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Emergency Preparedness Management

Policy: 
It is the policy of Mahaska Health Partnership to respond to a real or threatening disaster by organizing all available resources to be deployed in the most efficient and effective possible manner in order to save lives, limit casualties, limit damage, and restore normal operations as soon as possible. 

Background:
 Effective planning is intended to reduce the impact of emergencies on the quality of patient care and increases the hospitalís ability to continue to provide necessary patient services. Planning takes into consideration the hospital facility, space, personnel, supplies, communications, and other resources needed to provide essential services under less than ideal conditions.

Objectives:
The objectives for the Emergency Preparedness Management Program are to: 

provide alternate sources of essential utilities 
maintain availability of adequate supplies including water, gases, food, and essential medical and supportive materials
provide alternate communication systems in the event of failure of the primary system 
provide facilities for isolation and decontamination of persons contaminated with nuclear, biological, and chemical contamination. 
provide maximum safety and protection for patients, visitors, and personnel
protect and maintain physical plant facilities
ensure that knowledgeable staff are available to respond to an emergency 
define alternate roles and responsibilities of personnel 
evaluate the effectiveness of this plan biannually and to ensure performance improvement

Scope:
The Emergency Preparedness Plan defines processes through which Mahaska Health Partnership provides effective response to external and internal disasters and emergencies. The scope of the program is hospital wide to include all clinical, managerial, and support services. When necessary, the scope of the program is community wide to include, but not limited to, local, state and federal agencies; fire and rescue squads; businesses; Emergency Medical Systems; Department of Health; utilities; and relief organizations such as the Red Cross and FEMA.

Performance:
Performance of the Emergency Preparedness Management Plan will be measured through the establishment of standards aimed at measuring staff knowledge, level of staff participation, monitoring activities, incident reporting, and safety equipment testing and inspection. 

Effectiveness:
The Emergency Preparedness Management Plan is reviewed during the annual review of Environment of Care compliance and performance improvement activities.


Emergency Preparedness Management Plan


1. Disaster Procedures

The Emergency Preparedness Management Plan comprises several component plans, covering various types of emergencies or disasters. Disasters are defined as natural or man-made events within the hospital or in the surrounding community, which significantly disrupt the environment of care and/or patient care and treatment activities. They include damage to patient care or treatment areas due to loss of utilities (power, water, telephones) as a result of floods, riots, accidents or emergencies within the hospital or surrounding community. 

2. Integration with Community-wide Emergency Preparedness Efforts utilizing Contact list 

Notification of External Authorities

The Chief Operating Officer or designee will be responsible for the notification of outside authorities for assistance and additional resources.

4. Personnel Notification

All Department Directors or designees are responsible for contacting the appropriate number of personnel in their department. If the emergency or disaster occurs during hours when Directors are not within the facility, the Nursing Supervisor or designee is responsible for seeing that the Disaster notification lists are activated. Departments with staff on duty at the time of the disaster or emergency are to report to their Directors immediately.

5. Personnel Emergency Assignment

The following list outlines the main responsibilities of each department during an emergency or disaster. Each department is responsible for a disaster response plan within their respective areas.

a. Administration
Provide administrative support

b. Admitting
Process inpatient admissions using disaster tags from ED
Staff the main switchboard
Cancel elective admissions
Create a medical record for each patient according to disaster tag and obtain further demographic information

c. Anesthesia
Assist with Surgical procedures as needed

d. Auxiliary/Volunteers
Volunteers to remain to assist as required
Available staff reports to Personnel Pool

e. Community Health
Follow policy of community health disaster plan
Maintain operations
Assist as needed through communication with hospital EOC 

f. Clinical Labs
Notify Command Center if services are limited
Verify blood availability

g. Dietary Services
Establish communication with Command Center to understand scope of Disaster
Continue normal operations
Provide food for disaster staff
Implement department plan for patient food service as required by scope and type of disaster
Assess food supply on hand

h. Emergency Department
Maintain communication with EMS for status of off-site emergency status
Notify CEO or designate of necessity of to activate plan
Serve as Triage and Immediate Care area
Complete disaster triage tags for each patient
Maintain Communication with Command Center with current Disaster status

i. Environmental Services
Prepare to assist with damage clean up for facilities incidents
Coordinate housekeeping activities in Triage and treatment areas

j. Maintenance 
Coordinate facilities and utility management
Coordinate rescue and repair activities
Conduct damage assessment

k. Materials Management
Supply ED and treatment areas with needed supplies 
Manage acquisition of medical supplies as directed

l. Ambulance
Transport patients as needed
Maintain communication with ED on status of field operations and casualties

m. Nursing
Nursing staff report to their units
Nursing units are to prepare bed availability and provide to EOC
Prepare to discharge all possible patients

n. Operating Room
Surgical Services Director or designee will communicate status of disaster within OR area
Surgical Services Director, Supervisor or designee will maintain communication with ED to facilitate smooth flow of patients to OR
OR will notify Inpatient Nursing Team Leaders of all impending cases and their bed needs

o. Pharmacy
Maintain disaster drug supplies to the ED
Continue operations

p. Radiology
Staff x-ray operations in the ED
Remain open and wait for further instructions

q. Respiratory Care
ED and trauma therapists to report to ED
Unassigned personnel check with department for assignments
Verify availability of compressed gasses

r. Telecommunications/Hospital Operators
Announce disaster plan activation as directed by Hospital 
CEO or designee
- Overhead page per policy
- Notify Administrator-On-Call
Provide overhead announcements as instructed by appropriate persons

s. Transfusion Services
Remain open to provide services, as needed

The following departments shall be on stand-by. These departments should remain operational but be prepared for requests for assistance. Available staff should report to the Personnel Pool.

Gift Shop
Physical Therapy
Financial Services functions
Quality Assurance
Physicians Clinic Staff
All others not listed above

6. Management of Space, Supplies and Security

Patient Care Areas
a.Patient Care areas will be established for triage, major injuries, and routine emergency operations.

b.Minor injuries will be sent to ED waiting room or a designated area in the hospital

ED Nurse Station
a.Will be center of operations for patient movement.

b.Assigned staff will be responsible for registering patients and maintaining a disaster log of all incoming patients, their exit and destination when leaving ED.

c.Assign a person to monitor incoming EMS reports and maintain communication with EOC via telephone,  Fastcommand messaging, or UHF radio

Visitor and Relative Waiting Area
a.Space will be allocated for all visitors and relatives of incoming disaster victims. The suggested area will be the dining room.

b.A person will be assigned to oversee the area and coordinate information.

Traffic Control
a.Assigned personnel will be responsible for providing external traffic control, including access to the Emergency Department by emergency vehicles, traffic and parking; and internal security to keep treatment areas clear of unauthorized personnel.

b.Security personnel will also be assigned to the Emergency Department to provide internal crowd control, and to secure treatment areas if requested.

c.Local Law Enforcement agencies may be utilized as necessary and available.

Fatalities
a.The policy on hospital post mortem care and mass fatality management will be utilized(located on intranet ED, Disaster Preparedness, and on Fastcommand sites

Elevator Usage
a.During any internal or external disaster, usage of certain elevators within the hospital complex will be restricted for controlled access of patients and hospital staff.

b.Security personnel or designee will be posted by each elevator to control access.

Emergency Supplies
a.The Operations Chief is responsible for coordinating with the Materials Management Director in order to identify any medical supplies, beds or other items that will be required to meet the needs of the patients. The Materials Management Director will make arrangements for the acquisition of the appropriate type and numbers of supplies.

b.The Emergency Department shall work with the Laboratory Director or Blood Bank Supervisor to assure that the hospital maintains an adequate supply of blood to meet the needs of the patients. As the scope of the disaster becomes known to field EMS personnel they will relay information to the ED who in turn will notify the lab. The Laboratory will work with designated blood banks to arrange the delivery of the proper blood products.

c.Should there be an interruption or shortage of food, the Director of Support Services in conjunction with Dietary Services shall make arrangements for an alternative source of food, or additional deliveries of food. 

d.Should there be an interruption in the supply of  water, the Director of Support Services shall make arrangements with local suppliers to provide the hospital with drinking water. 

7. Facility Evacuation

Facility evacuation will follow hospital policy and procedure.( located on intranet in Safety, ED, and Fastcommand site.

8. Alternative Care Sites

a.Physical Therapy - This area will accept minor injuries.  Personnel for this area will be at the discretion of the Labor Pool Team Leader.  Basic first aid measures will be performed with rapid treatment and discharge. Supplies for this area will be provided by materials management as needed.

b.PACU - This area will assist with the flow of patients that are requiring further diagnostic studies or awaiting surgical interventions.  Personnel for this area will be at the discretion of the Surgery Director.

c.Emergency Department - This area will receive patients that require emergent care with high probability of survival.

d.Day Surgery Ė This area may assist with any overflow from the minor injury area

e.In the event that patient load exceeds the hospitalís capacity, it may become necessary to divert or transfer casualties to other local institutions.  These accommodations may be in cooperation with the Mahaska County Emergency Manager in cooperation with the hospital EOC.

f.Refer to the evacuation and shelter policy and Procedure prior to transferring any patent to another facility. ( Located on intranet Disaster Preparedness, ED, and Fastcommand

9. Patient Management During Emergencies

In the event of a disaster, scheduling of patients for nonemergency care will cease. All patients will be notified that elective surgeries and diagnostics will be temporarily halted. Directors of each patient care area are responsible for assessing and coordinating discharge of appropriate patients. Information on disaster victims will be made available to the chaplains, social workers and appropriate relief agencies by the Public Relations Officer.

10. Alternative Sources of Essential Utilities

The use of alternative sources of essential utilities will follow hospital policy and procedures at the discretion of the CEO and EOC

11. Back-up Communication Systems

The use of back-up communication systems may be utilized by the EOC and other areas of the hospital. The IT Department will be available to assist with the maintenance of the communications systems. UHF Radios are available for the EOC and ED

12. Isolation and Decontamination Facilities

The use of isolation and decontamination facilities will follow MSDS or CDC guidelines. Hospital isolation policies are available on the intranet

13. Alternate Personnel Roles and Responsibilities

Triage Team Responsibilities
Triage Team members include:
Triage Nurse - This nurse will be decided upon by the EMS Director or Designee
Transporters - The necessary number of transporters will be decided upon by the EMS Director or Nursing Supervisor
Reception Clerk - Two (2) clerks shall be available.
Triage Team Function

a.Initial examination, reception, classification and identification of all casualties.

b.Decontamination of casualties, as necessary.  Refer to MSDS or CDC guidelines for decontamination procedures

c.Assignment to treatment areas.

d.Transfer of the dead to the holding room.

Triage Nurse Responsibilities
a.Assist Reception Clerks with compiling of information and tagging incoming casualties.

b.Assist in assuring that all casualties are tagged correctly.

Emergency Services Director Responsibilities
a.Departmental Preparation
Assess department readiness and coordinate operations for transport of patients to this facility or to other institutions. Notify Administration/EOC of department status and number of available beds.

b.Organization
Assign team members to areas of need.

a.Departmental Preparation
1. Assignment of personnel to triage.
2. Oversee departmental preparation.
3. Notify Executive Directors of expected number and types of casualties as soon as this information is available.
4. Assign one person to answer incoming calls 
5. Secure the department by closing all entrances to the department.  The only entrance to the department will be through the triage receiving area without  other authorization
6. Maintain accurate count of expected casualties.

b.Organization
1. Oversee the triage area and assign additional personnel as needed.

c.Communications
1. Provide periodic status reports to the EOC
2. Facilitates interdepartmental communications.

14. Orientation and Education of Personnel

An orientation and education program for personnel who participate and implement the emergency preparedness plan will address:

a.specific roles and responsibilities during emergencies

b.information and skills required to perform duties during an emergency

c.back-up communication system to be used during disasters

d.how supplied and equipment will be obtained during disasters

Each department/unit is responsible for insuring that its personnel are adequately trained and capable of carrying out their required disaster tasks. Department Directors are responsible for providing new personnel with a department specific orientation to the Emergency Preparedness program. The goal of the department specific orientation is to provide new personnel with current emergency preparedness information and skills regarding departmental roles and responsibilities, job specific roles, emergency communications, and how supplies and equipment are obtained during an emergency.

The Hospital Education Department has overall responsibility for coordinating the orientation and education program for new employees associated with Management of the Environment of Care. The Hospital Education Department and Disaster Coordinator are responsible for managing the Emergency Preparedness program orientation and education program.

The members of the Safety Committee collaborate with the Hospital Education Department and individual team leaders to develop content and materials for general and departmental orientation and for the annual mandatory program. The educational materials are reviewed at least annually and are updated as needed.

15. Performance Monitoring

The Hospital Safety Committee is responsible for establishing performance improvement standards to objectively measure the effectiveness of the Emergency Preparedness program. The committee determines appropriate data sources, data collection methods, data collection intervals, analysis techniques and report formats for the performance improvement standards. 

The Safety Committee report summarizes performance compared to the performance improvement standard. If deficiencies are identified, a plan of action is developed to address the deficiency. The Safety Committee is responsible for evaluating the relevance of performance improvement standards.

Performance standards will include the following:

a.Emergency preparedness knowledge and skills of staff
b.The level of staff participation in emergency preparedness
c.Monitoring and inspection activities
d.Emergency and incident reporting procedures 
e.Inspection, preventive maintenance and applicable testing

16. Annual Evaluation

The Safety Committee will evaluate the Emergency Preparedness Management Plan each year. The annual evaluation uses a variety of information sources including the reports from internal policy and procedure review, incident report summaries, Disaster after action reports, meeting minutes, Safety Committee reports, and other summaries of activities. In addition, findings by outside agencies such as accrediting or licensing bodies, community agencies, or qualified consultants are used. The annual review examines the objectives, scope, performance, and effectiveness of the Emergency Preparedness program. The findings of the annual review are presented in a narrative report supported by relevant data. The report provides a balanced summary of the Emergency Preparedness program performance over the preceding 12 months. Strengths are noted and deficiencies are evaluated to set goals for the next year or longer term.