It is the policy of Mahaska Health Partnership to have defined procedures to protect the life and safety of both patients1 and staff should there be a hazard that causes the healthcare facility to decide either to shelter-in-place or to evacuate. This procedure is to used in conjunction with the present Hospital Evacuation Policy and Plan.
1. Alternate Care Site: a building or facility to which patients from the evacuated health care facility can be taken to for continued care and treatment and shelter
2. Assembly Area: In a complete evacuation, this is an area(s) where patients are processed before going to the Patient Staging Area(s) for transport out of the healthcare facility. (The Assembly Area(s) could be the patient rooms)
3. Complete Evacuation: evacuation of the entire facility
4. Emergency Management Plan (Disaster Plan): the procedures, developed by Mahaska Health Partnership, to manage an internal or external hazard that threatens patient, staff, and visitor life and safety.
5. Emergency Operations Center (EOC): a village, town, city, county, regional, state central command and control facility responsible for managing an emergency situation
6. Healthcare Facility: a facility where patients/residents, who need assistance in caring for themselves, are supervised by healthcare professionals
7. Mahaska Health Incident Command: This is used to refer to the authority that makes any decision, coming from the healthcare facility Command Center (HCC).
8. Horizontal Evacuation: evacuation beyond corridor fire doors and/or smoke zones into an adjacent secure area on the same floor.
9. House Supervisor: for the purposes of this policy, this refers to the person, who has the authority, at any given moment, to intervene to protect patient, staff, visitor and facility safety
10. Incident Site Evacuation: evacuation of persons from the room or area of the incident.
11. Local Authorities: for the purposes of this policy this includes, but is not limited to the chief elected official, local Emergency Management Director, Law Enforcement, Fire Department, Public Health, EMS and Human Services.
12. Partial Evacuation: an evacuation of certain groups of patients/ residents or of areas within the facility.
13. Patient Transport Area: In a complete evacuation, this is an area(s) to which patients are sent for transport out of the healthcare facility.
14. Remote Vehicle Staging Area: In a complete evacuation, this is a remote area(s) at which vehicles that will transport patients from the evacuated facility will wait until summoned by the Healthcare Facility Transportation Supervisor.
15. Response Agency Incident Commander: The person, usually first on-scene, such as the Fire Department, Law Enforcement, etc. that assumes command and is responsible for the management of the incident.2
16. Shelter-in-Place: a protective action strategy taken to maintain patient care within the facility and to limit the movement of patients, staff and visitors to protect people and property from a hazard
17. START: a rapid assessment of every patient, determining which of four categories (Red-Immediate, Yellow-Expedient, Green-Stable, Black-deceased) patients should be in and visibly identifying these categories for rescuers, who will treat the patients.
18. Triage Tag: this is “slip of paper” that is attached to a patient, usually by Emergency Medical Services (EMS) in the field, to provide key information about the patient. The “tag” includes and identification number and a color-coded system to document the acuity level of the patient.
19. Unified Command: a structure that brings together the "Incident Commanders" of all major organizations, involved in the incident, in order to coordinate an effective response while at the same time carrying out their own jurisdictional responsibilities.
20. Vertical Evacuation: evacuation from one floor(s) to the floor(s) below or above.
Part A: Decision to Shelter-in-Place versus Evacuation
1. The staff person, who identifies an internal hazard or who is notified of an external hazard, is responsible to notify the house supervisor immediately. If a disaster occurs in a patient care area, or threatens a patient care area, employees should remove patients who are in immediate danger. DO NOT WAIT FOR INSTRUCTIONS. Patients should be taken to the nearest safe area on the same floor if possible. If the patients are not in immediate danger and the alarm has been activated, WAIT for evacuation orders.
2. Shelter-in-place is the preferred option, unless the decision is made by the house supervisor to evacuate, considering the circumstances of the incident.
a.Mahaska Health Partnership is to initiate its Emergency Management Plan and operate under the Incident Command System. Refer to Emergency Preparedness Disaster Plan documents H,J, and K
b.The Mahaska Health Partnership Incident Command will assess the need for the diversion of incoming patients. Emergency Medical Services are to be notified by the Liaison Officer, if patients are to be diverted. The Liaison Officer is also to notify the county EOC, if activated. If the county EOC is not activated, serious consideration should be made to ask the county EOC to activate.
c.The appropriate referral facilities/agencies are to be notified that admissions are to be canceled as are scheduled procedures.
3. The decision to shelter-in-place or evacuate is to be made in consultation with the response agency Incident Commander and also Unified Command, if established, e.g. the local Emergency Management Director, Fire Department, Law Enforcement, Public Health, EMS, Human Services and others, as appropriate.
a. If there is no response agency Incident Commander, Mahaska Health Partnership Incident Command is to do all that is necessary to protect the life and safety of its patients, staff and visitors. Hospital Incident Command is to notify EMS, Fire, and Law Enforcement of its decision.
b.Prior to the actual need to shelter-in-place or evacuate, Mahaska Health Partnership is to consult with the local Emergency Management Director, Fire Department, Law Enforcement, Public Health, EMS, Human Services and others, as appropriate so that these agencies are aware of this plan and its procedures.
Note: Mahaska Health Partnership may decide to both evacuate parts of the facility and also shelter-in-place in another part of the facility.
Part B: Decision to Shelter-in-Place
1.The Hospital Incident Command is to make an assessment whether the healthcare facility faces an internal or external hazard or both.
2.If the decision is made to shelter-in-place due to an internal and/or external environmental hazard, the Hospital Incident Command will notify local authorities as appropriate, and will make an assessment for the need to initiate environmental engineering interventions. The primary decisions are:
a.The decisions on how to protect patients, staff and visitors by movement to a more secure area will be made by healthcare facility Incident Command in collaboration with the response agency Incident Commander or Unified Command, as appropriate.
b.The decisions on how to protect the building will be made by healthcare facility Incident Command, based on the known hazards and their effects on the building and its inhabitants in collaboration with the response agency Incident Commander or Unified Command, as appropriate.
3.The healthcare facility is to initiate a process to secure the building (lockdown).Refer to Emergency Preparedness document “T” Campus accessibility
4.Staff is to be advised to stay within the building and to advise all patients and visitors to stay within the building until further notice.
5.If shelter-in-place is expected to last for more than 24 hours, Mahaska Health Incident Command is to inform all departments that all resources are to be conserved. For example: (the following list is not meant to be inclusive)
a.Establish a patient management plan, including identifying the current census, the cancellation of elective admissions and procedures, etc.; establish a workforce plan, including a plan to address staff needs for the expected duration of the shelter-in-place (Planning).
b.Establish communications and a back-up communications plan with the local Emergency Management, Fire Department, Law Enforcement, Public Health, EMS, Human Services and others, as appropriate and the Emergency Operations Center (when activated). The healthcare facility Public Information Officer is to refer all communications through the Joint Information Center. (Liaison) Refer to Emergency Preparedness document “O”
c.Provide local Emergency Management with a “situation report”, including resources needed e.g. The amount of generator fuel available and the duration that this fuel is expected to last (Logistics).
6.Each department head/critical function1 is expected to provide to the Logistics Chief, within one hour of the activation of healthcare facility Incident Command, the resources that is has available, the expected duration of these resources and the contingency plan to conserve these resources, should replenishment of supplies be in jeopardy.
7. Mahaska Health Incident Command is to determine in collaboration with the response agency Incident Commander or Unified Command, as appropriate, when shelter-in-place can be terminated and to identify the issues that need to be addressed to return to normal business operations, including notification of local authorities about the termination of shelter-in-place.
Part C: Decision to Evacuate
1.In the event of a hazard, which requires a complete or partial evacuation of the facility, if it is necessary to protect the life and safety of patients, staff and visitors, the Mahaska Hospital Incident Command or Chief Executive Officer is to give the order to evacuate in collaboration with the response agency Incident Commander or Unified Command, as appropriate.
2.If the circumstances are such so that there is no immediate danger to the life and safety of patients, staff and visitors, Mahaska Health Incident Command is first to determine the availability of transportation resources and destination sites (internal and external) before giving the order to evacuate. Until the time that these resources are determined, the healthcare facility Incident Command shall give the order to shelter-in-place.
3.Once transportation resources and destination sites (internal and external) are identified Mahaska Health Incident Command shall give the order to activate the procedures to initiate an orderly and timely transfer of patients to the pre-designated destination site(s).
4.The following are the procedures to be followed to evacuate the building or a portion of the building, when it has been determined that the healthcare facility is unsafe or unable to deliver adequate patient care2.
5.When it is determined that evacuation is necessary, healthcare facility Incident Command will provide directives according to its communications policy, e.g.3 call the switchboard and instruct the operator to make an announcement over the PA system. The specific directive will depend upon the level of evacuation required (Incident Site, Horizontal, Vertical, or Complete). Healthcare facility Incident Command will determine to which area(s) (internal or external) the patients are to be moved.
a. If an Incident Site Evacuation is necessary, the directive will state “Incident Site Evacuation”: evacuate from (room number or name of area) to (room number or name of area). All available staff please report to (designated location)
b. If a Horizontal Evacuation is necessary, the directive will state “Horizontal Evacuation”: evacuate from (area) to (area). All available staff please report to (designated location)
c. If a Vertical Evacuation is necessary, the directive will state “Vertical Evacuation”: evacuate from (floor) to (floor). All available staff please report to (designated location)
d. If a Complete Evacuation is necessary, healthcare facility Incident Command will define the sequence of evacuation and when to begin the movement of patients to the Assembly Area(s) and/or to the Patient Transport Area(s).
5. The following procedures apply to Incident Site, Horizontal and Vertical Evacuation.
a. After the directive of the evacuation, all available staff is to report to a designated area. Staff will be assigned to departments needing additional help at the direction of the Operations Chief.
b. It is possible that once an evacuation is announced the potential exists for a significant number of people to volunteer their help during the emergency, including family members, visitors and nearby residents. The Planning Officer at the facility should help manage this influx and assign personnel to register and credential, as appropriate, these volunteers and assign them to a specific area.
c. All patients, not on their respective units, are to be returned to their respective units, if possible. If this is not possible, ancillary staff (e.g. Radiology Department, Physical Therapy, etc.) are to maintain the census of all patients and their room numbers and report this census to the Planning Chief. Ancillary staff and patients are to remain in place until further directives are received.
d. After the evacuation of the patients and others (family members, visitors) from the area to be evacuated, staff, in collaboration with the local Fire Department, is to apply a “visual cue4” to the door of the room to indicate that the room has been cleared. This can be in the form of a note or the room taped off.
e. Staff is to be prepared to evacuate from the area all patients, along with visitors and staff, according to the level of acuity of the patients.
1) Evacuation Level 45: self-sufficient patients, who are ambulatory, require minimal nursing care and are candidates for rapid discharge to home or to a temporary shelter(s).
2) Evacuation Level 3 (GREEN): Ambulatory patients, who require moderate nursing care and require assistance in evacuation
3) Evacuation Level 2 (YELLOW): Patients, who are non-ambulatory, require frequent supportive nursing care and observation (e.g. post-operative patients, step-down unit patients)
4) Evacuation Level 1 (RED): Patients, who are non-ambulatory, require continuous nursing care and observation (i.e. ICU, Telemetry, isolation rooms and other patients with special needs)
f. Place the patient's chart, medications, clothing and valuables, and patient's ID in a bag with the patient's name clearly marked in indelible ink on the bag to accompany the patient as they are evacuated. If a triage tag is provided to the patient, ensure that number is place on the bag as well.
g. The charge nurse or designee is to compile a list of all patients in the area(s) that are being evacuated.
h. If time permits and there is no threat to the safety of the staff, the staff are to return to obtain any devices necessary for daily living (glasses, dentures, prosthesis) and any other valuables and belongings. Staff may also want to collect their own personal belongings.
i. Mahaska Health Incident Command is to make the necessary arrangements to secure the evacuated area, primarily to keep people from re-entering the evacuated area.
j. Staff are to enforce “Keep to the Right” when moving down hallways.
k. Staff should remain with patients in the relocated area until the patient(s) has been reassigned/handed off.
l.Upon completion of evacuation of each area, staff is to report to healthcare facility Incident Command that the evacuation of the area has been completed. This includes providing the Incident Command with copies of information on all patients that have been evacuated including at a minimum the patient's name and where they have been evacuated to. The retrieved “ Evacuation Flow Tags” will be reconciled with then current admission records to establish confirmation of patient evacuation and their relocation venue. In addition, staffing schedules will be consulted to establish confirmation that hospital staff have relocated to a safe haven. Department Directors or Unit Managers will be responsible for establishing confirmation that any visitors to their work unit have been safely evacuated to designated areas.
m.In the event that an evacuation is necessary, the Admitting Department, with assistance from the Social Services and Discharge Planning, will notify patient families and/ or guardians to appraise them of the situation, status and location as soon as reasonably possible after the immediate safety of the patients,staff,and visitors has been secured.
6. The following procedures apply to Complete Evacuation
a. All the procedures identified in Section 5 are also to be followed for a Complete Evacuation.
b. The following additional procedures are also to be implemented:
1) Sequence of Evacuation: Mahaska Health Incident Command in collaboration with the response agency Incident Commander or Unified Command, as appropriate will determine which floors and/or smoke zones are evacuated first and in which order. Those floors that are most in danger or the floors of the incident are to be evacuated first. Then adjacent floors are to be evacuated. Otherwise, evacuation is to start at the top floor and work downwards. In all incidents, patients are to be evacuated according their Evacuation Category Level beginning with level 4 (PURPLE).
2) Mahaska Health Incident Command is to identify area(s) for both Assembly and Patient Transport.
c. Assembly Area(s): The following activities will take place in the Assembly Area(s):
Note: Patients are not to be moved to the Assembly Area(s) until there is confirmation that there are transportation resources and destination sites (internal and external).
1) Patients are to be assessed for rapid discharge, if appropriate.
2) Staff is to maintain care of the patient in the Assembly Area(s) and continue to assess acuity.
3) Staff are to make every effort to obtain the following “Patient Evacuation Information" (see Form A) , if the patient is to be transported to another destination site: (Data in BOLD is required information)
Name of Sending Facility
Evacuation Category Level Number
Date of Birth
Patient Medical Record Number
Receiving Facility (destination site, if known)
Time discharged from the Assembly Area(s)
Equipment sent with the patient6
Whether or not family has been notified about the transport of the patient to another destination
Name of primary attending physician
Medications (treatments) and Allergies Information
Type of isolation (if applicable)
Special Considerations and Precautions (e.g. police hold, mental health, suicide watch, etc.)
Other Information or Directives (code status such as “DNR”)
4) Mahaska Health Incident Command is responsible for accounting for all staff. Hospital Incident Command is also to maintain a log of staff, who accompanies patients to destination sites with consideration, to the extent possible, for their lodging, food, and other needs.
d. The Patient Staging Area(s) is the designated area(s) for patients, who are being discharged and also for those patients, who are being transported to external destination sites.
Note: Patients are not to be moved to the Patient Transport Area(s) until there is confirmation that there are transportation resources on-site. Until that time, the patients shall continue to stay in the Assembly Area(s).
1) A triage tag is to be applied by the Disposition Unit Leader to all patients, who are being transported to destination sites. The patient is also to be triaged according to the START7 and Jump START triage protocols (or other appropriate triage protocols), that is, a color code is to be assigned to the patient based on the patient's acuity. The triage tag number is the number that will be used to track the patient after leaving the evacuated healthcare facility to destination sites.
Note: The triage tag should be put on the patient's chart, if there is concern that the patient may lose the tag or tear it off.
2) A staff person is to be assigned to match the triage tag number to the list of patients, being transported, that was generated in Part C.5.f.
3) This same staff person must also match any patients, being discharged or being sent to a temporary shelter, to the same list that was generated in Part C.5.f.
4) Demographic information for all patients, both those, who were discharged and those who are being evacuated along with the triage tag number, are to be entered into the electronic, centralized database within one hour or, as soon as possible, of the patient leaving the healthcare facility according to the “Policy on Patient Tracking”.
5) The on-site healthcare facility Discharge Unit Leader shall assure that each patient, being transported to a destination site, has the following information logged:
The patient's triage tag number
The name of the staff person accompanying the patient
The transport company and vehicle number
The names of the patient(s), being transported in that transport vehicle (see Form B)
The destination site
6) Each patient, being transported by private vehicle, has the following information logged:
the license number of that vehicle
the name(s) of the patient(s), being transported in that vehicle (see Form C)
the destination site
e. Remote Vehicle Staging Area
1) To maintain open access to the healthcare facility Patient Transport Area(s)8, the healthcare facility Incident Command will activate the Remote Vehicle Staging Area. (This area(s) is to be pre-identified).
2) The Remote Vehicle Staging Area Supervisor is responsible for sending vehicles to the healthcare facility Patient Transport Area(s) as requested by the Healthcare Facility Transportation Supervisor.
Note: Mahaska Health Partnership is to make every effort to pre-identify and use only authorized vehicles for patient transport. However, it is recognized that circumstances may be such that authorized vehicles may not be available and the healthcare facility may need to resort to the use of private vehicles. The use of private vehicles poses risks to the healthcare facility and those being transported. The following protocols are examples of the best efforts that can be made to “authorize” drivers of private vehicles.
4)All vehicles need to be documented before being sent to the healthcare facility from the Remote Vehicle Staging Area. The Remote Vehicle Staging Supervisor will verify the following information for each vehicle before it is sent to the healthcare facility (see Form C):
License Tag Number of the Vehicle
Proof of Insurance
Driver's License Number
5)Form C is to be given to the driver of the vehicle by the Remote Vehicle Staging Area Supervisor to present to the healthcare facility Transportation Supervisor at the healthcare facility.
6)No patient is to be released to a vehicle without obtaining Form C from the driver. The Transport Supervisor is to verify all the information on Form C before assigning a patient for transport by the private vehicle.
f. Methods for Evacuating Patients
1) The Hospital is to use elevators, if permitted by the Fire Department.
2) Ambulatory patients are to be guided down the stairs, accompanied by a staff person with a ratio, based on the acuity of the patients. For example, ambulatory patients, needing assistance, may be assisted with belts or “fore and aft” carry, shoulder-to-shoulder human chain, mother carries baby, etc.
3) Evacuate ambulatory patients first. Gather these patients together and have them form a chain by holding hands. Do not leave ambulatory patients without staff guidance.
4) Children should be handled like other patients, except that in ambulatory evacuation alternate the older and younger children in the evacuation line, if time and circumstances permit.
5) Disoriented patients (e.g. psychiatric) should be handled like other patients. If time and circumstances permit, alternate the confused ambulatory patients between coherent patients.
6) Non-ambulatory patients may need special equipment such as stair chairs and stoker baskets are an option and require staff to be trained in their use.
7) All staff will complete annual training modules on Emergency Preparedness. Additional training on use of special equipment(i.e. Stair chairs) will be provided to essential designated staff during initial departmental orientation, during disaster exercises, and as necessary as part of a just-in-time training initiative associated with an emergency event.
g. Alternate Care Sites
1) The Mahaska Health Partnership is to identify two types of Alternate Care Sites:
The first type is to include facilities that are geographically close to the healthcare facility in those cases where the hazard has affected only the healthcare facility.
The second type is to include facilities that are geographically distant from the healthcare facility in those cases where the hazard has affected the entire area around the healthcare facility.
2) The healthcare facility on-site Transport Unit Leader is to triage the patients as they are being transported to the various Alternate Care Sites. Evacuation Acuity Level 3 and 4 patients are to have priority for transport.
3) The healthcare facility is to identify facilities9 in the sequential order that it will use these facilities to shelter evacuated patients, based on the acuity level of the patients that the facility can manage. The following is a list of facilities, to be used in sequential order, for exemplary purposes only:
Hospitals (for Evacuation Acuity Levels 1, 2, 3, 4)
Skilled nursing facilities (for Evacuation Acuity Levels 1, 2, 3)
Clinic buildings (for Evacuation Acuity Levels 1, 2)
Hotels (for Evacuation Acuity Levels 1, 2)
4) Mahaska Health Partnership is to pre-identify Alternate Care Sites and have Memoranda of Understanding with these facilities in case the healthcare facility needs to utilize these facilities in an evacuation.
a) Iowa Methodist Medical center will be utilized through Critical access agreements.
b) Pella Regional Hospital may be utilized as a geographically close alternate site.
c) Mahaska Health Partnership Public Health South may be used as an in town alternate site.
5) Supplies and equipment for the Alternate Care Sites
For each Alternate Care Site, Mahaska Health is to pre-identify what equipment and supplies are already available on-site and at what quantity.
For each Alternate Care Site, Mahaska Health is to pre-identify what equipment and supplies will need to be delivered to the site and at what quantity. The EOC, if activated may be able to assist with the procurement of these supplies and equipment.
6) Staffing for the Alternate Care Site
Mahaska Health Partnership is to assign one of its staff as Site Supervisor of the alternate Care Site.
The staffing plan for the Alternate Care Site will need to take into consideration the acuity of the patients at each site.
There is to be an agreement with the Alternate Care Site to pre-identify any of its staff, who can be retained for patient care or other services.
If possible, a Mahaska Health Partnership staff person is to accompany the patient to the Alternate Care Site and hand over the patient to the staff there with a briefing on the care and treatment of the patient.
It is important to keep in mind that staff from the evacuated healthcare facility will be tired and stressed and may not be able to provide care at the Alternate Care Site, until they get the necessary rest and recuperation.
7) The Site Supervisor at each Alternate Care Site is responsible for triaging patients, based on changes in patient acuity, and moving them to a more appropriate facility.
1) The city/county Emergency Management Director is to be notified that the Mahaska Hospital has been evacuated.
2.) The regulatory agency for Mahaska Health Partnership is to be notified that the healthcare facility has been evacuated (Joint Commission, DIA, etc.)
Part D: All Clear
1. In the case of a partial evacuation and shelter-in-place, healthcare facility Incident Command will provide directives according to its communications policy, e.g. notify the switchboard to announce all clear and return to normal operations can commence.
2. In the event of a complete evacuation, the Mahaska Health Partnership Public Information Officer will contact the EOC and request that the local media make an announcement notifying Mahaska Health employees when they should return to work.
2. All hospital regulatory agencies must be notified that an evacuated healthcare facility is being reopened.
Part E: Recovery
1. The healthcare facility is to have a policy on business continuity so as to provide direction for the return to normal operations. Refer to Emergency Preparedness document “H”.
3. Mahaska Health Partnership is to have a plan for Critical Stress Debriefing to assist staff in their recovery.
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