Download GHSU Emergency Operations Plan

Augusta, GA
Emergency Operations Plan
October 6, 2011
Georgia Health Sciences Health System
Emergency Operation Plan
TABLE OF CONTENTS
Section
Topic
Section I
Purpose
4
Section II
Scope &
Applicability
Organization
Data
Definitions
Hazard
Vulnerability
Analysis (HVA)
5
Section III
Section IV
Section V
Section VI
Section VII
Section VIII
Section IX
96 Hour
Capabilities and
Sustainability
National Incident
Management
System (NIMS)
All Hazards
Command
Structure
Responsibilities
and Authority
Section X
Communication
Plan
Section XI
Resources and
Assets
Page #
Annex/Reference
5
7
10
 Current Hazard Vulnerability Analysis
(HVA)
13
16
18
20
 List of HICS Command Structure
Positions and appropriate Georgia
Health Sciences Health System titles
 Georgia Health Sciences Health
System HICS Organization Chart
Letter of Authority for Program
21
29
Section XII
Safety and
Security
34




Bomb Threat (ESF 13A)
Locking of Hospital Perimeter Doors
Photo I.D./Access Card
Riot/Civil Disturbances (ESF-13D)
Page 2 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
Section
Topic
Page #
Annex/Reference
 Hostage Emergency (ESF-13C)
 Infant/Child Abduction Or Elopement
Response (ESF-13B)
Section XIII
Section XIV
Section XV
Section XVI
Section
XVII
Staff Roles and
Responsibilities
37
Managing
Utilities During
Emergencies
39
Managing
Patient Clinical
and Support
Activities
Testing of the
Emergency
Operation Plan
Appendix
40













Triage Policy
Mass Care
Hazardous Material
Evacuation Plan
Severe Weather
Incident Stress/EAP
Mass Fatality Plan
Decontamination Plan
Toxic Cloud
Fire Response
Radiation Management Plan
Bioterrorism Plan
Emerging And Pandemic Respiratory
Illness Plan (ESF-25B)
43
47
49
Hazard Vulnerability Assessment
HICS Job Action Sheets
HICS Forms
Page 3 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
I.
PURPOSE
A. The purpose of the Emergency Operations Plan (EOP) is to describe the
coordinated response and recovery to the wide range of natural and
manmade events that may disrupt normal operations and require a
preplanned response to internal and external emergencies and disasters.
The EOP highlights the basic strategies and mechanisms Georgia Health
Sciences Health System will use to mobilize resources and conduct activities
to support emergency management efforts.
The EOP presents an All-Hazard approach to disaster management. All
Functional Annexes (annexes which address specific incidents / events) will
be designated Annex A-Z. Internal Support Annexes (annexes which detail
the procedures of a specific resource or asset within the facility) will be
designated Annex AA – AZ.
B. The intention of the emergency management program is:
1. To provide maximum safety and protection from injury for patients,
visitors, and staff.
2. To attend promptly and efficiently to all individuals requiring medical
attention in an emergency situation.
3. To provide a chain of command to enable maximum use of resources.
4. To maintain and restore essential services as quickly as possible following
an emergency incident or disaster.
5. To protect property, facilities, and equipment.
6. To satisfy all applicable regulatory and accreditation requirements.
Page 4 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
II.
SCOPE
A. The Emergency Operations Plan (EOP) applies to the continuation of patient
care operations and support functions during a hospital or community-wide
incident. The plan was developed as an “all hazards” approach to be
adaptable to respond to a variety of scenarios that might occur. This EOP
consists of procedures and other reference data, as well as the Annexes,
which address high-risk hazards identified by the Hazard Vulnerability
Analysis (HVA). The EOP is a living plan and will be revised as needed to
reflect federal, state or local changes in policies, procedures, or regulatory
requirements.
B. This Emergency Operation Plan describes the processes for coordinating six
critical areas including:
1. Emergency communication strategies.
2. Managing resources and assets during emergencies.
3. Safety and security during emergencies.
4. Staff roles and responsibilities.
5. Managing utilities during emergencies.
6. Patient clinical and support activities during emergencies.
C. The Emergency Operation Plan and associated procedures and processes
are designed to comply with the Joint Commission Emergency Management
standard requirements and the National Incident Management System
(NIMS) objectives.
III. ORGANIZATION DATA
A. The EOP is designed to assure appropriate staff response to a wide variety of
emergency situations. The primary emphasis is on short-term management
of critical patient care and business operation disruptions. The program is
designed to address the emergency response needs of all patient care and
business operations of Georgia Health Sciences Health System. The EOP
applies to Georgia Health Sciences Health System employees, members of
medical staff, and house staff, agency personnel, volunteers, and contracted
vendors.
Page 5 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
B. Business Identification
Subject
Address
Telephone Number
Website address
Hospital Leadership
Incident Command and
Authorized Personnel to
execute EOP
Licensed Beds
Business Information
1120 15th Street
Augusta, GA 30912
706.721.CARE (2273)
800.736.CARE (2273)
www.mcghealth.org
President
CEO
Administrator-on-call (AOC)
Alternate: Administrative Nursing Supervisor
297 Medical/Surgical
140 Critical Care
59 Emergency Services
12 Operations Rooms
Georgia Health Sciences Health System can
surge up to 70 more beds
Page 6 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
IV. DEFINITIONS
Terminology
Definition
All Hazards
The Homeland Security Presidential Directive
defines “all-hazards" as preparedness for domestic
terrorist attacks, major disasters, and other
emergencies.
A dangerous event that normally can be managed by
the Medical Center. An emergency can be internal
and external disruptions, natural or man-made
disasters, events or catastrophes that significantly
disrupt patient care and treatment, or that results in
sudden or increased demands for Georgia Health
Sciences Health System.
A crisis response beyond the scope of local
resources and usually overwhelms the community.
Disasters are distinguished from emergencies by the
greater level of response required.
A government agency whose function is to assist
during an Emergency - may be local, state, or
federal. Examples: Augusta – Richmond County
Emergency Management Agency (EMA). EMA’s
primary function is to implement programs that prepare
the County for major emergencies. EMA is responsible
for countywide, interagency preparedness. EMA
ensures that the County’s overall emergency plans
integrate the procedures and resources of all County
agencies and outside organizations. EMA serves as
the link between the County and other entities –
regional, State, Federal, non-profit, and private sector
partners – for emergency planning and operations.
Health Alert Network (HAN) is an internet-based
system designed to broadcast warnings of an
impending or current emergency and links hospitals,
paramedics, dispatch centers, law enforcement,
public health officials and other healthcare system
participants within local and regional communities
The location where the Hospital Incident Command
team coordinates activities during an emergency. It
is managed using the Hospital Incident Command
System (HICS).
The management system used to manage and
coordinate activities during an emergency.
Emergency
Disaster
Emergency
Management Agency
(EMA)
Health Alert Network
(HAN)
Incident Command
Center
Hospital Incident
Command System
Page 7 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
Terminology
Definition
(HICS)
Incident Commander
The person responsible for all aspects of an
emergency response; including developing incident
objectives, managing all incident operations,
application of resources as well as responsibility for
all persons involved.
Job Action Sheet
A document that includes an identification title,
purpose, to who they report to, and critical action
tasks. Job Action Sheets include action steps listed
by time periods and the format allows for personnel
to document each action undertaken and record
decision timeframes.
LiveProcess *
LiveProcess is a company that provides a software
platform for emergency managers in hospitals,
healthcare systems and regional coordinating entities
to prepare for and respond to emergency situations.
Georgia was the first state to adopt the software
platform statewide.
Local Emergency
The Local Emergency Planning Committee
Planning Committee
(COMMUNITY RESPONSE PARTNERS)/
(COMMUNITY
Community Awareness Emergency Response
RESPONSE
Committee (CAER) are the forum for citizens,
PARTNERS)/Community businesses, and government to share information
Awareness Emergency
and collaborate on disaster plans to improve the
Response Committee
County’s preparedness for all hazards.
(CAER)
Georgia Emergency
Oversees and coordinates all components of the
Management Agency
statewide emergency medical system.
(GEMA)
* Effective 01/01/2012, this system will be replaced by GHA911; the platform of
the Georgia Hospital Association. The GHA911 platform will include all
capabilities of LiveProcess.
Common
Acronyms
Definitions
CAER
EMA
EOC
GEMA
HAN
ICC
Community Awareness Emergency Response Committee
Augusta – Richmond Emergency Management Agency
Emergency Operations Center
Georgia Emergency Management Agency
Health Alert Network
Incident Command Center
Page 8 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
Common
Acronyms
Definitions
HICS
IC
ICS
JAS
JIC
JIS
COMMUNITY
RESPONSE
PARTNERS
LIP
NIMS
MOU/MAA
PIO
Hospital Incident Command System
Incident Commander
Incident Command System
Job Action Sheet
Joint Information Center
Joint Information System
Local Emergency Planning Committee
Licensed Independent Practitioner
National Incident Management System
Memorandum of Understanding/Mutual Aid Agreement
Public Information Officer
Page 9 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
V. HAZARD VULNERABILITY ANALYSIS (HVA)
A. Process
The Hospital Emergency Management Committee (HEMC) conducts a
hazard vulnerability analysis (HVA) of the medical center and outlying
buildings to identify human, technological and natural vulnerability risks.
Facility specific risks, hazards and vulnerabilities are identified based on the
probability of the occurrence. Probability is determined by the historical
frequency of events in the community (e.g. fires, severe weather) as well as
the consideration of the geographic location of the site to flood plains, major
transportation routes and neighboring sites. The level of preparedness, which
is defined by what resources are available, offsets severity of the impact to
the organization. A percentage is assigned to the hazard to make risk-based
choices to address vulnerabilities, mitigate hazards, prepare for, respond to
and recover from emergencies/disaster events. A summary of the results
provides a way of prioritizing hazards and drives the hazard specific planning.
The HEMC analyzes the risk assessment, evaluates reports, approves
actions to address identified issues, implement policies and procedures, and
provides resources and planning efforts in the appropriate area(s).
B. Summary
Georgia Health Sciences Health System is vulnerable to the following
hazards based on its geographic location:
HIGH RISK
DESCRIPTION
Severe Weather
(44%)
Tornado (56%)
The most common type of tornado, the relatively weak
and short-lived type, occurs between March and May.
Tornados most likely occur during the spring, but have
occurred from March through October.
Severe Thunderstorms
These storms occur in the area. The largest numbers of
these storms occur between March and September;
however, dependent upon meteorological conditions,
severe thunderstorms can occur during any month,
including winter. Facility damage may include broken
windows, water intrusion, damaged entry doors, power
outages, and wind debris (trash cans, tree limbs, etc.).
Winter Weather
Snow and ice storms periodically threaten the area.
Winter storms can damage hospital property, create
safety risks, and damage infrastructure components
Page 10 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
HIGH RISK
DESCRIPTION
such as power lines. Staffing issues are the most
serious concern for the facility. Snow and/or ice storms
most recently struck the area during 2002-2004.
Excessive Hot Weather
The area has experienced significant episodes of
excessive hot weather resulting in deaths.
Droughts
The surrounding area and hospital are not immune to
drought periods, the most recent having occurred during
1998-2008. The 1998-2008 droughts are the longest
and most severe in over 100 years. Droughts may
impact the hospital through municipality supplied water
use restrictions and increased campus fire danger.
Biological Pandemic Flu
(56%)
Mass Casualty
Healthcare providers will play a crucial role in the event
of a pandemic. Pandemics have the potential to cause
great depression to the hospital and community. Large
numbers of persons seeking medical assistance may
overwhelm hospital staff and deplete resources.
Negative pressure rooms, ventilators, and personal
protective equipment (PPE) may be in short supply.
Also, further stresses may be placed on the hospital due
to childcare issues or fearful staff refusal to work during
the pandemic. A thorough understanding and planning
for surge capacity combined with enforced basic
infection control concepts will assist the hospital with
managing patients.
Flood, External
(43%)
In Richmond County, several variations of flood hazards
occur due to the different effects of severe
thunderstorms, tropical storms, seasonal rains, and
other weather related conditions. Street drains may not
be able to handle the volume or rainwater; this flooding
situation may impact vehicle and foot traffic in the areas
surrounding the medical facility.
The Lake Thurmond Dam is on the Savannah River and
located twenty river miles north of Augusta. A dam
failure is remote; however, the local EMA has a plan and
procedure to cover levee penetrations. If levee
penetrations are not covered, the facility should expect
Page 11 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
HIGH RISK
DESCRIPTION
floodwaters to reach the second floor, in a “worst case”
scenario.
HazMat (41%) Chemical
Exposure
Hazardous materials release could result in chemical
exposure and may result in Mass Casualty. Local
industry capacity and the network of interstate highways
and railways result in vulnerabilities to hazardous
material releases from stationary sites and
transportation resources. The steady traffic of hazardous
material transports along Interstates (I-20, I-520) and
heavy railway traffic along rail lines (CSX, Norfolk
Southern) through the area could result in a moderate to
large accidental release of hazardous materials.
C. Results
The HVA results are shared with the community response ESF partners. The
needed resources and vulnerabilities are communicated to the community
response agencies so the capabilities of the community are identified and are in
line with the community priorities. This process occurs at the time of the annual
evaluation of the program and/or whenever the needs or vulnerabilities change.
Roles and responsibilities are discussed; funds for lacking resources are
solicited (e.g. grants); and joint training and exercises are conducted to work on
a coordinated and effective response. Identification of High Priority Hazards will
result in development of a new Annex to specifically address the issue.
Mitigation of the Hazard may be accomplished through development of a hazard
specific plan (Annex) resulting in a downgrading of the priority the following
year. Annexes include specific measures to mitigate, prepare, respond and
recover for each priority emergency. Responsibilities are also outlined.
Page 12 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
VI. 96 HOUR CAPABILITIES AND SUSTAINABILITY
Georgia Health Sciences Health System will conduct a 96 hour capabilities and
sustainability assessment within 90 days of the completion of the annual Hazard
and Vulnerability Assessment. This process is used to determine how long the
medical center can sustain operations when the community cannot support the
hospital. In this event, the Federal systems and the community are unable to
support the medical center for at least 96 hours, the command team would
assess critical supplies, medical care needs, staff resources and, in partnership
with the community response partners, consider whether to close or evacuate
portions or all of the facility, or continue under altered standards of care.
Factors that limit continued services include the lack of resources (e.g. water).
The command team will make every effort to extend the use of the resources
(e.g. conservation of resources, service reduction, partial staged evacuation and
full evacuation, if necessary).
Page 13 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
Normal- Generator Fuel (Only)
Emergency- Shut down some floors, cancel elective surgeries
Normal- Power Loss (Power Only)
Emergency -- Switch to generators/portable generators from vendors or EMA
Normal- Natural Gas (Natural Gas Only)
Emergency--vendor assistance, EMA provided assistance
Normal- Power Loss with Natural Gas Loss
Emergency- Call fuel vendors for additional fuel, contact county EMA for
assistance.
Normal- Portable Water
Emergency- Contact Purchasing for emergency vendors on file, contact county
EMA. Implement waterless methods for patients and kitchen.
Normal- Sewer
Emergency- Contact Purchasing for emergency vendors on file, contact county
EMA. Implement waterless methods for patients and kitchen.
Normal- Gasoline
Emergency- Contact fuel vendors and county EMA for assistance. Limit fuel use to
emergency cases only.
Normal- Central Distribution
Emergency- Curtain some services, discharge some patients
Normal- Clinical Supplies- Clinical Departments
Emergency- Curtail some services, discharge some patients
Normal- Water (Sanitary)
Emergency- Water conservation (sponge baths, waste disposal)
Normal- Food Services
Emergency - pre-planned non-select menus, portion control, regulated service
hours
Normal- Linen
Emergency- Conserve as resupply dictates. Move to disposable paper products.
Normal- Portable Oxygen Cylinders
Emergency
Normal- Disaster Supplies- Offsite (36 pallets of supplies)
Emergency
Normal- Pharmaceuticals (includes Chempack - 2)
Emergency- Call contact orimary wholesaler for additional supplies.
Page 14 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
Normal- Staffing
Emergency
0 Hours
24 Hours
48 Hours
72 Hours
96 Hours
Page 15 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
VII. NATIONAL INCIDENT MANAGEMENT SYSTEM
A. To align with the Federal, State and local entities, Georgia Health Sciences
Health System has integrated the National Incident Management System
(NIMS) objectives into the organization’s plan to provide an effective and
efficient structure for preparedness, incident management, and emergency
response. The Emergency Operation Plan and corresponding policies,
procedures and annexes were developed to address the emergency
management phases:
1. The Mitigation phase of emergency management involving proactive
efforts to minimize the severity and impact of a potential disaster and
reduce the potential for an event to occur. Georgia Health Sciences Health
System activities designed to reduce the risk and potential damage
include:
a. Structural construction projects to mitigate the facilities by
reinforcement, bracing, anchoring, bolting, strengthening or
replacement of the building.
b. Non-structural hazard mitigation efforts include segregated storage of
hazardous materials in secondary containment; conformance to
building and fire codes as well as inspection, testing and maintenance
of emergency systems (e.g. uninterruptable power supply (UPS) and
back up of information systems data).
2. The Preparedness phase involves the planning, and training exercises,
equipment acquisition and other management activities that build Georgia
Health Sciences Health System capacity to manage the effects of
emergencies as well as mobilize essential resources.
3. The Response phase involves putting preparedness plans into action.
Georgia Health Sciences Health System mobilizes its resources and
focuses on tactical activities to address a disaster event. The following
response components include:
a. Assume Command and determine need for activation of the Incident
Command Center
b. Staff is recalled through the overhead page system, pagers, and
telephone tree or cascade system.
c. Utilize the Hospital Incident Command System (HICS) to ensure there
is a clear chain of command for effective management. Assign staff to
hospital incident command staff positions and provide an initial
briefing.
d. Develop Incident Action Plan prior to each operational period.
e. Responders review incident action plans and obtain briefing(s). Work
to meet incident objectives using procedures, annexes, checklists and
forms. Initiate interim contingency plans to deal with system failures.
Page 16 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
f. Allocate scarce resources and coordinate with the local response
agencies.
g. Request additional assistance from mutual aid partners, as well as the
State. In the event that response efforts in the local community cannot
support the hospital, the hospital will strive to continue to sustain
services. The Medical Center Command Team will assess the
situation throughout the incident and determine whether evacuation or
facility closure is feasible and reasonable based on the following
criteria:
a. Patient and staff safety,
b. Staffing ratios,
c. Resources and supplies availability, and
d. Local authority mandate (e.g. Uniform Command).
4. Recovery phase involves those efforts to resume critical support
functions, continue the provision of care, and secure reimbursement funds
if appropriate. The facility procedures, job action sheets and forms include
demobilization/recovery actions to restore the services to normal
conditions based on the manageable patient census using normal staffing
patterns and resources and/or when other community responders begin
their demobilization. Once the systems are restored for resuming normal
treatment, the incident is evaluated to identify opportunities for
improvement and develop initiatives to mitigate the effects of future
incidents.
B. Staff Reporting Structure
The EOP is based on these key organizational systems:
1. The Hospital Incident Command System (HICS) is utilized as an effort to
coordinate with the community responders. The Incident Command
System is adaptable to meet the size and complexity of an incident by
using recognized lines of authority and the model is in direct correlation
with the East Central Georgia Public Health Office of Emergency
Preparedness, local Fire Department, local Police Departments as well as
neighboring hospital incident command system (ICS) structures. Staff
report to the Incident Commander who is defined as being in charge of the
response.
2. The Multi-agency Coordination System provides interactive management
components and the organizational structure of supporting agencies at the
Federal, State, local, and regional levels through mutual-aid agreements
and other assistance arrangements.
3. The Public Information System is used for communicating timely and
accurate information to the public during emergency situations.
Page 17 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
4. Unified Command is in place when more than one agency or organization
has command responsibilities such as during a hazardous material
release when the fire department, Environmental Protection Agency
(EPA), water authority and the hospital work together to analyze
information, and develop a common set of objectives.
VIII. ALL HAZARDS COMMAND STRUCTURE
The Hospital Incident Command System (HICS) is an organizational and
management framework used to execute a response to an incident/event and it
is consistent with the emergency management system used in the community.
The specific organizational structure established for any given incident will be
based upon the needs of that incident. The Incident Action Plans will be
developed, as appropriate, to the scope and duration of the incident. The
Incident Command System (ICS) organizational structure described below is
consistent with NIMS requirements and identifies key positions and lines of
authority in response to an internal or external disaster situation. An ICS
organization is composed of the Incident Command (IC), Command Staff, and
the general staff with functions as shown below. The HICS Form 207
Organization Chart is utilized during incidents to document assigned HICS
positions.
Page 18 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
Page 19 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
IX. RESPONSIBILITIES & AUTHORITY
A. The Director of Safety and Security and the Emergency Management Specialist are
responsible for the overall management of the emergency management program
including: program development; implementation and assessment; identification and
control of risks; staff educational needs; and consultation, monitoring and
assistance.
B. The Director of Safety and Security and / or the Emergency Management Specialist
serves as the Chairperson of the Hospital Emergency Management Committee.
C. The Emergency Management Specialist represents Georgia Health Sciences Health
System at the local, regional and state planning meetings and coordinates overall
preparedness efforts at Georgia Health Sciences Health System.
D. The Hospital Emergency Management Committee is a multidisciplinary improvement
team, which includes administration, clinical and support staff who are responsible
for implementing and maintaining the Emergency Operation Plan and associated
annexes and procedures, the annual evaluation, the Hazard Vulnerability Analysis,
exercise documentation and performance improvement activities. The Hospital
Emergency Management Committee reports to the Safety Committee.
E. Medical Staff and Administration ensure there is involvement with the organization
leaders to plan and respond to emergencies.
F. Department Managers are responsible for orienting staff to the department and
facility-wide Emergency Operation Plan procedures. Managers are also responsible
for the development and management of specific department disaster policies and
procedures (as applicable), ensuring that they are evaluated and revised (as
appropriate), verifying all staff are trained on their individual roles and responsibilities
consistent with the emergency operation plan; and staff participate in the
implementation of the plan.
G. Employees are responsible for participating in training and demonstrate core
competencies in the emergency management program. Employees receive
disaster response training upon hire and annually thereafter. Employees must
ensure their behaviors, work practices and operations are safe, and in accordance
with departmental procedures, the provisions of the Emergency Operations Plan,
and clinical judgment.
Page 20 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
X.
COMMUNICATION PLAN
A. Modes of Communication Available
Communication Type
Definition/Capabilities
Alphanumeric pagers
Can be used to communicate with large
number of staff provided with these
devices.
Landline telephones
Landlines may be used for person to
person communication or facsimile
transmission.
Cellular telephones
Cellular telephones may be used for
person to person communication, text
messaging, instant messaging, or email.
Overhead paging system (PH)
Can be used to quickly distribute
emergency information to large numbers of
staff, patients, and patient families.
Email
May be used to send messages, charts,
images, etc. to one or more persons or
facilities.
May be used for continued one on one
communication with one or more, persons
or facilities.
Instant Messaging (IM)
LiveProcess *
* See notation, Pg 8
SouthernLinc radios,
The standard internet based emergency
management platform.
The combination of cellular telephone with
portable radio capabilities.
HEAR system radios
For communication with hospital
Emergency Department (ED) and
Emergency Medical Services (EMS) units.
Amateur Radio Operators (HAM)
Can relay information to another facility,
across the region, or the state.
GHSU Alert
Can be used to communicate with large
number of staff utilizing cell phone, office
phone, home telephone, and email
simultaneously.
Page 21 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
Communication Type
Definition/Capabilities
Georgia Health Alert Network
(HAN)
The communication program to establish
the communication, distance-learning, and
information released by local, state or
federal public health authorities, meant to
inform the health and medical services of
likely or imminent dangers to the health of
the community.
B. Notification When Emergency Response Measures Are Initiated
1. The activation and termination of this plan is under the authority and
direction of the Incident Commander. The Incident Commander
designees in order of preference are:
a. the Administrator-on-Call,
b. the Administrative Nursing Supervisor.
2. The Incident Commander will gather the following incident information:
a. Whether a chemical or radiological substance was released.
b. The time of the incident.
c. The location of the incident.
d. The number of causalities and types of injuries.
e. The number of trauma victims and ones that are ambulatory.
f. Whether decontamination is needed or being conducted on site.
g. The types of treatment given.
3. The Incident Command Center (ICC) is located in the Pathology
Conference Room or Room BP5270; at the discretion of the Incident
Commander. The ICC contains preprinted HICS forms, Job action
sheets, procedures and annexes; telephones and fax machines;
computers with internet access; general office supplies; and a
photocopier. The ICC phone number is 706.721.6200 and the fax
number is 706.721.1042.
4. The General Labor Pool is established in the 3 West Ampitheatre room
number BI3079. The phone number is 706.721.1539.
5. The Family Access Center is established in room BT-1810.
6. The Medical Staff Labor Pool is established in the 4th floor Ampitheatre
Room number BP 4306.
7. The Media Center is established in the Small Auditorium Room number
BC-140.
Page 22 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
8. Employees are notified when the plan is activated by one or more of the
following:
a. Alphanumeric pagers
b. Telephones: landline and cellular
c. Overhead paging system
d. Email
e. LiveProcess automated messaging system
Alert/Emergency management incident codes are:
Alert /
Emergency
Management
Incidents
Code Triage
Meaning
Disaster - any incident, natural or man-made that causes or
poses widespread danger to occupants and property to the
extent that normal services are disrupted.
Internal Disaster - occurs on the Hospital Campus (e.g. utility
failure).
External Disaster - occurs at any other Health System site or
elsewhere in the community e.g. multi casualty – multi-vehicle
accident, earthquake, flood, nuclear biological chemical incident).
Code Triage
Standby
Code Grey
All disaster response areas are set up with a duty officer assigned
Code Orange
Decontamination Event (Biological, chemical, or radioactive)
Code Blue
Cardiac or Respiratory Arrest
Code Red
Fire or Smoke Emergency
Code Pink
Infant/child abduction
Code Green
Severe weather
Code Black
Active Shooter on premises
Code White
Paging system not functional
Bomb Threat
Page 23 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
B. Ongoing Communication Of Information And Instructions To Staff
1. Once the emergency response measures are initiated, additional staff may
be called in by:
a. Alphanumeric pagers,
b. Telephones: landline and cellular,
c. Overhead paging system (PH), or
d. LiveProcess automated messaging system.
2. Staff and LIP information and instructions can be distributed by:
a. Alphanumeric pagers,
b. Telephones: landline and cellular,
c. Overhead paging system,
d. Email, and
e. LiveProcess automated messaging system.
3. During an area-wide disaster (e.g. severe weather), the phones may be
overloaded with calls or it may be impractical to call each staff member
individually, therefore alternative communication includes email and
LiveProcess automated messaging system.
4. Internal communication is accomplished by obtaining information from
different departments by:
a. Telephones,
b. Cell phones,
c. SouthernLinc radios,
d. Pagers/text pagers,
e. Email,
f. Overhead paging
g. Runners, or
h. Fax machines.
HICS Form 205 – Incident Communications Plan will document what
communication equipment is used and HICS Form 213 Incident Message
Form provides a standardized approach for recording messages received.
5. Additional communication available for communicating externally includes:
a. LiveProcess,
b. HEAR system radios, and
c. Amateur Radio Operators (HAM).
6. During an emergency or incident, standard terminology and plain
language will be used for all communications.
7. The Incident Commander will assign responsibilities. HICS 203 Form
Organization Assignment List and HICS 204 Branch Assignment List will
be utilized when assignments are made.
Page 24 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
8. Staff utilizes and completes the HICS forms to provide regular situation
updates (e.g. HICS 201 Incident Briefing Form, 202 Incident Objective
Form, HICS 251 Facility Systems Status Report).
C. Notifying External Authorities Of Emergencies
The Hospital Incident Commander will assign a Liaison Officer to ensure
external authorities are notified and necessary communication is maintained.
The Liaison officer will contact the East Central Georgia District Emergency
Operations Center first. Incidents that cause imminent danger to personnel
and or patients, personnel will dial 9-1-1 to report the incident.
Communicating with External Authorities Once Response Is Initiated
To ensure connectivity between the Hospital and the regional area once
response measures are initiated, the Liaison Officer will provide regular
Situation Reports (SITREPS) to the East Central Georgia Health District
Emergency Coordinator. SITREPS shall include priorities and resource
needs, as well as, resource availability (personnel and equipment, all factors
influencing situation. Communication may be conducted via Landline
telephone, Cell Phone, Live Process, Satellite Phone or HAM radio.
Communication with Patients Including Relocation to Alternate Care Sites
1. Patient communication is coordinated through the Incident Command
Center.
2. Outpatients and their families receive information through
a. Messengers.
b. Telephone calls to family members.
c. Information posted on the hospital extranet site.
d. Press releases through the Public Information Officer (PIO).
3. Inpatients will receive briefings of pertinent information by
a. Messengers.
b. Flyers delivered with meal trays.
c. If patients are relocated to an alternate care site, patients and their
families will receive regular briefings consistent with regulations
regarding patient confidentiality information including:
i. The general condition of the patient.
ii. The alternate care site name and address.
Page 25 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
iii. The anticipated timeframe for relocation to the alternate care site.
4. The Family Assistance Center is located CMC Conference room # BT1810.
D. Communication With The News Media - Circumstances and Plans
Georgia Health Sciences Health System maintains a cooperative relationship
with the news media, which balances the public need for information with the
responsibility to safeguard the patient's right for privacy.
Communication is coordinated through the Public Relations Office which assigns
a Public Information Officer. The PIO is responsible for developing informational
summaries for reporters so that timely and accurate information is provided to the
public during emergency situations. In addition, the PIO is the spokesperson for
Georgia Health Sciences Health System and is responsible for media and public
inquiries, rumor response and media monitoring.
The Georgia Health Sciences Health System media center is located room BC140 and will be the responsibility of the department of Public Relations.
Media personnel may not leave this area without an escort. Security personnel /
designees will be assigned to the media center.
Refer to the Risk Communications plan found in Risk Communications Section of
Annex AA: Internal Support for all roles and responsibilities regarding the Media
Center / Joint Information Center and / or Public Information Officer.
E. Communication With Purveyors Of Essential Supplies
The Logistics Section Chief will contact vendors that provide essential
resources and supplies. Vendors are listed in the Hospital Resource
Directory located in the GEORGIA HEALTH SCIENCES HEALTH SYSTEM
Resource Binder.
H. Communicating With Healthcare Organizations In The Geographic Area
And Essential Elements in Command Structure
meets regularly with its community response partners to ensure cooperative
planning among healthcare organizations that provide services to a
contiguous geographic area thus facilitating the timely sharing of information
about:
Page 26 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
1. Essential elements of their command structures and control centers for
emergency response,
2. Names, roles, and telephone numbers of individuals in their command
structures,
3. Resources and assets that could potentially be shared or pooled in an
emergency response, and
4. Names of patients and deceased individuals brought to their organizations
to facilitate identification and location of victims of the emergency.
5. Usage of common communication equipment and data sources to allow
for communications when the infrastructures (i.e. phone lines, computer
lines) have been impacted. The Hospital Resource Directory is utilized.
J. Patients and Deceased Individuals
The planning among the community response partners may include the
sharing of names of patients and deceased individuals brought to their
organization to facilitate identification and location of victims of the
emergency. At Georgia Health Sciences Health System, patients and
deceased individuals are identified and communicated to the Patient
Information Officer and the American Red Cross if on site. After approval by
the Risk Manager, the Public Information Officer provides updates and
briefings to staff, visitors, families and the news media.
K.
Family Assistance Center
The Family Access Center will be located in the CMC conference room BT1810 and will provide assistance to patient family members as well as anyone
who believes a family member may have been brought to Georgia Health
Sciences Health System.
Local agencies, faith-based organizations, and other applicable organizations
may (with approval of the FAC Unit Leader and the Volunteer Coordination
Center) assist to provide emotional support services.
Georgia Health Sciences Health System may provide information and
resources to the local Family Assistance Center (FAC) to support the
family/friends and to provide answers to questions, concerns and assist with
family reunification services.
Refer to the Family Access Center Plan found in Annex AA: Internal Support
Elements for all roles and responsibilities of the FAC and its personnel
L. Communication With Alternate Care Sites
Page 27 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
The Command staff will determine, in collaboration with the East Central
Georgia Public Health District, any off site alternate care sites that would
meet the needs of Georgia Health Sciences Health System patients. Multiple
modes of backup communication (e.g. fax, computer, phone, two way radio,
etc.) are available to keep the lines of communication flowing. The Incident
Command Center will provide the alternate care site with briefings as to the
status of the operational capability, and the anticipated need for assistance to
receive patients should it become necessary.
M. Backup Communication
In the event that community infrastructure is damaged and/or Georgia Health
Sciences Health System experiences a communication failure, redundant and
alternative communication systems are in place and include:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Overhead paging system,
Runners,
LiveProcess,
HEAR system radios,
Satellite phones,
Amateur Radio Operators (HAM),
Cell phones, and
SouthernLinc radios.
UHF and VHF radios,
Email and Text Messaging
Georgia Health Sciences Health System meets regularly with the community
response partners to insure there is a coordination of common equipment and
data sources in the event infrastructures (i.e. phone lines, computer lines) are
negatively impacted. Common resources have been established with the
local hospitals to be used during incident response.
Page 28 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
XI. RESOURCES AND ASSETS
A. Obtaining Required Supplies At Onset Of Response
Key aspects of a disaster response are pre-designated in advance
through the Hospital Emergency Management Comittee. During an
emergency response, the Incident Command Center will coordinate the
allocation of resources, based on need and priority. The management of
Logistics is managed through the Logistics section within the Hospital
Incident Command System.
1. The existing inventory will be utilized first upon activation of the ICC.
Materials Management, Pharmacy, Food Services and Facility Services
manage the inventory throughout the year and ensure supplies are rotated
and inspected for degradation.
2. If additional resources are needed, supplies for disaster response (triage,
decontamination, etc.), PPE, water, fuel, staff (via time keep system),
medical and surgical resources, and pharmaceutical supplies are stored in
caches on and off site. The Logistics Chief will coordinate with the Director
of material Management to deploy these caches.
3. When the existing inventory of critical supplies are at minimal par levels,
outside vendors will be contacted. The East Central Georgia Public
Health District Emergency Operations Center is the primary coordinating
agency for Hospiital resource request. Back up coordination can be
achieved through coordination with the Georgia Health Sciences Health
System Emergency Management / Public Safety office or the East Central
Georgia Public Health Office of Emergency Preparedness.
Replenishing Pharmaceutical Supplies
Georgia Health Sciences Health System contracts with several
pharmaceutical companies and can obtain additional pharmaceuticals when
needed. If electricity and the emergency generator power are lost, the
automated dispensing carts will not open. Individual patient medications will
be obtained directly from the pharmacy.
The Strategic National Stockpile (SNS), a cache of chemical antidotes, drugs
& medical supplies deployed after a biological, radiological, or chemical attack
is available if needed through the East Central Georgia Public Health Office of
Emergency Preparedness. The Strategic National Stockpile Chempack
program provides a cache of nerve agent antidotes throughout the nation to
Page 29 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
assist medical personnel in their response to a nerve agent terrorist attack are
available to the Pharmacists if needed.
B. Replenishing Non-Medical Supplies
1. Food: A 10 day supply of food is available on site to serve staff and
patients. Food Services does a complete inventory every week of all food
and non-food items within the department. They also complete daily
inventories on high-moving items like dairy, produce and bread.
2. Linen: A one and a half days par level is maintained on site
3. A 4 day reserve of drinking water is located in the Walton Way warehouse.
If additional drinking water is needed until normal service can be restored,
see available vendors listed on the Hospital Resource Directory (HICS
Form 258). In the event 96 hours of water is not available at the time of
true need and the facility is unable to obtain additional supplies, a decision
will be made 36 hours prior to exhaustion of water resources by the
Command Team to stage an evacuation.
4. The facility is equipped with emergency generators that will accommodate
five days of diesel fuel. In the event additional fuel is needed the vendor
will be contacted when fuel reaches the sixty percent remaining mark (see
Hospital Resource Directory).
5. Personal protective equipment re-supply will be coordinated through
logistics and communicated with existing vendors first. Any unresolved
needs will be forwarded to the East Central Georgia Public Health District
Emergency Operations Center.
C. Managing Volunteers And Staff
1. Disaster credentialing policies for medical staff and other volunteers will be
utilized to augment staff if needed through the Labor Pool and
Credentialing Unit.
2. All volunteers will report to the Volunteer Coordination Center before being
assigned to any area of the hospital (this includes both medical and non
medical volunteers), See Internal Support Annex – Volunteer Coordination
Section.
3. HICS Form 252 - Section Personnel Time Sheet is used to record each
Section’s personnel time and activity.
Page 30 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
4. The Incident Commander is empowered to authorize volunteer caregivers
to assist hospital staff in the event that the organization is unable to meet
immediate patient needs without the volunteers.
5. The Chief Medical Officer is responsible for granting privileges to the
Volunteer Licensed Independent Practitioners (LIP) and this is outlined in
the Georgia Health Sciences Health System Medical Staff Bylaws.
6. HICS Form 253 - Volunteer Staff Registration is used for Volunteers to signin for an operational period.
D. Managing Staff Support Activities
The Support Branch Director under the Logistics section manages staff
support activities. Additional resources are requested through the East
Central Georgia Public Health Office of Emergency Preparedness. Current
available resources include:
Housing for staff will be provided. Staff is given space in unoccupied patient
rooms and/or other available space. Incident stress debriefing and counseling
is coordinated through the Family Care Unit (FCU) See Internal Support
Annex – FCU Section.
E. Managing Staff Family Support Needs
Staff Family Support activities are under the jurisdiction of the Logistics
section. Georgia Health Sciences Health System strives to prepare staff
personal readiness by encouraging staff to prepare for emergencies at home.
1. Employees will be able to call family to ensure their safety.
2. The Family Coordination Unit will be available to assist employees with
locating family members in emergency situations. See Annex AA – Internal
Support Elements for additional information.
3. The 1225 warehouse will be utilized for staff pets if needed (See Pet Care
– Annex K). Protection from the elements will be provided (heating in the
winter and shade from the sun). The space will be used for exercising the
pets. Staff is encouraged to have plans for their pets prior to an
emergency. For example, the pet should have a kit that includes a carrier;
crate and leash. In addition, there should be a water proof container (e.g.
plastic bag) that houses a photo of the pet along with veterinary records
including proof of immunizations, pet food for 96 hours, water and food
bowls, medications, toys and a blanket. Time will be given to employees to
care for their pets.
Page 31 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
F. Potential Sharing Of Resources And Assets With Other Hospitals
1. Georgia Health Sciences Health System and the community participate
in statewide exercises and community-based planning. To promote
interoperability, Georgia Health Sciences Health System
representatives meet regularly with the ESF 8 Planning Group (hosted
by East Central Georgia Public Health) to prioritize plans to support the
community. This includes identifying the resources and supplies that
will be available for an emergency response and comparing it with
what they may need in an emergency. Gaps between on-hand
resources and needed resources are supplemented by Mutual Aid
Agreements (located in the e.g. EOP Resource Binder). Georgia
Health Sciences Health System has signed a mutual aid agreement
(MAA) all members of the Georgia Hospital Association.
2. Biomedical Engineering will inventory all critical equipment not in use. If
additional clinical equipment is needed, contracts with vendors and
suppliers of critical equipment and supplies is available.
3. In the event, resources/assets need to be shared with other hospitals; the
Incident Commander at Georgia Health Sciences Health System is
responsible for deciding whether resources can be shared and what
quantities.
4. The Procurement Leader utilizes the HICS Form 256 Procurement
Summary Report to track procurements. This document includes
purchase order information, dollar amount and vendor. Requested
equipment is recorded on HICS Form 257 Resource Accounting Record to
document what was received, the condition of the resource and when it
was returned.
G. Potential Sharing Of Resources Outside Of The Community
Coordination of healthcare resources and assets outside of the operational
area during an event is the function and responsibility of the East Central
Georgia Public Health Office of Emergency Preparedness. The County EOC
ensures that those who are located at the scene have the resources (e.g.
personnel, tools, and equipment) they need for the response and also acts as
a liaison between local responders and the State. Chempack is one of the
mutual aid resources that may be deployed to other nearby sites.
Page 32 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
H. Transporting Patients, Meds And Equipment To Alternate Care Sites
1. In the event of a surge, all inpatient cases will be assessed for the ability to
discharge early to increase the bed capacity. In addition, an initiation of
auxiliary treatment areas is outlined.
2. Evacuation procedures for complete and partial evacuation of the hospital
are current and are reviewed regularly. In the event of a fire or other
internal emergency, patients will be relocated to another safe part of the
hospital.
3. In the event the hospital is deemed unsuitable for continued occupancy or
cannot support adequate patient care, the Incident Commander will
authorize evacuation.
4. Evacuation equipment includes: MedSleds, Wheelchairs, Gurneys, and
Baby Aprons.
5. Georgia Health Sciences Health System Children’s Medical Center,
Georgia Health Sciences Health System Ambulatory Care Center will be
used as the primary Alternate Care Sites. Other Alternate Care sites will be
established in accordance with the Mutal Aid contract through Georgia
Hospital Association.
6. HICS 255 - Master Patient Evacuation Tracking Form is utilized by the
Patient Tracking Manager to record information concerning all patients
disposition during an evacuation. The Medical Care Branch Director
utilizes the HICS Form 260 Patient Evacuation Tracking Form to document
details and account for each patient transferred to another facility.
I. Transporting Clinical Information To Alternate Care Sites
1. Georgia Health Sciences Health System has entered into a Mutual Aid
Agreement with other facilities within the area, which could accept patients
in the event of an evacuation.
2. The Operations Section is responsible for providing patient information as
appropriate and ensuring the family is notified of the patient transfer. The
Planning section tracks patients and personnel to the alternate care site.
The HICS-254 Disaster Victim/Patient Tracking Form is used to account
for victims seeking medical attention. Qualified hospital staff will
accompany the patients. Periodic information sharing will occur between
the hospitals receiving victims through telephone or other communication
methods (e.g. internet). Georgia Health Sciences Health System staff will
take appropriate steps to ensure patient information remains confidential
even during emergency conditions.
Page 33 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
XII. SAFETY AND SECURITY
A. Internal Security And Safety Operations
1. Safety is a priority at Georgia Health Sciences Health System. The
assigned Safety Officer will document actions taken to mitigate hazards on
HICS Form 261 Incident Action Safety Analysis.
2. Security access, crowd control and traffic functions are managed through
the Security Branch Director position of HICS. Depending on the type of
incident, increased vigilance/patrolling; increased monitoring of ID badges
and the securing of non-critical doors will be implemented. Ongoing
security measures are in place for identifying staff, visitors and patients:
identification badge, patient wrist bands, staff identification badges, HICS
vests, visitor badges, and contractor badges.
3. Staff members are required to wear their I.D. Badges when working in the
facility.
4. Security personnel may be augmented as required using personnel
assigned by the Labor Pool and / or the Georgia Health Sciences Health
System Public Safety Department.
5. All employees must immediately report any suspicious person(s) or
activates to Security.
6. Georgia Health Sciences Health System has a process for locking down
the facility. See Policy # EC.4.15 App C.
7. A Trauma Officer of whom is a post certified police officer and an
employee of MCG Public Safety is co-located in the Emergency
Communications Center.
8. In incidents of special circumstances (e.g. bomb threat) chain-of-custody
procedures will be followed. Evidence will be stored at the discretion of
the Trauma Officer and the MCG Public Safety Office.
9. Patients admitted from local and state correctional institutions will be
treated in accordance with standing policy (Prisoners as Patients policy #
9.59).
Page 34 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
B. Roles Of Community Security Agencies And Coordination
1. The Security department works collaboratively with the local Police
departments. The Police Department provides Georgia Health Sciences
Health System with prompt response when needed and also shares local
crime statistics and informational warnings to ensure Georgia Health
Sciences Health System has current local information.
2. The Security Branch Director will identify material resources for rent or
purchase (e.g. barriers, fencing, and storage) and notify the local EOC of
the current situation. The Security Branch Director will maintain a copy of
all vendor contacts in the Resource Directory.
3. Requests for community security functions will be placed through the East
Central Georgia Public Health Office of Emergency Preparedness/EOC.
4. The Unified Command system will be established between Georgia Health
Sciences Health System and the responding agencies to ensure a safe
and effective response. In the event external law enforcement agencies
are utilized, the Security Branch Manager will act as the liaison with the
lead officer of the agency.
C. Process For Managing Hazardous Materials And Waste - Radioactive,
Biological And Chemical
1. The Hospital is equipped to manage decontamination with specified
chemical agents, provided the agent and concentration are known. The
Hospital has the capability for incident decontamination, using the
decontamination shower located either in the Emergency Department (low
numbers of patients or at the Community Decon Center located in the
Harper St Parking Deck, outside of the ER. Selected staff are trained to
provide decontamination. See Annex F: CBRN - Decontamination.
2. Radiological exposures are managed in partnership with the Radiation
Safety Officer. See Annex F: CBRN - Decontamination.
3. Biological exposures will be handled in the same manner as chemically
contaminated patients once the agent is known. Initial patients may enter
the Emergency Department (ED) without knowledge of the contamination.
Typically, biological agents have a latent period and therefore patients
presenting to the ED will no longer be contaminated and will need to be
treated according to the agent involved. If the agent is communicable, the
patient will be placed into an isolation room or cohorted with patients that
have similar symptoms/diagnosis. See Annex F: CBRN-Decontamination.
Page 35 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
4. Storage of contaminated patient belongings will be conducted in
advisement by the Richmond County Hazardous Material Response
Team. Since ability to return contaminated items depends upone the
contaminant, disposition of said items will be at the discretion of the
Richmond County Haz Mat Unit.
5. Hazardous waste procedures for labeling, storage, and disposal are
outlined in the Hazardous Materials And Waste Management Plan.
D. Control Movement Of Individuals Within Health Care Facility
The Facility Lock Down procedure can be implemented to control admission
to the entrance and other doors. Depending on the incident type, the Incident
Command Center will determine what controls (e.g. decontamination,
isolation) will be put into place prior to patients entering the facility to ensure a
secure and safe environment. The Hospital has triage tags for use in
emergency situations to identify, process, and triage patients and provide a
means to identify clothing and other personal property. Incoming patient
information will be transmitted from triage to the Incident Command Center.
Patient care updates will be transmitted to the Command Center using a
logging system implemented at each treatment unit. The Patient Information
Officer and Risk Manager, working with the Family Assistance Center staff,
will coordinate notification to the patient’s family and release of patient
information to the American Red Cross.
E. Control Traffic Accessing the Health Care Facility
1. Security will be responsible for external vehicular flow of traffic, which
would prioritize emergency vehicles, and all other necessary traffic flow to
the area.
2. If more help is needed that cannot be provided by hospital personnel, local
law enforcement agencies or the County EOC will be contacted for
assistance.
3. In the event of closure or rerouting of streets, staff, patients and visitors
will be notified though public media and detour signs will be obtained from
the County EOC.
Page 36 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
XIII. STAFF ROLES AND RESPONSIBILITIES
A. Staff Roles Are Defined In The Emergency Operation Plan
Roles and responsibilities of staff are outlined in the Emergency Operation
Plan Manual and the Hospital Incident Command System is used to ensure
there is a clear chain of command for effective management. Positions are
filled based on the size of the incident and Job Action Sheets are used for
defining and performing a specific emergency response functional role.
Incident Action Plans are also used during an incident, which list decision
considerations specific to managing that situation by timeframe and
complement the facility procedures.
B. Staff Training For Assigned Roles
1. The Hospital Emergency Management Comittee designs drills and
exercises with scenarios and objectives based upon findings from the
hazard vulnerability analysis as well as from critiques from past exercises
and/or actual events. HICS is utilized during these events, which provides
staff with the opportunity to practice and train for their roles during an
emergency. Personnel are assigned to the various command positions,
and receive a briefing and a Job Action Sheet that outlines the
responsibilities and actions for that specific assigned job function.
2. Managers are responsible for the development and management of
specific department disaster policies and procedures. Managers are also
accountable for ensuring that the plans are evaluated and revised, and for
ensuring staff are trained on their individual roles and responsibilities
during a disaster/emergency event.
3. NIMS training is provided to hospital personnel that would have a role in
emergency preparedness, incident management, and/or emergency
response during an incident. This training prepares staff to assume one or
more roles based on situational need and available resources.
a. All staff identified for HICS positions are required to
complete training equivalent to the federal ICS 100, 200,
700, and 800 course levels.
b. The Director of Safety and Security and the Emergency
management Specialist have completed training equivalent
to the federal ICS 100, 200, 300, 400, 700, and 800 course
levels.
Page 37 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
C. Organization Communicates To Licensed Independent Practitioners
1. The Chief of Medical Staff represents the physicians in the Incident
Command Structure.
2. LIPs have roles and responsibilities defined on job action sheets (e.g.
Operations Branch pertaining to patient care).
D. Process For Identifying Care Providers During An Emergency
1. Employees are required to display their employee identification badges. If
an employee does not have his/her badge or it cannot be located,
temporary badges can be obtained through the Parking Office in Room
BO-106 upon verification that they are employees.
2. Personnel are assigned through the Labor Pool in coordination with the
Incident Command Center to cover positions and functions in the Hospital
Incident Command System. Employees are provided with vests that
clearly identify the HICS position title.
3. The Incident Commander is empowered to authorize volunteer caregivers
to assist hospital staff in the event that the organization is unable to fully
meet immediate patient needs without the volunteers. The credentials of
volunteer providers will be verified through the Volunteer Coordination
Center. Volunteer licensed independent practitioners will be identified
from other licensed independent practitioners by the use of ID badges.
Page 38 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
XIV. MANAGING UTILITIES DURING EMERGENCIES
A. Alternative Means Of Providing Utilities
In the event that utilities are compromised or disrupted, procedures and
contingency plans are detailed in the Emergency Operation Plan Annex H –
Utiliites Failure, for each specific utility. These plans are coordinated in
advance to ensure to the extent practicable, there is uninterrupted service.
External options and contracts for essential services are coordinated through
the Incident Command Center (Logistics section). The acquisition of
equipment parts or outside contractors will be coordinated with the Support
Branch.
Facility Services Operations has personnel on duty, 24 hours a day, 7 days a
week, 365 days a year. Facility Services Central Dispatch Center can be used
to obtain contact with personnel currently on duty and the callback lists should
be used as needed.
Page 39 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
XV. MANAGING PATIENT CLINICAL & SUPPORT
ACTIVITIES
A. The Clinical Activities: Patient Scheduling, Triage, Assessment, Through
Discharge
1. Scheduling, modifying or discontinuing services is under the coordination of the
Operations section. Patient care schedules are reviewed to determine if early
discharges and elective surgeries can be postponed or alternative care would be
more beneficial for the patient(s).
2. Surgical Services managers will inform the ICC of cases currently in surgery and
expected closure times. Surgery in progress will be completed as soon as
possible. No new cases will be started until authorized by the IC.
3. The Labor Pool, located in BI3079, may be activated to collect and inventory staff
and volunteers. The Labor Pool & Credentialing Unit will receive requests and
assign available staff as needed, and maintain adequate numbers of personnel
to ensure patient care is appropriate. Human Resources representatives will
manage the Labor Pool.
4. The triage process, which may occur in a tent outside of the Emergency
Department, just inside the ED, or in another area determined by the events at
hand, determine who needs further evaluation/medical care. The patient’s
treatment area and the severity of the injuries are documented on a triage tag.
HICS Form 206 Staff Medical Plan outlines resources for medical care of
injured/ill. Simple Triage and Rapid Treatment (START) is used to separate the
patients into four groups:
a. Immediate Care: Patients need advanced medical care at once and
are in critical condition and would die without immediate assistance.
b. Delayed Care: Patients are in stable condition but require medical
assistance.
c. Minor: Patients need first aid and are not in need of advanced medical
care.
d. Deceased: Patient is not breathing and an effort to reposition the
airway has been unsuccessful.
5. Personnel that have received training and have practiced decontamination
procedures receive patients contaminated by hazardous materials.
Patients will be decontaminated prior to receiving care unless lifesaving
interventions are necessary first.
Page 40 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
B. Clinical Services For Vulnerable Populations
Patients that have clinical needs (e.g. geriatric, chronic conditions) that fall
outside of the scope of services or ability of the organization to care for them
will be transferred to another healthcare facility with capable resources to
provide appropriate care. In the event transferring a patient is not
immediately possible, Planning and Operations will work together to obtain
the appropriate resources (e.g. staff, medications for anxiety, etc.) to maintain
appropriate delivery of care. The activation of the HICS Mental Health Unit
Leader will be implemented in the event patients with mental health needs
present.
C. Personal Hygiene And Sanitation Needs
The Operations Section Chief and Infrastructure Branch Director are
responsible for ensuring hygiene and sanitation needs are met. The
Infection Prevention and Control Authority and Administration Policy outlines
procedures for using antimicrobial soap and water, and alcohol-based
products. Infection Control will be included in decision-making processes.
Approved hand sanitizers will be used whenever available.
D. Mortuary Services
The current morgue capacity is 8 decedents. See Mass Fatality Plan (Annex
B) for any situation where decedents outnumber available coolers.
E. Documenting And Tracking Patient Clinical Information
1. The Casualty Care Unit Leader will coordinate triage and treatment
activities. Patients are triaged and tracked using the "John Doe System".
Patients are tagged with a triage tag, admitted and the clinical information
is documented on the tag. Each patient is assigned and identified by a
unique control number. This number is printed on the triage tag; medical
forms/requisitions; patient valuables envelope and patient wristband. HICS
Form 259 – Hospital Casualty/Fatality Report is used by the Patient
Tracking Officer to document the number of injuries and fatalities.
2. Information System downtime policies & procedures for managing clinical
information will be utilized to document and track patient clinical
information in the event of an unplanned information technology system
outage. Procedures will include the following (See Registration Downtime
Procedure):
o The manual registration form should be completed in its entirety to
include demographic, guarantor, next of kin, emergency contact,
and insurance information.
Page 41 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
o Using the information from the manual registration form, APAS will
determine if a medical record number exists for the patient, or if a
new MRN must be assigned (see Determining if a Medical Record
Number Exists below).
o Once the patient’s MRN and downtime suffix are determined, they
should be written on the manual registration form.
o Manual labels will be created using Microsoft Word or Forms on
Demand (See Attachment 1).
o A copy (front and back) of the patient’s insurance card(s) and
pictureID will be made (if available), labeled, and stapled to the
manualregistration form.
o A label will be placed on an ED Patient Log and once the log
contains 5 patients, it will be sent to Pharmacy via Order Comm.
o If OrderComm is unavailable, the log should be faxed.
o Once the log is sent a new one will be started, and this process will
continue until the system is recovered.
F. Victims Disabled/Seniors
1. Victims with disabilities and seniors include people who are vulnerable or
at risk and cannot comfortably or safely use some of the standard
resources offered in a disaster situation. All attempts will be made not to
separate these victims from their families/support and to meet their needs.
A point person(s) will be assigned to assist these victims and if possible a
hospital staff person will be assigned to assist one or two victims.
Information on all victims with specials needs will be reported to the ICC.
2. All efforts to contact organizations that represent the interests and rights of
individuals with disabilities to request assistance in treatment and
placement. All patients with special needs who are admitted will be
referred to a social worker/case manager. All patients transferred to
another facility will have a list of their special needs to accompany them
and if necessary a volunteer to assist with the transfer. All patients
discharged from the hospital will be evaluated for any special needs
required for home care, relocation for sheltering or temporary residence.
Page 42 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
XVI. TESTING THE EMERGENCY OPERATIONS PLAN
A. The Organization Tests Its EOP Twice a Year
Functional and / or Full-Scale Exercises are conducted at least two times
each year, either in response to an actual emergency or in a planned
exercise. All exercises will be conducted in accordance with the Homeland
Security Exercise and Evaluation Program (HSEEP). Documentation is
located in the Drills and Exercises Binder.
B. Exercises will include
To ensure staff gains the opportunity of preparation for an emergency, at
least one exercise scenario includes an influx of patients. This process
allows staff to practice using the disaster plan, as well as, teaches them how
to handle multiple patients when they are working in unusual conditions.
At least one planned exercise involves hospital evacuation including a
scenario where the hospital cannot be supported by the local community. In
addition, tabletop drills involving the community and hospital are conducted to
evaluate the community’s emergency response plan.
C. Exercise Scenarios Are Realistic And Related To HVA Priorities
The Hospital Emergency Management Comittee designs drills and exercises
with scenarios and objectives based upon findings from the hazard
vulnerability analysis (HVA), as well as, from critiques/after action reports
from past exercises and/or actual events. In addition, Georgia Health
Sciences Health System participates in exercises designed by Federal, State,
and / or Local authorities that have scenarios based on risk in the
geographical location.
D. During Planned Exercises, an Individual Monitors Performance
During planned exercises, the hospital designates a person(s) to observe, at
minimum, the following core performance areas on the Observer Form:
1. Communication: the effectiveness of communication internally, as well as
external communication with emergency response agencies, public health
and other healthcare organizations within the community.
2. Resource mobilization and availability including assets, personal
protective equipment and supplies.
Page 43 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
3. Safety and security.
4. Event notification: including activation of the Hospital Incident Command
System (HICS); notification of staff and external authorities and staff roles
and responsibilities.
5. Patient management: including triage activities, patient identification and
tracking and support, staff roles and responsibilities.
6. Utility systems.
7. Patient, clinical and support care activities.
E. Exercises Are Critiqued To Identify Deficiencies And Improvement
In compliance with Homeland Security Exercise and Evlaution Program
(HSEEP), all exercises will be conducted through a series of planning steps in
the creation and development process of the exercise. Immieidiatley following
the execution of the exercise, a “Hotwash” will be conducted with participants
and observers to record feedback. Within seven days of the exercise
completion an After Action Review will be conducted involving a multidisciplinary process that includes administration, clinical (including
physicians) and support staff. Upon identification of the both good areas and
areas needing improvement, an Improvement Plan will de created which list
each area needing improvement, the recommended actions to correct, who it
is assigned to and the due date for the task to be completed. This information
may be found in the Drill and Exercises Binder located in the Emergency
Management Office.
AUTHORITIES AND REFERENCES
A.
Federal Government References:
1.
2.
3.
4.
5.
6.
Occupational Safety and Health Administration (OSHA) 1910.34
Exit Routes, Emergency Plans, and Fire Prevention
Occupational Safety and Health Administration (OSHA) 1910.120
Hazardous Waste Operations and Emergency Response
Department of Homeland Security (DHS) National Response
Framework, as amended
Federal Emergency Management Agency (FEMA) Emergency
Preparedness Guide for Business and Industry
Federal Emergency Management Agency (FEMA) State and Local
Guide 101 (SLG-101)
Homeland Security Presidential Directive #5 (HSPD #5)
Management of Domestic Incidents
Page 44 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
7.
8.
B.
Homeland Security Presidential Directive #8 (HSPD #8) National
Preparedness
Homeland Security Presidential Directive #18 (HSPD #18) Medical
Countermeasures
National References:
1. National Fire Protection Association (NFPA) 99: Standard for Health
Care Facilities
2. National Fire Protection Association (NFPA) 101: Life Safety Code
3. National Fire Protection Association (NFPA) 1600: Standard in
Emergency Management and Business Continuity Programs
4. Joint Commission Emergency Management
C.
State Government References:
1.
2.
3.
4.
D.
Local Government References:
1.
2.
3.
E.
Georgia Emergency Operations Plan (EOP), as amended
Georgia Hurricane Plan, as amended
South Carolina Emergency Operations Plan (SCEOP), as amended
South Carolina Hurricane Plan, as amended
Richmond County, GA Emergency Operations Plan, as amended
Columbia County, GA Emergency Operations Plan, as amended
Aiken County, SC Emergency Operations Plan, as amended
Georgia Health Sciences Health System Inc Policies
1. EC 4.10.3 Emergency Management Plan
2. EC 4.10.4 Mitigation
3. EC 4.10.6 Re-establishmnet of Operations
4. EC 4.10.7 Staff Notification
5. EC 4.10.12 Relocation & Evacuation
6. EC 4.10.13 Alternate Site
7. EC 4.10.14 Incident Command Staff
8. EC 4.10.15 Community Organization Command
9. EC 4.10.19 ICC Roles
10. EC 4.10.20 Alternative Means
11. EC 4.10.21 Chemical Radioactive Decon
12. EC 7.10.7 Utility Systems Managment
13. EC 7.40 Hospital Emergency Generators
14. EM 01.01.01 Emergency Management
15. ACS 1.01 ED Registraion Downtime Procedure
Page 45 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
16. ACS 1.02 Scheduling / Check in / Check out downtime procedure
17. ACS 1.03 IDX Scheduling and Patient Management System Downtime
and Recovery Procedure
18. ACS 1.05 Call Center Emergency Plan
19. ACS 1.06 Procedure for APAS Code D Protocol
20. Prisoners as Patients Policy # 9.59
Page 46 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
Hazard Vulnerability Analysis (HVA) Summary
Page 47 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
Hazard Vulnerability Analysis Summary (continued)
Page 48 of 49
Georgia Health Sciences Health System
Emergency Operation Plan
Due to formatting issues the Job Action Sheets and HICS Forms will be
kept in separate file. To be combined when printed
Page 49 of 49