag per person per day.

3. Bagged ice is available from a number of distributors. When arranging for ice, keep in mind that ice is obviously perishableand you will probably need to retain the refrigerated delivery truck to preserve the product while it is being distributed.

1. The general planning factor is 8 to 10 toilets per hundred people. In areas where people are well dispersed, additional toiletsmay be needed to keep the walk to sanitary facilities reasonable.

2. In requesting portable toilets, ensure that the contract for providing the toilets includes the requirement to service them on aregular basis. A local or nearby firm that has existing arrangements for waste disposal is often preferable.

3. Portable toilets should be sited at least 100 feet for any water source or cooking facility. To prevent disease, it is desirable tohave hand-washing facilities in the vicinity of toilets.

1. Shelter and mass care facilities and mobile feeding units generally aim to provide at least two, and preferably three, simplemeals per day – cereal, sandwiches, and soup. When requesting feeding service, provide not only an estimate of thenumber of people that need to be fed, but also indicate the number of those who are infants and children 1 to 3 years of ageso that suitable food can be provided.

1. St. Vincent Health Division Supply Chain

A. Resource Group Division Supply Chain delivers supplies to SVMH one time daily, 7 days a week

B. Par levels of clinical supplies are based on three days of usage at capacity

C. Resource Group Division Supply Chain has plans and procedures in place for opening the center and supplyingmaterials after hours and on weekends when an emergency event or disaster occurs.

2. Pharmaceuticals

A. Pharmaceutical Supplies for SVMH are obtained through McKesson They have a distribution point in WashingtonCourthouse Ohio approximately 175miles from the hospital

3. Linen Delivery:

A. Linen is taken care of in-house

4. Surgical Supplies

A. Surgery keeps 100's of surgical instrument trays ready, disposable supplies for surgery trays are more readily available.

B. Without steam surgery does not have enough trays to last one day at normal case load

C. CVOR keeps several trays ready, can last one day without steam, can handle one day's emergency cases aftercancelling elective surgeries

D. 3 days of disposable supplies are kept in the department

E. Surgery personnel can scrub with Avagard if water curtailed, plenty on hand, CVOR surgery requires water to scrub.

F. Endoscopy has enough resources to finish the day's cases.

5. Food and Nutrition Services (FNS)

A. Produce is delivered daily Monday through Saturday

B. Dairy products are delivered weekly on Tues / Fri

C. Meat and dry goods are delivered Monday / Friday

D. FNS has paper plates, napkins, plastic utensils and disposable cups to last 4 days if water curtailed

E. FNS keeps about 60 cases of plain water (liters) on hand

6. Clinics

C. Portable Toilets

D. Food


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A. Cardio-Vascular Rehab and Multi-Specialty Clinic have only juice and crackers on hand, would need nourishment toshelter in place.

7. Diesel Fuel (additional info in Annex E – Utilities)

A. SVMH has i diesel fuel tanks for the emergency generators

1. Underground Storage Tank 9,000 gallons

2. Fuel supply levels that trigger refilling the tanks have been established at

a. 6,000 gallons for the underground tankResourcesRESOURCE INVENTORYResource Quantity Location Expiration Comments

SUPPLEMENTAL MATERIALS-RADIOLOGIC/HAZMAT EVENTRADIOLOGICAL INSTRUMENT INVENTORYType ofInstrument

Number inStock

Owner


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RADIOLOGICAL INCIDENT RESPONSE CHECKLISTAction Item Assigned

1. If the situation requires it, isolate the site and deny access.

2. Classify incident, provide basic situation information to dispatch, and identify responseresources required. See Incident Classification page 3, this appendix.Level I – IncidentLevel II – EmergencyLevel III – Disaster

3. Record situation on a Hazardous Materials Incident Report (see Appendix 4) andprovide to the SVMH EOC

4. The SVMH EOC should relay situation information to emergency responders, whoshould dispatch forces in accordance with their SOPs

5. Determine extent of danger to responders and establish initial requirements forpersonal protective equipment (PPE) by SVMH Staff.

6. Ascertain extent of danger to staff, patients and visitors; determine specific areas ifany, at risk.

7. Develop initial action plan to contain and control the release of radiological material.

8. Determine appropriate protective actions. If evacuation is contemplated, notify St.Vincent Health Division and the Division Patient Transfer Center as soon as possible.

9. Warn clinics and professional offices not in the SVMH main building, provideprotective action recommendations and instructions, and determine requirements forassistance. Provide assistance requested.

10. If evacuation will be conducted, provide traffic control and be prepared to providetransportation to those who lack it.

11. If possibility exists of casualties that are contaminated with radiological material,ensure EMS units and other hospitals are so advised.

Action Item Assigned

12. Notifications: The Indiana State Department of Health, Indoor and RadiologicalHealth Program must be contacted for radiological accidents. They can provideassistance as needed. .

13. If water or wastewater systems are threatened by radioactive contamination, advisethe City of Elwood water utility system operators so they may implement preventativemeasures.

14. If on-scene technical assistance is required, request assistance from industry orappropriate state or federal agencies.

15. If additional response resources are required, request them.

16. Provide updated information on the incident to the public through media releases.

17. Continuously document actions taken, resources committed, and expenses incurred.

18. Retain message files, logs, and incident-related documents for use in incidentinvestigation and legal proceedings and to support claims for possible reimbursementfrom the responsible party or state and federal agencies.

Use vehicles, barricades, barrier tape, etc.


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19. Assess contamination and determine which areas are safe to re-enter. Determineand implement remediation measures for other areas.

20. As evacuated areas are determined to be safe to reenter, advise staff they mayreturn.

21. If some areas will require long-term cleanup before they are useable develop andimplement procedures to mark and control access to such areas. NOTE: Clean up is theresponsibility of the responsible party.

22. Conduct post-incident review of response operations.

Incident Classification.Level I – Incident. An incident is a situation that is limited in scope and potential effects; involves a limitedarea and/or limited population; evacuation or sheltering in place is typically limited to the immediate area ofthe incident; and warning and public instructions are conducted in the immediate area, not community-wide.This situation can normally be handled by one or two local response agencies or departments acting under anIncident Commander (IC), and may require limited external assistance from other local response agencies orcontractors.Level II – Emergency. An emergency is a situation that is larger in scope and more severe in terms of actualor potential effects than an incident. It does or could involve a large area, significant population, or criticalfacilities; require implementation of large-scale evacuation or sheltering in place and implementation oftemporary shelter and mass care operations; and require community-wide warning and public instructions.You may require a sizable multi-agency response operating under an IC; and some external assistance fromother local response agencies, contractors, and limited assistance from state and federal agencies.Level III – Disaster. A disaster involves the occurrence or threat of significant casualties and/or widespreadproperty damage that is beyond the capability of the local government to handle with its organic resources. Itinvolves a large area, a sizable population, and/or critical resources; may require implementation of large-scale evacuation or sheltering in place and implementation of temporary shelter and mass care operationsand requires a community-wide warning and public instructions. This situation requires significant externalassistance from other local response agencies, contractors, and extensive state or federal assistance.HAZARDOUS MATERIALS INCIDENT REPORTINITIAL CONTACT INFORMATIONCheck one: This is an ACTUAL EMERGENCY This is a DRILL/EXERCISE

1. Date/Time of Notification: Report received by:

1. Known damage/casualties (do not provide names over unsecured communications):

CHEMICAL INFORMATION

2. Reported by (name & phone number or radio call sign):

3. Company/agency and position (if applicable):

4. Incident address/descriptive location:

5. Agencies at the scene:

7. Nature of emergency: (check all that apply)

___ Leak ___ Explosion___ Spill___ Fire___ Derailment ___ Other

Description:

8. Name of material(s) released/placard number(s):

9. Release of materials:

has ended is continuing Estimated release rate & duration:

10. Estimated amount of material, which has been released:

11. Estimated amount of material, which may be released:


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IMPACT DATA

12. Media into which the release occurred: ________ air ________ ground ________ water

13. Plume characteristics:

a. Direction (Compass direction of plume):c. Color:

b. Height of plume: d. Odor:

14. Characteristics of material (color, smell, liquid, gaseous, solid, etc)

15. Present status of material (solid, liquid, gas):

16. Apparently responsible party or parties:

ENVIRONMENTAL CONDITIONS

17. Current weather conditions at incident site:

Wind From: Wind Speed (mph):Temperature (F): ______

Humidity (%): ______ Precipitation: Visibility: __________

18. Forecast:

19. Terrain conditions:

HAZARD INFORMATION

(From ERG Guidebook, MSDS, CHEMTREC, or facility)

20. Potential hazards:

21. Potential health effects:

22. Safety recommendations:

Recommended evacuation distance:

23. Estimated areas/ populations at risk:

24. Special facilities at risk:

25. Other facilities with Hazmat in area of incident:

PROTECTIVE ACTION DECISIONS

26. Tools used for formulating protective actions

________ a. Recommendations by facility operator/responsible party

________ b. Emergency Response Guidebook

________ c. Safety Data Sheet

________ d. Recommendations by CHEMTREC

________ e. Results of incident modeling (CAMEO or similar software)

________ f. Other:

27. Protective action recommendations:

____ Evacuation ____Shelter-In-Place ____Combination ____No Action

____ Other

TimeActionsImplemented____________________________________________________________________________________________

_________________________________________________________________________________


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EXTERNAL NOTIFICATIONS

_________________SUPPLEMENTAL MATERIALS-COMMUNICATIONSCOMMUNICATIONSPBX / PHONE SYSTEM

RADIOS

AMATEUR RADIO EQUIPMENT

_________________________________________________________________________________

_________________________________________________________________________________

28. Evacuation Routes Recommended:

29. Notification made to:

National Response Center (Federal Spill Reporting)1-800-424-8802

Indiana Environmental Hotline (State Spill Reporting) 1-800-451-6027

CHEMTREC (Hazardous Materials Information)1-800-424-9300

30. Other Information:

SVARH PBX phone Number is 765-646-8269

SVMH Internal Radios

SVARH radios operate on several radio channels

Channel 1 (Facilities management)

TX 469.675 MHz DCS tone 664, RX 464.675 MHz

The repeater is located in the 8th Floor penthouse

Channel 2 (Security)

TX 469.925 MHz PL tone 127.3 RX 464.925 MHz

The repeater is located in the Plant 5 air handling room

Channel 3 (Disaster)

TX/RX 467.2625 MHz DCS 32

SVARH Satellite Phones

SVARH has numerous satellite phones with service:

SVMH has a. Kenwood dual band amateur radio in it with battery back-up. The antenna is between the north towner and thesouth tower.. the cable is located in the Security Office.

SVMH has an amateur radio station.The radio is a Kenwood all band radio. The radio is connected to a 2 meter / 70 cm dualband vertical mounted on the nortgh corner of the south tower . The radio has two power options 1)13.8 volt power supply fromcommercial power, or 2) battery backup maintained on a float charger.

A list of the licensed amateur radio operators at SVMH is in this appendix.


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• ICOM IC-706MKIIG HF/VHF/UHF• Hy-Gain TH-7DX Thunderbird HF antenna• G5RV HF Antenna• Folded Dipole HF Antenna• 2m/70cm Base/Rpt Antenna• PC integrated with Radio with

◦ WinLink 2000 Functioning◦ PSK31 Functioning

COMPUTERS

Name License Type Comments

CODE READY

HCA's corporate office in Nashville, TN has an amateur radio station with HF capability. The licensed amateur radio operators atthe corporate office are listed in Attachment 1 to this appendix. Their amateur radio station includes the following equipment:

HCA's corporate office monitors the following bands and frequencies in the event of a disaster:

20 meter14.250 MHz

40 meter 7.200 MHz

80 meter 3.875 MHz

There are four laptop computers designated and programmed for EOC use. They are stored inside the server room in the firstfloor administrative hallway. The laptops have a secondary use as replacements for the nursing units' computers on wheels whenone of those needs service. In that situation the EOC laptops can be located on the Agility (RFID equipment locator) system.

The computers designated as EOC are (listed as "laptop" on Agility):

PZMCA1EISM11

PZMCA1EISM13

PZMCA1EISM14

PZMCA1EISM16

List of Licensed Amateur Radio Operators

FCC Licensed Amateur Radio Operators at

As of 10/10/16

NameCall SignLicense ClassExpiration

FCC Licensed Amateur Radio Operators at St. Vincent Health

As of January 2013

NameCall SignLicense ClassExpiration

Employee Information web site


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COMMUNICATIONS MATRIXFacilityMainPhone

Fax SatellitePhone

EMCCellphone

Amateur Radio FrequencyMonitored

Email Other systemsMonitored

SVARH

EOC

CountyEOC

1. FROM (SENDER) Use proper name to identify who is sending the message. Include title and agency as appropriate.

2. TO (RECEIVER) Use proper name and/or HICS position title as appropriate to identify for whom the message is intended.

3. DATE RECEIVED Use the international standard date notation YYYY-MM-DD, where YYYY is the year, MM is the month ofthe year between 01 (January) and 12 (December), and DD is the day of the month between 01 and 31. For example, thefourteenth day of February in the year 2006 is written as 2006-02-14.

4. TIME RECEIVED Use the international standard notation hh:mm, where hh is the number of complete hours that havepassed since midnight (00-24), and mm is the number of complete minutes that have passed since the start of the hour(00-59). For example, 5:04 PM is written as 17:04. Use local time.

5. RECEIVED VIA Indicate communication system.

HICS 213 – INCIDENT MESSAGE FORM

HICS 213 – INCIDENT MESSAGE FORM

PURPOSE: PROVIDE STANDARDIZED METHOD FOR RECORDING MESSAGES RECEIVED BY PHONE OR RADIO.

ORIGINATION: ALL POSITIONS.

ORIGINAL TO: RECEIVER.

COPIES TO: DOCUMENTATION UNIT LEADER AND MESSAGE TAKER.

INSTRUCTIONS:

Print legibly, and enter complete information.


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6. REPLY REQUESTED Indicate whether a reply was requested and to whom reply should be addressed, if different fromSender.

7. PRIORITY Indicate level of urgency of the message.

8. MESSAGE (KEEP ALL MESSAGES/REQUESTS BRIEF, TO THE POINT, AND VERY SPECIFIC) Transcribe complete,concise and specific content of message.

9. ACTION TAKEN (IF ANY) Note any action taken in response to message. When message is routed to any additionalrecipient, indicate who received, time received, action taken or other comments, and next person to whom message wasforwarded.

10. FACILITY NAME Use when transmitting the form outside of the hospital.

All revision dates: 02/2017

Attachments:

Appendix 1_Examples of Mitigation Activities.docxAppendix 2_Examples of Prepardness Activities.docxAppendix 3_Examples of Response Activities.docxAppendix 4_Examples of Recovery Activities.docxAppendix 5_Plain Language Codes and Scripts.docxAppendix 6_Local Resources Telephone Numbers.docxAppendix 8_Operating Guidelines During Emergencies.docxDistrict 6 Call Rotation 2017.docxDistrict 6 Hospital Preparedness Directory.xlsxEstimated Oxygen Cylinder Duration in Minutes.docximage2.jpgMercy Annual Emergency Mgt Plan Review for 2016.docxMercy Emergency Phone Number Call List 2017.xlsxPandemic Warehouse List 2017.xlsPandemic Warehouse List 2017.xlsSurvivability Index_2017.docxSV Mercy HVA 05 2016.xlsx

Approval Signatures

Approver Date

Francis Albarano: Administrator 02/2017

Ann Yates: Director 02/2017

WHEN TO COMPLETE: When intended Receiver is unavailable to speak with the sender or when a

communication includes specific details which accuracy needs to be ensured.

HELPFUL TIPS: This form is suitable for duplication using carbonless copy paper.


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