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Emergency Operations Policy Manual

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Mission and Purpose: 
The mission of Chatham Hospital in respect to All Hazards Emergency Operations is to respond to emergency situations and disaster scenarios; to ensure that casualties and property damage are minimized; to restore normal operations and to coordinate all emergency management activities with the Chatham County Emergency Operations Center (EOC) as well as with other local emergency response agencies.  

Chatham Hospital's Emergency Operations Plan (EOP) utilizes the Hospital Incident Command System (HICS) and National Incident Management System (NIMS) requirements and Joint Commission Standards to provide a flexible all-hazards emergency preparedness, response, recovery and mitigation framework.  The purpose of this plan is to provide an ALL Hazards approach to be utilized as a guide in the event of an emergency, crisis or disaster scenario that would affect the safety and well being of our patients, visitors, employees and community partners / stakeholders who may be affected by the event.

This plan is applicable to Chatham Hospital and it's facilities.

The Chatham Hospital Emergency Management Committee, along with its community partners conducts an annual Hazard Vulnerability Analysis (HVA) to identify emergency planning and educational priorities.  The specific policies that are addressed are based upon the HVA as well as organizational identified needs.

This policy will be continually updated and evaluated and will include recommendations based on disaster training and drills. 

The Fast Command System will be utilized in conjunction with Emergency Management and Environment of Care policies.  Job Action sheets and responsibilities for each role are listed on the Fast Command System.  The Fast Command System is accessible through the Chatham Intranet Homepage – Fast Command link. 

The Emergency Operations Plan and associated policies will be located in the Emergency Management and Environment of Care manuals and on the Fast Command System.

Each department will be involved in establishing an essential personnel list and duties roster.

Declaration of a disaster will be initiated by the Emergency Department attending physician and the Administrator-on-Call.  A “Code D” will then be announced by the ED charge nurse three (3) times over the hospital-wide overhead paging system. At that time, a representative from each department will respond to the Command Center for further instruction.  (See Internal and External disaster plans for further direction).

In the event of a disaster drill requiring decontamination; the disaster will be paged as “Code D – Haz-Mat”. 

A hospital Command Center will be set up in the Small Conference Room in the event of a disaster and/or disaster drill. All in-house personnel will initially be dispatched from the Command Center to fulfill the various roles and needs of the event. It will be imperative that the Command Center be aware of where personnel are located and any needs that still need to be met.   When needed, labor pools and / or staging areas shall also be established to deploy personnel as needed throughout the hospital.  Once an Operations Section has been established, requests for personnel and / or resources will be made to the Operations Chief.

Chatham Hospital understands that if a community – wide and regional disaster is occurring, the facility has to be prepared to be self-sufficient, as response times of local, regional or national assistance may be delayed.  Chatham Hospital will develop disaster plans to strive for a minimum of 96 hours of self-sufficiency.

As conditions return to normal, the EOP will be deactivated in a phased manner to ensure that pertinent information is recorded as well as to guard against a re-escalation of the incident.

Command Staff and Responsibilities:
The Incident Management team is responsible for incident management during an emergency.  It will consist of key senior leadership, medical staff, and technical/medical experts that have received training on emergency management and the Hospital Incident Command System,  Job Action sheets, which can be found on the Fast Command System contain more detailed information on specific roles and responsibilities.

The Incident Commander 

Will be the most appropriate and trained personnel.  

Will establish and maintain command until that duty is delegated or relinquished to an appropriate replacement.
Will generally be:

a) Administrator or Administrator on-call or
b) CNO or
c) House Supervisor or
d) Safety Officer or
e) RRT – clinical or
f) Most senior Clinical Director

Responsibilities: Organize and direct the Hospital command Center; give overall strategic direction for hospital incident management and support activities including emergency response and recovery; and authorize total evacuation if warranted.

The Incident Commander will designate the following Section Chiefs (dependant on the size of the event):

Operations Chief 

Will generally be:

a)Clinical Supervisor or
b)ICU / Medical Surgical Director or
c)CNO or
d)Most senior Clinical Director

Operations will be in charge of the Labor Pool (Staging) which will be in the Large Conference Room, once established. All staff who are called in will report directly to the labor pool for distribution. All requests for resources will be directed to the Operations Chief.

Responsibilities: Develop and implement strategy and tactics to carry out the objectives established by the Incident Commander.

Planning Chief (depending on the magnitude of the incident and / or the anticipated duration of the incident this position will be filled or incorporated with the Operations Chief's responsibilities).

Will generally be:

e)Clinical Supervisor or
f)ICU / Medical Surgical Director or
g)CNO or
h)Most senior Clinical Director

Responsibilities: oversees all incident- related data gathering and analysis regarding incident operations and assigned resources, develops alternatives for tactical operations, conducts planning meetings and prepares the Incident Action Plan for each operational period.

Logistics Chief 

Will generally be:

a)Materials Management Director or
b)Pharmacy Director or
c)Nutritional Services Director or
d)Most senior Materials Management member

Responsibilities: organize and direct those operations associated with the provision of human resources, material and services to support the incident activities and participate in incident action planning.  Logistics will be responsible for the acquisition of resources from internal and external sources. Requests for any resource other than personnel will go through logistics.  

Finance / Administrative Chief 

Will generally be:

a)CFO or
b)Business Office Director

Responsibilities: Finance accounts for costs associated with the event, and is responsible for tracking response and recovery costs, issuing invoices, setting up vendor contracts and file claims.  This is mandatory for any county, state or federally declared disaster for reimbursement.

Safety Officer

Will generally be:

a)Environment Of Care Director or
b)Maintenance Director or
c)Security Officers as designated 

Responsibilities: Ensure safety of staff, patients and visitors; monitor and correct any hazardous conditions; has the authority to halt any operation that posses immediate threat to life and health.

Public Information Officer

Will generally be:

a) Hospital President or
b) their designee

Responsibilities: serve as a conduit for information to internal and external stakeholders, including staff, visitors and families and the news media as approved by the Incident Commander.: 

Liaison Officer

Will generally be:

a)Hospital President or
b)their designee

Responsibilities: Function as the incident contact person in the Hospital Command Center for representatives from other agencies.

The Job Action sheets contained in this plan contain emergency response and recovery information in an easy to follow checklist format.  These are on the Fast Command System

Immediate Interventions:

a)Any patient in the ED that will need to be admitted will immediately be admitted with skeleton orders to ICU or Med-Surg unit.
b)Other than during drills; all out- patient procedures and testing will be delayed and/or rescheduled.
c)Other than during drills; all elective and / or out patient surgeries will be delayed and/or rescheduled.
d)ED patients not needing admission, however needing extended or continued care will be sent to the out patient treatment room, Med-Surg floor and/or Sleep Lab rooms as appropriate.

Decontamination – in the event of a decontamination event, the following personnel will initially be dispatched from the Incident Command Center and/or Operations Chief

a)Maintenance Department Director
b)Available Maintenance personnel
c)Emergency Department CNA
d)Any needed personnel requested

Decontamination team members will prep and recon in the Forensic exam room (Corridor between ED and Imaging)

Personnel from ALL departments will be directed to fulfill needs / duties as determined by the Incident Commander.

Flow of patients and non-personnel

a)Red- and yellow-tag patients will be brought to the ED.
b)Green-tag triage patients may be brought to the Same Day Surgery/PACU area for treatment.
c)Overflow and non-event green-tag patients may be sent to the ED waiting room.
d)All families/visitors for ED patients will be sent to the Atrium.
e)Non-ED families and visitors will be asked to go to their perspective patient's room.
f)Black-tag patients will be brought to the Mammogram room or to the Hospital Shop area if a Pandemic flu type event.
g)Chaplains/Clergy will be directed to the ICU and/or Med-Surg waiting rooms.
h)Media will be directed to the grassy area behind the cafeteria in the employee parking lot.
i)Staff needing to recon will be directed to the Physicians Lounge.

Policies in this plan provide guidance for implementing basic emergency support functions, specific response situations and provide response guidelines for responding to specific incidents or hazards that have been identified as priorities in the HVA.

Code Black – Electricity Failure
Code "D" - External
Code “D” – Internal
Code “D” – Haz-Mat (External)
Code Green – Hospital Evacuation
Code Orange – Chemical Spill
Code Pink – Infant Abduction
Code Red (505) – Fire
Code Silver – Hostage Situation
Code Wind – Tornado
Code Yellow – Bomb Threat
Contingency Plans
Critical Bed Status/Surge Capacity
Decontamination Tent
Influx Plan

A copy of the EOP will be kept in the Emergency Department.  Copies of the plan should be distributed to appropriate units within the facility as well as to key members of the organization.  Electronic copy of the EOP and specific emergency policies and plans are located on the Chatham Hospital Intranet for employee access and familiarization.

The EOP will be reviewed and updated at a minimum of annually to ensure its accuracy or at any time a portion of it is changed.  Updates occur for the following: Regulatory change, new hazards identified or changes in existing hazards, drills/exercises identifying the necessity to make changes, actual disasters or emergencies, changes to infrastructure and/or funding of budget – related changes.