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Hospital Disaster Plan -
Standard Operating Guidelines

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Internal Disaster Plan

Evacuation for Internal Disasters

A. Reasons for Evacuation

1. To remove patients and personnel from actual or threatened danger such as fire, explosion, enemy attack, tornado, etc.

2. To free hospital beds for the care of incoming casualties.

B. Implementation of Internal Disaster Plan

1. The admitting office will be informed that an "internal disaster" is in effect. If fire is involved, they will call 9-1-1 (Emergency Communications Center). They will immediately notify all departments.

2. Patients will be evacuated from stricken areas to "safe" areas of the hospital.

3. The decision, as to the extent to which the plan is to be implemented, will be determined by the person in charge.

4. Roll call will be taken before, during and after evacuation, if possible.

Resources for Patient Transfer

Other area hospitals can be contacted for transfer of patients, additional supplies, or additional personnel.

Contact the Information Center, and Medical Records, if these other hospitals need to be contacted. They will need to know the number of patients to be transferred and the diagnosis or types of injuries.

Hospitals contacted will be asked to provide emergency ambulance pick-up for these patients if necessary.

Inter-Hospital Transfers

Policy: If, in the judgment of the physician or emergency physician (in conjunction with the private physician), the patient cannot be adequately cared for at this hospital, the patient should be transferred to an appropriate private care facility. This applies to the following conditions:

1. Severely ill newborn.

2. Severe burn patients that require burn center.

3. Severe cardiovascular trauma requiring open heart pump and/or intra-aortic balloon.

4. Patients requiring kidney dialysis.

5. Intracranial injuries.

6. Condition where the specialty physician cannot be reached, i.e. pediatric emergencies, complicated orthopedics, etc.

7. The specialty physician desires to transfer the patient after stabilization and examination.

Procedure for Transfer:

1. A copy of the patient's chart or treatment record accompanies him with all charting completed. X-rays and lab reports will be sent at the discretion of the transferring doctor.

2. That facility shall be contacted prior to the transfer and agree to accept the patient.

3. Physician to physician contact by telephone should take place prior to transfer.

4. A Certification of Appropriate Transfer should be completed and signed by the transferring physician, the patient, if possible, and the transfer nurse (see attached).

5. The patient has been adequately prepared for transfer according to his condition (IV established, pressure dressings, immobilization of fractures, patient airway) and is accompanied in the ambulance by competent personnel.

6. A nurse to nurse contact should also take place. This can be done after patient has left for transfer.

Hospital Evacuation Plan

A. In the event of fire or other internal disaster, all patients and personnel will have to be removed from immediate danger to a safer section of the building, behind fire doors or removed from the building.

B. Moving will be done first behind fire doors on the same floor and then if those areas become dangerous patients and personnel will be moved to lower floors or to the outside of the building.

C. Moving will be done in a systematic fashion by moving all patients and personnel closest to the danger first.

D. Each section of the building is numbered and given a letter (see floor plan). Make sure the fire doors are kept closed as much as possible when moving into each section.

Evacuation of First Floor Hospital

1. Activate the fire plan by pulling the fire alarm when a dangerous situation is found.

2. Start evacuating all patients and personnel from the immediate danger area, in a systematic manner.

3. The supervisor is responsible for calling 9-1-1 (Emergency Communications Center) and requesting all available fire and ambulance personnel to respond.

4. Orange Alert plan may be activated at the discretion of the supervisor.

Remember keep cool, calm, and collected and we should have a successful evacuation.

If we evacuate the entire building, everyone will report to the parking lot. A roll call will be made of each department area involved by the person in charge of each area. The supervisor will check with each department head to make sure everyone is accounted for.

External Disaster Plan

General Directions for the Implementation of the External Disaster Plan

Day Shift

1. The nurse receiving the communications from 911 the (Emergency Communications Center) or the office should implement the first step of the disaster plan by notifying the office that a disaster situation exists and requesting them to notify the following:

   1. Administrator

   2. Director of Nursing

   3. Emergency Room Supervisor

   4. Department Heads in hospital

2. The nurse in immediate charge will notify the doctor (or doctors) on call or she will ask another nurse to notify them.

3. Office personnel, at the direction of Administration or the Supervisor on duty, will then make the following announcement on the paging system and repeat it 3 times: "YOUR ATTENTION, PLEASE...ORANGE ALERT."

   • At this announcement, all department heads will report to the Command Center at ER desk for instructions.

4. Disaster manuals will be kept available by all department heads. Med/Surg and ER Safety Manual will keep current list of personnel and telephone numbers.

5. All patients involved will be triaged through the Receiving Station (the Emergency Department hallway).

6. The "Command Center" will be at the ER/Security Desk. Additional nurses should be requested through the Command Center. Other department heads or their alternates will contact the number of additional personnel they need.

Evening and Night Shifts

1. The relief or night supervisor will implement the first step of the disaster plan by announcing the Orange Alert and notifying the Administrator and the Director of Nursing that a major disaster situation exists.

2. She will then call the nurse on duty in the hospital unit who will notify the following people:

   1. Emergency Room Supervisor, who will assume triage nurse duties

   2. Doctor on call...then all other doctors on staff, as deemed necessary.

   3. Other "on call" people (e.g., surgery crew, lab, x-ray, respiratory therapy).

   4. Director of Nursing will call department heads at home from here.

3. The Supervisor will be in administrative charge until a person higher in line of authority arrives.

4. The on-call physician will be in medical charge.

Expansion of Facilities

A. Reception of Patient

1. A receiving and sorting station will be established in the Emergency Department hallway where all patients will be quickly tagged with a Disaster Tag and will be known by the number on the tag until more information is available.

   • Tie hospital disaster tag to ambulance tag with hospital tag on top. Put admitting time on tag. Send to appropriate Treatment Areas for lifesaving care with nurse assigned to each patient.

B. Treatment Areas

1. Surgery Suite - Immediate surgery required.

2. Outpatient Recovery Room and Surgery Recovery Room - Holding area for surgery and transfer patients.

3. Emergency Department - Patients needing life-support care.

4. Physical Therapy - Walking wounded waiting for care.

5. Physical Therapy Gym - Overflow for walking wounded.

6. ICU Care or direct hospital admits - Major medical patients.

7. Labor and Delivery - Obstetrical patients only.

8. Body holding hallway in Purchasing.

C. Personnel Assignments

1. Specific assignments will be issued to personnel by their department heads. Department heads should have more than one alternate.

2. All employees reporting on duty will go to their department. Their department head or alternate will then assign specific duties. (All nurses, nursing assistants and unit coordinators report to Command Center.)

3. The nurse assigned to a patient being moved from Triage must stay with this patient until relieved by another competent person or until the patient is admitted to a unit and signed off to appropriate person in charge of that unit.

D. Records

1. Records should be minimized, depending on circumstances.

2. Numbered disaster tags will be available in the Receiving Area and affixed to EVERY patient until the proper outpatient chart or hospital chart is prepared. Tie this tag on top of any ambulance disaster tag and record time.

3. Sufficient information should be recorded in order to aid in identification and determination of extent of injuries. This should be done in Treatment Areas rather than Receiving.

4. As soon as disaster tag information is obtained, remove the top sheet from the chart and send by runner to the Command Center in the Emergency Department or affix to clips outside each treatment area and Medical Records will prepare casualty list.

5. Report any major change of the patient's condition to this Command Center. If the top sheet on the tag has already been picked up, report any changes by messenger.

6. Respiratory Therapy, Lab, and x-ray should include the patient's disaster tag number and the patient's location in the hospital. Be sure these slips are made out.

E. Traffic Control

1. If necessary, the Administrator will notify 9-1-1 (Emergency Communications Center) and request assistance in handling external traffic.

2. Incoming patients and emergency vehicles will arrive at the Emergency Department entrance.

3. Discharged hospital patients will leave by the east solarium door. The admitting office will station personnel there to discharge patients.

4. Elevators will be utilized only for the movement of patients or equipment.

5. The loading dock will be used for incoming supplies.

6. The transfer of victims to other hospitals will take place at the Emergency Department entrance. The Holding Area for the transfer patients will be the Recovery Room until the Emergency Department is cleared and cleaned.

F. When Additional Bed Space is Needed

1. Empty beds in the hospital will be utilized first.

2. If necessary, the medical staff will discharge the following types of patients until adequate space is available:

   1. Diagnostic problems and observation cases that are not bedridden.

   2. Patients about to be discharged.

   3. Post-natal cases and babies after 24 hours post-partum. (Note: Special care must be taken in using OB beds in order to avoid contamination of facilities.)

1. Discharged hospital patients will leave by the east solarium door to avoid incoming casualties. Contact Admitting Office for assistance.

2. The Unit Coordinator or volunteer will call relatives of these patients for transportation.

3. Routine admissions will be discontinued until it is determined that space is available.

Extra cots, mattresses, and beds in storage will be set up in center wing upstairs by maintenance men. As a temporary measure, patients can be placed on blankets or mattresses on the floor.

Cots are available in ambulance garage. Extra cots will be obtained if necessary from other area hospitals.

Severe Thunderstorm/Tornado Protocol

If a tornado or unusually severe storm appears inevitable, precautions should be taken that include the following:

1. Draw all shades and close all drapes as protection against shattering glass.

2. Lower all patient beds to the lowest position, and move the bed away from the windows as much as possible.

3. Place blankets on all bed patients.

4. Close all doors.

5. Get as many ambulatory patients as possible into the hallways.

6. Be prepared to sound the Orange Alert.

7. Do not use the elevator.

An announcement will alert staff to turn weather radio unit on for severe weather warnings.

Civil Disturbance or VIP Admission Protocol

In the event of a riot situation existing or threatening the community, or if a Very Important Person (political figure, stage or screen personality, etc.) is to be admitted to the hospital the following procedure should be instituted:

1. The supervisor on duty shall immediately (upon notification of either of the above situations) order all doors in the institution locked.

2. The Police Department shall be notified immediately and asked to provide tight security around the entire building.

3. Notify the Hospital Administration.

4. Be prepared to call an "Orange Alert" or institute that part of the Disaster Plan you deem necessary.

Bomb Threat Procedure

A. Receipt of Warnings:

1. When a phone call is received:

   1. Prolong the conversation as long as possible;

   2. Be alert for distinguishing background noises, such as music, voices, aircraft, and church bells;

   3. Note distinguishing voice characteristics;

   4. Ask where the bomb will explode, and at what time;

   5. Note if the caller indicates knowledge of the hospital by his/her description of the location.

2. Notify authorities and key personnel:

   1. POLICE

   2. Administrator

   3. Director of Nursing, or Supervisor on duty at the time.

B. Search Procedure:

1. After the basic details are provided by the person receiving the call, the Administrator or his designee should make all the necessary decisions, issue orders, and prepare for the arrival of assistance.

   • Police should be put in complete authority upon arrival. Cooperation with the police and others involved is most important. Hospital personnel with master keys should be available.

2. The Administrator must depend upon his key personnel and the equipment immediately available.

   • Local authorities may not be as familiar with the floor plan as hospital personnel, nor will they have sufficient manpower to conduct an adequate search within a reasonable period of time.

   • Therefore, the building will be divided into sections, and certain employees be made responsible for the search in each assigned area.

3. Watch for and isolate suspicious objects such as packages and boxes.

4. Public areas such as the lobbies, cafeterias, public toilets, and stairwells should be thoroughly searched.

5. The search should be thorough, eliminating those areas which are locked and unavailable to the public.

   • If the caller indicates the area in which the bomb is located, this area should receive immediate attention. Tight security should be maintained on each area searched until the entire search is completed.

6. Elevators should be kept available for local authorities.

7. If what appears to be a bomb is found, DO NOT TOUCH IT. Clear the area and obtain professional assistance. Also, try to isolate the object as much as possible by closing doors.

8. Generally, personnel should remain calm and alert. Personnel should be properly trained so that patients will not become alarmed.

   • Notify the Administrator or his designee promptly of significant developments, and do not divulge to the patients that a bomb threat has been received.

   • In the event the patients do learn what is taking place, they should be reassured that all is well.

C. Evacuation:

If a bomb is found, the police will notify the proper authorities to come and disarm it. We WILL NOT EVACUATE unless a bomb is found. If evacuation becomes necessary, this will be a decision of the Administrator or person in charge and the police.

D. Reports:

Each person involved should report to the Administrator immediately after a thorough search of his area has been completed indicating the results of the search.

Key personnel should prepare written comprehensive reports to the Administrator outlining any difficulties encountered during the incident. These reports will be used to update or revise the existing bomb threat procedure.

Hazardous Material Incidents Protocol

A. Protect yourself.

B. Approach the scene with caution.

C. Attempt to identify the hazardous material.

1. Emergency Response Guidebook.

2. Poison Control Centers
   Describe the nature of the problem and they provide technical advice and how to handle the emergency.

D. Obtain further information and assistance for equipment, etc.

E. Avoid contact with hazardous material and person.

F. TRY to contain the material as much as possible in one place. Try decontaminating the person, as much as possible at the scene. Setting up the decontamination area should be done ASAP.

• With few exceptions WATER is the UNIVERSAL ANTIDOTE. For biological hazardous materials use BLEACH.

General Management of Decontamination Following Radiation Exposure

Before undertaking decontamination, detailed monitoring should be done and recorded. If clothing is contaminated, remove it carefully and slowly so that deposited material does not become airborne. Wear gloves, gown, mask, and shoe covers to protect yourself from contamination.

Place all contaminated material into large plastic bags and seal them.  Ensure that no unauthorized personnel are allowed into the patient decontamination area.  In practically all contamination cases, the material is easily removed by a gentle soap and water washing.

After the clothing has been removed, it is usually the face and hands that remain as contaminated areas. During the general survey of the patient any abrasion or break in the skin integrity should be carefully searched for.

Any such areas should be covered by a water proof adhesive dressing to prevent contamination and subsequent internal incorporation of the contaminated material. In washing a contaminated area, wash from the periphery towards the center of the most contaminated area.

Use paper towels to mop up the contaminated soapy water.  It is imperative to treat the skin gently. Do not use an abrasive scrub or strong detergent. Do not shave hairy areas. If redness or tenderness of the skin develops the procedure should be stopped.

It is important to realize that complete decontamination of the skin is not something that has to be achieved at all cost within the shortest possible time.

If externally contaminated skin cannot be cleaned after several tries, then a skin cream is applied and time is allowed for the skin to heal before repeated attempts at cleaning the following day.

General treatment for internal contamination is an involved process that is specific for specific isotopes. For example, for radioactive iodine the patient is given large doses of non-radioactive iodine to prevent uptake of the radioisotope by the thyroid gland.

Certain radioisotopes such as Tritium can be flushed from the body by volume diuresis.

Consider transfer to Decontamination Center.

Acute Management of Chemical Burns

Acute management of chemical burns, as with all emergencies, must begin with assessment of the patient's airway, breathing and circulation.

The next step is to effectively remove the offending chemical. The patient should be completely undressed and all identifiable particulate matter removed. Pooling of the chemical in skin folds, nail folds and hair bearing areas should be identified.

Immediate and prolonged irrigation should be sought. Immediate and prolonged irrigation should then begin. Care should be taken to protect personnel from the chemical. Successful irrigation may be monitored by checking the pH of the wound.

Once emergency therapy has been started, a specific history of the injury should be taken. This ideally includes the name and concentration of the chemical, duration of exposure and general health of the patient. Adequate tetanus prophylaxis is always necessary.

Repeat examinations of the burn wound should be made after several hours, at twenty-four hours and at one week.

Hospitalization of patients with chemical burns should be considered for those with debilitating illness, involvement of the eye, face, hand, foot, and perineum, burns greater than 15% TBSA and deep burns.

General Management of Pesticide Poisoning

1. Diagnosis - assess signs and symptoms

• Assess basic ABC first - Airway, Breathing, Circulation

• TREAT ABC first then assess other signs and symptoms

2. Assess exposure situation

1. Identify pesticide or pesticides involved

2. Attempt to quantify exposure - ask about dose, duration, route of exposure

3. Look for other toxic exposures - particularly solvents, vehicle used to dissolve pesticide

4. Specific laboratory tests -

   1. If organophosphate or carbamate - draw plasma and RBC cholinesterase level before treatment
      Cholinesterase Level Symptoms

      • >50% No symptoms

      • 20-50% Mild Poisoning

      • 10-20% Moderate Poisoning

      • <10% Severe Poisoning

   2. ABG, SMAC, CBC

      • Rodenticide anticoagulants - PT, PTT

   3. Pesticide levels - interesting and may help diagnosis but levels often not clinically helpful and tests expensive

      • serum organoclorine level

      • chlordane, DDT, Dieldrin, Lindane, Endrin

      • urine organophosphate level

      • Chlorpyrifos, diazinon, malathion, parathion

      • urine 2, 4D, 2,4 5T level

      • fat Dioxin level or serum

Release of Information to the News Media

The objectives of this guideline are:

1. To protect the privacy, health, and welfare of patients.

2. To address the public's need for information.

3. To improve the flow of information and avoid conflicts which may arise between the news media, hospitals, and physicians.

A. Hospital Spokespersons:

1. The nursing supervisor on duty is authorized to release information to the media based on these guidelines. If she is unavailable, she may delegate this to a qualified staff member who has knowledge of the situation and is familiar with these guidelines.

2. In the case of a disaster, a communication center will be set up. Medical Records personnel, the administrator, and the Director of Nursing are authorized to release information to the media.

3. When information cannot be released, the release should be refused with an explanation. If delays are encountered, the media should be so advised.

B. Release of Physician's Name:

1. The hospital may give news media representatives the name of the attending physician only with the physician's consent.

   • If that consent is given, the hospital may refer representatives of the media to the attending physician for information relative to the case.

C. Privacy Rights of Patients

1. Confidentiality (non-emergency patients) - Patient health care records or information regarding patients may be released only with the informed written consent of the patient or of a person authorized by the patient.

   • This same form should be used for "newsworthy persons" such as public officials or others who are prominent or well known in the community.

2. Emergency Situations - When consent is not immediately available.

   1. Where the identity is known by the media from other sources such as law enforcement personnel, basic information as listed under Patient Condition and Information Categories can be released.

   2. Where patient identity is unknown, general information on patient conditions without releasing identities is allowed. It's very important not to release the identity of accident victims before all family members have been notified.

Patient Condition

• Treated and Released

• Refused Treatment

• Refused Hospitalization

• Good: Vital signs including pulse, respiration rate, temperature and blood pressure are within normal limits. The patient is conscious and comfortable.

• Fair:  Vital signs are within normal limits, but the patient may be uncomfortable or suffering minor complications.

• Serious:  Vital signs may be outside normal limits and treatments are being directed toward assisting return of some vital signs to normal limits. There may be signs of organ system instability and mechanical systems may be necessary.

• Critical:  Vital signs are frequently outside normal limits and one or more organ systems are in failure. There are major complications responsive to outside stimulation or in a coma.

Information Categories

• Blood Loss:  Slight, moderate, or severe loss of blood may be reported.  If transfusions are required, this may also be reported.  The amount of blood transfused or blood lost in moderate or severe cases should be given if known.

• Burns:  State the extent of the burns, the specific part of the body burned and percentage of total body burned (40%, 50%, 60%, etc.).  The source of the burn, e.g., steam, sun, fire, chemical, may be given.

  • First degree - redness

  • Second degree - blistering and swelling of skin

  • Third degree - total destruction of the skin

• Foreign objects:  Foreign objects removed from a patient may be identified.

• Fractures:  Indicate the part of the body involved, e.g., arm, leg, wrist, foot, rib, and whether simple (bone not protruding from skin) or compound (bone protruding from skin).

• Frostbite:  State the extent of the frostbite and the specific part of the body frostbitten.

  • First degree - redness

  • Second degree - blistering and swelling of skin

  • Third degree - total destruction of the skin

• Head Injuries:  State that the head is injured.  If a skull fracture is confirmed by x-ray, that can be reported.

• Internal injuries: It can be stated that there are internal injuries.

• Lacerations (cuts): Report the general area of the body that was cut, e.g. arm, leg, chest, whether there are single or multiple lacerations, and whether any or all of the lacerations required stitches,

• Poisoning: Cases of suspected poisoning may be reported. The kind of substance ingested, if known, can be reported - such as weed killer, detergent, house cleaner, medicine, etc.

• Shooting or stabbing: It is permissible to state the wound was a result of a shooting or stabbing. The wound may be described as penetrating or grazing. The general part of the body wounded should be described.

  • The exact type of weapon used (e.g. butcher knife, 32 caliber revolver) should not be released.

• Unconsciousness: If a patient is unconscious when brought to the hospital, a statement of that fact may be made.

D. Medical Examiner's Cases

Requests for details other than the routine information given on any patient must be referred to the Medical Examiner on any of the following:

1. Any death wherein the body is unidentified or unclaimed.

2. All sudden deaths not caused by readily recognized disease, or wherein the cause of death cannot be properly certified by a physician on the basis of prior (recent) medical attendance.

3. All deaths occurring under suspicious circumstances, including those where alcohol , drugs, or other toxic substances may have direct bearing on the outcome.

4. All deaths occurring as a result of violence or trauma, whether apparently homicidal, suicidal, or accidental (including those due to mechanical, thermal, chemical, electrical, or radiation injury, drowning, cave-ins) and regardless of the time elapsing between time of injury and time of death.

5. All fetal deaths, stillbirths, or death of any baby within 24 hours after its birth, where the mother has not been under the care of physician.

E. Confidential cases where no information should be released

In a number of situations, no information - absolutely none - should be released about a person's treatment or hospitalization. Such confidential cases specifically include the following:

1. Persons admitted for mental illness

2. Persons admitted for drug or alcohol abuse

3. Births to single parents

4. Suspected or known suicide attempts

5. Victims or rape or other sexual assault

6. Suspected abuse of children

7. Cases of sexually transmitted disease

8. Persons who have specifically requested confidentiality

In response to inquiries regarding patients who fall into one of the above categories, the hospital spokesperson should simply indicate that the case falls into a category for which public comment is prohibited, and therefore no information on the matter may be released.

This also means that no acknowledgment of whether the individual is receiving care at the hospital may be made.

Last Updated: October 24, 2008