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Braun, Griffin, Henes, Howell, & Mansur |Effective January 2016
Table of ContentsIntroduction.................................................................................................................2
Cover Page..................................................................................................................3
Emergency Department Staff Compliance Sign Off....................................................4
Crisis Management Team Meetings & Revision Dates................................................5
First Action Page.........................................................................................................6
Types and Levels of Crisis........................................................................................6
Crisis Management Team Contact..............................................................................8
Crisis Management Team.........................................................................................8
Duties Of Each Crisis Management Team Member.................................................9
Internal Experts.....................................................................................................13
Crisis Risk Assessment..............................................................................................14
Incident Reports........................................................................................................16
Proprietary Information............................................................................................18
Crisis Communication Strategy.................................................................................19
Communication Strategy Worksheet......................................................................20
Secondary Contact Information................................................................................21
External Experts....................................................................................................21
Stakeholder Contact Strategy...................................................................................21
Contacting Stakeholder Groups.............................................................................21
Media Contact Information....................................................................................23
Media Inquiry Sheet...............................................................................................23
Fact Sheet..............................................................................................................25
Business Continuity Plan...........................................................................................28
Crisis Control Center Locations................................................................................30
Crisis Control Center.............................................................................................30
Materials for Crisis Control Center........................................................................31
Media Control Center.............................................................................................31
Post Crisis Evaluation Forms....................................................................................31
Appendix I Individual Crises Procedures..................................................................33
Tornado- “Code Wind”...........................................................................................33
Fire Emergency- “Code Red”.................................................................................36
Earthquake Emergency Plan- “Code Earthquake”.................................................43
Snow Emergency Plan- “Code Snow”.....................................................................44
Bed Bugs- “Code Grey”..........................................................................................51
Combative Patient- “Code Yellow”.........................................................................52
Emergency Facility Evacuation- “Code Plum”.......................................................53
Internal Disaster Plan- “Dr. Whitestone”...............................................................57
External Disaster- “Dr. Redstone”..........................................................................59
Infectious Disease Outbreak- “Dr. Charles”...........................................................69
Bomb Threat- “Operation Zero Zero Five”.............................................................70
Child Abduction- “Code Alert”...............................................................................75
Telephone Failure Plan- “Code Citrix”...................................................................78
Active Shooter- “Code Silver”................................................................................80
Hostage/ Volatile Situation With a Weapon- “Code Ten”.......................................84
Weapons of Mass Destruction- “Code Pink”...........................................................86
PAGE 1
IntroductionThe Emergency Preparedness Plan is a plan to address guidelines, best
practices, and regulatory requirements. The ultimate goal is to support the Comprehensive Emergency Management Program (CEMP) in meeting these action items. The Security Manager will complete these tasks through the Emergency Preparedness Committee who will guide the direction and focus of the Hospital's CEMP. By completing these tasks, the hospital's ability to respond to and identify supply, resource, or response plan needs can be accomplished.
PAGE 2
Cover Page This is the Floyd Memorial Emergency Department Crisis Management Plan,
effective November 1st 2015. This document is confidential and only to be used by employees of Floyd
Memorial Hospital and Health Services. This crisis management plan is not be copied or shown to anyone outside of the organization.
Four copies of this plan can be found on site. 1) The first is in the security office across from the triage window.2) The second is at the Emergency Department Registration desk. 3) The third is in the Emergency Department charge nurse’s office. 4) The fourth can be found in the administration office.
All staff of the Emergency Department are required to look at this crisis management plan and take a short quiz to demonstrate their knowledge annually.
o All other employees of Floyd Memorial Hospital and Health Services will be given information about this crisis management plan and any revision made to it annually via Healthstream.
Emergency Department staff will be asked to sign the following paper staying that they have read this crisis management plan and his or her supervisor will also sign the form stating that the employee did pass the aforementioned quiz to demonstrate his or her knowledge.
This crisis management plan was last revised on __________. At that time the crisis management team met and discussed any updates or changes that needed to be made to the plan and executed those changes appropriately.
Signed by Angela Mead, Head of Risk Management
_______________________________________________________ Date __________________
PAGE 3
Emergency Department Staff Compliance Sign Off
Supervisors, please keep a copy on file for each employee. This copy will be saved until the next year’s compliance sign off has been completed.
Staff member, by signing this compliance agreement you are stating that you have read and understand the information found in this crisis management plan, and that you have completed and passed the assigned quiz with your supervisor. You understand that refusing to comply with the procedures outlined here could result in disciplinary action or termination.
Staff Member Signature _________________________________________ Date ___________
Supervisor Signature ____________________________________________ Date __________
PAGE 4
Crisis Management Team Meetings & Revision DatesThe crisis management team is to meet every four months. At that time
revisions will be made and any changes documented on the following pages. It is necessary to keep track of changes made and the date that those changes become effective. Rehearsal dates are to be decided at the quarterly crisis management team meeting and crises should be rehearsed no less than twice a year, in accordance with the Hospital Incident Command System. The Crisis Management Lead is accountable for making sure that the crises are rehearsed and evaluated in a timely manner. Meetings for the next one-year period will be set at the December meeting before the year begins.
If there were to be a crisis, the Crisis Management Team will meet within ten days after the crisis for an evaluation meeting. The purpose of this meeting is to evaluate and correct flaws in the Crisis Management Plan.
Crisis Management
Team Meeting and Revision
Date
Crisis Communications
Manager SignatureChanges Made
1/7/2016
5/5/2016
9/1/2016
12/1/2016
1/5/2017
5/4/2017
9/7/2017
12/7/2017
Crisis Type First Rehearsal
Crisis Communications Manager Initials
Auditor Initials
Second Rehearsal
Crisis Communications Manager Initials
Auditor Initials
PAGE 5
First Action Page
TYPES AND LEVELS OF CRISIS Level 3 - Major Crisis. A major crisis, within the scope of this plan, is an incident posing major risk to hospital personnel, visitors, or resources that has caused or has the potential for causing fatalities or injuries and/or major damage. Such an incident is equivalent to a hospital-wide ‘state of emergency,’ and is expected to require activation of the Floyd Memorial CMP and CMT in order to provide an immediate emergency response. Floyd Memorial may request assistance from the City of New Albany, other State agencies or request federal. A Level 3 crisis may develop from incidents beginning at the Level 1 or 2 stages. Examples of major crises may include one or a combination of the following perils: active shooter, infectious disease, fire, explosion, severe weather conditions, earthquake, building collapse, flood, wind, chemical release, radioactive contamination, major civil disturbance, bomb threat, aircraft emergency, barricade or hostage situation, or other acts of terrorism.
Level 2 - Issue-Driven Crisis. Includes issue driven and/or slowly developing situations that negatively impact Floyd Memorial and/or its patients and faculty. The incident may be severe and cause damage and/or interruption to normal operations. A partial or full activation of the CMP is needed. Floyd Memorial may be the only affected entity. Examples of issue driven crises may include, but are not limited to the following: unscheduled or planned protests or disruptions; civil disturbances; unauthorized occupancy of hospital areas; sexual assaults; and hate crimes.
Level 1 - Limited Crisis. A limited crisis, within the scope of this plan, is any incident, potential or actual, which will not seriously affect the overall functional capacity of the hospital, but nevertheless requires some degree of action. In some cases, a limited crisis may be small enough that the affected department can effectively resolve the issue. In other cases, assistance from hospital security and/or off-campus emergency response groups may be required according to the standard operating procedures of Floyd Memorial. While some damage and/or interruption may occur, the conditions are localized and full CMP activation is not needed. Examples of Limited Crises in the context of this plan may include, but are not limited to the following: localized chemical spill, plumbing failure or water leak.
In case of crisis situation any Emergency Department staff can refer to this flowchart and seek assistance from their supervisor if needed.
PAGE 6
1. Moving from top to bottom, following the arrows please answer the questions in the boxes.
2. Once you have honestly and thoughtfully answered the questions in each box evaluate which level your current crisis falls into. Please note that a “yes” to one question denotes that level of crisis. Once you have answered yes please go no further.
3. Based on what level the crisis is, act accordingly based on the processes outlined in the CMP.
PAGE 7
PAGE 8
Level 3 CrisesIs there a crippling threat to
hospital buisness?Is the media giving this incident
major attention?Is there considerable pain and
suffering because of this incident?
If yes to one or more level 3 questions:Activate full CMP
Activate CMT-Ensure key personnel are
contactedIf no, follow arrow
Level 2: Issue Driven CrisesIs this problem beyond the
capabilities of normal operating teams?
Will this attract media attention?Will this cause damage for and
exteneded period of time?Does this incident affect multiple
departments or people?
If yes to one or more level 2 questions:
Notify CMT mamagerActivate pertinent parts of CMP
Carry out CMT assignments based on specific crisis
Contact key emergency personnelIf no, follow arrow
Level 1: Limited CrisisIs there immediate danger to
patients visitors or staff members?
Will this attract media attention?
If yes to level 1 questions:Notify house supervisor and
hospital securityNotify CMT leader and place
on alertIf no to these questions, the situation should be handled
as it progessses
Crisis Management Team Contact
CRISIS MANAGEMENT TEAM
Role on Crisis Management Team Name
Primary Phone
Number
Work Phone
NumberEmail Address
Crisis Management Lead Angela Mead (xxx) xxx-xxxx (812) 949-
5890 [email protected]
Security Lead & Backup Crisis Management
Lead Andrew Williams (xxx) xxx-xxxx (812) 948-
om
Assistant to the Crisis Management Lead Carolyn Lenz (xxx) xxx-xxxx (812) 981-
6655 [email protected]
Backup Assistant to the Crisis Management
LeadMarilynn Smith (xxx) xxx-xxxx (812) 981-
m
Crisis Control Room Coordinator Shannon Allen (xxx) xxx-xxxx (812) 949-
m
Backup Crisis Control Room Coordinator Teresa Bennet (xxx) xxx-xxxx (812) 948-
m
Crisis Communications Spokesperson Angie Rose (xxx) xxx-xxxx (812) 948-
7603 [email protected]
Backup Crisis Communications
SpokespersonAngie Glotzbach (xxx) xxx-xxxx (812) 949-
om
Secondary Crisis Communication Spokesperson
Haley White (xxx) xxx-xxxx (812) 949-5475 [email protected]
Backup Secondary Crisis Communications
SpokespersonCarla Christie (xxx) xxx-xxxx (812) 981-
7291 [email protected]
Legal Counsel John Hofmann (xxx) xxx-xxxx (812) 206-6053 [email protected]
Backup Legal Counsel Rodney Scott (xxx) xxx-xxxx (812) 206-6044 [email protected]
Chief Executive Officer Dr. Daniel Eichenberger (xxx) xxx-xxxx (812) 981-
om
Internal Auditor & Backup Administration Representative
John Fortune (xxx) xxx-xxxx (812) 948-4313 [email protected]
Hospitality Lead Meredith Lambe (xxx) xxx-xxxx (812) 949-5519
PAGE 9
Assistant to & Backup Hospitality Lead Emily Byrd (xxx) xxx-xxxx (812) 949-
5803 [email protected]
Emergency Department Lead Linda Minton (xxx) xxx-xxxx (812) 949-
5503 [email protected]
House Supervisor/ ER Operations Lead
House Supervisor at the time of incident
DUTIES OF EACH CRISIS MANAGEMENT TEAM MEMBER Crisis Management LeadAngela MeadAndrew Williams
Mission: Organize and direct Crisis Command Center. Responsibilities:
Immediate:o Initial Assessment of Crisiso Reference Crisis Flow Chart o Activate CMTo Activate CCC
Appoint to Acting: (if necessary): o Operations Impact Officero Records Officero Operations & Logistics Chief
Intermediate:o Authorize resources as needed or requested by CMT o Communicate crisis status to stakeholderso Approve media releases
Extended:o Declare end to crisis and deactivate (CCC)
Post Evento Convene CMT for a debrief on lessons learnedo Approve revisions identified by CMT as critical from lessons learned
Security Lead (SL) Andrew Williams
Mission: Monitor and have site authority over the safety of rescue operations and hazardous conditions and organize and enforce site protection and traffic security. Responsibilities:
Immediate:o Implement action to protect life, property and safeguard the hospitalo Notifies administrators of major emergencieso Monitors hospital emergency warnings and intercomo Requests assistance from city, county, state, and federal government as directed by the
Crisis Management Leado Activate and monitor emergency warning and evacuation systems
PAGE 10
o Obtain outside safety and security assistance as requiredo Hand out and ensure CMT vests and hats are worn by requisite responders o Provide vehicular and pedestrian traffic control
Intermediate:o Update CMT as needed to security and safety concernso Secure affected area and provide control into and out of areao Maintain contact with assisting agencieso Ensures safety and security staff documents all actions and observations
Extended: o Monitor safety and security staff for stress and fatigue and ensure replacement resources
are available Post Event:
o Convene internal and external safety and security assistance discuss and document “lessons learned”
o Generate lessons learned list to be shared with CMT
Secondary Crisis Communications ManagerCarolyn LenzMarilynn Smith
Mission: Assist crisis management lead in all capacities.Responsibilities:
Immediate:o Assist with all crisis management lead duties as askedo Take and relay calls to and for Crisis Management Lead
Post Event:o Take meeting minutes following a crisis in order to make revisions to CMP
Crisis Control Room CoordinatorShannon AllenTeresa Bennet Mission: Facilitate activation of Crisis Command Center. Contact hospital maintenance to ensure items for CCC are acquired. Manage CCC resources. Responsibilities:
Immediate: o Obtain CCC supplieso Contact necessary agents to ensure that supplies are replenished and refilled as needed.o Work closely with all members of CMT, ensuring that all needs are met
Intermediate: o Identify needs for local, regional, state follow-ups or updates with appointed or elected
officials at the local, regional or state level(s) Post Event:
o Coordinate ongoing communication follow-ups (internal or external) to support Crisis Management Lead
Crisis Communications Spokesperson Angie Rose
PAGE 11
Angie Glotzbach
Mission: Provide information to the news media and to CMP media contacts. Responsibilities:
Immediate: o Factually assess situation and collect information regarding nature of crisis/emergency o Contact key publics with planned statemento Prepare status message(s) for dissemination to the community, and news media o Communicate message(s) via Facebook, web site, phone, and phone o Serve as official spokesperson to news media
Intermediate: o Continue to monitor crisis/emergency by remaining in contact with CMT and other
official sources as necessary to gain updated information o Update messages regularly and/or as need be to community, news media o Assess/determine need for formal news conference o Provide campus location for news conference(s), working space for news media o Coordinate news conference(s) o Assist news media
Extended: o Continue to monitor/communicate updated messages o Accommodate news media
Post Event:o Generate lessons learned list to be shared with CMTo Organize and deliver copies of all communication documentation for records
Legal CounselJohn HofmannRodney Scott
Mission: Advise CMT on legal issues and concerns.Responsibilities:
Immediate:o Review media releases for legal concernso Work with Crisis Communications Spokesperson to ensure there are no legal liabilities
Post Event:o Review any legal actions takeno Suggest necessary revisions to CMP
Chief Executive OfficerDr. Daniel Eichenberger
Mission: Ensure the distribution of critical information and data to CMT members, and monitor the utilization of financial assets and oversee the acquisition of supplies and services in support of the crisis. Responsibilities:
Immediate: o Ensure formulation and documentation of an incident-specific action plan o Call Board of Directors and inform them with accurate comprehensive information as it
is received
PAGE 12
o Sign-off on key financial decisions Intermediate:
o Approve a “cost-to-date” incident financial report o Obtain expense reports and cost updates as appropriate o Determine priority funding for resources in support of CMT and CMP
Post Event: o Inform CMT of expenditures and assist in post crisis evaluation
Internal Auditor and back-up Administration RepresentativeJohn Fortune
Mission: Record pertinent information in the CCC and manage HIPPA requirements as well as lead post-crisis evaluation. Work closely with legal counsel to ensure legal requirements are met.Responsibilities:
Immediate: o Create incident response record. Carefully log and document activities and actions within
CCCo Assure that information provided to external stakeholders is appropriate and accurate as
well as within HIPPA and legal guidelines.o Log and document all external information (news reports, press alerts, etc.)
Post Event: o Host and facilitate post crisis evaluation meeting.o Provide access to log if necessary
Hospitality LeadMeredith LambeEmily Byrd
Mission: In the event of crisis, provide hospitality resources to those in need. Facilitate all comfort related services.Responsibilities:
Immediate:o Prepare 3A wing as hospitality centero Contact local hotels for outside services and discounted rateso Ensure vending machines are stockedo Make available resources such as phone books and mapso Ensure chapel is operational as well as make available counselor and Chaplino Issue free food vouchers
Post Event: o Debrief and provide insight on ways to approve hospitality in the event of a crisis.
Emergency Department LeadLinda Minton
Mission: Organize and direct aspects related to admission, instruction, and all functioning tasks required to run ER.Responsibilities:
Immediate: o Communicate crisis to concerned units
PAGE 13
o Assess crisis impact on various ER functions including admission, instruction, and support.
o Formulate an operations response plan in coordination with CMT o Ensure proper documentation for incoming/outgoing patients
Intermediate:o Maintain communication with essential personnelo Manage expectations of concerned family members, faculty, and other constituencieso Follow-up on actions takeno Appoint additional coordinators, if necessary
Post Event:o Assess effectiveness of response o Identify lessons learnedo Develop improvement strategies
ER Operations LeadHouse Supervisor/ER operations lead. (Acting)
Mission: Assist emergency department lead with all listed responsibilities. Ensure that the Emergency Department has the resources necessary to continue providing excellent patient care.
INTERNAL EXPERTS
Department or Expertise Name
Primary Phone
Number
Work Phone
NumberEmail Address
Bed Control Gretchen Brown (xxx) xxx-xxxx (812) 949-7124
Chaplain Rob Schettler (xxx) xxx-xxxx (812) 949-5711 [email protected]
Employee Assistance Program Amy Brown (xxx) xxx-xxxx (812) 981-
7296 [email protected]
Environmental Services
Sharon Goldsmith (xxx) xxx-xxxx 812-949-
5717Sharon.Goldsmith@fmhhs.
com
Food and Nutrition Lisa Shoopman (xxx) xxx-xxxx (812) 949-5599
Human Resources Jennifer Watson (xxx) xxx-xxxx (812) 949-5511
Infection Prevention Tamara Pursell (xxx) xxx-xxxx (812) 949-5719
Information Technology Systems Brian Cox (xxx) xxx-xxxx (812) 948-
7500 [email protected]
Maintenance Craig (xxx) xxx-xxxx (812) 949- [email protected]
PAGE 14
Monteleone 5781
Patient Registration Laurie Scarff (xxx) xxx-xxxx (812) 949-5563 [email protected]
Patient Services Kathy Rose (xxx) xxx-xxxx (812) 948-7584 [email protected]
Pharmacy Lowell Anderson (xxx) xxx-xxxx (812) 948-7404
Supply Chain David Davis (xxx) xxx-xxxx (812) 949-5640 [email protected]
Telecommunications Travis Baker (xxx) xxx-xxxx (812) 948-6736 [email protected]
Volunteer Services Becky Nunn (xxx) xxx-xxxx (812) 948-6734 [email protected]
Crisis Risk Assessment All the individual crisis management plans can be found in Appendix I. These
crises are listed from the most likely to least likely based on geographic location and past incidents.
Tornado- “Code Wind”
The purpose of this procedure is to establish an alert for associates, visitors, and patients in the hospital when weather conditions are of a nature to produce tornadoes.
Fire Emergency- “Code Red”
It is the purpose of the written fire plan to acquaint associates with the procedures, which have been established in the event of an actual fire.
Earthquake Emergency Plan- “Code Earthquake”
This plan outlines the needed action in the event of an earthquake. Where to assemble and who to contact.
Snow Emergency Plan- “Code Snow”
It is the goal of Floyd Memorial Hospital and Health Services to provide adequate staff in the event of a snow emergency.
Bed Bugs- “Code Grey”
PAGE 15
In the event of this crisis, we will eliminate bed bugs from all rooms in the hospital to prevent the spread of vermin.
Combative Patient- “Code Yellow”
Combative patient, visitor or associate; Security intervention needed immediately.
Emergency Facility Evacuation- “Code Plum”
To describe a plan that provides guidelines for a safe and effective evacuation of all or part of the hospital.
Internal Disaster Plan- “Dr. Whitestone”
Any situation that may place a patient, visitors, or associate within the hospital in indirect danger, but does not have an effect on any neighborhoods or outside areas.
External Disaster- “Dr. Redstone”
This plan of action will act as a guide in the event of an external disaster that impacts the normal operation of the hospital. This plan is a quick, simplistic format that centers around the Emergency Center (E.C.) and how all disciplines impact on the processing of patients through the system.
Infectious Disease Outbreak- “Dr. Charles”
To ensure the safety of all patients, visitors, and staff on call. This will be used to provide a quick response to an outbreak of infectious diseases in the hospital.
Bomb Threat- “Operation Zero Zero Five”
This plan outlines the action required whenever a bomb threat is made against Floyd Memorial Hospital and Health Services. The plan also includes the action required whenever a suspected explosive device is found or whenever an explosion occurs in the hospital.
Child Abduction- “Code Alert”
To ensure a safe and secure environment and measures are taken to protect newborns from unauthorized removal. To provide a quick response systems if potential infant abduction should occur.
Telephone Failure Plan- “Code Citrix”
The following procedure should be followed in the event of external interruption of telephone services.
Active Shooter- “Code Silver”
PAGE 16
The purpose of the “Code Silver” Active Shooter plan is to provide an immediate and effective response to an active shooter situation.
Hostage/ Volatile Situation with a Weapon- “Code Ten”
A hostage or volatile situation is taking place and weapons are involved, use extreme caution. Police have been notified. Code Ten or Code Ten Exterior will be paged in a situation considered to be extremely dangerous.
Weapons of Mass Destruction- “Code Pink”
In response to the realized potential that health care facilities may be directly or indirectly involved as the result of an act of weapons of mass destruction, it is the intent of Floyd Memorial Hospital and Health Services to develop a Weapons of Mass Destruction Management Plan in connect with the established Emergency Preparedness Program.
PAGE 17
Incident ReportsIncident Reporting Form
Use this form to report any workplace accident, injury, incident, close call or illness.
Return completed form to the Operations Supervisor, or Management.
This is documenting an:
Lost Time/Injury First Aid Incident Close Call Observation
Details of person injured or involved (to be filled in by person injured / involved if possible)
Person Completing Report:_____________________ Date:____________________
Person(s) Involved:___________________________
Event Details
Date of Event:_____________________ Location of Event:______________________
Time of Event:_____________________ Witnesses:___________________________
Description of Events (Describe tasks being performed and sequence of events):
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
*If more space is required please use the back of this sheet
Was event / injury caused by an unsafe act (activity or movement) or an unsafe condition (machinery or weather)? Please explain:
______________________________________________________________________
______________________________________________________________________
PAGE 18
TO BE COMPLETED ONLY IF LOST TIME/INJURY OR FIRST AID WAS REQUIRED
Type of injury sustained:
Cause of lost time/ injury or first aid:
Was medical treatment necessary?
Yes_____ No_____
If yes, name of hospital or physician:
Signature of Employee:_____________________________ Date:__________________
Signature of Supervisor:____________________________ Date:__________________
PAGE 19
Proprietary InformationProprietary Information
This Crisis Plan is proprietary and confidential. No part of this document may be disclosed in any manner to a third party without the prior written consent of Crisis Management Lead, Angela Mead. Information contained in this document shall be and remain private.
In the event of a crisis, the Floyd Memorial Hospital wants to be open and honest with its stakeholders. However, certain information should never be disclosed without the approval of CEO, Daniel J. Eichenberger, including but not limited to staff contact information and/or hospital policies.
The personnel contact information. The safety and security of all Floyd Memorial employees is a priority. The patients in the Emergency Room will be protected, including identity and hospital charges. We follow all HIPPA regulations.
All medical record, including the ones throughout the whole hospital are protected. The patients are in full control of their own records and can decide who sees them. Other than that, no one is may access medical records outside of hospital faculty and staff that needs the information for clinical purposes.
The financial records are all kept private unless otherwise instructed and a signed waiver from the patient is received. This includes all internal documents. In order to maintain a competitive edge, all discussions that occur behind closed doors should remain undisclosed. Transcripts from these discussions are included.
The names of victims and involved parties either caused by the crisis or not, are protected. In the tragic event of an injury or death to a patient or doctor, their names will not be released to the media until relatives are notified first. Then the secondary communications spokesperson, Haley White, should contact the media about this information.
Promotional developments are protected. Any and all promotional developments must be withheld until the appropriate release date.
In the event that a CMT member or any employee is unsure of whether information is regarded as proprietary, they should err on the side of caution.
PAGE 20
Crisis Communication StrategyWhile in the midst of a crisis, it is important that the Crisis Management
Team realizes that anything that is communicated is heard by many others than just the intended person. All communication needs to be planned strategically. The following checklist is to be used as a tool when formulating responses. It does not contain all things to be considered and depending on the circumstances, be aware that unique situations may arise.
Contextual Analysis:
What is the crisis? Was the crisis anticipated? If it was not anticipated, what were the underlying issue? What crisis category does the crisis fall under? What is the response time? What steps have been taken thus far? What has been done to reduce the risk?
Audience Analysis:
Who was affected by the crisis? Which stakeholders are most affected? What is the public’s perception of the crisis? What is the media’s role? What is the credibility of the organization?
Strategy:
What are the emergency department’s goals? What are the communication objectives? How does the CMT plan to measure the effectiveness of the the
communication strategy? Does our plan align with the goals of the department? Does our communication strategy align with the goals of the department? Is the plan feasible? Is the plan ethical?
Tactics:
Who is the media spokesperson? What channel of communication will be used? What media options are available? When is the best time to send a message?
PAGE 21
Crisis Type
Key Stakeholde
rs Contacted
Message Conveyed
Message Goal Strategy Tactics
Initial (Verifying ) Completed
Status
COMMUNICATION STRATEGY WORKSHEETThis chart serves as a beginning checklist to ensure the above questions are answered. This checklist is to be copied and used for multiple purposes.
PAGE 22
Secondary Contact Information
EXTERNAL EXPERTS Expertise or Organization
Primary Phone Number
After Hours Phone Contact Name (If Applicable)
Center for Disease Control (770) 488-7100 (770) 488-7100
Floyd County Health Department (812) 948-4726
Pager
332-5657
Indiana State Health Department (317) 233-7125
On call Epidemiologist
(866 )233-1237
Clark Memorial Hospital (812) 282-6631 (812) 283-2521 Kathy Neuner- Chief
Nursing Officer
Waters, Tyler, Hofman, & Scott LLC: Attorneys at
Law
(812) 949-1114 (812) 995-4065
Floyd County Sheriff Department (812) 948-5400
Yellow Ambulance (502) 636-0414 (502) 637-6511 Wayne Dunn – Fleet Manager
James Howard, Counselor
(812) 948-8000 James Howard
FEMA (202) 646-2500
Professional Arts Building
Coordinator
(812) 945-4200 JoAnn Struble
Kosair Hospital (502) 629-8086
Stakeholder Contact StrategyBelow is a list of stakeholders and publics. Ensure that you communicate
with each group that is part of your audience. If one of these listed titles contact you, refer to Media Inquiries Sheet on page 24.
CONTACTING STAKEHOLDER GROUPSEmployees:
PAGE 23
This includes management, employees, and families of the employees, if applicable. Employees will be notified by the automatic alert system in accordance to standing procedure. Employees should be familiar with the system from their annual Healthstream activities and their orientation discussion.
Communities:
Locally, neighborhood coalitions, community organizations, surrounding homes. The publics in the surrounding communities will be notified by the media releases and radio broadcasts as well as T.V. news. The situation will also be displayed on Floyd Memorial’s social media feeds.
Patients:
Patients within the hospital will notified by nurses. The nurses will get informed by an automatic alert system as well as via Switchboard if applicable. The automatic alert program will send emails and texts messages for all the employees that are on site. Patients not currently on property but expecting to be seen in the near future for an appointment will receive a call if the crisis changes their appointment time or services available. Each department or office will be responsible for notifying those affected patients.
Industrial/Business:
Pharmacies, teaming partners, other hospitals locally, and affiliated offices. These publics that are associated with Floyd Memorial Hospital and Health Services would be notified by automatic emails. Additionally, all other organizations within this public will receive a call from Dr. Eichenberger or another member of the Crisis Management Team if the crisis is expected to impact their business or routines.
Media:
General, local national and international. The media will be contacted by the Crisis Management Spokesperson. If any media outlet contacts the hospital for information or a statement please reference the media inquiry sheet.
Financial Stakeholders:
Investors, donors, and other financial institutions will want to know the impact on revenue and profitability and any likely future financial implications. Such stakeholders include creditors, suppliers, insurance companies and bankers. This group will be notified by the Backup Crisis Communications Spokesperson. They will be notified if the crisis at hand reaches the Level 3, or if the Administrator or his/her representative sees fit.
Governmental:
Local, state, regional, national. The city government office will be notified by the Crisis Communications Spokesperson via email or phone call to be decided at the time of crisis. These groups will be notified when the crisis at hand reaches a Level 3, or if the Administrator or his/her representative sees fit.
PAGE 24
MEDIA CONTACT INFORMATIONTelevision Stations
WHAS 502-582-7711 Newsroom
WDRB 502-584-6411 Newsroom
WAVE 3 502-585-2201 Newsroom
WLKY 502-893-3761 Newsroom
Newspapers
News and Tribune 812-206-2107 Mike Massek
Courier Journal 502-582-4683 Kim Kolarik
Radio Stations
WGTK 970 AM 502-339-9470 Newsroom
WNAS 88.1 FM 812-949-4278 Newsroom
WFPL 89.3 FM 502-814-6550 Stephen Georger
WHAS 840 AM 502-479-2222 Newsroom
MEDIA INQUIRY SHEETThe media inquiry information will be taken after a crisis has already taken place
and will serve as a document used to answer and fulfill any questions of what took place. The media personnel will contact the assistant to the Crisis Management Lead, Carolyn Lenz, either by work phone (812-981-6655) or by email at [email protected]. The routine that will take place will go as follows:
Contact Carolyn Lenz via phone or email. Ms. Lenz will then take the information and then either she or a member of
the Crisis Management Team will get back with them as soon as possible. Ms. Lenz will take the Inquiry to the Crisis Management Lead, Angela Mead,
and the Crisis Management Team. Within 48 hours a spokesperson from the team will contact the designated
person with a descriptive answer and reasoning as to what took place, what the status is, and the plan for going forward.
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Media Inquiries Sheet
Name of company: _____________________________________________________________________
Time and Date of call:___________________________________________________________________
Specific Inquiry for Information: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Title: ________________________________ Name:_____________________________________
Who took the call: _____________________________________________________________________
Best way to contact with a response: ____________________________________________________________________________________________________________________________________________________________________________
Signed off by: ___________________________________ Reviewed by: __________________________
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FACT SHEET When a crisis takes place and either the media or newsroom tries to contact
the Crisis Management Team about the incident, a fact sheet will be in place to take information and given to the appropriate person. If the team doesn’t have to time or information to answer right away, we, as a team, will fill out the Fact Sheet and get back with these companies.
The assistant and back up to the Crisis Management Lead will take the information they have and fill out the sheet. Once the information is imputed into the sheet and all the parts have been filled out, the spokesperson will then be allowed and expected to inform the media and news rooms the appropriate information.
The two members who will be in contact with both the newsroom and media outlets will be whoever the spokesperson delegates the information to, based on severity of the crisis.
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Fact Sheet for Floyd Memorial Hospital
Describe what happened:
Name of person? _______________________________ Title/Position___________________________
Responsibilities______________________________ Years of service____________________________
What happened? __________________________________________Date/Time___________________
Location______________________________________________________________________________
What was he/she doing at the time? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Who else was there? ____________________________________________________________________
What were they doing? ____________________________________________________________________________________________________________________________________________________________________________
How did and when did anyone else find out? ____________________________________________________________________________________________________________________________________________________________________________
News Media:
Media phone calls? _________________ Have reporters/TV crews arrived? ______________________
What information has been given out? By whom? Who authorized that? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
What visual materials are available for distribution to the media from the hospital? ____________________________________________________________________________________________________________________________________________________________________________
Who first reported the incident? _____________ Who first took the phone call? _________________
Time? _____________________________________ Date? _____________________________________
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Position? _____________________________________________________________________________
Who from the media reached out, and their position within the company? ____________________________________________________________________________________________________________________________________________________________________________
Additional Information:
How have similar situations been handled by Floyd Memorial Hospital? ____________________________________________________________________________________________________________________________________________________________________________Any unexpected problems which may hamper a smooth transition? __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
All information provided by______________________________________________________________
Phone number ________________________________ Cell number _____________________________
Fax number _________________________________ Employee ID number ______________________
Date _________________________________________ Time ___________________________________
PAGE 29
Business Continuity PlanIt will be important that the hospital return to business as quickly as possible. In many of these cases a business continuity plan may not be required if the crisis did not directly damage Emergency Department equipment or facilities. The Internal Auditor, the ER Operations Lead, and the Crisis Management Lead will decide if the Emergency Department facilities are still functional during and after a crisis.
If Emergency Department facilities are no longer functional
Emergency Department operations will be moved to the Spine Center, Wound Center, Pain Management Center, and Ambulatory Services Center. Because this area was the former Emergency Department it still features the room layout and functionality that will be required.
The Internal Auditor will be responsible for making sure that this area complies with all hospital policies and government regulations regarding safety, privacy, and patient care.
The Emergency Department Operations Lead will be responsible for briefing the Emergency Department staff on the changes to the location and how this affects their individual roles.
Bed Control Department will be responsible for communicating with Spine Center, Wound Center, Pain Management Center, and Ambulatory Services Center to find rooms to where Emergency Department Patients can be relocated.
The Crisis Management Lead will be in charge of collecting a small team to begin moving patients from the current Emergency Department to the Interim Emergency Department. Transport Department will be the primary pool from which these team members will be pulled.
The Crisis Communications Spokesperson will need to contact the media and ask that they notify the public that the Emergency has been relocated to the Green Valley lot and patients can receive care there. Security will be responsible for instructing traffic and approaching patients to report to the Green Valley lobby for Emergency Care.
The Hospitality Lead will be responsible for informing incoming patients that the Emergency Department wait is longer than usual. It should be recommended that those patients not suffering from a life threatening emergency contact a Floyd Urgent Care Center or their primary care physicians. Upon this recommendation the hospitality should offer patients a list of the surrounding Floyd Urgent Care Centers and their contact information.
After the crisis has ended returning the Emergency Department to a functioning state should be the number one priority.
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All members of the Crisis Management Team will be responsible for filling out Post Crisis Evaluation Forms and returning them to the Internal Auditor. The Internal Auditor will review these forms and will bring up recurring themes at the Crisis Management Review meeting to be held within ten days of the crisis to evaluate and change this plan as needed.
If Emergency Department facilities are still functional or after they become functional:
The internal auditor will be responsible for ensuring that the emergency department is restored to the standards, regulations, and policies that are required by government agencies as well as by hospital policy before patient treatment can resume. If only a portion of the emergency department was damaged or inactive then the internal auditor will need to ensure that those areas are back to aforementioned standards before treatment can resume.
If the portion that is unusable does not meaningfully hinder or disable patient care, then the remaining facilities should be active.
All members of the Crisis Management Team will be responsible for filling out Post Crisis Evaluation Forms and returning them to the Internal Auditor. The Internal Auditor will review these forms and will bring up recurring themes at the Crisis Management Review meeting to be held within ten days of the crisis to evaluate and change this plan as needed.
It will be the decision of the Internal Auditor, the ER Operations Lead, and the Crisis Management Lead to decide whether steps beyond what is outlined here need to be taken.
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Crisis Control Center Locations
CRISIS CONTROL CENTER1. The Paris Education Center is designated as the primary Crisis Control
Center located in the eastern most portion of the hospital.
2. In the event that the Paris Education Center is inaccessible then the Crisis Control Center will be held at the Floyd Memorial Medical Surgical Center located at 2125 State St, New Albany, IN 47150.
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Paris Education Center
MATERIALS FOR CRISIS CONTROL CENTERThe crisis team will have an open area to work. The items listed below should be supplied in both the control center and media center. These items should be in this room, even if they are pulled from the basement or already existing in the control centers.
Chairs Desks Computers and wireless
internet Printers Extra ink and toner Telephones Cell phones and chargers Battery-powered televisions
and radios White board stocked with
markers and erasers.
Pens and pencils Police radio Walkie-talkies Contact list Media directories Street and highway maps Copy machine First aid kits Cameras and film Transportation slips Copy of this crisis plan Floyd Memorial Letterhead
It is Shannon Allen’s, Crisis Control Room Coordinator, responsibility to contact maintenance and have them get these resources out of the storage in the basement. It is also their responsibility to get any of the resources that are missing from storage. If the basement is off limits due to the crisis, then it is this person's responsibility to gather these items.
It is Lisa Shoopman’s responsibility to for the food and nutrition for team. If food is the problem, it is this person’s responsibility to contact vendor and pick up if needed.
It is the responsibility of Angela Mead to bring a copy of this Crisis Communication Plan (CCP), and basic office supplies if it is not already in the crisis control room.
MEDIA CONTROL CENTERThe Media Control Center will be set up in any available conference room in
the Professional Arts Building. As noted previously, Shannon Allen will be responsible for contacting JoAnn Struble to establish the Media Control Center and collect the materials required.
Post Crisis Evaluation FormsThe information collected through the post-crisis evaluation will help the
Communication Management Team correct weaknesses and maintain the strengths of Crisis Management Plan. Each member of the Crisis Management team is expected to fill out a copy of this form and return it to the Crisis Management Lead. Per procedure, within ten days after a crisis the Crisis Management Team will hold
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an evaluation meeting for the purpose of evaluating and correcting flaws in the Crisis Management Plan.
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Post-Crisis Evaluation Form
CMT Member: ________________________ Date: _______________________ Time: ________________________
Location of Crisis: ___________________________________ Type of Crisis: ________________________________
Description of Crisis: ______________________________________________________________________________ _________________________________________________________________________________________________
The Crisis Management Plan was followed: Circle one
Not at all Somewhat used Completely
0 1 2 3 4 5 6 7 8 9 10
What role did you have in the crisis? Explain:
__________________________________________________________________________________________________________________________________________________________________________________________________
How was the crisis management process used? Explain:
__________________________________________________________________________________________________________________________________________________________________________________________________
What was most effective about the about the Crisis Management Plan? Explain:
__________________________________________________________________________________________________________________________________________________________________________________________________
What was the most difficult part when using the Crisis Management Plan? Explain:
__________________________________________________________________________________________________________________________________________________________________________________________________
What are your suggestions to better improve the Crisis Management Plan? Explain:
__________________________________________________________________________________________________________________________________________________________________________________________________
Were employees confused? Why?
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__________________________________________________________________________________________________________________________________________________________________________________________________
Did employees know what was expected of them? Why not?
__________________________________________________________________________________________________________________________________________________________________________________________________
Appendix I Individual Crises Procedures
TORNADO- “CODE WIND”PAG
E: EFFECTIVE DATE:
REVISION DATE:
Page 1 of 9/92
11/201508-04
The Weather Bureau, and/or local authorities will identify the storm conditions as a tornado watch or tornado warning.
General
Any associate who learns by mass communication, media, or other source that a tornado watch or tornado warning is in effect, will advise their Supervisor or Administration.Code name for the tornado warning will be “Code Wind”.
Administration
1. The Crisis Management Lead will declare "Tornado Watch" or "Code Wind" is in effect.2. Advise the Switchboard of the "Tornado Watch" or "Code Wind" activation so that it may be announced overhead.3. Establish command center in Administration as needed.4. Coordinate all "Code Wind" procedures and responses.5. Coordinate activities with the Floyd County Emergency Management Agency as well as other external public safety agencies as needed.6. See that necessary internal communications are arranged.
Telephone Operator
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For a “Tornado Watch”:
The telephone operator will page four times, “Attention please, attention please, a tornado “WATCH” has been issued for this area until further notice (or until a specific time).This announcement is to be repeated hourly until an all clear has been issued.
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PAGE: EFFECTIVE
DATE: REVISION
DATE:
Page 2 of 9/92
11/201508-04
For a “Tornado Warning”:
The telephone operator will page four times, “Attention please, attention please, a tornado warning has been issued for this area. “CODE WIND” is now in effect”.This announcement is to be repeated each thirty minutes until an all clear or a step down to a “Tornado Watch” is issued.
Switchboard will contact and notify off-site department for both the “Tornado Watch” and “Code Wind”.
a. Home Health Care 7447b. Information Systems 7500c. Urgent Care Center-Highlander 3650d. Urgent Care Center- 949-e. Palmyra Family Medicine 3701f. Floyd Memorial Family 3750
(Georgetown)g. HMR 949-h. Kleinert & Kutz 944-i. Charlestown Cardiovascular 256-j. Cancer Center 945-k. Physical Medicine 7416
For off-site facilities/departments
A. For a Tornado Watch:
Directors and Management
1. Advise associates of tornado watch condition.2. Activate the Norad radio station for current weather status
reports.3. Select an area away from potential flying glass, of refuge
for possible tornado warning (Code Wind) condition.4. Maintain Norad radio station update reports until tornado
watch advisory has been canceled.PAGE 38
PAGE: EFFECTIVE
DATE: REVISION
DATE:
Page 3 of 9/92
11/201508-04
B. For a Tornado Warning (Code Wind):
Directors and Management1. Advise associate of tornado warning conditions.
2. Instruct associates to request patients and visitors to move to an area of refuge within the building (away from possible direct line of flying glass).
3. Maintain Norad radio station update reports until the tornado warning has been canceled.
Cancellation
1. When the tornado watch or warning has been cancelled, the operator will announce:
“TORNADO WATCH”:“Attention please, attention please, the tornado watch for this area has been cancelled and an all clear has been issued”.
“TORNADO WARNING”:“Attention please, attention please, the tornado warning for this area has been cancelled and an all clear has been issued. “CODE WIND” is now cancelled”.
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FIRE EMERGENCY- “CODE RED”PAG
E: EFFECTIVE DATE:
REVISION DATE:
Page 1 of 07/0911/201508-01
Purpose
It is the purpose of the written fire plan to acquaint associates with the procedures, which have been established in the event of an actual fire also known as a “CODE RED.”
This plan should be reviewed with all new associates when they are hired during “New Associate Orientation.” All directors or their designees should review their department specific plans periodically, with associates; to insure a smooth operation of procedures should an actual fire (Code Red) take place.
Notification Procedures
Announce the fire by pulling the fire alarm pull box. Call the switchboard operator and give the exact location of the fire.
When the fire alarm system is activated either automatically or manually, the fire department is notified at the same time by the fire alarm system itself and by our third party alarm company, A-Sonic.
Switchboard operator will announce "Code Red" four times giving the location and type of alarm device, i.e.
"Automatic" (heat or smoke detector in ceiling), "Manual" (when pull station on wall is pulled), "Duct" (air ducts in building have smoke alarms in them), "Flow" (flow switches are located in sprinkler line and activated
when water is moving through lines), "Tamper" (tamper switches are located on sprinkler shut off valves).
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PAGE: EFFECTIVE
DATE: REVISION
DATE:
Page 2 of 07/0911/201508-01
General Rules
RACE: What to remember in the event you discover a fire.
R RESCUE
Patients and anyone else in harm’s way of Smoke and/or Fire
A ALARM
Pull Fire Alarm Station and Call the Switchboard at ext.7701.
C CONTAIN THE SMOKE/FIRE
Close all doors to rooms and corridors
E EXTINGUISH THE FIRE OR ESCAPE
Extinguish the fire if it safe to do so
(If smaller than a wastebasket)
Escape if you feel the fire is too big or if you feel uncomfortable extinguishing the fire.
The safety and well being of all associates is of the utmost importance to the hospital. Do not put yourself in harm’s way attempting to rescue someone or to put out a fire.
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PAGE: EFFECTIVE
DATE: REVISION
DATE:
Page 3 of 07/0911/201508-01
PASS: What to remember if you need to use a fire extinguisher
P PULL
Pull the pin at top of the fire extinguisher.
A AIM
Aim the nozzle of the extinguisher at the base of the flame.
S SQUEEZE
Squeeze the handle at the top of the fire extinguisher.
S SWEEP
Sweep the nozzle of the fire extinguisher from side-to-side.
Only attempt to extinguish a fire if it is small, a wastebasket or smaller, and it is safe to do so.
Do not open windows to vent smoke, etc. unless you have been instructed by the on- scene Fire Commander
Do not turn off the lights Remember, the greatest threat during a fire is panic caused by fear
Roles and ResponsibilitiesSecurity
1. Upon notification of the “Code Red”, a Security Officer will immediately respond to the alarm scene. This Officer will update the status of the situation advising whether or not the Code Red is an actual fire or a false alarm.
2. Security will be responsible for meeting with the New Albany Fire Department (NAFD) and escorting to the alarm scene and assisting as needed.
3. Security will be responsible for advising A-Sonic, the third party alarm company, of the status of the Code Red, recording their response time and the arrival time of the NAFD.
PAGE 42
PAGE 43
PAGE: EFFECTIVE
DATE: REVISION
DATE:
Page 4 of 07/0911/201508-01
4. Upon receiving the all clear from NAFD, security will advise the Switchboard of the“all clear” and reset the fire alarm system.
5. Security will also direct all news media representatives to a designated media area if the situation warrants.
Nursing Units1. Compartmentalize the area by closing all patient room doors and
checking smoke and stairwell barrier doors for proper closure.
2. Associates on all nursing units will report to the charge nurse of the unit. (In Mother/ Baby Unit, Place newborn babies with their mothers, if possible and if necessary).
3. Nursing associates shall concentrate on aiding non-ambulatory patients in the event an evacuation is necessary.
Maintenance1. Maintenance associates, not having assigned duties will report to the
scene of the alarm. These associates will be under the direction of supervisory personnel, in his/her absence, Security.
2. The Maintenance Department, in addition to usual boiler room responsibilities, will aid the on-scene Fire Commander or the Hospital's External Expert in regard to electrical apparatus, pumps, and other technical machinery as needed.
Environmental Services1. All designated Environmental Service associates will report to the
scene of the alarm. They will be responsible for responding to the alarm scene with a fire extinguisher in the event one is needed.
2. All other Environmental Services associates will remain in their work areas and wait for further instructions.
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PAGE 45
PAGE: EFFECTIVE
DATE: REVISION
DATE:
Page 5 of 07/0911/201508-01
Other Departments
1. Departments whose fire response is to evacuate the building will exit the building and go to their predetermined locations in the parking lot.
2. Associates, who evacuate their work areas and go outside, will go to these designated areas and remain there until they are told to return to work or given further instructions.
3. All other departments will “Shelter-In-Place” by closing their doors and remaining at their workstations and wait for further instruction. If the fire is in your work area begin evacuation procedures immediately.
Shelter-In-PlaceDo not evacuate until instructed by the on-scene Fire Commander or the Crisis Management Lead. The objective is to keep patients in their rooms with minimal movement. By sheltering-in-place it allows the fire suppression system to work and contain the fire and by shutting doors contain the smoke.
EvacuationUpon directive from the on-scene Fire Commander or the Hospital's Incident Commander, evacuate all patients and persons from the immediate fire area. This may mean the area immediately above, below, or adjacent to the fire.
1. If mass evacuation is necessary, be sure all patients are accounted for before leaving the area and that their medical charts go with them to ensure as little interruption to their care as possible.
2. Prepare to evacuate patients. All electrical equipment such as incubators, oxygen tents, suction machines, etc., is to be turned off in the threatened area if time permits or at the direction of the charge nurse.
PAGE 46
3. Remove non-ambulatory patients. Ambulatory patients will receive a minimum of nursing aid, inasmuch as they may be able to help themselves. All visitors with patients should be kept with patients and render aid
PAGE: EFFECTIVE
DATE: REVISION
DATE:
Page 6 of 07/0911/201508-01
Resume Normal Operations
Any management/non-management associates coming into the Hospital to offer assistance are to report to the Green Valley parking area. The Command Staff should report to the Hospital Command Center in Administration or other designated deemed safe and appropriate.
When the alarm condition ends and danger has ceased, the switchboard operator will announce, "Code Red" is canceled".
Fire Drill Procedure
In Compliance with HFAP and NFPA recommendations, the quarterly fire drills will now involve participation from associates and an actual fire scenario. Fire Drills will be conducted twice per shift per quarter. A fire drill will be conducted once during the specified shift during the week and once on the weekend.
The following steps will be taken in a fire drill.1. The Security Department will notify the fire department,” in about
5 minutes we will have a fire drill. If a real alarm occurs during this time, you will be notified immediately."
2. A poster of "flames" will be discreetly placed in an area picked by the Security Officer conducting the drill. A different location will be chosen on each shift for each of the six quarterly drills.
3. Observers will be used to evaluate drill procedure in compliance with the 20% rule of smoke compartments.
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PAGE: EFFECTIVE
DATE: REVISION
DATE:
Page 7 of 07/0911/201508-01
4. The associate who discovers the fire on the first and second shift will pull the alarm and call the Switchboard as if it were a real fire.
a. The associate who discovers the fire on the third shift will NOT pull the alarm but will call the Switchboard and report it verbally.
5. The Switchboard will then page Code Red for that location.
6. The observer will record the fire drill response as required. The fire drills will be scored on a 100 points scale. Any area receiving less than 90 points will require formal re- training on fire response.
7. Once the "fire" has been "extinguished" the Switchboard will be notified and will page the all clear.
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EARTHQUAKE EMERGENCY PLAN- “CODE EARTHQUAKE” PAGE:
EFFECTIVE DATE:
REVISION DATE:
SUBJECT: Earthquake Emergency Plan: Code Earthquake
Page 1 of 9/9211/201508-10
During an Earthquake
1. If you’re indoors get under a table, desk, or bed, or brace yourself in a strong doorway.Watch for falling, flying and sliding objects. Stay away from windows.
2. If you’re outdoors move to an open area away from buildings, trees, power poles, brick or block walls and other objects that could fall.
3. After initial shock, move all patients away from windows and protect them with mattresses, blankets, and/or pillows. Close all blinds.
After an Earthquake
1. Check for fires and extinguish them or summon help.2. Do not use lighters, matches, etc.3. Check for potential chemical hazards, gas leaks, or broken water
lines. Report any findings to Maintenance personnel.4. Check for injured persons, summon medical assistance for the injured
as needed.5. Check for persons who may be trapped, i.e. patient rooms, closets,
bathrooms, elevators, private offices, pipe tunnels, etc.Administration
1. Declare Earthquake Emergency Plan.2. Advise the Switchboard of the "Earthquake Emergency Plan" activation so that it may be announced overhead.
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SNOW EMERGENCY PLAN- “CODE SNOW”PAGE:
EFFECTIVE DATE:
SUBJECT: Snow Emergency Plan: Code Snow REVISION
DATE:
Page 1 of 6/0511/201508-07
Policy
It is the goal of Floyd Memorial Hospital and Health Services to provide adequate staff in the event of a snow emergency.
Purpose
The purpose of this policy is to provide a systematic plan for maintaining hospital operations in the event of a snow emergency.
Procedure
A. DEFINITION:A snow emergency is defined as a situation where in staffing requirements for essential patient care and service cannot be met because associates are unable to report for duty due to extreme snow/cold conditions, and/or supplies and equipment necessary to operate the hospital cannot be delivered.
One key to determining the need to declare a snow emergency is when the media labels city streets as “impassable” and the city bus service is discontinued. Likewise, the emergency will probably end when streets are “passable” and bus service resumes.
B. ELEMENTS:The Snow Emergency Plan consists of one or more of the following:
1. Providing transportation for associates who are essential to patient care and facilities’ services and who are unable to provide their own transportation.
2. Providing adequate staffing
3. Providing lodging for associates unable to leave the hospital.
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PAGE:EFFECTIVE DATE:
SUBJECT: Snow Emergency Plan: Code Snow REVISION
DATE:
Page 2 of 6/0511/201508-07
C. DECLARING A SNOW EMERGENCY AND IMPLEMENTING THE SNOW EMERGENCY PLAN:
1. When it appears that a snow emergency is imminent during normal working hours, the Crisis Management Lead will declare and implement the Snow Emergency Plan. After hours, the Nursing Supervisor will notify the Administrator on call, whose responsibility it will be to declare and implement the Snow Emergency Plan.
2. The Administrator on call will be identified as the Crisis Communication Lead. (If the Administrator on call is unable to come to the Hospital, an Administrator who can come to the Hospital will be in charge).
3. The Crisis Control Center Lead will establish the Crisis Control Center
4. The implementation of the Snow Emergency Plan will be announced via the Public Address System at the direction of the Administrator in charge. The announcement will be as follows: “Floyd memorial Hospital and Health Services’ Snow Emergency Plan is now in effect.”
5. The Switchboard will be responsible for following the phone tree list designed by Administration.
CI. CONTROL CENTER (Paris Education Center):Hospital Control Center will be located in the Paris Education conference room. The coordination of emergency operations will be handled from this area.Staff members to assist in hospital control will be assigned by the Crisis Communication Lead of the snow emergency.The following positions needed to assist with Hospital Control are as follows:
1. Transportation Coordinator(s) : Initially, and during peak hours, two people are desired; at other times, one person will be sufficient. One person will serve as a dispatcher.
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PAGE 52
AGE:EFFECTIVE DATE:
SUBJECT: Snow Emergency Plan: Code Snow REVISION
DATE:
Page 3 of 6/0511/201508-07
a.Peak hours are defined at 4:30 a.m. to 8:30 a.m.; 1:30 p.m. to 4:00 p.m.; and 9:00 p.m. to 11:00 p.m. Depending upon the severity of the emergency and the time of day, duties may be consolidated so that one person is in charge of Reception and Lodging and one person is in charge of Transportation and Dispatch.
2. Lodging Coordinator : Personnel to be assigned by the Control Center. One person is desired on both days and evenings.
3. During normal working hours, the administrative secretaries will assist with the Snow Emergency Plan, serving as reception or transportation personnel.
4. Administrator will determine the labor pool for the command center using staffing resources provided by Directors.
5. Supplies:
a. Transportation Slips – located in Control Center
b. Map of southern Indiana – located in Control CenterE. OBTAINING ESSENTIAL STAFF COVERAGE :
Department Directors or their designees are responsible for determining staffing needs for their units. Requesting associates to stay on duty to fill staffing vacancies may be appropriate. Factors such as the project length of the emergency, job function, overtime costs, other alternatives for staffing, etc., need to be considered when making these decisions. Staff not needed for their department are then
PAGE 53
identified and referred to the Control Center for reassignment or release.
Time Adjustments, after the snow emergency, Human Resources will determine the days for absenteeism/tardiness that will be excused and the PTO days which may be used for associates absent from or late to work.Hours paid for associates who worked during the snow emergency will be in accordance with policy.
F. TRANSPORTATION :Transportation control is handled through the Control Center, which is located in Administration. Department Directors or their designee requesting transportation of associates will call Administration and will be asked to provide the associate’s name, address, nearest major cross-street or intersection, phone number, scheduled work time, etc.
1. Determination for providing transport will depend on the number of available drivers, the need for the staff member, associate’s address and accessibility, priority of all associates needing transportation, and so on. The Control Center will explore options for transportation (i.e.: police department, fire department, National Guard, volunteer drivers). When transportation has been arranged, the associate will be notified by phone that someone is on the way and the name of the driver and the description of the vehicle will be provided. Persons transported to the hospital are advised to bring additional clothing and medications according to the weather predictions. Associates who refuse the offer of transportation will be assessed an occurrence of absence in accordance with the Absenteeism & Tardiness Policy.
2. Associates who arrive at the hospital via transportation are to “check in” at the Control Center in Administration on the way to their departments. Likewise, associates requiring transport home are to “check in” at the Control Center in Administration.
3. The hospital will provide transportation of associates who are essential to patient care and services. All efforts toward self-transportation
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PAGE:EFFECTIVE
DATE: REVISION DATE:
Page 4 of 6/0511/201508-07
should be exhausted prior to the provision of transportation by the hospital.
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PAGE:EFFECTIVE
DATE: REVISION DATE:
Page 5 of 6/0511/201508-07
4. Priority for transportation will be set in the Control Center. The proximity of associates to each other and/or to passable roadways will be given consideration.
5. Transportation will be considered initially for associates in and near Floyd Memorial Hospital and Health Services. Drivers will assist in identifying other heavily drifted and/or impassable roadways. Drivers will keep their safety and the safety of their passengers first and foremost.
The Transportation Personnel will:1. Receive incoming calls/requests from management
personnel for pickup of top priority personnel.2. Record data on the Transportation slips for both
“pickups” and “take homes.” The slips will include: transportation needs, name, phone, address, and directions.
3. Provide Transportation Slips to drivers.4. Instruct person awaiting transport home to wait in
the Green Valley Lobby area.5. When dispatcher has identified routes, notify persons
that a driver is en route.6. Assist reception personnel to note associates
arrivals. The Dispatcher will:1. Review the following information, which is compiled
annually, prior to the beginning of the usual snow season by Security:
a. A list of Hospital vehicles which are available for transportation and the intended plan for drivers of the vehicles; where to obtain care keys, etc.
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PAGE:EFFECTIVE
DATE: REVISION DATE:
Page 6 of 6/0511/201508-07
b. A list of possible volunteer drivers who have four-wheeled drive vehicles.
2. Obtain and control two-way radios or cell phones to be issued to drivers to facilitate communications while they are out of the hospital.Two-way radios may be available in Security or Maintenance.
G. LODGING, SUPPLIES, MEALS AND SERVICES :1. Lodging and Supplies – The Lodging Coordinator will:
1. Obtain a list of all available sleeping rooms (in the following order):
1) Empty beds on unoccupied (closed) patient units2) Empty beds on occupied (open) patient units3) Other Hospital areas4) Cots may be obtained from
Environmental Services Department
2. Linens may be obtained from Laundry – including blankets, towels, sheets, pillow cases, patient gowns.
3. Receive requests for lodging needs.
4. Assign and keep record of sleeping quarters.
5. Assist staff members with wake-up calls if needed.
6. Communicate lodging activities to Hospital Control when no one is serving in Lodging Coordinator role.
7. Associates in need of medications – injections and medication needs will be
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administered as directed by Pharmacy.
PAGE:EFFECTIVE
DATE: REVISION DATE:
Page 7 of 6/0511/201508-07
H. TERMINATION OF PLAN :
The Crisis Management Lead in will determine when the snow emergency has ended and the Snow Emergency Plan terminated. This will most likely occur when the streets are passable and buses are in service
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BED BUGS- “CODE GREY”PAG
E: EFFECTIVE DATE:
SUBJECT: Bed Bugs: Code Grey
REVISI
ON
DATE:
NUMBER:
Page 1 of6/05
11/201508-07
Purpose:In the event of a Bed Bug outbreak we need to make sure all the following procedures are followed. That will help us prevent a department wide infestation.
Procedure:1. We need to make sure that we first isolate the room and call
environmental services.2. Bag all of the patient’s belongings (including their clothes).3. The patient needs to immediately take a shower or bath and be
given new fresh linens to wear.4. The room must then be scrubbed from top to bottom.
You will hear "Code Grey room 123" over the loud speaker and in that event we need to make sure we keep all patients and staff out of that room, and keep unnecessary personnel off the floor.
The CMT will not need to be notified or activated unless bed bugs become a department wide infestation at which point the CMP needs to be enacted.
When the room has been cleaned and sanitized to the fullest, "All clear Code Grey, all clear Code Grey", and everyone may return back to their daily routines.
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COMBATIVE PATIENT- “CODE YELLOW” PAGE: Page
EFFECTIVE DATE : 9/00REVISION DATE:
SUBJECT: Combative Patient : Code Yellow NUMBER:
11/201508-14
Definition
Combative patient, visitor or associate; Security intervention needed immediately.
Procedure
A Code Yellow will be paged when Security is needed STAT for a situation involving combative patients, visitors or associates.
The following actions will be taken by Security when a Code Yellow is paged:1. ALL Security officers will respond immediately to appropriate area
with caution to assess the situation and determine if a Code Ten should be paged or to call the police department, if deemed necessary.
2. Security will cancel “Code Yellow” after the situation has been resolved.
The following actions will be taken by Associates when a Code Yellow is paged:
1. House supervisor will respond immediately to the appropriate area.
2. Associates will continue to work as normal unless otherwise told by Security or the House Supervisor.
3. All associates will avoid the area of the “Code Yellow” unless they are required to be there.
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EMERGENCY FACILITY EVACUATION- “CODE PLUM” PAGE :
EFFECTIVE DATE: 8/94 REVISION DATE:
SUBJECT: Emergency Facility Evacuation: Code Plum NUMBER:
11/201508-12
Purpose
To describe a plan that provides guidelines for a safe and effective evacuation of all or part of the hospital.
Policy
In most cases, evacuation will not be necessary or advisable. If it is determined, however, that some or all of the facility may not be suitable for occupancy, partial or total evacuation may be warranted.
The order to evacuate may be given by the person in charge of the hospital at the time of the emergency or the ranking Fire Department or emergency response personnel following an emergency event that significantly compromises the overall safety of the building.
Procedure
Decision to Evacuate:
1. Factors upon which the decision to evacuate may be predicated will include, but not be limited to the following:
a. Structural Integrity of the building – following an episode such as an earthquake, engineering personnel will conduct a cursory inspection of the building to assess the building’s structural integrity. If it is determined that, due to structural damages, the building is no longer safe for occupancy, evacuation will ensue.Should severe structural damages present immediate hazard or if obvious life endangerment is identified, (prior to the arrival of engineering personnel) occupants should make every effort to protect themselves from harm and vacate visibly unsafe areas.
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PAGE : EFFECTIVE
DATE: 8/94 REVISION DATE: SUBJECT: Emergency Facility Evacuation: Code Plum
NUMBER:
11/201508-12
b. Emergency/Life Threatening Conditions – Earthquakes are often accompanied by ensuing emergencies such as fire and chemical releases. Should a fire or hazardous material release cause significant life hazard to building occupants, it may be the decision of the Fire Department, engineering, safety officer, etc., to effect full or partial evacuation.
Administration
1. Evaluates situation and orders evacuation of affected area, if necessary.a. Partial evacuation: moving patients to a neighboring safe area.b. General evacuation: moving all patients in the hospital from the
hospital.2. Provides PBX with evacuation information and requests
evacuation announcement.3. Establishes command/evacuation center and staff pool.4. Contacts President of Medical Staff to evaluate the need for
additional medical support.5. After normal working hours, notifies department managers and
administrative staff to report to hospital as needed.House Supervisor/Charge Nurse/Department Manager/Designee
1. Assumes responsibility of directing the evacuation of patients from the affected area.
2. Requests personnel from staffing pool as needed to assist with evacuation.
3. Evaluates the means of evacuation:a. Ambulatory – Gather them first. Appoint personnel to go with
them to the safest part of same floor (toward an exit). Direct personnel where to take them if they must leave the floor.
b. Wheelchair – Appoint personnel to obtain wheelchairs and move patients to safest part of floor (toward an exit). Direct personnel where to take them if they must leave the floor.
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PAGE : EFFECTIVE
DATE: 8/94 REVISION DATE: SUBJECT: Emergency Facility Evacuation: Code Plum
NUMBER:
11/201508-12
c. Stretcher and helpless patients – Some may be able to walk down with support.
Others may need to wait for stretcher bearers. If necessary, roll patient in blanket and pull along floor to safety place (toward an exit).
Nursing/Other Designated Personnel
1. Do a patient count prior to evacuation.
2. Evacuate patients. In the event of a fire, move patients past nearest fire barrier. NOTE: The fire barriers in this hospital exist between east and west wings on each floor.
The set of double fire doors on each wing is the dividing line between wings.
3. Moves patients along corridor walls, assuring traffic is not blocked. Always evacuate patients downward toward ground level unless the route is cut off. Use fire safe stairway nearest your location.
Patients shall be evacuated first from those areas most severely threatened by the disaster.
If time permits, the medical record should go with each patient
If time permits, all equipment should be turned off and all drug cabinets should be locked and secured prior to leaving the area.
House Supervisor/Designee
1. Check area after evacuation to verify that all patients, visitors and staff are clear of area.
Crisis Management Lead
1. Notify Emergency Medical Services of need for general evacuation of facility.
2. Mobilizes community resources implementing single hospital evacuation
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plan.3. If radioactive of chemical isolation and decontamination are
required, notifies appropriate agency for assistance.
PAGE : EFFECTIVE
DATE: 8/94 REVISION DATE: SUBJECT: Emergency Facility Evacuation: Code Plum
NUMBER:
11/201508-12
Post Evacuation Security
After the facility has been evacuated, all entrances should be guarded by Security to prevent unauthorized personnel from re-entering the building until re-entry has been cleared or until the facility has been permanently secured.
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INTERNAL DISASTER PLAN- “DR. WHITESTONE” PAGE:
EFFECTIVE DATE: SUBJECT: Internal Disaster Plan: Dr. Whitestone REVISION
DATE:
Page 1 of 9/9211/201508-09
Internal Disaster
Any situation that may place a patient, visitors, or associate within the hospital in indirect danger, but does not have an effect on any neighborhoods or outside areas.Examples of Internal Disaster
Floor, broken steam lines, computer downtime, etc.Administration
1. Declare "Dr. Whitestone".
2. Advise the Switchboard of the "Dr. Whitestone" activation so that it may be announced overhead.
3. Establish command center in Administration as needed.
4. Coordinate all "Dr. Whitestone" procedures and responses.
5. Coordinate activities with the Floyd County Emergency Management Agency as well as other external public safety agencies as needed.
6. See that necessary internal communications are arranged.To Announce an Internal Disaster
1. Call the Switchboard and give exact location of disaster.2. The Switchboard will page, “Dr. Whitestone, please report to . . .”
giving area affected, four times over the paging system. This will notify the associates designated to respond to an internal disaster.
3. This announcement will inform associates that there is a dangerous situation in that area and to avoid the area until the Switchboard announces an all clear.
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PAGE:EFFECTIVE DATE:
SUBJECT: Internal Disaster Plan: Dr. Whitestone REVISION
DATE:
Page 2 of 9/9211/201508-09
4. If an External Disaster creates an internal disaster, such as a tornado, or an earthquake, etc. the appropriate external disaster code will be paged.
To Announce the All Clear
When disaster is clear, the Switchboard will announce over the intercom system, “Dr. Whitestone, please call the switchboard” two times.
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EXTERNAL DISASTER- “DR. REDSTONE”PAGE:
EFFECTIVE DATE: REVISION DATE:
Page 1 of 1o6/9411/2015
NUMBER: : 08-02SUBJECT: External Disaster Plan Dr. Redstone
Purpose
This plan of action will act as a guide in the event of an external disaster that impacts the normal operation of the Hospital. This plan is a quick simplistic format that centers around the Emergency Center (E.C.) and how all disciplines impact on the processing of patients through the system.
All areas to have a working knowledge of the disaster plan will review this plan. Each area should understand the process and procedures related to their area. All directors and managers for any changes that need to be made should review it periodically.
This plan of care of mass casualties should be rehearsed at least twice a year, if real events occur they will count in place of the drill where applicable.
According to the office of the Floyd County Emergency Management Agency, the local hospital, wherever situated, is one of the focal points of active civil care of a disaster.
Our mission in a disaster is to receive casualties, and provide appropriate treatment in a triaged manner. Discharge of minor injuries, continued care of seriously and critically ill patients, and moving them out of the emergency setting to appropriate areas for more intensive, invasive treatment.
ActivationWhen is the disaster plan placed into effect?
1. When Floyd County Emergency Management Agency activates the disaster plan
2. When the number and acuity of patients is such that the Emergency Center staff cannot adequately care for them.
Who may declare the plan to be in effect?1.Administration2. Administrator-on-call
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3. Emergency Center Physician4. Director of Emergency Services, upon consult with the Administrator-on-
call5. House Supervisor or Crisis Management Lead, upon consult with the
Administrator- on-call
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PAGE:EFFECTIVE
DATE: REVISION DATE:
NUMBER:SUBJECT: External Disaster Plan - Dr. Redstone
Page 2 of 106/9411/201508-02
ProceduresA. Notification
1. The Switchboard Operator will notify administrator on-call.2. The Switchboard Operator would immediately contact the Administrator-
on-call first.3. The Crisis Management Lead will be contacted in the event of a disaster.4. The Switchboard Operator will be responsible for following the phone list designated by Administration.5. Each Director/Manager will keep an up-to-date list of associates’ phone numbers at their home in the event that staff is needed to be called back due to the emergency.6. The Nursing Supervisor will notify all off duty ED associates to report to the Emergency Department.7. The Switchboard Operator will notify the on-campus non-attached
buildings individually.8. The paging code for the disaster will be "Dr. Redstone" and shall be
paged six (6) consecutive times.9. All clear signal "Dr. Redstone, report to the switchboard" will be paged
six consecutive times.B. Emergency Center Activities
Emergency CenterThe Emergency Center will be the center of action during any disaster. The patients will be received in the Emergency Center through two (2) points, the ambulance shelter and the triage area. All patients will be seen according to triage status. The Emergency Center will be in constant communication with the disaster site and medical personnel.
Emergency Center Physician:1.The Emergency Center physician will be responsible for rapid
assessment, assign a preliminary diagnosis, ordering tests, and treatments on all incoming patients.
2. They will inform staff in a timely manner in regards to admission, transfers, surgical, and any other patient destination.
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DATE: REVISION
DATE:NUMBER:
SUBJECT: External Disaster Plan - Dr. Redstone
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3. They will advise staff mode of transport and communicate arrangements with receiving physician.
4. They will process all medical record issues in a timely manner, understanding that we are in a state of disaster.C. Emergency Center Clinical Supervisor
1.Responsible for maintaining a consistent flow of information to the Director and the Crisis Management Lead.
2.Assures that all areas have responded to the Emergency Center.3. In the event the nursing supervisor is not on duty, the clinical
Supervisor will assume these responsibilities.4.The Clinical Supervisor will be very mobile within the department, and
maintain communications with all areas of the department.D. Emergency Center Triage TeamThe triage nurse will be an RN in the Emergency Center assigned by the Team Leader, and have a running knowledge of all the rooms and understand the importance of proper placement of the trauma, cardiac, and general treatment patient.
1.The triage nurse will be placed in the ambulance shelter to do a rapid assessment of all incoming patients to the department.
2. They will assign rooms to each patient keeping a record of placement on white board for reference at all times.
3. The triage nurse should not be the team leader.4. This position is completed when all patients have been delivered
from the scene.5. The nurse will then return to the department to assist in patient
care.6. The triage team will evaluate and assign a preliminary diagnosis.
The triage team is to include: One (1) M.D. if available One (1) R.N. One (1) Emergency
Center
Emergency Center Team Leader:1.Will be responsible for the flow of patients in the department along
with trouble shooting problems that may arise.2.Will focus mainly on patient care and interdepartmental issues.
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3.Will report any issues related to other departments to the director in a timely manner.
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DATE: REVISION DATE:
SUBJECT: External Disaster Plan - Dr. RedstoneNUMBER:
Page 4 of 106/9411/201508-02
Emergency Center Staff Nurse:1.Will receive room assignments by the team leader and receive all patients.2. Will perform a rapid secondary assessment and start interventions
according to the department standards
3. Will assist the doctor as needed with procedures.4. Flexibility is a must in this position, to increase the rapid
progression of patient through the department
Emergency Center Technician:
1.Will follow the doctor and take assignments according to need.2. Will be responsible for setting up needed trays, vital signs, getting
needed equipment, cleaning wounds, dressings, and helping as needed.3. Will report to the team leader any problems that might arise.4. The Emergency Center tech will stay on the first floor while the disaster is
in progress. 5. They will also help relay information to the triage nurse as needed.6. They will return to routine duties after all patients have been
processed from the disaster.7. Restocking and taking care of regular patients at this point will be the priority.
Emergency Center Unit Secretary:1.Will remain at the nurses station at all times during the disaster.2. Will be responsible for orders to other areas and communications that
come into the department. IHAN radio system The telephone The fax machine
3. They will maintain normal functions of their jobs at all times.4. They will report any problems to the team leader.5. They will coordinate calls to other areas in the hospital that will receive
patients from the Emergency Center.
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PAGE:EFFECTIVE
DATE: REVISION DATE:
Page 5 of 106/9411/2015
NUMBER: A 08-02SUBJECT: External Disaster Plan - Dr. Redstone
Communication:The Paris Education Center will house the Command Center where all internal communication is to take place. Media should be directed to the Media Control Center following procedure outlined in the Crisis Control Section. All telephone communications shall be directed through Emergency Center Patient Registration during external disasters. (Note: after 7 p.m., all telephone calls to Patient Registration are automatically forwarded to the Emergency Center Registration Desk.)
Departmental Responsibilities Administration:
1.Establish command center in Administration.2.Coordinate all disaster procedures and responses.3.Coordinate activities with other hospitals and Floyd County Emergency
Management4.See that necessary internal communications are arranged.5.Keep media aware of developments.
Infection Control:1. Infection Control Nurse needs to be contacted.
House Supervisor:
1.Act as Crisis Management Lead until relieved.2. Directly responsible for bed control and facilitating the movement of
patients out of the Emergency Center to other areas of the hospital depending on the total number of estimated incoming patients to the Emergency Center.
3. The House Supervisor will call in extra staff or pull staff from other areas to assist as needed.
4. The area receiving the patient will come to the Emergency Center with enough help to transport the patient back to their areas.
5. They will return the stretcher to the Emergency Center immediately.
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PAGE:EFFECTIVE
DATE: REVISION DATE:
NUMBER:SUBJECT: External Disaster Plan - Dr. Redstone
Page 6 0f 106/9411/201508-02
Patient Registration and Health Information Management:1.Patient registration will use regular downtime policy for
registration. Each chart will have an ident-a-tag sticker placed on the top of the fact sheet.
2.Both numbers will identify each patient.3.One (1) person from Health Information Management will report to
the Switchboard to assist with incoming callsMedical Staff:
1.The Director of Medical Staff Services will coordinate Medical Staff based on the needs of the Emergency Center Physicians.
2. The incoming Medical Staff members will check with the Emergency Center Physicians upon arrival at the hospital.
3. In the case of evacuation of patients from one section of the hospital to another, or evacuation from the hospital premises, the Chief of Emergency Medicine, in conjunction with the Chairman of Medicine and Surgery, will authorize the movement of patients by direction of the Incident Commander.
All policies concerning patient care will be a joint responsibility of the Chief of Emergency Medicine, in their absence the Chief of Staff, and the Crisis Management Lead. All members of the Medical Staff of the hospital specifically agree to relinquish direction of the professional care of their patients to the Emergency Department and the Departments of Medicine and Surgery, in case of emergency.
Medical Staff Services Department:1.Check with the Emergency Center to ascertain which and/or how
many physicians need to be contacted.2.Contact "in-house" physicians to report to the Emergency Center.3.If necessary, form a telephone pool, with an Administrative Assistant
to summon physicians to the hospital.Environmental Service and Laundry:
1.All Environmental Services and Laundry associates will remain in the work area.
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2. Assist in the labor pool as needed.
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DATE: REVISION DATE:
SUBJECT: External Disaster Plan - Dr. RedstoneNUMBER:
Page 7 of 106/9411/201508-02
Food and Nutrition Services Department:1. The Food and Nutrition Services Department must be prepared to
furnish quantities of coffee, fruit juices, broth, etc.2. The Food and Nutrition Services Director will issue instructions
canceling regular menus and will prepare for mass feedings of patients, casualties, and staff upon orders from the President or person in charge.
3. In the absence of the Food and Nutrition Services Director, the Food and Nutrition Services Manager or any Food and Nutrition Supervisor will be in charge.
4. Plans for handling long term feeding (2 weeks) are located in the Procedure Book in the Food and Nutrition Services office.
Maintenance Department:1.The Maintenance Department will be responsible for maintaining
the integrity of utility services to the hospital.2. Augment and support where identified and applicable, primarily
security and traffic control needs.3. Distribute battery-operated lights to augment emergency
generator in case of power failure.
Biomedical Services:1.The Biomedical Department (including Biomedical and
telecommunications technicians) will be put on alert to respond to the Emergency Center, as a priority, in the event of Biomedical or Telecommunications equipment failure.
2.Assist with locating or repairing needed biomedical equipment. Outpatient Surgery:
1.Outpatient Surgery Center will be a holding area for non-critical admissions from the Emergency Center.
2.A Radiology and Laboratory associate will be available to this area as needed.
3.Outpatient Surgery associates should report to their departments to be available for service as directed by their supervisorCentral Processing:
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1.Associates should report to their department and be available to provide needed supplies to the Emergency center as requested.
2.Assist as needed.
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DATE: REVISION DATE:
NUMBER:SUBJECT: External Disaster Plan - Dr. Redstone
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Orderlies:1.Report to the Emergency Center to help in the transport of
patients within the department and will assist the Emergency Center staff as needed.
2.Go get extra stock for the Emergency Center.3.Assist as needed.
Pharmacy:1. A pharmacist must be available to provide controlled substances to the
Emergency Center as needed.2. After hours, the on-call pharmacist will be notified to respond to
hospital by the house supervisor if deemed necessary.3. Supply medications on demand.4. Supply runners to take medications to areas specified, if necessary.
Security Department:1.Ensure the security of the Hospital by implementing lockdown
procedures.2. Police the flow of traffic outside of the hospital.3. Ambulance driveways will be kept clear.4. Only authorized vehicles and persons will be admitted.5. Authorized vehicles and persons are defined as vehicles transporting
victims, supplies, and individuals involved in the disaster.Volunteer Department:
1. The Director of Volunteers shall maintain a listing of volunteers and phone numbers at the hospital and at home to call volunteers in to assist in a disaster.
2. Volunteers are to receive their orders from the Director of Volunteers. They can be utilized to run errands, dispense food and drinks, etc.
Human Resources Department:1. Associates will report to the Education Conference Room, to
assist the Social Services Director with families.2. Will serve as back-up Family Contact Liaison if Social Services
associates are not available.Critical Care Services:
1. The Critical Care areas will work on moving patients out of the department to free space to accept patients from the Emergency Center.
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DATE: REVISION DATE:
SUBJECT: External Disaster Plan - Dr. RedstoneNUMBER:
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2.When admission to the Critical Care areas are made, the nurse receiving that patient will come to the Emergency Center and report to the house supervisor or the unit secretary to receive information on the location of the patient and the needed paperwork for admission.
3.This nurse should bring enough help to safely transport the patient back to their area.
4.The immediate return of the stretcher is also their responsibility. Surgery:
1.The Surgery Department will be called to stand by when the disaster is called.
2. They will accept their patients the same way as the critical care areas.3. They will report to the house supervisor and the unit secretary to
receive needed paperwork and information before taking the patient to surgery.
4. They will receive a brief report by the nurse as they arrive at the room.
5. The surgery crew will transport the patient to surgery immediately after the brief report.
6. Surgery staff will return the stretcher immediately to the Emergency Center.
Laboratory:1. They will respond to the Emergency Center and draw blood and
transport specimens to the Laboratory as ordered.2. Assist as needed. Radiology:3. They will respond to the Emergency Center and take x-rays and provide
other radiological needs as ordered.4. Assist as needed.
EKG (Cardiology):1.They will perform all needed EKG's as ordered.2. Assist as needed.
Respiratory Therapy:1.The therapist will be responsible for all treatments and also for
calling any backup personnel if needed.2.The therapist is responsible for maintaining respiratory stock.3.Assist as needed.
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PAGE:EFFECTIVE
DATE: REVISION DATE:
SUBJECT: External Disaster Plan - Dr. Redstone NUMBER:
Page 10 of 106/9411/201508-02
All Other Areas:1. The floors will be aware of their bed situation and be on standby for
moves within the hospital or direct admissions from the Emergency Center.
2. Provide staff as ordered for the labor pool.3. Assist as needed.
Urgent Care Center:1. The Director of Emergency Services will inform Urgent Care that an
external disaster is in effect.2. Urgent Care will remain on standby.3. The Urgent Care Center will remain open until the disaster has been
cleared.
Coroner:1. The Coroner will follow the disaster plan developed for external
disasters for the Coroner's Department.2. The coroner will assess the scene and make a decision on the
temporary morgue/ mobile morgue.
Labor Pool1. Associates will report to the House Supervisor or their designee at
the designated Labor Pool area.2. The House Supervisor or their designee will designate assignments
for each.
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INFECTIOUS DISEASE OUTBREAK- “DR. CHARLES”PAGE:
EFFECTIVE DATE: REVISION DATE:
SUBJECT: Infectious Disease- Dr. Charles NUMBER:
Page 1 of 19/9211/201508-09
Infectious Disease
Any situation that may cause an outbreak and a sudden increase in occurrences of a disease in a particular time and place. It may affect a small and localized group or impact upon thousands of people across an entire continent.
Examples of Infectious Diseases
Please refer to CDC examples as a reference list- (Center for Disease Control)
Also if anything was needed from a staff perspective please contact Tamara Pursell.
1. Declare "Dr. Charles".
2. Advise the Switchboard of the "Dr. Charles" activation so that it may be announced overhead.
3. Establish command
4. Coordinate all "Dr. Charles" procedures and responses.
5. Coordinate activities with the Floyd County Emergency Management Agency as well as other external public safety agencies as needed.
6. See that necessary internal communications are arranged.
To Announce an Infectious Disease1. Call the Switchboard and give exact location of disaster.
2. The Switchboard will page, “Dr. Charles", please report to . . .” giving area affected, four times over the paging system. This will notify the associates designated to respond to an internal disaster.
3. This announcement will inform associates that there is a dangerous situation in that area and to avoid the area until the Switchboard announces an all clear.
4. When disaster is clear, the Switchboard will announce over the intercom system, “Dr. Charles, please call the switchboard" two times.
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PAGE 84
BOMB THREAT- “OPERATION ZERO ZERO FIVE”PAGE
: EFFECTIVE DATE:
REVISION DATE:
Page 1 of 4/9611/201508-03
This plan outlines the action required whenever a bomb threat is made against Floyd Memorial Hospital and Health Services. The plan also includes the action required whenever a suspected explosive device is found or whenever an explosion occurs in the hospital.
Read the instructions to learn what your duties and responsibilities are as a Floyd Memorial associates. Know what “Operation Zero Zero Five” means when you hear it announced over the speaker system.
This is a plan of mutual aid and cooperation between departments and associates of Floyd Memorial Hospital and Health Services to search, secure, and protect the patients, associates, and hospital property against confusion or damage resulting from a bomb threat. An effort has been made to organize the plan in such a manner that is will be flexible enough to meet changing needs that arise during a period of emergency.
General Information
The bomb, the bomber, location sensitivity, and community relations must be evaluated in determining the actions to be taken in the event of a bomb threat.
The Bomb – Any container common to all areas of the hospital must be considered as a potential bomb container. Explosives most commonly used are commercial dynamite, black powder, and plastic explosives. Black powder is usually encased in a section of pipe.The Bomber - A former patient, a relative of a patient, an associate, a former associate, a mentally disturbed person, all with real or imagined grievances, the criminal or revolutionist with intent to kill or disrupt are all prime suspects in bombings.
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PAGE: EFFECTIVE
DATE: REVISION
DATE:
Page 2 of 4/9611/201508-03
Location Sensitivity – All areas of the hospital are to be considered as easily accessible to potential bombers and must be evaluated as to their relationship to the time period the bomb threat is received. Large areas of the hospital normally used on the 7 a.m. – 5 p.m. basis would be less desirable to the bomber than the 24-hour sections, due to their limited accessibility and their relationship to the patients. NO AREA CAN BE OVERLOOKED OR IGNORED IN THE SEARCH PATTERN .Community Relations – The climate of the relationship within the community between races, schools, labor unions, and outside disaster must be evaluated in order to properly judge the extent and probabilities that lead to bomb threats.
Crisis Management Team1. Establish command center in Paris Education Center
2. Establish media command center in Professional Arts Building3. Coordinate all bomb threat procedures and responses.4. Coordinate activities with other hospitals and Floyd County
Emergency Management Agency as well as other external communications as needed.
5. See that necessary internal communications are arranged.6. Keep media aware of developments.
The following three-stage sequence will be activated for all bomb threats. Escalating to the next stage will be decided by the CEO or representative, the Security Lead, and the External Bomb Squad Lead. There will not be time for long deliberation and it is assumed that these three individuals are prepared to make this decision in a swift, knowledgeable manner.
During normal strikes, protests, and disasters, 99% of all bomb threats are false. Stage one assumes that it would be sufficient to organize and conduct the search.
Whenever race riots, uncontrolled strikes, protests or disaster affecting a majority of one class of society occur, the percentage of false threats drops to 95%. In this case, Stage
Two would be considered most effective.
Stage One - No evacuation - search procedure and business as usual.Stage Two - Evacuation of all visitors, outpatients, emergency room patients, office associates and those associates not directly involved in patient care or in search procedures. (Evacuation of associates refers to
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safe distance evacuation; associates should not be released from duty or sent home at this point in time.)Stage Three - Complete evacuation of the hospital.
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PAGE: EFFECTIVE
DATE: REVISION
DATE:
Page 3 of 4/9611/201508-03
The Security Lead will establish communications with police officials to determine the community temperament when any bomb threat is received.
The Crisis Management Lead will prepare the complete report of the incident
General Instructions
The code name for the Bomb Threat Plan is “Operation Zero Zero Five.” In announcing that the Bomb Threat Plan is being activated, the switchboard operator will announce twice, over the public address system, “Operation Zero Zero Five – Stage One/Two/Three is now in effect.” At this time, the switchboard operator will also make an announcement asking that all two-way radios and cellular phones be turned off.Any hospital associate who answers a phone and a threat of a bomb is made, must make a written note of the time and fill out the Bomb Threat Form, male or female voice, and message received. Call switchboard operator a relay message, stating your name, department and phone number where message was received. DO NOT TALK TO OTHER ASSOCIATES. PASS WRITTEN MESSAGE TO YOUR SUPERVISOR FOR THE HOSPITAL RECORDS.
The Switchboard operator will then relay the message to the the Crisis Management Lead, and he/she will give instructions on implementing which option to page.The Crisis Management Lead, will immediately call the county emergency number, 911, and report the bomb threat to them. They will send police and fire officials to the hospital. With their assistance, we can evaluate community temperament to determine validity of the threat and implement the search procedure accordingly.
Day Bomb Threat – If the bomb threat is received during normal office hours, after authorized by the Incident Commander, the switchboard operator will notify these departments by phone: Security, Maintenance, Environmental Services, and Human Resources.Night Bomb Threat – If the bomb threat is received when normal offices are closed, after authorized by the President’s designee, the switchboard operator will notify the President, and Vice Presidents, Director of Security, Director of Nursing, Facilities Management Director, and advise them of
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Operation Zero Zero Five being in effect. They will report for duty and supervisor implementation of the plan. The Medical Staff Executive Committee will be informed by direction of the Incident Commander.
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PAGE: EFFECTIVE
DATE: REVISION
DATE:
Page 4 of 4/9611/201508-03
Directors who are at home and are notified by telephone, the operator will state “Operation Zero Zero Five is now in effect at Floyd Memorial Hospital and Health Services.” These key persons must be responsible for knowing what this statement means. The switchboard operator will not have time to explain what the call signifies nor to spell out details of the alert.
Preventive Steps
When community relations’ conditions make preventive steps advisable, the following measures should be taken upon direction of the Incident Commander.
1. Advise all associates to increase vigilance in their normal work areas.2. Set up patrols of critical areas – restrooms, hallways, stairways,
entranceways, elevators, loading dock, waiting rooms, snack bar, and exterior perimeter.
3. Lock and keep a constant patrol of doors to electrical switchgear, laundry chute rooms, linen rooms, locker rooms, telephone wire rooms, dumb waiter areas, mechanical rooms, all restricted areas and lobby.
4. Check and secure all emergency power.5. Secure and patrol all electrical panels and circuit breaker boxes.6. Report all suspicious persons or acts.
The Crisis Management Lead will implement the preventive steps by a called Supervisor Meeting. These steps can be taken without undue burden on any department as they follow a common sense pattern of enforcement for normal activities within the hospital.
Search Procedure
When the Bomb Threat Plan is activated, the control center for the search will be the Administrative Board Room during normal hours of operation and Classroom #1 for other than normal hours.
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PAGE: EFFECTIVE
DATE: REVISION
DATE:
Page 5 of 4/9611/201508-03
The search labor pool will be formed of all hospital associates not directly involved in patient care in the Cafeteria under the supervision of the Security Lead. Calls for labor pool will be as follows:
1. Nursing Division for patient assistance.
2. Security, Maintenance, and Environmental Services for main hospital search.
The search will be conducted in an orderly manner, without alarm and without haste. Each section will be responsible for their own area of activity.
The Bomb device can be concealed in most any containers. It is the box, bag, carton or package that seems out of place that is suspected. DO NOT TOUCH OR MOVE IT. Contact Security Office, extension 5788, to implement plan for when suspected bomb is found.
The switchboard will make an announcement asking all visitors/associates/physicians to shut off all two-way radios and cellular phones.
When Suspected Bomb Device Is Found1. Do not touch or move the device.2. Report to control center, giving time, location, and your name.3. Stand by and await security associates to show them the exact location.
All ClearThe Crisis Management Lead, will advise the switchboard operator to
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page “Operation Zero Zero Five, Canceled.” This signifies to all associates the danger has passed and the bomb threat has ended.
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CHILD ABDUCTION- “CODE ALERT”PAGE
: EFFECTIVE DATE:
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Purpose
To ensure a safe and secure environment and measures are taken to protect newborns from unauthorized removal. To provide a quick response systems if potential infant abduction should occur.Goal: To minimize the possibility of a successful infant abduction.
PolicyAll newborns will have a transmitter sensor and band affixed to the ankle after the initial bath and documented on the care plan and in sensor registry.
The sensor will be deactivated if the newborn must leave the monitored areas. If the newborn is taken out of the monitored area without the sensor being deactivated, an alarm will sound, and the Mother/Baby staff will initiate the Infant Abduction Code (Code Alert).
Information on infant safety and security will be given to parents upon admission to postpartum and with the initial newborn instructions.
Response to AlarmWhen the alarm is activated, the operator will page “Code Alert” three times, announcing the alarming exit. All appropriate personnel hearing the page must respond and investigate the alarming exit before turning alarm off. See departmental specific duties.
The Crisis Management Lead will approve an “All Clear” when infant is accounted for.
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In the Event of a Paged “Code Alert”Every department’s response team will:
Know the profile of the potential abductor:- usually heavy-set woman- often wears scrubs and/or layered clothing to appear pregnant- carries large bag, suitcase or backpack- asks many questions, often about routines and policies- stays in area longer than normal visitors; frequently visits
prior to intended abduction date- often works with a partner
Associates must adhere to the confidentiality policy. We do not want to alarm the patients, associates, visitors or the general public.
Immediately check all large bags, packages, and backpacks, which would be large enough to hold a newborn.
Guests attempting to leave the hospital will be asked to cooperate until the “All Clear” isannounced.
Be aware of any unusual disturbances on the unit as abductors may work with a team who could divert attention away from the abduction site.
If you find the abductors with an infant, delay then until Security/police arrive.
Observe suspect very closely; height, weight, body build, hair and eye color, complexion, and any distinguishing features.
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Administration
1. Determine that an actual abduction or abduction attempt has occurred.
2. If the abduction was thwarted go to steps "6 - 9". If the infant is determined missing, advise the Switchboard of the "Code Alert" activation so that it may be announced overhead.
3. Establish command center in Administration.4. Coordinate all "Code Alert" procedures and responses.5. Coordinate activities with the New Albany Police Department as well as
other externalpublic safety agencies as needed.
6. See that necessary internal communications are arranged.7. Take care of the effected family.8. Coordinate media updates.
Return of the InfantNotification Notify key people immediately Notify mother and other family members of a possible return of their
infant
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TELEPHONE FAILURE PLAN- “CODE CITRIX”PAGE:
EFFECTIVE DATE: REVISION DATE:
Page 1 of 9/9211/201508-08
EXTERNAL TELEPHONE FAILURE
The following procedure should be followed in the event of external interruption of telephone services:
1. The switchboard will page that the external telephone system is non-operational. If it is known approximately how long repairs will take, this should also be announced.
2. Patient Registration will act as a liaison among the area physicians’ offices to retrieve and send written orders for patient care and services needed.
3. If the hospital telephone service is uninterrupted, we will use standard operating procedures.
INTERNAL TELEPHONE FAILURE
The following procedure should be followed in the event of internal interruption of the hospital’s telephone system:
1. The switchboard will page on the manual paging system that the telephone system is non- operational. The switchboard should also announce approximately how long the system will be non-operational.
Emergency Bypass Phone Numbers
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Department/Unit Main Phone # Bypass Phone #Switchboard 812-944-7701 812-981-6655Switchboard - Cell Phone 812-786-8387IS Helpdesk 812-948-7500 812-981-6620Patient Registration 812-949-5520 812-949-7878Medical Records (HIM) 812-949-7422 812-949-78802B Nurse Station (224-237) 812-949-6710 812-948-74932C Nurse Station (239-251) 812-949-7564 812-948-75392D Nurse Station (252-272) 812-948-7429 812-948-7540PCU Nurse Station 1 (2101-2110) 812-948-7428 812-948-7541
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Temporary Telephone System Outages
Use your department’s emergency bypass phone. If you experience problems reaching another department, use the temporary bypass number listed above for that department.
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PCU Nurse Station 2 (2111-2120) 812-949-7902 812-948-7542PCU Nurse Station 3 (2121-2132) 812-948-7606 812-948-7543PCU Nurse Station 4 812-949-7903 812-948-7544CCU Nurse Station 1 812-948-7425 812-948-7547CCU Nurse Station 2 812-949-7925 812-948-7548CVCU Nurse Station 1 812-949-7017 812-948-7551Respiratory Therapy 812-948-7415 812-948-7552Cardiology 812-948-7406 812-948-7553ER Registration 812-949-5930 812-949-5693ER 812-948-6742 812-948-7556Lab - Reception 812-948-7405 812-949-7797Lab - Chemistry 812-948-7604 812-949-7871Cath Lab 812-949-7100 812-949-7884Information Desk 812-948-7400 812-949-78743C Nurse Station 812-948-7421 812-949-57243A Nurse Station 812-949-5633 812-949-5720Labor and Delivery 812-949-5574 812-949-57154A Nurse Station 812-948-7418 812-949-57144C Nurse Station (PEDS) 812-948-7426 812-949-5716Surgery Nurse Station 812-948-7417 812-949-5681Security Office 812-949-5788 812-949-5689Outpatient Surgery 812-948-7601 812-949-5802Outpatient Cardiovascular Unit 812-949-7955 812-949-5827Food & Nutrition 812-944-7701 ext. 2429 812-949-5533Pharmacy 812-948-7404 812-949-5967Maintenance 812-948-6757 812-981-6538
ACTIVE SHOOTER- “CODE SILVER” PAGE
: EFFECTIVE DATE:
REVISION DATE:
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Purpose
The purpose of the “Code Silver” Active Shooter plan is to provide an immediate and effective response to an active shooter situation.
PolicyCode Silver is the Floyd Memorial Hospital code for an active shooter. “Code Silver” will be overhead paged in the event of an actual active shooter situation.
ProcedureA. Active Shooter
The intent of most active shooters is to kill as many people as quickly as possible. Therefore, the traditional law enforcement response of “surround and contain” allows the subject to accomplish his goal. In order to save lives, the law enforcement agency having jurisdiction will initiate an immediate response. Security Officers will support this response as described herein.
B. HostagesActive shooters do not take hostages. FMH Administrative Policy 08 -15 will govern response to hostage situations: Code Ten – Hostage Situation/Weapon Involved Response Plan issued September 2000.
C. Alert NotificationUpon discovery of an active shooter situation, or a person entering the facility with a weapon displayed at Floyd Memorial Hospital, the Switchboard will be notified by dialing “0.” The Switchboard will immediately notify the New Albany Police Department (NAPD) by calling 911, giving all available information, and identifying the most appropriate location for a police response.
The Switchboard will then overhead page:PAGE 98
“May I have your attention please, Code Silver” and the location.This will be repeated three times.
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D. Security ResponseThe Security Officer in the Monitor Station will attempt to track the active shooter using CCTV and alarm systems and incoming calls from all floors. All Security Officers on patrol will assist with clinical response in patient care areas as described below. Security Officers will not attempt to interdict an active shooter.
E. Clinical Response in Patient Care Areas1. Clinical staff and support staff in patient care areas will remain calm
and calm the fears of patients and visitors.2. Staff, patients and visitors will immediately go into patient rooms,
close the doors and use beds to barricade the doors.3. Staff, patients and visitors will then lock themselves in patients’
bathrooms and remain there until rescued by responding law enforcement officers or a “Code Silver All Clear” is paged.
4. Staff, patients and visitors will stay as low to the floor as possible.5. Staff, patients and visitors will remain quiet and still.6. Under no circumstances is staff; patients and visitors to flee from the
area or leave the facility unless instructed to do so by law enforcement officers or to protect themselves from imminent physical dangers.
7. If staff members can safely call the Switchboard or 911 using a cell phone or landline from the area in which they are concealed they should do so, giving as much information as possible including:a. Description of the suspect(s),b. Number and types weapons,c. Subject’s direction of travel, andd. Location and condition of any known victims.
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F. Non-Clinical Staff Response in Non-Clinical Areas, Physicians’ Practices, Business Offices, etc.1. Staff should remain calm, and calm the fears of others.
2. Non-clinical staff, patients and others will immediately proceed to areas that can be locked, i.e., offices, conference rooms, bathrooms, etc.
3. Staff and others will stay as low to the floor as possible, using desks, filing cabinets and other furniture as cover.
4. Staff and others will remain quiet and still.
5. Staff and others will remain behind locked doors until rescued by responding law enforcement officers or a “Code Silver All Clear” is paged.
6. Under no circumstances is staff and others to flee from the area or leave the facility unless instructed to do so by law enforcement officers or to protect themselves from imminent physical dangers.
7. If staff members can safely call 911using a cell phone or landline from the area that they are concealed they should do so, giving as much information as possible including:a. Description of the suspect(s),b. Number and types weapons,c. Subject’s direction of travel, andd. Location and condition of any known victims.
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G. Hospital Crisis Management LeadThe nature and duration of Code Silver will normally preclude the activation of the Hospital Crisis Management Lead during the event. However, as soon as the active shooter is neutralized, the Hospital Command Center opened to deal with after-action issues including:1. Inner and outer perimeters established by law enforcement.2. Treatment and evacuation of the injured.3. Safety sweep for unknown hazards by law enforcement.4. Evacuation of some or all of the facility.5. News media response.
H. Alert CancellationUpon the guidance and direction of NAPD, the cancellation of the Code Silver will be announced.The Switchboard will then overhead page:“May I have your attention please, cancel Code Silver.”This will be repeated three times.
I. CritiqueThe Crisis Management Lead and the Chief Executive Officer will conduct acritique of any Code Silver and include administration, directors and employees or departments involved, and NAPD representatives. The purpose of this critique is to evaluate Code Silver policies and procedures, the effectiveness of the Security Department and other departments’ response, and to revise and update policies and procedures for future incidents.
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HOSTAGE/ VOLATILE SITUATION WITH A WEAPON- “CODE TEN”PAGE:
EFFECTIVE DATE: REVISION DATE :
NUMBER:
Page 1 of 9/0011/201508-15
If a hostage or volatile situation is taking place and weapons are involved, use extreme caution. Police have been notified.Code Ten or Code Ten Exterior will be paged in a situation considered to be extremely dangerous. When paging the Code Ten, please remember to include the location.Extreme caution is to be used when responding. The Switchboard will contact the Police Department upon immediately hearing the Code Ten paged.
Actions taken by Security for a Code Ten or Code Ten Exterior:1. Security Officer will respond immediately to the area obtaining as
much information as possible and will relay this information to the Switchboard who will in turn contact the Police Department.
2. Upon arriving at the specific area, Security will gather additional information and relay this to the Switchboard who will relay to the New Albany Police Department. Security Officers will assist with subject(s), located subject(s), or decide if subject(s) should be approached.
A. If the subject is to be approached, an attempt will be made to keep all associates away from the area in order that appropriate action can be determined.
B. If the subject is not to be approached, Security will remain at a safe distance keeping associates away from the area until police arrived. Subject will be kept in sight at all times, if possible.
C. Administration will be notified of events as soon as possible.D. All efforts to coordinate and cooperate with the Police
Department will be made.E. Cancel Code Ten will be paged when it has been determined to
be safe.F. If it is determined that additional assistance is needed,
associates in the Maintenance Department will be contacted.
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Actions taken by Associates when Code Ten or Code Ten Exterior is paged
1. Associates are to remain in their immediate areas when a Code Ten or Code Ten Exterior is paged.
2. All doors to patient rooms, kitchen areas, closets, etc., are to be closed immediately.
3. Associates are to assist in keeping areas secure until the Code Ten has been cleared. Visitors should NOT be allowed to leave during a Code Ten.
4. Associates are to report any problems or suspicions to Security immediately.
Cancel Code Ten will be paged when it has been determined to be safe.
Administration
1. Activate CMP and determine the severity of the situation.2. Establish command center in the learning center.3. Coordinate all "Code Ten" post-incident procedures and responses.4. Coordinate activities with the New Albany Policy Department as
well as other external public safety agencies as needed.5. See that necessary internal
communications are arranged.6. Take care of the affected family and staff members.7. Coordinate media updates as appropriate.
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WEAPONS OF MASS DESTRUCTION- “CODE PINK”
PurposeIn response to the realized potential that health care facilities may be directly or indirectly involved as the result of an act of weapons of mass destruction, it is the intent of Floyd Memorial Hospital and Health Services to develop a Weapons of Mass Destruction Management Plan in concert with the established Emergency Preparedness Program.
ScopeThis plan will identify actions to be taken in the event that Floyd Memorial suspected that an exposure, actual or potential, weapons of mass destruction act has presented itself to the hospital.
Definition of Weapons of Mass DestructionWeapons of Mass Destruction includes the use of explosive devices, may be radiological, micro-organisms (bacteria, viruses, and fungi) or toxins from living organisms to produce death or disease in humans, animals, and plants.
Recognizing a Weapons of Mass Destruction EventA weapons of mass destruction event may be suspected when increasing numbers of otherwise healthy persons with similar symptoms seek treatment in hospital emergency departments, physician’ s offices, or clinics over a period of several hours, days, or weeks. The most common features of an outbreak caused by bioterrorism include:
A rapid increase (hours to days) in the number of previously healthy persons with similar symptoms seeking medical treatment;
A cluster of previously healthy persons with similar symptoms who live, work, or recreate in a common geographical area;
An unusual clinical presentation; An increase in reports of dead animals;
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REVISION DATE:
11/2015
Lower incidence rates in those persons who are protected (e.g., confined to home; no exposure to large crowds)
An increased number of patients who expire within 72 hours after admission to the hospital
Any person with a history of recent (within the past 2-4 weeks) travel to a foreign country who presents with symptoms of high fever, rigors, delirium, rash (not characteristic of measles or chicken pox), extreme myalgias, prostration, shock, diffuse hemorrhagic lesions or petechiae; and/or extreme dehydration due to vomiting or diarrhea with or without blood loss.
Immediate results of any explosive device. A hazards vulnerability analysis survey was conducted by Floyd
Memorial Hospital and Health Services to identify our potential risk of a mass causality event. Our analysis indicates that our area is most vulnerable to a chemical event. We have identified industrial ammonia as our most likely potential agent.
Infection Control1. The infection Control Nurse will be notified of the possible WMD event.
2. They will evaluate the situation and give clinical and professional guidance on the matter.3. Provide information that will be used to protect the incoming patients, those already under inpatient care, staff, and visitors.4. Depending on the size and scope of the event, act as the Incident Command Center’s Medical/Technical Specialist.
Activation of External Disaster CodeThe President/CEO or designee in collaboration with the infection prevention lead will make the determination to implement the External Disaster Plan as deemed necessary to support the Weapons of Mass Destruction Management Plan.
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Upon notification, the infection prevention lead in collaboration with the Crisis Management lead will make the decision for the need to contact other internal and/or external entities such as the “Medical Subcommittee- Louisville/Jefferson County Crisis Group, Security, Lab, and other hospital departments.
Patient ManagementBecause of its locations, clinical, and mechanical services, the space immediately adjacent to the Emergency Department, the Wound Care Center, and Pain Management Department, will serve as the Patient Management area for Weapons of Mass Destruction patients.
In the event that isolation/negative airborne air pressure is determined to be necessary, two portable HEPA air filter exhaust systems are maintained to provide this need.
Plan ReviewThis plan will be reviewed at least annually by the Emergency Preparedness Committee and updated to comply with local, state, or federal guidelines.
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