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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 civic-
minded 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 Bio-
terrorism 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.
Evacuation Planning for Hospitals
Draft 5/15/06
EVACUATION PLANNING FOR HOSPITALS
TABLE OF CONTENTS
Introduction 1
Facility Issues 2
1. Comprehensive Layout of Hospital Campus 2
2. Building Directory 3
3. Departmental Detail 3
4. Staging Areas 3
People Issues 4
System for Prioritizing/Triaging and Tagging Inpatients for Evacuation 5
Tracking Tools 6
Identifying and Readying Patients for Evacuation off the Inpatient Unit 7
Support Services Issues 8
Evacuation Task Force Membership 9
Attachments
1. Hospital Campus Stacking Diagram 11
2. Building Directory Inventory for Evacuation 12
3. Department Evacuation Template 13
4. Patient Care Unit Evacuation Template Tool #1 15
5. Patient Care Unit Evacuation Template Tool #2 16
6. Visitor Tracking Evacuation Template 17
7. Staff Evacuation Template 18
8. Patient Critical Evacuation Information Form 19
9. Suggested Medications for Staging Areas 21
10. Evacuation Tool Kit 23
Evacuation Planning for Hospitals
Draft 5/15/06
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 Katrina’s
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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Evacuation Planning for Hospitals
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Examples:
? Patient care areas
? Critical patient care area
? Non patient areas
? Vacant space
? Hazardous chemicals p
? Connecting Bridges ?
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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Evacuation Planning for Hospitals
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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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Evacuation Planning for Hospitals
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n System for Prioritizing/Triaging Patient for evacuation
n Tagging system to identify levels of care
n Identifying and readying patients for evacuation
q Medical Records
q Critical Medications
n Accounting for Patients/families/visitors/staff
q System for inventory of patients/staff
q System to designate when rooms/floors are empty
n 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 Priority for Evacuation off nursing unit Priority for Transfer to another
– REVERSED START PRIORITY healthcare facility – TRADITIONAL
START PRIORITY
RED - STOP These patients require maximum These patients require maximum
assistance to move. In an evacuation, support to sustain life In an
these patients move LAST from the evacuation. These patients move
inpatient unit. These patients may FIRST as transfers from your facility
require 2-3 staff members to transport to another healthcare facility.
YELLOW – These patients require some These patients will be moved
CAUTION assistance and should be moved SECOND in priority as transfers from
SECOND in priority from the inpatient your facility to another healthcare
unit. Patients may require wheelchairs facility.
or stretchers and 1-2 staff members to
transport
GREEN - GO These patients require minimal These patients will be moved LAST
assistance and can be moved FIRST as transfers from your facility to
from the unit. Patients are ambulatory another healthcare facility.
and 1 staff member can safely lead
several patients who fall into this
category to the staging area.
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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Evacuation Planning for Hospitals
Draft 5/15/06
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 patient’s information using the patient’s
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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Evacuation Planning for Hospitals
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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 patient’s 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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Evacuation Planning for Hospitals
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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 facility’s 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 Planning for Hospitals
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Evacuation Task Force Membership
Chairperson:
Roe Long, RN, MBA
Vice President, St. Luke’s 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. Luke’s and Roosevelt Hospital Centers
Kathryn Ebe,
Beth Israel Medical Center, Kings Highway Division
Yvonne Guariglia,
Safety Officer, St. Luke’s & 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. Luke’s 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. Luke’s & Roosevelt Hospital Centers
Peter Oliva,
Pharmacy, Beth Israel Medical Center
Anthony D’Alessandro, 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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Evacuation Planning for Hospitals
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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. Luke’s 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 O’Connell
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
RESEARCH ?
floor ROOF
MACINE
RESEARCH ?
12 ROOM
MACINE
RESEARCH ?
ROOF ROOF 11 ROOM ROOF
NURSING UNIT ANIMAL MACINE
RESEARCH ? RESEARCH ?
MED SURG 10 RESEARCH ROOM
NURSING UNIT NURSING UNIT NURSING ON CALL
RESEARCH ?
MED SURG SURGICAL 9 UNIT PSYCH ROOMS
CLOSED NURSING UNIT NURSING
LABS RESEARCH ?
NURSING UNIT CARDIAC 8 UNIT PSYCH
NURSING UNIT NURSING UNIT MEDICINE ADMINIST
BIOMED
MEDICINE ICU 7 ADMIN RATION
NURSING NURSING
NURSING UNIT NURSING UNIT OUTPATIENT
UNIT UNIT
MEDICINE ICU REHAB
6 MED/SURG REHAB
NURSING
NURSING UNIT NUC. MED/ NUC
MECHANICAL RM UNIT VACANT
PEDIATRICS CARDIOLOGY
5 MEDICINE
NURSING UNIT OR LOCKERS/FAN ENDOSCO
? LABS LABS/EKG
MATERNITY ROOM 4 PY
OPERATING CYSTO/AMB ULTRASO
? RADIOLOGY CATH LAB/EPS
ROOMS/PACU SURG 3 UND
OUTPATIE
CENTRAL MAT OUTPATIENT MEDICAL
NT
STERILE MGT/PHARMACY CLINICS RECORDS
2 CLINICS
CAFETERIA/DIN
LOBBY/ADMITTIN
ING
G/ PAT MEDICAID
ROOM/TRANSP EMERGENCY EMERGEN
OFF MRI/SECURITY
ORTATION DEPARTMENT CY DEPT
UM/ADMINISTRATI
OFFICE/FOOD
ON
SERVICE OFFI 1
MACHINE
KITCHEN KITCHEN MACHINE RM MACHINE RM
B RM
BUILDING
BUILDING 1 BUILDING 2 BUILDING 3 BUILDING 5
4
Key
Hazardous
Patient Care
Chemicals
Area
? Present
Critical Care Connectin
Patient Area ? g Bridges
Non Patient
Care Area
VACANT
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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 Service/Department/Unit Horizontal Evacuation Vertical Evacuation Building Evacuation
Basement
floor:
floor:
floor:
floor:
floor:
floor:
floor:
floor:
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Evacuation Planning for Hospitals
Attachment #3 Departmental Evacuation Template
Hospital:
Building: Floor:
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)
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________________ Floor _____________________
Total Number of Staff on Unit at Start time of Evacuation:
RNs: LPN’s NA’s/PCA’s US MD Other
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
UNIT WORKSHEET Page ____ of ______
HOSPITAL: __________________________________________________________________
Unit Name: _____________________________ Unit Location: Building______________________________ Floor _____________________
PATIENTS Date and
Destination:
(use Addressograph to imprint Mode of Time Arrival at
Category Equipment Needs Accepting Facility for
patient name or utilize patient Transportation patient left Destination
Patient Transfer
labels) unit
¨ Red (significant ¨ Ambulatory Date: Indicate destination: ¨ Yes
resources for ¨ Oxygen
¨ Wheelchair ¨ No
transport) ¨ Monitor
¨ Yellow ¨ Stretcher
(moderate ¨ Ventilator Time: Equipment leaving with
¨ Bassinet pt: Time:
resources for ¨ Pump
transport) ¨ Isolette Contact:
¨ Other (indicate)
¨ Green ¨ Other (indicate)
(minimal resources)
¨ Red (significant ¨ Ambulatory Date: Indicate destination: ¨ Yes
resources for ¨ Oxygen
¨ No
¨ Wheelchair
transport) ¨ Monitor
¨ Yellow ¨ Stretcher Time:
(moderate ¨ Ventilator Time: Equipment leaving with
¨ Bassinet pt: Contact:
resources for ¨ Pump
transport) ¨ Isolette
¨ Other (indicate)
¨ Green ¨ Other (indicate)
(minimal resources)
¨ Red (significant ¨ Ambulatory Date: Indicate destination: ¨ Yes
resources for ¨ Oxygen
¨ No
¨ Wheelchair
transport) ¨ Monitor
¨ Yellow ¨ Stretcher Time:
(moderate ¨ Ventilator Time: Equipment leaving with
¨ Bassinet pt: Contact:
resources for ¨ Pump
transport) ¨ Isolette
¨ Other (indicate)
¨ Green ¨ Other (indicate)
(minimal resources)
16
Evacuation Planning for Hospitals
Attachment #6
VISITOR TRACKING EVACUATION TEMPLATE
Unit Work Sheet Page ____ of ______
HOSPITAL: __________________________________________________________
Unit Name: ________________________________ Unit Location: Building______________________ Floor _________________________
Name and Telephone Contact Number
Name of Patient visiting Time Left Unit Destination Arrival at Destination
of Visitor
¨ Yes
¨ No
Initials:_______
¨ Yes
¨ No
Initials:_______
¨ Yes
¨ No
Initials:_______
¨ Yes
¨ No
Initials:_______
¨ Yes
¨ No
Initials:_______
¨ Yes
¨ No
Initials:_______
17
Evacuation Planning for Hospitals
Attachment #7
STAFF EVACUATION TEMPLATE
UNIT WORKSHEET Page ____ of ______
HOSPITAL: __________________________________________________________________________
Unit Name: _______________________________ Unit Location: Building________________ Floor _____________________
STAFF NAME DEPARTMENT 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:_______
18
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=_____ P=__________R=____________BP=___________________
Do Not Resuscitate Yes No (Copy Attached) Advanced Directives: Yes No (Copy Attached)
Isolation Status: Contact Droplet Airborne Other:
Precautions: Aspiration Seizure Fall Elopement 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 Combative Wanders Withdrawn
Mental Status: Oriented x ______ Alert Sedated Forgetful Confused
Transfers: Independent Supervision Partial Assist Total Assist
Assistive Devices: None Cane Walker Wheelchair Glasses Dentures: Upper Lower Hearing Aid
Prosthesis Type__________
Pressure Ulcer: Yes No Location:
Restraint: Type___________ How Long___________
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 Medications added
And Name and Infusion If pump going
Access site Gauge Amount concentration Rate Asset Tag Number
Endotracheal Tube size: _______ Level at Lip:_______ Trach Tube size:______
Ventilator Settings at time of transfer:
Mode: Assist Control Intermittent Other:_________
FIO2: ________________% 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 Strength Oral/ Inj/Top Category Quantity
Oral Prep
Acetaminophen 325mg Tab Pain 500
Aspirin 325mg Tab Pain/CV 100
Clopidogrel 75mg Tab CV 100
Erythromycin 250mg Tab Antibiotic 50
Furosemide 40mg Tab CV 100
Ibuprofen 400mg Tab Pain 500
Lisinopril 10mg Tab CV 100
Metoprolol 50mg XL Tab CV 100
Oxycodone/APAP (CII) 5/325mg Tab Pain 500
Pediatric Oral Prep
Acetaminophen 160mg/5ml Liq Pain 100
Erythromycin 200mg/5ml Liq Antibiotic 10
Ibuprofen 100mg/5ml Liq Pain 100
Injectable Prep
Cefazolin 1gm IM Antibiotic 20
IVPB
Ciprofloxacin 400mg IVPB Antibiotic 20
Diphenhydramine 50mg IM Antihistamine 50
IVP
Diphtheria & Tetanus IM Vaccine 50
Toxoid
Enoxaparin 30mg SC LMWH 20
60mg 20
80mg 20
Furosemide 40mg IM CV 50
IVP slow 1-2min
Gentamicin 80mg IM Antibiotic 50
IVPB
Haloperidol 5mg IM Antipsychotic/ 50
Sedative
Insulin R 100units/ml SC Hypoglycemic 100
, 10ml
Lidocaine 1% 30ml SC Local 25
2% 30ml anesthetic 25
Lidocaine w. epin 1% 30ml SC Local 10
anesthetic
Lorazepam (CIV) 2mg IM Antianxiety/ 100
IVP slow Sedative/
(=2mg/min) Anticonvulsant
Meperidine (CII) 50mg IM Pain 30
SC
Metoprolol 5mg IVP slow 1-2min CV 50
Methylprednisolone 40mg IM Corticosteroid 50
500mg IVP slow 20
21
Evacuation Planning for Hospitals
Attachment #9 SUGGESTED MEDICATIONS FOR STAGING AREAS
(Dose =125mg,
IVP over 3min)
Morphine (CII) 2mg IM Pain 50
10mg SC 50
IVP
Moxifloxacin 400mg IVPB Antibiotic 20
Phenytoin 100mg IVP slow Anticonvulsant 50
(=50mg/min)
Tetanus Immune IM Immune 10
Globulin Globulin
Code Cart trays See Minimum 3
-Adult/Pediatric attached
Oral Inhaler
Albuterol MDI Asthma/COPD 50
Ipratropium MDI Asthma/COPD 50
Opthalmic Prep
Erythromycin 3.2gm Opthalmic oint Antibiotic 50
Sulfacetamide 10% 3.5gm Opthalmic oint Antibiotic 50
External Prep
Silver Sulfadiazine 20gm Topical cream Antibiotic 20
Cream
Miscellaneous
Supplies
Alcohol swab 500
Calculator 1
Drug reference 1
Gloves Small 100
Medium 100
Label 1 roll
Needle 18G x 1in 100
NS 0.9% 10ml Diluent/ 50
Line flush
Patient Profiles 1
Pen/Marker 10
Plastic Bag 4x6 50
9x12 50
SWFI 10ml Diluent 50
Syringe 1ml 100
5ml 100
Prepared by Sara S. Kim, Pharm.D
12/05
22
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- EVACUATED-
identifies 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
23
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