CENTER FOR BIOTERRORISM PREPAREDNESS AND PLANNING

EVACUATION PLANNING FOR HOSPITALS DRAFT DOCUMENT

MAY 2006

This publication was supported by Grant Number U3RHS05957-01-00 from the Health Resources and Services Administration. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HRSA. All inquiries about the Continuum Health Partners Evacuation Planning for Hospitals may be addressed to: Bioterrorism Hospital Preparedness Program c/o NYC Department of Health and Mental Hygiene 125 Worth Street, RM 222, Box 22A New York, NY 10013 Phone: 212-788-4277

CENTER FOR BIOTERRORISM PREPAREDNESS AND PLANNING

Continuum Health Partners, Inc. was formed in January, 1997, as a partnership of two venerable health care providers, Beth Israel Medical Center and St. Luke's-Roosevelt Hospital Center. Building upon the strengths of both institutions, the partners soon established a broad-based, integrated health services network extending throughout the New York metropolitan region. In May, 1998, the partnership was joined by a third distinguished institution, Long Island College Hospital, located in the Brooklyn Heights/Cobble Hill section of Brooklyn. Continuum continues to grow with the addition of another outstanding institution with a 100-year tradition of excellent specialty care, the New York Eye and Ear Infirmary. Continuum Health Partners, Inc., has an annual operating budget of $2.1 billion. Its hospitals deliver inpatient care through nearly 3,100 certified beds located in seven major hospital facilities in Manhattan and Brooklyn. Continuum providers also see patients in group and private practice settings and ambulatory centers in the Bronx, Brooklyn, Queens and Manhattan, and in Westchester County. All four Continuum partner institutions were established more than a century ago by civicminded individuals with a shared commitment to improving health, and health care, in their communities. Continuum established The Continuum Emergency Management Committee (CEMC) in October 2001. The CEMC is comprised of membership and expertise in emergency management from all of its partners and this partnership has enabled each member institution to be better prepared for an all hazards approach to planning. Continuum is also one of four CBPPs in NYC (Center for Bioterrorism Preparedness and Planning). Our continued work through our CEMC and our partnership with the NYCDOHMH has enabled us to advance our readiness and achieve excellence in emergency management planning.

Process The recommendations that are encompassed in this document have been made as a result of efforts from subject matter experts from the six hospitals that make up Continuum Health Partners, Inc. The Continuum Emergency Management Committee (CEMC) convened a subcommittee to analyze, recommend and implement comprehensive evacuation plans based on the experiences shared from the hospitals in New Orleans who were victims of Hurricane Katrina. The subcommittee met over the course of three months and further subdivided the work into three task forces: a facility task force, a patient care task force and a support service task force. Each task force met and created formal recommendations which were then presented to the CEMC for adoption/approval. This document details some of the more pertinent recommendations and applies them generically for use by all hospitals in their evacuation planning. This is by no means a comprehensive document but one that addresses some of the high level issues in evacuation planning. Continuum is in the process of implementing the tools and plans encompassed in this document and anticipates that there may be changes made to the templates and process flow in the future.

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EVACUATION PLANNING FOR HOSPITALS TABLE OF CONTENTS

Introduction Facility Issues 1. Comprehensive Layout of Hospital Campus 2. Building Directory 3. Departmental Detail 4. Staging Areas People Issues System for Prioritizing/Triaging and Tagging Inpatients for Evacuation Tracking Tools Identifying and Readying Patients for Evacuation off the Inpatient Unit Support Services Issues Evacuation Task Force Membership Attachments 1. Hospital Campus Stacking Diagram 2. Building Directory Inventory for Evacuation 3. Department Evacuation Template 4. Patient Care Unit Evacuation Template Tool #1 5. Patient Care Unit Evacuation Template Tool #2 6. Visitor Tracking Evacuation Template 7. Staff Evacuation Template 8. Patient Critical Evacuation Information Form 9. Suggested Medications for Staging Areas 10. Evacuation Tool Kit 11 12 13 15 16 17 18 19 21 23 1 2 2 3 3 3 4 5 6 7 8 9

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Introduction A full hospital evacuation is a difficult process to envision, and, in the past, has been considered a remote possibility. The 2005 hurricane season showed us that full scale hospital evacuations are not only a possibility, but a grim reality. Many lessons were learned from Hurricane Katrinas onslaught of the New Orleans area and this document attempts to put those lessons into recommendations for NYC hospitals to use to review and revise their current evacuation plans. The vast majority of hospitals in the NYC area have evacuation plans in place that deal with the most common evacuation they face, fire. However, fire plans are not comprehensive and do not address all of the issues. Fire evacuation plans are written to effect rapid evacuation of the affected are a, but rarely address a full facility evacuation that may be necessary over time (several hours to several days) Drills of the Fire Evacuation plan are routinely conducted but seldom include the actual evacuation of area; therefore, the plan is never stressed to see if it actually works. Because these plans deal with one reason for the evacuation, fire, vulnerability analyses performed have not included other pertinent issues such as: ? Location and vulnerability of generators (flooding) ? Ability to evacuate from roof ? Equipment necessary to move patients ? Staging areas ? Transportation to other facilities

Evacuation plans should be written to encompass all gradations of an evacuation, from the defend in place scenario up to and including a full scale hospital evacuation. For the purposes of this document, we will only be addressing up to an entire campus evacuation. As stated previously, the recommendations and plans presented here are a work in progress and will be refined as they are implemented in the Continuum hospitals. Scope of Evacuations Evacuation planning must be done keeping in mind that the scope of the evacuation can grow over time depending on the nature of the event. In fact, an evacuation can start as a defend in place scenario, where minor adjustments are made to accommodate the event, but essentially no one is moved. The defend in place strategy can move over the course of several hours or days to a full scale campus evacuation, where the entire hospital, its patients and staff must be relocated. Examples of escalating scope of evacuations: Defend in place Single Department/floor/unit Section Multiple floors/units within a single building Entire building to another location on campus Entire campus evacuation Citywide evacuation In addition the time frame around evacuations can be different, ranging from a rapid evacuation in the case where the event is life threatening to a slow growing need to evacuate as was the case in New Orleans during Hurricane Katrina.

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Types of Evacuations Traditionally hospitals have focused on horizontal and vertical evacuations. Horizontally moving to a safer location on the same floor, or vertically (up or down) to another floor that is unaffected by the event. Hospitals now need to put in place planning that encompasses moving patients/staff and others to a safe haven/staging area in preparation for a move to another facility. Creating Comprehensive Evacuation Plans In order to address the full scope of the stages of evacuations, it is necessary to put together plans that address three basic elements: Facility Issues People Issues Support Services Issues Additionally, it is important to understand that these plans are designed so that the hospital utilizing them can scale the evacuation to their individual needs and recognizes the fact that the process of evacuation may escalate over the course of several hours to several days, from clearing several floors to a full campus evacuation. Facility Issues Evacuation plans need to include tools that allow the HEICS team, and in particular, the Incident Commander, the ability to identify rapidly areas of the hospital that require a high priority for evacuation, areas of vulnerability and areas that have potential risk. A drill down building by building, then floor by floor within buildings is necessary to get to the specific details of the evacuation itself. Identification of staging areas where patients will be sent temporarily should be identified early on so that routes to safe haven can be incorporated into the specific departmental evacuation plans. In addition, hospitals must work with their Engineering and Facility Departments to evaluate the feasibility of evacuation of patients from a rooftop. Structurally many buildings cannot support the weight of a helicopter; therefore it is necessary to determine if this is a feasible evacuation route. 1. Comprehensive Layout of the Hospital Campus The easiest way to obtain a high level look at the entire hospital campus is by utilizing a simple stacking diagram. These can be easily created in either excel or word. The stacking diagram will give a floor by floor view of: ? ? ? ? Patient care areas Critical patient care area Non patient areas Vacant space

These areas can be coded using a grayscale coloring scheme so that plans can be easily and quickly reproduced and distributed during the event. Symbols should be used to identify areas that contain hazardous chemicals or materials as well those floors that may have connecting bridges between buildings.

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Examples: ? ? ? ? ? ? Patient care areas Critical patient care area Non patient areas Vacant space Hazardous chemicals Connecting Bridges

p ?

An example of a stacking diagram can be found in Attachment #1. 2. Building Directory: A building directory will provide detail of each department, service and/or administrative offices that are on each individual floor of the building. This is critical in understanding priority for evacuation as well as for assurance that all staff, patients and others have been accounted for. It is recommended that when gathering this data, the main evacuation routes should also be identified to assist the Incident Commander and others in understanding how traffic will flow during the evacuation. An example of a building directory template can be found in Attachment #2 3. Departmental Detail The next and final level of detail necessary is the departmental level detail. Each service, nursing unit or department should create a departmental evacuation plan using a standard template. The template should be brief and include critical information only. For the purposes of the evacuation, where it is critical that patients be quickly taken out of harms way, the template concentrates on gathering the patient care information necessary. The recommended template includes: Department/Unit/Service type Number and type of beds Specialized Medical equipment Presence and type of hazardous chemicals Locked or open unit Presence and type of medical gases Location of fire exits Evacuation route Location of staging area

These templates, once completed, should be kept both in the command center and in the department itself, reviewed and revised annually and shared with staff on an annual basis. An example of a template for Departmental Details can be found in Attachment #3 4. Staging Area When an evacuation entails a single department/floor or unit, or even multiple floors within a single building, patients should be assigned to vacant beds in other non affected units within the hospital

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campus. It is also feasible that patients could be sent to closed units for an interim period until it was deemed safe for the patients to return to their original floors. In the case where an entire building or entire hospital campus requires evacuation, it is assumed that this will take place over time, and in an orderly fashion, at the direction of the Incident Commander. In this scenario this plan assumes the following: ? The Emergency Department will go on diversion and the inflow of patients will stop. Instead, the ED will begin to function as a dispatcher.

NOTE: The arrangements for transfer for patients to other healthcare facilities will be the responsibility of the Liaison Officer, who will coordinate this directly with the receiving facility in consultation with the NYSDOH, NYCDOHMH, and GNYHA. The physical transfer of the patients, (arrangements for ambulance, ambulette, etc) will fall under the auspices of the Transportation Unit Leader in consultation with the Office of Emergency Management. ? A staging area will be utilized as an interim location for inpatients prior to transport to other healthcare facilities, or prior to discharge if so determined. Patients coming from the inpatient unit will to the pre determined staging area, and once there, be re-assessed. Patients will remain in the staging area until such time as transfer has been arranged. At that point patients will be transported to the Emergency Department where they will be readied for transfer.

Staging area(s) should be large enough support several patients on stretchers and/or allow set up of cots or air mattresses. A discharge area should be designated for patients who are stable enough to discharge home, but are awaiting transportation or family members to pick them up. Staffing for the staging area should be consistent with the level of acuity on the inpatient units, and consist of physicians, registered nurses, nursing assistants and other clerical staff. The Planning Chief would assume the responsibility for staffing this area initially out of the labor pool and/or redeploying staff from the ambulatory setting. As the inpatient units were evacuated, staff from that area would then report to the labor pool for redeployment to the ED or staging area as necessary. The overall responsibility for the care delivered in the staging area would fall under the responsibility of the Operations Chief under the Medical Care Director. The staff in the staging area would participate in the tracking and reconciliation of patients as they move from point to point. People Issues In any evacuation scenario, whether it be a single floor, single building or total hospital campus, assessing, triaging, tracking and reconciling patients, staff, visitors and others as they move throughout the evacuation is the single most important aspect of the plan. Clear lines of authority are also necessary to coordinate a systematic and safe evacuation. The use of ICS is imperative to the success of any evacuation. A review of the ICS for hospitals reveals no need to create additional positions; however, each floor or inpatient unit needs to have a person coordinating the evacuation for that area. For the purposes of this document, we will refer to that position as the UNIT EVACUATION LEADER. The Unit Evacuation Leader should be an administrative or operational person, one that is assigned to the area being evacuated by the Incident Commander. This role should not be assumed by clinical staff of that nursing unit as they will be occupied with triaging, and readying patients for transport. This document will cover the following areas:

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n n n n n

System for Prioritizing/Triaging Patient for evacuation Tagging system to identify levels of care Identifying and readying patients for evacuation q Medical Records q Critical Medications Accounting for Patients/families/visitors/staff q System for inventory of patients/staff q System to designate when rooms/floors are empty Develop Evacuation Kit for every area

System for Prioritizing/Triaging and Tagging Inpatients for Evacuation A systematic method for triaging inpatients is key to a successful evacuation. A rational movement of patients from the inpatient unit to a staging area prior to transfer to another location/healthcare facility is necessary to move patients quickly and safely. It is essential, however, to realize that the triage priorities that most clinical staff are accustomed to in emergency response, i.e. the traditional START system, must be approached differently in an evacuation. Inpatients that are ambulatory and relatively stable will have first priority for moving off the inpatient nursing unit. These patients are less resource intensive and many can be led off the unit with one or two staff members. Patients who are non ambulatory, acutely ill, unstable or require life saving equipment will require the most resources for moving. As stated, for the purposed of evacuation triaging, the categories of START are reversed for the evacuation, however, they will revert back to the original priority once the patient reaches the staging area prior to transfer because you will want to get the most unstable patients moved to a healthcare facility first. See the chart below for the prioritization: Triage Level RED - STOP Priority for Evacuation off nursing unit REVERSED START PRIORITY These patients require maximum assistance to move. In an evacuation, these patients move LAST from the inpatient unit. These patients may require 2-3 staff members to transport These patients require some assistance and should be moved SECOND in priority from the inpatient unit. Patients may require wheelchairs or stretchers and 1-2 staff members to transport These patients require minimal assistance and can be moved FIRST from the unit. Patients are ambulatory and 1 staff member can safely lead several patients who fall into this category to the staging area. Priority for Transfer to another healthcare facility TRADITIONAL START PRIORITY These patients require maximum support to sustain life In an evacuation. These patients move FIRST as transfers from your facility to another healthcare facility. These patients will be moved SECOND in priority as transfers from your facility to another healthcare facility. These patients will be moved LAST as transfers from your facility to another healthcare facility.

YELLOW CAUTION

GREEN - GO

These assessments must be made with clinical staff on the units. As the assessments are completed it is recommended that the staff utilize a tagging system to clearly indicate what level of priority the patient has been given. Fluorescent tags, which are pre-strung are one method of flagging patients. These can be affixed to the patient in some manner, one method being to apply these tags to the patient wrists (on the same arm as their patient ID band). The use of NCR paper

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with three copies should be considered in developing these tags as this will assist in the reconciliation process. The tags can be imprinted with the patients information using the patients addressograph plate or labels with bar codes, depending on the system utilized in the organization and as the patient moves from point to point, one of the copies can be torn off and used in the tracking and reconciliation process. Tracking Tools Tracking the movement of patients, staff, visitors and vendors throughout the organization during an evacuation is imperative to the reconciliation process that must occur to assure that everyone has gotten out safely. Three tools were developed for this purpose: q Patient Tracking tool q Visitor Tracking tool q Staff Tracking tool The patient tracking tool is composed of two documents, one to categorize the patients by location and the other to indicate the level of care required during evacuation. The Patient Care Unit Tracking Tool 1 documents the exact location of every patient ASSIGNED to the unit. This tool takes into account patients who may be off the floor at diagnostic tests or procedures, as well as patients who may still be in the emergency department or the Admitting office awaiting transport to the unit. This tool assists in the reconciliation of total patient census (assigned census) vs. actual census (patients present on the floor). The determination of whether a patient who is in the procedure area returns to the unit for evacuation or is evacuated from the procedure area to the staging area will be determined by the Incident Commander in consultation with the Unit Evacuation Leaders of each area. The Patient Care Unit Tracking Tool 2, documents the evacuation triage level assigned to the patient as well as equipment needs, mode of transport, time of departure from the inpatient unit and time of arrival to the staging area. Each of these tools will be faxed to the EOC (to the attention of the Incident Commander) as well as to the staging area to assist in reconciliation. In addition, the responsibility for tracking and reconciliation of patients will fall under the direction of the Patient Tracking Officer. Tracking patient visitors as well as others that might be on the floor is equally important. Accounting for the staff as well should be done in a methodical manner. See Patient Care Tracking tool 1 Attachment #4 See Patient Care Tracking tool 2 Attachment #5 See Visitor Tracking tool Attachment #6 See Staff Tracking tool Attachment #7 Designating when a floor is empty It is important to validate that all patients and staff have been cleared from the patient unit and then secure the floor. The Unit Evacuation Leader should conduct a walk through of each room including support space. As each room is checked it is recommended that some method of indicating that the room is empty is utilized. This can easily be accomplished by affixing a sticker or posting a sign on each of the doors within the area.

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Identifying and Readying Patients for Evacuation off the Inpatient Unit Medical Information The transfer of critical patient information from one geographic area to another as well as to other healthcare facilities is important. In such a scenario there will not be time for providers to review patient medical records or even transfer these records with the patient. Therefore a summary of the pertinent information is required. Healthcare organizations that utilize electronic medical records should consider including an emergency patient summary in their planning and installation of such systems. However, it should also be recognized that in the event an evacuation is necessary, electronic systems may be down, so extracting this information will become impossible and therefore manual methods must be identified. The brief summary should be completed prior to moving the patient and copies of critical pieces of information should go with it including: n Copy of Medication Administration Sheets n Copy of most recent set of complete medical orders n Copies of Latest lab reports n Copy of DNR n Copy of Advanced Directives n Restraint Orders n Physician Commitment papers See Attachment #8 Critical Patient Information Medical Records The hospital must assure that a process is in place to secure medical records. This should be discussed with the Medical Records department and policies should be developed that address the securing and transfer of records. There are three areas that should be addressed in formulating a policy to deal with the securing of medical records: 1. Old/Discharged Records: Distinction needs to be made between active records and inactive records (patients who have previously been discharged but whose records have not been forwarded to Medical records). Medical Record personnel should work with unit staff to collect all medical records on the unit. These records should be placed in a storage box and appropriately marked with permanent marker. 2. Active patients Medical Records: As patients are readying to leave the patient care unit, the Medical Record staff should collect all active medical records on the unit. These should be placed in a storage box and appropriately marked with permanent marker. (Active Medical Records- Name of Patient Care Unit). 3. Split Medical Records: Consideration needs to be given to split charts. Split Charts are medical record documents that are part of the patients current hospitalization but due to volume (most usually from prolonged hospitalization); non urgent information has been removed from the active chart and stored elsewhere. The Medical Records staff must work with the unit staff to collect all split medical records on the unit. These should also be placed in a storage box and appropriately marked with permanent marker. (Split Medical Records- Name of Patient Care Unit) It is also recommended that once secured, the medical records be safeguarded from water damage. Boxes of medical records can be placed in clear plastic bags which are then sealed in order to protect them from water damage. Clear plastic bags should be utilized so that the markings on the boxes can be easily viewed. Medications

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Hospitals must work with their pharmacies to identify what medications need to accompany patients and/or be available in the patient staging area. It should be recognized that several hours may elapse until transportation to another healthcare organization is accomplished and provisions for critical medications to be made available at the staging area is essential. In addition, emergency medications and equipment to address cardiac and respiratory arrests must also be provided at the staging area. Many hospitals now utilize code carts whose medication drawers can be easily removed and relocated to the staging area. It is recommended that in drafting these policies hospitals work with their pharmacies to assure the movement of critical life saving medications and equipment. Finally, the transferring facility should assess if the receiving facility has specific patient medications. In the instance where a specific patient medication is critical and not available at the receiving institution, the sending facilitys pharmacy department should arrange to transfer the medication to the receiving facility. See Attachment #9 Suggested medications for staging areas. Evacuation Toolkits Pulling together the materials, documents and supplies to assist in evacuating a patient care floor cannot be left to the last minute. Each healthcare organization should consider assembling an evacuation toolkit for each patient care area and keeping this with their emergency equipment, for example with their Code carts. An example of such a toolkit is given in Attachment #10. Support Services Issues Comprehensive evacuations plans should give consideration to the following areas and assure that plans are in place to address each: Systematic shutdown of medical gases, utilities and generators: plans must include the procedures for shutting down and securing gases, electricity, and water not only floor by floor as they become evacuated, but entire buildings as they empty. Telecommunication systems for relocated areas As units evacuate to staging areas it is critical that alternate forms of communications be utilized. Publication of staging area phone numbers in the plan is one method. Hospitals can also consider using their redundant communication plans as well (i.e. two way radios and/or cell phones) Supplies: Plans should be drafted that assure that medical supplies, food, water, and linen are moved to the staging area for patients. Security finally plans should address the securing of floors, buildings and equipment to protect the assets of the hospital.

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Evacuation Task Force Membership

Chairperson: Roe Long, RN, MBA Vice President, St. Lukes Roosevelt Hospital Center Co-Chair Continuum Emergency Management Committee Facility Task Force: Susan Gold Vice President, Beth Israel Medical Center Petrie Division David Masini, BSE Assistant Vice President, Administration St. Lukes and Roosevelt Hospital Centers Kathryn Ebe, Beth Israel Medical Center, Kings Highway Division Yvonne Guariglia, Safety Officer, St. Lukes & Roosevelt Hospital Centers Len Layvand Biomedical Engineering Director/Safety Officer Long Island College Hospital Virna Morales, HEM Safety Director Beth Israel Medical Center, Petrie Division Patient Care Task Force Patricia Dillman, RN Director of Nursing; Critical Care St. Lukes and Roosevelt Hospital Centers Raymond Cosner, R.H.I.A. Director of Medical Records, Beth Israel Medical Center Petrie/PACC Division Mary Ann DiMaggio R.H.I.A Director of Medical Records, St. Lukes & Roosevelt Hospital Centers Peter Oliva, Pharmacy, Beth Israel Medical Center Anthony DAlessandro, BS, MS Director of Pharmacy, Beth Israel Medical Center Petrie Division Anthony Nolosco, Director of Pharmacy, Long Island College Hospital Linda Fox, RN BSN Director of Nursing, Patient Access Services Beth Israel Medical Center Petrie Division

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Kathy Peterson, RN, MSN, CEN Nurse Manager, ICU; Beth Israel Medical Center Kings Highway Division Kathleen Rogers, RN, BSN, Nurse Manager, Beth Israel Medical Center, Kings Highway Division Vincent Virone, Director of Pharmacy, St. Lukes Hospital Center Barbara Denninger, RN, MSN Vice President for Nursing Long Island College Hospital Support Services Task Force John Byrne Chief Operating Officer, Long Island College Hospital Lewis Kohl, DO Chair Emergency Medicine, Long Island College Hospital Dennis OConnell Director of Safety and Security, New York Eye & Ear Infirmary Robert Zick Corporate Director of Security, Continuum Health Partners Ed Robbins Emergency Department, Long Island College Hospital Nancy Escala Project Coordinator, Continuum Emergency Management

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Evacuation Planning for Hospitals ATTACHMENT #1 Hospital Campus Stacking Diagram

ROOF MACINE ROOM floor 12 ROOF RESEARCH ? NURSING UNIT MED SURG CLOSED NURSING UNIT NURSING UNIT MEDICINE NURSING UNIT MEDICINE NURSING UNIT PEDIATRICS NURSING UNIT MATERNITY OPERATING ROOMS/PACU CENTRAL STERILE CAFETERIA/DIN ING ROOM/TRANSP ORTATION OFFICE/FOOD SERVICE OFFI KITCHEN BUILDING 1 Key Patient Care Area Critical Care Patient Area Non Patient Care Area VACANT Hazardous Chemicals Present Connectin g Bridges ROOF NURSING UNIT MED SURG NURSING UNIT SURGICAL NURSING UNIT CARDIAC NURSING UNIT ICU NURSING UNIT ICU MECHANICAL RM 5 OR LOCKERS/FAN ROOM CYSTO/AMB SURG MAT MGT/PHARMACY LOBBY/ADMITTIN G/ PAT MEDICAID OFF UM/ADMINISTRATI ON KITCHEN BUILDING 2 ? ? 4 3 2 11 10 9 8 7 6 ROOF MACINE ROOM MACINE ROOM ANIMAL RESEARCH NURSING UNIT PSYCH NURSING UNIT PSYCH MEDICINE ADMIN NURSING UNIT MED/SURG NURSING UNIT MEDICINE LABS RADIOLOGY OUTPATIENT CLINICS RESEARCH ? RESEARCH ? ROOF MACINE ROOM ON CALL ROOMS LABS ADMINIST RATION NURSING UNIT REHAB VACANT ENDOSCO PY ULTRASO UND OUTPATIE NT CLINICS RESEARCH ? RESEARCH ? RESEARCH ? RESEARCH ? BIOMED OUTPATIENT REHAB NUC. MED/ NUC CARDIOLOGY LABS/EKG CATH LAB/EPS MEDICAL RECORDS

EMERGENCY DEPARTMENT 1 B MACHINE RM BUILDING 3

EMERGEN CY DEPT

MRI/SECURITY

MACHINE RM BUILDING 4

MACHINE RM BUILDING 5

? ?

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Evacuation Planning for Hospitals ATTACHMENT #2 Building Directory Inventory for Evacuation

Hospital Name: General Hospital NYC

Building Name: Hospital Building #1

Floor Basement floor: Service/Department/Unit Horizontal Evacuation Vertical Evacuation Building Evacuation

floor:

floor:

floor:

floor:

floor:

floor:

floor:

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Evacuation Planning for Hospitals Attachment #3 Departmental Evacuation Template

Hospital: Building: Department/Unit/Service: Unit/Floor Type: ____ Critical Care (OR, ICU, Recovery, ED) ____ Patient Care specialty (Telemetry, Hemodialysis) ____ Patient Care General ____ Outpatient care ____ Support patient care (labs, x-ray, EEG, EKG) ____ Support non patient care (food, mat. Mgt, transport) ____ Administrative (office, Medical Records) ____ Research ____ Other (mechanical rooms, storage, engineering shops) Floor:

Number of beds on unit __________ Specialized Medical Equipment present on unit: Infusion Pumps; Portable ventilators; Portable Oxygen; Portable Suction Unit; Ambu bag; Defibrillator; Monitors Specialized Medications:

Hazardous Chemicals present on unit: Yes No; If yes identify chemical and quantity

Is this a locked unit?

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Attachment #3 Departmental Evacuation Template

Yes

No

Do you have medical gases? Yes No; If yes: Piped Cylinder

Location and Exits: Attach Floor plan that includes location of medical gas shut off valves; location of exits; pull stations, extinguishers, sprinkler systems, designated smoke and fire doors.
Evacuation Route: Horizontal: To ______________________ via

Vertical: Down to:______________________________________________ Up to: _________________________________________________

Staging Area for full building evacuation:________________________________________

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Evacuation Planning for Hospitals Attachment #4

PATIENT CARE UNIT EVACUATION TEMPLATE TOOL #1

HOSPITAL:______________________________________________________ Unit Name: ______________ Unit Location: Building________________ Total Number of Staff on Unit at Start time of Evacuation: RNs: LPNs NAs/PCAs US MD Other Floor _____________________

A. PATIENT CENSUS ON UNIT AT START TIME OF EVACUATION: B. TOTAL PATIENT CENSUS C. PATIENTS TO BE ACCOUNTED FOR A B =

PATIENTS OFF UNIT FOR PROCEDURES/OR/RADIOLOGY/DIALYSIS AT TIME OF EVACUATION:

Patient Name Room Number Current Location

Total # of patients off unit in other areas =

SCHEDULED ADMISSIONS TO THE UNIT THAT HAVE NOT ARRIVED AT TIME OF EVACUATION:
Patient Name Room Number Admitted from (ED, clinic, Admitting, etc)

Total # of patients admitted to unit, not yet arrived =

PATIENTS AT RISK AT TIME OF EVACUATION: (i.e. Suicide precautions, patients in restraints, Bipap, Active labor, Temporary External Pacer)
Patient Name Room Number Risk Issue

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Evacuation Planning for Hospitals Attachment #5

CONTINUUM HEALTH PARTNERS

PATIENT CARE UNIT EVACUATION TEMPLATE PART TWO Page ____ of ______

UNIT WORKSHEET HOSPITAL: __________________________________________________________________ Unit Name: _____________________________ PATIENTS (use Addressograph to imprint patient name or utilize patient labels)

Unit Location: Building______________________________ Floor _____________________ Mode of Transportation Ambulatory Wheelchair Stretcher Bassinet Isolette Other (indicate) Ambulatory Wheelchair Stretcher Bassinet Isolette Other (indicate) Ambulatory Wheelchair Stretcher Bassinet Isolette Other (indicate) Time: Equipment leaving with pt: Date: Indicate destination: Yes No Time: Contact: Time: Equipment leaving with pt: Date: Indicate destination: Yes No Time: Contact: Time: Equipment leaving with pt: Date and Time patient left unit Date: Destination: Accepting Facility for Patient Transfer Indicate destination: Arrival at Destination Yes No Time: Contact:

Category

Equipment Needs

(significant resources for transport)

Red Yellow

Oxygen Monitor Ventilator Pump Other (indicate)

(moderate resources for transport)

Green

(minimal resources) Red (significant resources for transport)

Yellow

Oxygen Monitor Ventilator Pump Other (indicate)

(moderate resources for transport)

Green

(minimal resources) Red (significant resources for transport)

Yellow

Oxygen Monitor Ventilator Pump Other (indicate)

(moderate resources for transport)

Green

(minimal resources)

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Evacuation Planning for Hospitals Attachment #6 Unit Work Sheet

VISITOR TRACKING EVACUATION TEMPLATE

Page ____ of ______

HOSPITAL: __________________________________________________________ Unit Name: ________________________________ Name and Telephone Contact Number of Visitor Name of Patient visiting Unit Location: Building______________________ Time Left Unit Destination Floor _________________________ Arrival at Destination Yes No Initials:_______ Yes No Initials:_______ Yes No Initials:_______ Yes No Initials:_______ Yes No Initials:_______ Yes No Initials:_______

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Evacuation Planning for Hospitals Attachment #7

STAFF EVACUATION TEMPLATE

UNIT WORKSHEET HOSPITAL: __________________________________________________________________________ Unit Name: _______________________________ STAFF NAME DEPARTMENT Unit Location: Building________________ Floor _____________________ Time Left Unit Destination Arrival at Destination Yes No Initials:_______ Yes No Initials:_______ Yes No Initials:_______ Yes No Initials:_______ Yes No Initials:_______ Yes No Initials:_______ Page ____ of ______

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Evacuation Planning for Hospitals Attachment #8

Patient Critical Evacuation Information * Patient Name: (PRINT) ______________________________ Medical Record Number: ____________________________

Admission Date: ______________ Sending Facility:______________________________________ Consent Obtained for Transfer: Yes No Unable to Obtain

Emergency contact: _____________________Telephone #_______________ Notified of Transfer YES NO Attending Physician: __________________ Notified of Transfer YES NO

Primary Diagnosis: ____________________________________________________________________ Secondary Diagnoses: __________________________________________________________________ Allergies: __________________________________________________________ Vitals at Time of Transfer: T=_____ Do Not Resuscitate Yes Isolation Status: P=__________R=____________BP=___________________ Yes Other: No (Copy Attached)

No (Copy Attached) Advanced Directives: Droplet Fall Elopement Airborne

Contact

Precautions: Aspiration Seizure

Other:_____________________________

Oxygen: Mask Cannual Other:___________ Oxygen Requirement:_____________ Tube Feeding: Yes No Enteral Formula:__________________________ Diet: Regular Low Salt Diabetic Bland Other:___________ Feeds Self YES No Other Intravascular Device Central Line PICC Line Arterial Line Other:________________ Foley Yes No Incontinent Yes No Bowel Bladder Behavior: Cooperative Disruptive Belligerent Sedated Combative Wanders Forgetful Confused Withdrawn

Mental Status: Oriented x ______ Alert Transfers: Independent Supervision

Partial Assist

Total Assist Dentures: Upper Lower Hearing Aid

Assistive Devices: None Cane Walker Wheelchair Glasses Prosthesis Type__________ Pressure Ulcer: Yes No Location: How Long___________

Restraint: Type___________

ADL Independent Supervision Partial Assist Total Assist

Over
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Evacuation Planning for Hospitals Attachment #8

*Attach Copy of Patient medication administration record.

Patient Critical Evacuation Information * Continued

List IV access and infusing fluids or medications: IV Fluids And Amount Medications added Name and concentration

Access site

Gauge

Infusion Rate

If pump going Asset Tag Number

Endotracheal Tube size: _______ Level at Lip:_______ Trach Tube size:______ Ventilator Settings at time of transfer: Mode: Assist Control Intermittent FIO2: ________________% Other:_________

Rate:_______________________ PEEP:__________________

Pressure Support: _____________ Other: ___________________ Other important information about this patient: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________
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Evacuation Planning for Hospitals Attachment #9 SUGGESTED MEDICATIONS FOR STAGING AREAS

EMERGENCY EVACUATION PHARMACEUTICAL SUPPLIES Medication

Oral Prep
Acetaminophen Aspirin Clopidogrel Erythromycin Furosemide Ibuprofen Lisinopril Metoprolol Oxycodone/APAP (CII)

Strength
325mg 325mg 75mg 250mg 40mg 400mg 10mg 50mg XL 5/325mg 160mg/5ml 200mg/5ml 100mg/5ml 1gm 400mg 50mg

Oral/ Inj/Top Category

Tab Tab Tab Tab Tab Tab Tab Tab Tab Liq Liq Liq IM IVPB IVPB IM IVP IM SC IM IVP slow 1-2min IM IVPB IM
Pain Pain/CV CV Antibiotic CV Pain CV CV Pain Pain Antibiotic Pain

Quantity
500 100 100 50 100 500 100 100 500 100 10 100 20 20 50 50 20 20 20 50 50

Pediatric Oral Prep

Acetaminophen Erythromycin Ibuprofen Cefazolin Ciprofloxacin Diphenhydramine Diphtheria & Tetanus Toxoid Enoxaparin Furosemide Gentamicin Haloperidol Insulin R Lidocaine Lidocaine w. epin Lorazepam (CIV) Meperidine (CII) Metoprolol Methylprednisolone

Injectable Prep
Antibiotic Antibiotic Antihistamine Vaccine LMWH CV Antibiotic Antipsychotic/ Sedative Hypoglycemic Local anesthetic Local anesthetic Antianxiety/ Sedative/ Anticonvulsant Pain CV Corticosteroid

30mg 60mg 80mg 40mg 80mg 5mg

50 100
25 25 10 100

100units/ml SC , 10ml 1% 30ml SC 2% 30ml 1% 30ml SC 2mg 50mg 5mg 40mg 500mg IM IVP slow (=2mg/min) IM SC IVP slow 1-2min IM IVP slow

30 50 50 20

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Evacuation Planning for Hospitals Attachment #9 SUGGESTED MEDICATIONS FOR STAGING AREAS

Morphine

(CII)

2mg 10mg 400mg 100mg

Moxifloxacin Phenytoin Tetanus Immune Globulin Code Cart trays -Adult/Pediatric

(Dose =125mg, IVP over 3min) IM SC IVP IVPB IVP slow (=50mg/min) IM

Pain Antibiotic Anticonvulsant Immune Globulin

50 50 20

50
10 Minimum 3

See attached MDI MDI 3.2gm 10% 3.5gm 20gm Opthalmic oint Opthalmic oint Topical cream

Oral Inhaler
Albuterol Ipratropium
Asthma/COPD Asthma/COPD Antibiotic Antibiotic Antibiotic 50 50 50 50 20

Opthalmic Prep External Prep

Erythromycin Sulfacetamide

Silver Sulfadiazine Cream

Miscellaneous Supplies
Alcohol swab Calculator Drug reference Gloves Label Needle NS Patient Profiles Pen/Marker Plastic Bag SWFI Syringe
500 1 1 100 100 1 roll 100 50 1 10 50 50 50 100 100

Small
Medium

18G x 1in 0.9% 10ml

Diluent/ Line flush

4x6 9x12 10ml 1ml 5ml

Diluent

Prepared by Sara S. Kim, Pharm.D 12/05

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Evacuation Planning for Hospitals Attachment #10

EVACUATION TOOL KIT

Laminated Evacuation Triage levels Pre-Strung Fluorescent Tags (Colors: Red, Yellow, Green) Removable Labels- 2-1/2# round Labels- 250 to a roll- EVACUATEDidentifies areas that have been checked and evacuated Labels for Addressograph Permanent Markers Rubber Bands for Medical Records Patient Tracking Tools Staff Tracking Tools Visitor Tracking Tools Patient Critical Evacuation Information Form Sheet Protectors for Transfer Documentation to Accompany Patient Non-Skid Socks for Ambulatory Patients without Shoes Wind Up Flashlight Fluorescent Vest

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