EMERGENCY OPERATIONS PLAN Procedure No. EP-08-009

Hospital Emergency Operations Plan

Objectives and Background
University of Toledo Medical Center has developed and implemented an emergency management program designed to:
1. Prevent or lessen the impact that a disaster may have on the institution and the community (mitigation);
2. Identify resources essential to disaster response and recovery and facilitate their access and utilization (preparedness);
3. Prepare staff to respond effectively to disasters or emergency situations that affect the environment of care (response) and test response mechanisms; and
4. Plan processes for reestablishing operations after the incident (recovery).
Scope
This plan is designed to outline the basic infrastructure and operating procedures utilized to mitigate, prepare for, respond to, and recover from emergency situations that tax the routine operating capabilities of the University of Toledo Medical Center (UTMC).
For planning purposes, portions of the current hazard vulnerability analysis are included as an appendix.
This plan covers all UTMC facilities and areas and its comprehensive implementation is the responsibility of all hospital personnel.
Framework and Planning
UTMC recognizes that success of emergency response activities is due to an integrated effort by all functional areas of the Hospital and certain external agencies. In order to ensure coordination of Hospital and community resources allocated to the disaster response effort, the Hospital utilizes the Hospital Incident Command System (HICS) and establishes a command center, if warranted by the specific situation. The HICS model is compatible with the National Incident Management Systems (NIMS) and all training in the ICS system was based on the NIMS model and different members of the team have been trained to various predetermined levels by the Emergency Preparedness Task Force.
? ICS700 – General Staff (Not expected to assume roles in ICS)
? ICS 100HC, 200HC & ICS700 – Managerial Staff (Expected to assume roles in ICS)
? ICS 100HC, 200HC, 300, 400, 700, 800 – Emergency Management Staff (Run ICS events)
The primary purpose of the incident command system is to provide administrative coordination and support for all UTMC resources allocated to the response effort and to establish effective communication and coordination with external agencies that may assist in the response effort. All local acute care hospitals have adopted the HICS model.
HVA (Hazard Vulnerability Analysis)
HICS facilitates a flexible, ?all hazards? approach to emergency management that can be adapted to respond to a variety of emergencies. The Emergency Preparedness Task Force recognizes that certain emergency situations are more likely to occur or to have an adverse impact on UTMC or the community. Therefore, as a part of its mitigation and preparedness activities, University of Toledo Medical Center conducts an annual hazard vulnerability analysis, designed to:
? Identify emergency situations that could occur in this environment
? Assess their potential impact on the institution and the community
? Assess the hospital’s preparedness to respond to and recover from them.
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The hazard vulnerability analysis is used to assess the hospital’s current emergency management activities and to identify necessary changes, additional planning activities, and specific exercise scenarios. Because UTMC is a Level 1 trauma center; a tertiary and quaternary care center; and a primary receiving hospital for acute and critical disaster victims, program and contingency plan priorities have been developed in consultation with:
University of Toledo Main Campus
Hospital Council of Northwest Ohio (HCNO)
Lucas County Emergency Management Agency (LCEMA)
Metropolitan Medical Response System (MMRS)
Regional Medical Response System (RMRS)
Ohio Department of Health (ODH)
Ohio Hospital Association (OHA)
Toledo Lucas County Health Department
Other healthcare providers surrounding UTMC (pharmacists, hospice, etc.)
UTMC works very closely with the Hospital Council of Northwest Ohio to identify and plan for the care of those with disabilities during disaster. UTMC is one of 22 hospitals within the northwest Ohio region that network quarterly to address emergency preparedness efforts. In addition, UTMC participates in community-wide drills exercising the Mass Care Sheltering Model (see HCNO website, http://www.hcno.org/disaster-trauma/regionalresources.html).
Emergency Plans
The Emergency Preparedness Task Force of the UTMC Safety Committee reviews UTMC’s hazard vulnerability analysis. Emergency plans contained within the Annex, developed as the result of a hazard vulnerability analysis, are designed to guide personnel in the initial stages of specific emergency situations that may seriously overtax or threaten to overtax the routine capabilities of the Hospital. If an emergency situation warrants, the Hospital Emergency Incident Command System (HICS) will be activated and a command center will be established to coordinate and sustain response efforts.
The basic framework and specific emergency plans have been coordinated with other local hospitals to become a part of the City of Toledo Metropolitan Medical Response System (MMRS), Regional Medical Response System (RMRS) plan, domestic preparedness (WMD) plan, and the county’s general emergency operations plan (EOP).
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The UTMC currently has emergency plans in place to guide initial response to a variety of emergency events and these items are found in a variety of departments with responsibility for these plans (Environmental Health & Radiation Safety, Facilities Maintenance and Infection Control Departments, etc.). Each plan contained in the Annex will describe the process for initiating and terminating each incident. The authority to initiate activation of response and recovery efforts is the responsibility of the appointed Incident Commander as described within each emergency plan.
Code Yellow: Mass Casualty Incidents (Medical and Trauma) ANNEX “A”
Code Black: Bomb Threats ANNEX “B”
Code Orange: Hazard Materials Incidents (chemical, biological and radiation emergencies) ANNEX “C”
Code Gray: Severe Weather/Tornado ANNEX “D”
Code Adam: Missing Child and Infant Abduction ANNEX “E”
Code Red: Fire ANNEX “F”
Code Green: Evacuation and Shelter-in-Place ANNEX “G”
Code Blue: Medical Emergency Response Team ANNEX “H”
Code White: Emergency Staffing Due to Severe Weather/Snow Storm ANNEX “I”
Code Brown: Missing Adult Patient ANNEX “J”
Institutional Lockdown Procedures ANNEX “K”
Infectious Disease Agents (Pandemic/Epidemic) ANNEX “L”
Code Copper: Communication Involving Utility Emergencies: Including Loss of Electrical, Communications, Steam, Water, Sewer, Vacuum, Medical Gases, Broad IT Interruptions ANNEX “M”
Code Violet: Violent Situations ANNEX “N”
Patient Surge and Alternate Care Sites (Under Community Response)
Mass Fatality Plan ANNEX “O”
Emergency Credentialing (Medical Staff Bylaws)
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Through the 2014 hazard vulnerability analysis, the Emergency Preparedness Task Force identified the following as posing the greatest risk:
? Mass Casualty Incident (Medical or Trauma)
? Tornado
? Radiological Exposure, External
? Radiological Exposure, Internal
? Supply Shortage
? Chemical Exposure, External
In addition, UTMC has worked with regional emergency preparedness groups, Hospital Council of Northwest Ohio (HNWO), the Ohio Hospital Association (OHA), the Lucas County Emergency Planning Committee (LEPC), the MMRS, the RMRS, and area/regional hospitals to establish state-wide mutual aid compacts and individual mutual aid agreements. The corresponding mutual aid plans are activated if UTMC or another area facility must be evacuated due to an emergency situation that affects the environment of care or needs additional resources in order to remain operational during emergency response.
Emergency Operating Procedures
In emergency situations, certain standing policies and procedures of the Hospital and rules and regulations of the Medical Staff may be waived by the Incident Commander, the Medical Care Director, or other first-tier incident command center staff to ensure that essential patient care can be rendered and that the facility can be secured.
For example, under normal circumstances, the individual patient receives the highest quality medical care that the Hospital is capable of providing. In an emergency situation that involves a mass influx of acute and critically injured patients, the philosophy may change to provide the best available medical care for the greatest number of patients.
CRITICAL STAFF CONSIDERATIONS
Roles of Key Personnel Assigned Under HICS
The Hospital utilizes the Hospital Incident Command System (HICS) to coordinate essential services and assign basic responsibilities during disaster response. This system is flexible and allows the Hospital to activate and organize a command structure based on the response needs of the actual event. In most cases, Hospital Administrators and other key staff will assume disaster response responsibilities consistent with their primary responsibilities.
The basic HICS structure, utilized at UTMC is as follows:
? Incident Commander—The House Supervisor, or the Administrator-on-call assumes the role of incident commander initially. After consultation with other Command Center staff, the House Supervisor or Administrator-on-call may relinquish responsibility to another more qualified Incident Commander based on the nature of the emergency. The incident commander organizes and directs the Command Center and provides overall direction for hospital operations. To ensure appropriate coordination and documentation of disaster response activities, the incident commander may assign the following functions to members of the Administrative or Support staffs.
? Safety & Security Officer – Identifies and takes steps to mitigate factors that may affect the safety of responders. Organizes and enforces scene/facility security by restricting building and grounds access and directing traffic.
? Liaison Officer – Establishes contact and works with external agencies responding to the disaster.
? Public Information Officer – Establishes a public information center away from the Command Center and provides official information to the media. The Public Information Officer will coordinate release of patient information with the Command Center.
? Medical Specialist – Various individuals with technical expertise related to emergency event serving in a consultative role to Command Staff.
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? Executive Leadership – Various executive staff including President, VPs, Provosts, Deans, Chairman whose departments may be directly impacted by the emergency event.
? Operations Chief – Organizes and directs activities to ensure that the goals and assignments of the Command Center are carried out and that all necessary patient care and support functions are appropriately staffed.
? Logistics Chief – Organizes and directs maintenance and supply operations to ensure that patient care and support services have the supplies, equipment, and utilities necessary to perform essential functions.
? Finance Chief – Tracks expenditures for cost recovery and to ensure that funds can be allocated for special purchases essential to disaster response.
? Planning Chief – Develops and presents an action plan for sustaining operations given the disaster scenario at 4, 8, 24, 48, to 96 hours from the time of the incident, and beyond. Various Environmental Health and Radiation Safety staff have been trained to assume this role.
A pictorial representation of the HICS model is located on the following page.
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Staff Roles
During a disaster situation, all Hospital personnel and designated Medical Center personnel are considered essential to the operation of the Hospital. The HICS model allows for easy expansion of the basic incident command structure to include additional personnel assignments designed to accommodate the needs of specific disaster situations. Designated staff will be assigned to fill HICS positions and have been trained to assume these roles.
The contingency plans establish and outline the role of some employees during specific emergency situations. In some emergencies, the Hospital may establish a personnel pool to supplement or staff essential response or operating functions. In those situations, employees may be assigned responsibilities commiserate with their abilities but outside their normal job responsibilities. (See Annex ?A? Code Yellow for additional staffing information.)
Identification of Hospital Personnel
All Hospital employees are required to wear their Medical Center identification badges at all times. If the Institutional Lockdown Procedure is implemented employees who report to the Hospital for disaster response and are not wearing their ID badges may be issued a temporary badge by UTPD, once their identities and role in the response effort has been verified.
Employees who are assigned key roles in the HICS structure are issued identification vests, designed to clearly identify their role in the response effort.
Disaster Privileges
Disaster privileges may be granted for volunteer Licensed Practitioners who are not members of this Medical Staff when the Medical Center’s Emergency Operations Plan has been activated. The EVP, VPMA or highest ranking member of the administrative management available, or the Chief of Staff or highest ranking member of the Medical Staff available, may grant disaster privileges under the general process outlined. Granting of disaster privileges under these circumstances is discretionary with above stated authorized individuals based upon available information regarding the extent of the disaster, staffing capabilities, number and type of injuries anticipated, etc. Specialty Specific Privileges may be granted to the volunteer Licensed Practitioner only after the Medical Center receives a valid government issued photo identification issued by a state or federal agency and a second verifying source of at least one of the following:
? A current Medical Center photo ID card that clearly identifies professional designation;
? A current medical license to practice, and a valid photo ID issued by a state, federal or regulatory agency;
? ID that certifies the individual is a member of a disaster medical assistance team (DMAT), or Medical Reserve Corp. (MRC) or Emergency System for Advance Registration of Volunteer Health professionals (ESAAR-VHR) or other recognized state or federal organizations or groups;
? ID that certifies a state, federal or municipal entity has granted the individual the authority to administer patient care under emergency circumstances;
? Presentation by a current Medical Center or Medical Staff member who can vouch for the practitioner’s identity and who possesses personal knowledge regarding the volunteer’s ability to act as a Licensed Practitioner during a disaster; or
? Primary source verification of the license obtained by the Medical Center.
Staff and Family Support
Because all Hospital personnel and certain Medical Center personnel are considered essential during emergency response situation, the Hospital recognizes its responsibility to provide meals, rest periods, psychological, and other personnel support. In addition, the Hospital recognizes that providing support, such as communication services and dependent care, to employees’ families during emergency situations allows employees to respond in support of the essential functions of the Hospital.
The Logistics Section Chief, working through the Support Branch Director and his/her unit leaders will initiate support programs and activities, based on the demands of the specific emergency.
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Contingency plans for specific needs that can be anticipated have been established and tested during drills or actual plan implementations. These include, but are not limited to:
? Emergency child care
? Emergency transportation
? Staff/family lodging and meals
? Psychological and bereavement counseling (provided jointly through Department of Psychiatry and Pastoral Care)
? Staff/family prophylaxis or immunization
? Initiating Emergency Response and Notifying Staff
? Fatality Management
? Volunteer Management Plan
? Pet Management Plan
If a community disaster occurs in which disaster victims will be brought to the UTMC for treatment (See EOP flow chart on next page):
1. The external agency of jurisdiction (i.e., local EMS communication system, TFD and/or law enforcement) will notify UTMC’s Emergency Department (ED) using the local EMS communication system.
2. The ED Charge Nurse who receives the call will connect the caller with the ED attending physician or ED Director.
3. The ED attending physician or charge nurse will take the call and verify information received by talking with EMS, or Toledo Police.
4. When the ED attending has verified the information, he/she will notify the Hospital Operator and UTPD at x2600 to initiate the Emergency Operations Plan and the HICS protocols.
5. An emergency page will go out to the House Supervisor or the Hospital Administrator-on-call, Senior University Police Officer, Medical Director of the ED, ED Director, Environmental Health & Radiation Safety and the Trauma attending, if necessary.
6. The Incident Command Center will be open and collectively these individuals will assign an Incident Commander and initiate the EOP and staff notification and instructions (via OH Trac, UT Alert, overhead page or call lists), as appropriate for particular situation. Essential off-duty staff will be notified by activating departmental call lists. The Liaison Officer will notify off-site business occupancies and clinics.
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Potential Emergency or Disaster Event (mass casualty, fire, severe weather, bomb threat, power loss) at UTMC.Contact/Page Key Incident Command Staff to Command Center DH2107 or ML045 this includes Safety & Health Rep., UTPD, Facilities, ED Manager, Admin. Coord. (Hosp. Admin Rep)Appoint Incident CommanderDetermine Size of Event and appropriate responseMinor events will be monitored by Safety and Health, UTPD and ED until concludedIncident Commander will activate HICS protocols as directed in the Emergency Operations Plan and start to assign positionsWith Confirmed Victims/Patients(This includes patient care and Safety issues)Close Command CenterPROCESS ENDEDFLOWCHART PROCESS FOR DISASTER RESPONSE AT UNIVERSITY OF TOLEDO MEDICAL CENTERMC = Main CampusHSC = HealthScience CampusVP for HR/Campus Safety is notified, along with CommunicationsCode Yellow Mass CasualtyInfect. Disease Agent Plan (Pandemic Flu)Code OrangeCode GreenCode VioletPost-event critique/ hotwash is completed by Safety and Health staffPost-event critique document is reviewed by Emergency Prepardness Task Force of the Safety & Health CommitteeWith Potential Victims/Patients or No Victims/Patients7/11PROCESS ENDEDPROCESS ENDEDIncident Commander continue to assign HICS positions as needed based on size of Event Major EventMinor EventVictims or potential victims?YESNODecide on Appropriate Annex to ActivateCode CopperCode BlackCode GrayCode WhiteCode RedDecide on Appropriate Annex to ActivatePreparednessEvaluationRecoveryResponse MitigationClose Command Center if OpenedClose Command CenterPost-event critique/ hotwash is completed by Safety and Health staff
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CRITICAL COMMUNICATION ISSUES
Alternate Scenarios Activating the EOP
If an emergency situation affects the operation of the facility, the employee who discovers the situation will report it to his/her supervisor immediately. The supervisor will notify the House Supervisor, Hospital Administrator-on-call, Environmental Health & Radiation Safety or Facilities Maintenance. If appropriate after consultation with key personnel, the House Supervisor or Administrator-on-call will initiate the plan and notify the paging operator to issue the appropriate overhead code or group page and instructions. Essential off-duty staff will be notified by activating departmental call lists.
Patient Safety Event activating the EOP
As an event (bad, critical, otherwise) unfolds it is crucial to recognize the trigger point. In this case, a significant patient safety event occurring at the UTMC. An event could be identified, as such, based upon the following characteristics:
? Reportable in nature to a regulatory or certifying authority
? Newsworthy
? Meets the definition of ?sentinel event?.
Once the trigger is identified, Incident Command (ICS) should be initiated through one or more of the following series of events, with the order dependant on the situation:
? Alerting the administrative supervisor and/or administrator on-call
? Contacting UTPD (X2600), or hospital operators
o The Environmental Health & Radiation Safety department (EHRS) (419-530-3600). EHRS will assist with setting up the command center, the incident command structure, including identifying which roles should be filled, in addition to the ?Incident Commander?. Additional roles may include public information officer (PIO) – responsible for briefing senior leadership/UTMC staff and media releases, Liaison – responsible for communicating with other agencies (UNOS, CMS, ODH, JC, etc), and Operations, Planning, Logistics, and Finance Section chiefs.
Communication with the Public
All communication with the media is vetted through the PIO/Office of Communications. See Annex A ?Code Yellow?, section eight, Office of Communication.
Communication with Other Health Care Organizations
UTMC communicates with other healthcare organizations via various computer systems. Surgenet is used to communicate numbers of patients, surge capacities, resources and mass casualty numbers. OHTrac is used to track patients, and also allows for command structures at different hospitals and community entities to communicate via an electronic internet portal.
If electronic means fail, we also have the MARCS radio, satellite phone, and land lines (conference calls).
Communication with Patients’ Families
Refer to flow of patient information.
Notifying External Agencies
Whenever a situation adversely affects the Hospital’s ability to provide services to the community, the Hospital notifies appropriate authorities and city-county agencies and coordinates mutual aid and other response activities through the county Emergency Operations Center (EOC), if appropriate, or directly with receiving hospitals.
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The House Supervisor or Administrator-on-call (or other individual) functioning as the incident commander, will work with UTPD or Hospital Operators to make initial notification to external authorities, if necessary. Once the incident command system has been initiated, the Liaison Officer will establish and maintain necessary communication with external agencies and authorities. The Communication Manual is located in the Command Center (MLB Board Room).
OHTrac will also be used to communicate third party information on patients to FBI, police, health department, etc. All patient information will be communicated via the Liaison Officer.
Hospital Communication During Emergency Response
The Hospital will use established communication channels (i.e., telephone, overhead announcements, digital pagers, 2-way radios, OHTrac, UT Alert, ARES) whenever possible, to communicate vital information during a disaster. If established communication channels are unavailable, the Command Center will establish a 2-way radio relay or runner/courier system to communicate vital information throughout the Hospital. Through the MMRS, local Amateur radio operators have been assigned to each acute care hospital to provide an alternative communication system between and among the hospitals, the scene commander, the community emergency operations center (EOC) and other external agencies. In most cases, the radio operator assigned to UTMC will operate out of the command center, or near UTPD as necessitated by the emergency event.
The Hospital has an established Emergency Communication Procedure that outlines problem identification and reporting, user notification, and interim procedures for primary communication systems. (See Annex ?A? Code Yellow for additional communication information and Emergency Communications Procedure, EP-08-011.)
CRITICAL UTILITY (INFRASTRUCTURE)
Alternative Sources of Utilities
The Hospital has established alternative sources of essential utilities to meet the needs of patient care and essential support functions during an internal disaster.
? Generators will supply emergency power to patient care and other critical areas during a power outage. (See Contingency Plan for Power Outage, this document, and Utilities Management Plan.)
? Vendors will supply water to the Hospital during emergency situations. (See Facilities Emergency Preparedness Plan Annexes.)
? Medical gas will be supplied by cylinders.
For more detailed information, see Utilities Management Plan and 96-hour chart (Appendix 8 attached).
CRITICAL RESOURCES
Non-Medical Emergency Supplies and Equipment
Each patient care unit and some ancillary, support, and administrative areas maintain an emergency supply box that contains extension cords, flashlights, batteries, and other supplies essential during a facility emergency.
Emergency supply carts have been created and are maintained for initial response to specific disaster situations, such as mass casualty events, hazardous materials incidents, and power outages. (See Central Service role in mass casualty events.)
Procurement and delivery procedures for supplies and equipment known to be required during specific emergency situations have been incorporated into the specific emergency plan.
If additional or unanticipated emergency supplies are needed, the Unit Coordinator or designee will call the Command Center or send the request by runner to MLB Board Room or Mulford Library (backup command center in Alumni Lounge in basement). The Logistics Chief, working with the Materials Supply and Nutrition Supply Unit
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Leaders and the Finance Chief, will work to procure additional supplies, as needed. (See Resource Manual in Command Center.) The Liaison Officer can contact Lucas County EOC to request additional supplies.
Pharmaceutical and Other Medical Supplies
The support branch director, through the Supply Unit Leader, will procure various supplies that will be required throughout the response and recovery phases of an emergency using the following resources:
– Pharmaceutical supplies: Director of Pharmacy Services
– Medical supplies: Central Distribution and Materials Management
The Northwest Ohio region will share medical equipment and resources through coordination by the Hospital Council of Northwest Ohio utilizing Surgenet and the disaster list server.
All supplies will be monitored using NIMS/HICS forms.
Extended Events
The UTMC has established agreements with its vendors to supplement routine supply/equipment needs during an acute or prolonged disaster situation. Working with the Hospital Council of Northwest Ohio, MMRS and RMRS, the UTMC has established a pharmaceutical cache of specific medications that are required to prophylax or treat patients and staff in response to certain emergencies identified by the hazard vulnerability analysis. Through the RMRS and activation of statewide emergency protocols access to the National Pharmaceutical Stockpile can be initiated as warranted by the emergency event. Authority to request federal assets is held by UTMC pharmacy and Environmental Health and Radiation Safety.(EHRS) One pharmacist and two individuals from EHRS will be formally trained in the SNS protocols on an annual basis and documented through the Safety Test Bank. The individual responsible for SNS request will hold a position in the Logistics Section under the Support Branch Director and Supply Unit Leader. See also?Hospital Request Form for Strategic National Stockpile?. See also ?request for SNS?. Mutual aid agreements allow for the UTMC to request assistance from neighboring hospitals and businesses to sustain the institution for the required 96-hour period.
Based on the 96-hour extended event chart (Appendix 8) the UTMC has developed the following scenarios to deal with the inevitable unavailability of supplies in connection with emergency events. *Note: these plans are adjusted based on the emergency event and have been vastly simplified for this document. These actions will be directed by the Annexes to this plan.
? Plan ?A? – During Plan ?A? as the emergency event unfolds and the Support Branch Director under the direction of the Logistics Chief will monitor and track current supply levels and will order those items identified as ?in short supply? and contact the purchasing department for assistance. Patients will be treated as normal.
? Plan ?B? – During Plan ?B? if UTMC is unable to treat patients due to a major, unrecoverable utility failure, or other serious infrastructure problem, some or all patients will be evacuated from the UTMC to other surrounding facilities as directed by the incident commander.
? Plan ?C? – During Plan ?C? if UTMC is unable to provide normal patient treatment, either due to material shortages or infrastructure failures, and also patients are unable to be evacuated from the facility due to emergency conditions in the surrounding regions, the UTMC will provide care to the greatest extent possible through the use of the incident management system and reliance on the UT Main Campus resources.
CRITICAL CLINICAL ACTIVITIES
Decontamination
The Hospital has the capability for small to medium size incident decontamination, using either a portable or permanent decontamination unit. All Emergency Decon Team members are trained to provide decontamination through required HAZWOPER operations level class and annual continuing education. In addition, the Hospital has
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identified and trained additional staff to support its decontamination capabilities in the Emergency Department until the team arrives and sets up. (See Annex ?C? Code Orange.)
Inpatient and ED Patient Management
Different emergency situations or types of disasters require different patient management strategies.
Special Needs Populations within the Medical Center
Individuals with special needs such as: hearing or sight impaired, requiring oxygen, pediatric, elderly, Non-English speaking individuals, long term dialysis patients, etc. have been considered during planning and exercises to meet the needs of all our patients. Patients having specific physical disabilities, such as amputations, coma-patients, patients with neurological conditions, orthopedic limitations, and/or spinal cord injuries that are many times located in the Rehabilitation Facility shall receive special preference when conditions necessitate evacuation within the facilities or to offsite locations. Special assistance will be provided to the Rehabilitation Facility’s patients due to its location on the sixth floor of the facility and additional personnel will be appropriated to assist the facility and its staff.
Patients who have psychiatric needs, and those requiring hemodialysis, a special diet, or oxygen are documented and will receive special considerations in the event of an emergency. Ambu bags are available for use in patients requiring oxygen and will be used in the event evacuation or a back-up oxygen supply is necessary. A listing of these and other supplies can be found in the disaster resource lists locat