Welcome to Boone County Hospital

Emergency Management Plan

SCOPE OF SERVICES:
Boone County Hospital's Emergency Management Plan's, (EMP) scope is to provide for a program that ensures effective mitigation, preparation, response and recovery to disasters or emergencies affecting the environment of care.

BCH has adopted, modified and implemented the incident command management structure called, “Hospital Emergency Incident Command System”, (HEICS).

OBJECTIVE:
The objective of the Emergency Management Plan is to effectively prepare for, manage an emergency and restore the facility to the same operational capabilities as pre-emergency levels.

GOALS:
The goals of the Emergency Management Plan includes the following:

Identifying procedures to prepare and respond to potential disasters or emergencies;

Providing education to personnel on the elements of the Emergency Management Program;

Establishing and implementing procedures in response to an assortment of disasters and emergencies;

Identifying alternate sources for supplies and services in the event of a disaster or emergency.

RESPONSIBILITY:
The Safety Officer in conjunction with the Safety Committee is responsible for developing, implementing and monitoring all aspects of the Emergency Management Program at Boone County Hospital, including hazard vulnerability analysis, mitigation, preparedness, response and recovery.

SPECIFIC PROCEDURES IN RESPONSE TO A VARIETY OF EMERGENCIES BASED ON A HAZARD VULNERABILITY ANALYSIS PERFORMED BY THIS HOSPITAL:
Boone County Hospital has developed specific procedures in response to potential disasters and emergencies that may occur. Additionally, the hospital will perform routine hazard vulnerability analysis to identify areas of vulnerability and undertake provisions to lessen the severity and/or impact of a disaster or emergency that could affect the services provided by the hospital. The following are some of the possible situations that may occur:

Mass Casualty Incident

Chemical Spill/Exposure

Biological emergencies

Bomb Threat

Utility Failure

Tornado

Severe Weather

INITIATING THE PLAN, INCLUDING DESCRIPTION OF PLAN ACTIVATION:
The plan will be initiated when it has been determined that a disaster has occurred or has the potential for occurring.

Definition of an Emergency:
An emergency is an unplanned event that can cause deaths or significant injuries to patients, staff or the public; or can shutdown the hospital, disrupt operations, cause physical or environmental damage or threaten the hospital's financial standing or public image.

When the hospital is notified of a disaster or the potential for a disaster, the person receiving notification will immediately notify the CEO or the most senior individual present, in the event of his/her absence, of the situation whether it be an internal or external disaster. The House Supervisor will respond to the site of an internal disaster and report back to the CEO or the most senior individual present the status of the situation. The CEO or the most senior individual present will evaluate the disaster to determine whether the Emergency Management Plan will be activated. If the plan is to be activated, the CEO or the most senior individual present will notify the Switchboard Operator. The CEO or the most senior individual present will inform the Switchboard Operator if he/she needs to announce on the overhead PA system, “Code D, Internal or External”. Code D will not always need to be announced.

Before the implementation of the Code D, the Emergency Services staff has the ability to activate the “Trauma Alert”. This will allow additional appropriate staff to respond to the Emergency Room.

Implementation of the hospital's Emergency Management Plan will be conducted at least semiannually (and no less than four (4) months apart or more than eight (8) months apart), either in response to an emergency or as a planned drill. One (1) exercise per year shall include an influx of volunteer or simulated patients for organizations that offer emergency services or are designated receiving stations.

The hospital's HEICS plan identifies who is in charge of specific activities and when they are to assume oversight responsibilities.

This Hospital cooperates with all local, county and state emergency management drills. The Safety Officer is a member of the countywide emergency management system and coordinates with other agencies on any large scale drills. The hospital will fully cooperate with other disaster response agencies, i.e., fire department, police department, Boone County Emergency Management and other outside agencies.

COMMAND STRUCTURE:
The command structure utilized by this facility in coordination with the communitywide command structure is the “Hospital Emergency Incident Command System”.

COOPERATIVE PLANNING:
Boone County Hospital / Public Health participates in cooperative planning for emergencies with the following healthcare organizations in our geographic area:

Mary Greeley Medical Center

HRSA

During the cooperative planning sessions with these organizations, the following issues are discussed and identified:

Elements of each organization's command structures and operations centers

List of names, responsibilities and phone numbers of individuals in each organization's command structure

List of resources that can be pooled/shared for response to emergency situations

Mechanism to send information on patients and deceased individuals to cooperating organizations to help facilitate identification and location of victims of the emergency

NOTIFICATION OF EXTERNAL AUTHORITIES:+
Boone County Hospital shall have two-way radio equipment and operators, which are familiar with the equipment.

NOTIFICATION OF PERSONNEL WHEN EMERGENCY RESPONSE MEASURES ARE INITIATED:
In an emergency which is so wide-spread to be considered an emergency and/or involving mass casualties, hospital personnel, regardless of position may be expected to report to the hospital for duty as soon as it is feasible to travel.

Each department manager maintains a current callback list of all employees.

A current copy of the callback list will also be maintained through the hospitals disaster preparedness coordinator.

Once the Emergency Management Plan has been activated, the department manager may assign a staff member to initiate the callback list or the labor pool leader may initiate the callback list.

Calling of staff will be directed by the nature and magnitude of the incident.

In the event there are excess personnel, the Operations Center will communicate with department managers regarding rescheduling of personnel for future needs.  The medical staff will report to the Chief of Staff for assignments.

IDENTIFICATION OF PERSONNEL IN EMERGENCIES:
Personnel on duty during activation of the emergency management plan will be identified by identification nametag which is to be worn at all times, by all staff while on duty.
Boone County Hospital staff should have their own identification, (name badge).

Identification of personnel reporting to the hospital in the event of an emergency will be given “staff identification” tags at the time of “signing-in” at the Labor Pool.

ASSIGNMENT OF PERSONNEL IN EMERGENCIES TO COVER ALL NECESSARY STAFF POSITIONS:

Personnel reporting to the hospital in the event of an emergency shall report to the Labor Pool to sign in.  Personnel who have been directed to report to their assigned unit will do so, all others will be assigned to areas where help is needed by the Labor Pool. Personnel may not necessarily be assigned to their regular duties.  Personnel will be asked to perform various jobs, which will be considered vital to an effective operation. As staff arrives at the hospital, the Labor Pool will assign employees to cover tasks.  The Labor Pool will reassign employees as necessary as the needed.

MANAGEMENT OF PATIENTS DURING EMERGENCIES (I.E., SCHEDULING, MODIFICATION OR DISCONTINUATION OF SERVICES, CONTROL OF PATIENT INFORMATION AND PATIENT TRANSPORTATION):

Upon activation of the Emergency Management Plan, as directed by medical chief of staff, normal admission requirements will be abolished.

Initially, admissions to the hospital will be limited to those whose survival depends upon services obtainable only through hospital bed care.

Outpatient care will be restricted to those whose lives may ultimately depend upon the present expenditure of medical supplies and health manpower time.

All elective admissions and procedures will be canceled including elective surgery, non-emergent outpatient procedures and transferring patients who are stable to be discharged.

Patients may be transferred to other facilities so those emergency victims may be accommodated.

STAFF ACTIVITIES AND SUPPORT:
The hospital will provide for staff support activities in the event of an emergency, which include, but may not be limited to:

Housing/lodging needs

Transportation needs

Family support needs, as necessary such as childcare

Incident stress debriefing and counseling

MANAGEMENT OF SPACE, SUPPLIES AND SECURITY:
Essential supplies, pharmaceuticals, medical supplies, equipment, food, water, linen and utilities must be provided to meet shelter requirements for up to two weeks.  Procedures are in place for the procurement of additional supplies in an emergency. Supplies are available through purchasing and pharmacy.

At the time the Emergency Management Plan is activated, the Engineering Department personnel on duty or on call may be responsible for locking all exits and entrances. If the “Code D” is announced the facility should be locked down immediately. Employees of the hospital are required to wear nametags or carry cards identifying them as employees.  Only persons with proper identification shall be admitted to the hospital during an emergency.  All staff responding to the hospital during the activation of the emergency management plan will be expected to enter through the North doors by the West ambulance garage.

See Emergency Management Preparations Policy, Emergency Management Committee Meeting Policy, Emergency Management Security Policy, Emergency Management Bed Space Availability Form, Emergency Water Supply Policy, Emergency Management Supplies, Utilities and Equipment Policy and Emergency/Disaster Nearby Community Policy.

SECURITY ACTIVITIES:
In the event of a disaster, the Engineering Department and other assigned personnel shall maintain control of entry and egress from the facility.  The engineering and other assigned personnel will also maintain crowd and traffic control.

See Emergency Management Security Policy.

COMMUNICATION:
The Incident Commander may approve media access to main facility or off site facility. Only the appointed public information officer will interact with the media.

EVACUATION OF THE FACILITY:
When a situation arises requiring evacuation of patients from threatened or affected areas; safety of lives is Boone County Hospital's primary concern.  Authority to order an evacuation is vested only in the Chief Executive Officer or his/her designee.  Patients shall be evacuated to an area of safety (Public Health Building) by whatever means are available.  Formal agreements are in place with ambulance services and neighboring facilities to transfer patients as necessary.  All personnel have been trained in evacuation procedures.  Evacuation routes are posted throughout the hospital.

See Emergency Management Evacuation Policy.

ESTABLISHING AN ALTERNATE CARE SITE WHEN THE ENVIRONMENT CANNOT SUPPORT ADEQUATE PATIENT CARE:
Formal agreements are in place so that, patients may be transferred to a facility that can provide adequate patient care.  The evacuation officer will be responsible for inter-facility communication between the hospital and the designated alternative care site and for retaining records of which patients were transferred to and from an alternative care site.  The patient care unit transferring the patient is responsible for obtaining copies of the patient's medical records, gathering personal belongings and insuring the patient's medications are continued throughout the transfer.  If any hospital equipment is transferred with the patient, the patient care unit is responsible for documenting what equipment was transferred with the patient so that the equipment may be retrieved during the recovery phase post emergency.  The following agreements are in place:

Ambulance mutual aid agreements for transfer of patient between facilities.

Transfer agreements have been made between neighboring facilities.

Vendors will be contracted for emergency acquisitions of medical supplies, pharmaceuticals, food, equipment, water, linen, emergency repair services, etc.

Note: Alternate care sites must be able to provide the necessary resources to care for patients, i.e., emergency power, site access and security, access to or the ability to obtain utility resources such as medical gases, vacuum, etc., communications, staff.

See Emergency Management Evacuation Policy.

CONTINUING AND/OR RE-ESTABLISHING OPERATIONS FOLLOWING AN EMERGENCY:
The hospital has mechanisms in place to restore the operational capabilities of the facility to pre-emergency levels. Once the emergency is over, the Damage Assessment Team including the Director of Engineering, Safety Officer, Risk Manager and administration representative will begin assessing the damage to the facility and the environmental concerns to determine whether the facility can safety provide medical care to the community and provide a safe environment for patients, staff and visitors.

Pictures and/or videos will be taken of all damages to the facility's buildings, grounds, equipment, etc., including all off-campus structures.

Architects and building inspectors may be called in to determine if the buildings are safe for occupancy.

All potential environmental concerns will be evaluated for proper function, i.e., hazardous waste, fuel tanks, to ensure there is not leakage into the local sewer or water system or any other impact on other environmental concerns.

Ensure employee support programs have been instituted, i.e., crisis counseling, flexible work hours, cash advances, day care, particularly if your staff and the hospital have been directly impacted by the emergency.

Clear debris and secure unsafe buildings as necessary.

Restore internal and external communication devices.

Inventory equipment and supplies for damage and determine if additional supplies need to be obtained from suppliers. Pictures/videos will be taken of all damaged supplies and equipment for insurance purposes. Damaged supplies and equipment will be retained until approval is received from the insurance agent for disposal.

Notify the community, through local media services, what services the hospital will be providing and where they will be provided in the event services are moved off the hospital campus.

Notify the hospital's insurance agent and contact a third-party expert to prepare the claim.

Ensure records and data have been protected and restore information as necessary from backup tapes

Keep detailed records.

ALTERNATIVE SOURCES OF ESSENTIAL UTILITIES:
The hospital will provide for alternative sources of essential utilities including:

An emergency source of electrical power capable of operating all essential electrical equipment and a plan for failure of back up generators;

An alternate source of safe water;

An alternate source for safe medical gas and vacuum delivery;

An alternate means of waste disposal in the event of sewage system failure;

Sufficient fuel to last for at least two weeks of expanded operation.

See Disruption of Services Procedure Policy, Disruption of Hospital Services Notification Policy, Disruption of Services Electric Policy, Medical Gas Policy, Natural Gas Policy, Sewage Policy and Water Policy.

BACKUP COMMUNICATION SYSTEM:
The hospital will provide for alternate communication methods in the event of a failure.  Two‑way radio equipment and cell phones shall be available in the event of an emergency.

See Emergency Management Communications Policy and Failure of Telephone System Policy.

FACILITIES FOR RADIOACTIVE OR BIOLOGICAL/CHEMICAL ISOLATION AND DECONTAMINATION:
There is a designated decontamination area (east ambulance garage) with a separate ventilation system or ventilation shutoff available for radioactive or chemical isolation and decontamination.  Personnel are trained in the response to radiation or hazardous material contamination.

ALTERNATE ROLES AND RESPONSIBILITIES OF EMPLOYEES DURING EMERGENCIES:
Employees may not be assigned to their regular duties.  Employees will be asked to perform various jobs, which will be considered vital to the effective operation of the hospital.  Employees will be assigned duties based on the needs of the hospital.  Employees will be referred to the Labor Pool, who will follow instructions for personnel responsibilities from the Command Center. The Labor Pool will assign staff upon arrival to the hospital.

ORIENTATION AND EDUCATION PROGRAM FOR THOSE WHO PARTICIPATE IN IMPLEMENTING THE PLAN:
Personnel will attend orientation upon hire and an annual update of their specific roles and responsibilities and the skills they require to perform their duties during an emergency.  In-service education will be given on the backup communication system and obtaining supplies/equipment in the event of an emergency.  The Safety Officer is responsible for in-servicing personnel at the hospital wide emergency management program.  The department manager is responsible for in-servicing department personnel on the department specific Emergency Management Plan.

PERFORMANCE STANDARDS:
The Safety Committee on an ongoing basis monitors performance regarding actual or potential risk related to one or more of the following:

Staff knowledge and skills

Level of staff participation

Monitoring and inspection activities

Emergency and incident reporting

Inspection, preventive maintenance and testing of safety equipment

To identify opportunities for improvement, the Safety Committee will follow the organization's improvement methodology, the FOCUS PDSA model. The basic steps to this model will consistently be followed, and include planning, designing, measuring, analyzing/assessing, improving and evaluating effectiveness.

Should the Safety Committee feel a team approach (other than the Safety Committee) is necessary for performance and process improvement to occur, the Safety Committee will follow the organization's performance improvement guidelines for improvement team member selection. Determination of team necessity will be based on those priority issues listed (high risk, volume and problem prone situations and sentinel event occurrence). The Safety Committee will review the necessity of team development, requesting team participation only in those instances where it is felt the Safety Committee's contributions toward improvement would be limited (due to specialty, limited scope and/or knowledge of the subject matter). Should team development be deemed necessary, primarily, team members will be selected on the basis of their knowledge of the subject identified for improvement, and those individuals who are "closest" to the subject identified. The team will be interdisciplinary, as appropriate to the subject to be improved.

ANNUAL EVALUATION OF THE EMERGENCY MANAGEMENT PLAN:
The performance and effectiveness of the Emergency Management Program shall be reviewed by the Safety Committee, the Performance Improvement Committee and Administration.

US Patent Numbers 7,720,998 B2, 7,836,207