Hospital Disaster Plan -
Standard Operating Guidelines
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Evacuation for Internal Disasters
A. Reasons for Evacuation
To remove patients and personnel from actual or threatened danger such as fire,
explosion, enemy attack, tornado, etc.
To free hospital beds for the care of incoming casualties.
B. Implementation of Internal Disaster Plan
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.
Patients will be evacuated from stricken areas to "safe" areas of the
The decision, as to the extent to which the plan is to be implemented, will be
determined by the person in charge.
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
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.
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:
Severely ill newborn.
Severe burn patients that require burn center.
Severe cardiovascular trauma requiring open heart pump and/or intra-aortic balloon.
Patients requiring kidney dialysis.
Condition where the specialty physician cannot be reached, i.e. pediatric emergencies,
complicated orthopedics, etc.
The specialty physician desires to transfer the patient after stabilization and
Procedure for Transfer:
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
That facility shall be contacted prior to the transfer and agree to accept the patient.
Physician to physician contact by telephone should take place prior to transfer.
A Certification of Appropriate Transfer should be completed and signed by the
transferring physician, the patient, if possible, and the transfer nurse (see attached).
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.
A nurse to nurse contact should also take place. This can be done after patient has left
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
Activate the fire plan by pulling the fire alarm when a dangerous situation is found.
Start evacuating all patients and personnel from the immediate danger area, in a
The supervisor is responsible for calling 9-1-1 (Emergency Communications Center) and
requesting all available fire and ambulance personnel to respond.
Orange Alert plan may be activated at the discretion of the supervisor.
Remember keep cool, calm, and collected and we should have a successful
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
General Directions for the Implementation of the
External Disaster Plan
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
Director of Nursing
Emergency Room Supervisor
Department Heads in hospital
The nurse in immediate charge will notify the doctor (or doctors) on call or she will
ask another nurse to notify them.
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:
ATTENTION, PLEASE...ORANGE ALERT."
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.
All patients involved will be triaged through the Receiving Station (the Emergency
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
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.
She will then call the nurse on duty in the hospital unit who will notify the following
Emergency Room Supervisor, who will assume triage nurse duties
Doctor on call...then all other doctors on staff, as deemed necessary.
Other "on call" people (e.g., surgery crew, lab, x-ray, respiratory therapy).
Director of Nursing will call department heads at home from here.
The Supervisor will be in administrative charge until a person higher in line of
The on-call physician will be in medical charge.
Expansion of Facilities
A. Reception of Patient
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.
B. Treatment Areas
Surgery Suite - Immediate surgery required.
Outpatient Recovery Room and Surgery Recovery Room - Holding area for surgery and
Emergency Department - Patients needing life-support care.
Physical Therapy - Walking wounded waiting for care.
Physical Therapy Gym - Overflow for walking wounded.
ICU Care or direct hospital admits - Major medical patients.
Labor and Delivery - Obstetrical patients only.
Body holding hallway in Purchasing.
C. Personnel Assignments
Specific assignments will be issued to personnel by their department heads. Department
heads should have more than one alternate.
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.)
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.
Records should be minimized, depending on circumstances.
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.
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
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.
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.
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
If necessary, the Administrator will notify 9-1-1 (Emergency Communications Center) and
request assistance in handling external traffic.
Incoming patients and emergency vehicles will arrive at the Emergency Department
Discharged hospital patients will leave by the east solarium door. The admitting office
will station personnel there to discharge patients.
Elevators will be utilized only for the movement of patients or equipment.
The loading dock will be used for incoming supplies.
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
Empty beds in the hospital will be utilized first.
If necessary, the medical staff will discharge the following types of patients until
adequate space is available:
Diagnostic problems and observation cases that are not bedridden.
Patients about to be discharged.
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.)
Discharged hospital patients will leave by the east solarium door to avoid incoming
casualties. Contact Admitting Office for assistance.
The Unit Coordinator or volunteer will call relatives of these patients for
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.
If a tornado or unusually severe storm appears
inevitable, precautions should be taken that include the following:
Draw all shades and close all drapes as protection against shattering glass.
Lower all patient beds to the lowest position, and move the bed away from the windows as
much as possible.
Place blankets on all bed patients.
Close all doors.
Get as many ambulatory patients as possible into the hallways.
Be prepared to sound the Orange Alert.
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:
The supervisor on duty shall immediately (upon notification of either of the above
situations) order all doors in the institution locked.
The Police Department shall be notified immediately and asked to provide tight security
around the entire building.
Notify the Hospital Administration.
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:
When a phone call is received:
Prolong the conversation as long as possible;
Be alert for distinguishing background noises, such as music, voices, aircraft, and
Note distinguishing voice characteristics;
Ask where the bomb will explode, and at what time;
Note if the caller indicates knowledge of the hospital by his/her description of the
Notify authorities and key personnel:
Director of Nursing, or Supervisor on duty at the time.
B. Search Procedure:
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.
The Administrator must depend upon his key personnel and the equipment immediately
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.
Watch for and isolate suspicious objects such as packages and boxes.
Public areas such as the lobbies, cafeterias, public toilets, and stairwells should be
The search should be thorough, eliminating those areas which are locked and unavailable
to the public.
Elevators should be kept available for local authorities.
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
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.
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.
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.
Material Incidents Protocol
A. Protect yourself.
B. Approach the scene with caution.
C. Attempt to identify the hazardous material.
Emergency Response Guidebook.
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
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
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
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
Certain radioisotopes such as Tritium can be flushed from the body by volume
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
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
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
Identify pesticide or pesticides involved
Attempt to quantify exposure - ask about dose, duration, route of exposure
Look for other toxic exposures - particularly solvents, vehicle used to dissolve
Specific laboratory tests -
If organophosphate or carbamate - draw plasma and RBC cholinesterase
level before treatment
Cholinesterase Level Symptoms
ABG, SMAC, CBC
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
The objectives of this guideline are:
To protect the privacy, health, and welfare of patients.
To address the public's need for information.
To improve the flow of information and avoid conflicts which may arise between the news
media, hospitals, and physicians.
A. Hospital Spokespersons:
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.
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.
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:
The hospital may give news media representatives the name of the attending physician
with the physician's consent.
C. Privacy Rights of Patients
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.
Emergency Situations - When consent is not immediately available.
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.
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.
Treated and Released
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.
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.
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
Frostbite: State the extent of the frostbite and the specific part of the body
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.
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:
Any death wherein the body is unidentified or unclaimed.
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
All deaths occurring under suspicious circumstances, including those where alcohol ,
drugs, or other toxic substances may have direct bearing on the outcome.
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.
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
Persons admitted for mental illness
Persons admitted for drug or alcohol abuse
Births to single parents
Suspected or known suicide attempts
Victims or rape or other sexual assault
Suspected abuse of children
Cases of sexually transmitted disease
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
This also means that no acknowledgment of whether the individual is receiving
care at the hospital may be made.
Last Updated: March 18, 2011