Emergency Operations Plan (DOC)

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					I.      INTRODUCTION


A.      EMERGENCY OPERATIONS PLAN

The Emergency Operations Plan of University Hospital is designed to expand hospital services in
coordination with other emergency facilities to provide care to the community and its patients during
internal and external disaster situations.

This emergency operations plan includes how the UMDNJ – University Hospital will establish and
maintain a program to ensure effective response to disasters or emergencies affecting the environment of
care. This plan addresses four phases of emergency management activities: mitigation, preparedness,
response and recovery.

A hazard vulnerability analysis is completed to identify hazards and the direct and indirect effect these
hazards may have on University Hospital.

Copies of this plan shall be distributed to the Newark Office of Emergency Management and the Essex
County Office of Emergency Management to inform them of the scope of the disaster capabilities.

The Chief Executive Officer or designee will be responsible for the initiating and phasing in of the
hospital’s Emergency Operations Plan.

The Department of Hospital Support Services will offer additional education and training for Hospital
staff including management and emergency responders. All staff must receive annual emergency
preparedness training. After completing the training staff will be able to:

    Describe the purpose of the Emergency Operations Plan.
    Describe the difference between an internal and external disaster.
    Identify locations of areas used for treatment and disaster management.
    Identify the resources available to University Hospital in the event of a disaster.
    Describe/explain the four phases of an evaluation and evacuation procedures.
    Identify the internal and external disaster situation announcements.
    Identify who will provide crowd control and information to the media.
    Know who to obtain assistance for hearing impaired and non-English speaking customers.
    Explain how a disaster situation is terminated.
    Identify the primary and secondary administration and nursing command post locations.
    Know how to notify essential departments/units during a disaster.

Supplemental training will be provided by Department/Nurse Managers on their department/unit
specific emergency preparedness (contingency) plan.



Revised: August 2, 2004
Emergency Operations Plan
University Hospital


II.    OBJECTIVES

The Emergency Operations Plan identified the following processes to manage disaster and emergencies.

       a.       Identify specific procedures in response to a variety of disasters based on a hazard
                vulnerability analysis performed by the hospital;

       b.       Initiate the plan including a description of how, when, and by whom the plan is activated;

       c.       Define and when appropriate, integrating the hospital’s role with community wide
                emergency response agencies (including the identification of who is in charge of what
                activities and when they are in charge) to promote interoperability between the hospital and
                the community;

       d. Notify external authorities of emergencies;

       e. Notify personnel when emergency response measures are initiated;

       f. Identify personnel during emergencies;

       g. Assign available personnel in emergencies to cover all necessary staff positions;

       h. Manage the following during emergencies and disasters:

                  Patients activities including scheduling, modifying, or discontinuing services, control of
                   patient information, and patient transportation;
                  Staff activities (for example, housing, transportation, and incident stress debriefing);
                  Staff-family support activities;
                  Logistics of critical supplies (for example, pharmaceuticals, medical supplies
                   food supplies, linen supplies, water supplies);
                  Security (for example, access, crowd control, traffic control); or
                  Interaction with the news media

       i. Evacuate the entire facility (both horizontally and, when applicable, vertically) when the e
          environment cannot support adequate patient care and treatment;

       j. Establish an alternative care site(s) that has the capabilities to meet the clinical needs of
          patients when the environment cannot support adequate patient care including processes that
          address, when appropriate,

                 Management of patient necessities (for example, medications, medical records) to and
                   from the alternative care site;
                 Patient tracking to and from the alternative care site,

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Emergency Operations Plan
University Hospital


             Interfacility communication between the hospital and the alternative care site, or
             Transportation of patient, staff, and equipment to the alternative care site, and

       k. Continuing and/or re-establishing operations following a disaster.


In addition, the plan identifies the following resources such as:

       l. An alternate means of meeting essential building utility needs (for example, electricity,
          water, ventilation, fuel sources, medical gas/vacuum systems) when the hospital is designated
          by its emergency plan to provide continuation service during a disaster or emergency;

       m. Backup internal and external communication systems in the event of failure during disasters
          and emergencies;

       n. Facilities for radioactive or chemical isolation and decontamination; and

       o. Alternate roles and responsibilities of personnel during emergencies, including who they
          report to within a command structure that is consistent with that used by the local
          community.




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Emergency Operations Plan
University Hospital


III.   OPERATIONS AND CONTROL

A.     COMMAND CONCEPTS OF OPERATIONS

University Hospital will utilize a unified incident command approach to manage emergency operations
affecting or impacting University Hospital and its surrounding community. Once the Administrator On-
Call has made the decision to implement the emergency operating procedures, the command post will be
opened. The Nursing Office Center will receive all nursing issues. The following members of executive
management (unified command) or their designees will be responsible for the command and control of
resources and operations at the hospital facility until normal operations are resumed:

       UNIFIED COMMAND (Executive Management)
       Chief Executive Officer
       Vice President Finance
       Chief of Staff
       Vice President Ambulatory Care
       Vice President Operations
       Vice President Nursing
       Executive Director Nursing
       Administrator On-Call

B.     CHAIN OF COMMAND FOR EMERGENCY ACTIONS :
       1.     CHIEF EXECUTIVE OFFICER
       2.     CHIEF OF STAFF
       3.     VICE PRESIDENT AMBULATORY CARE
       4.     VICE PRESIDENT FINANCE
       5.     VICE PRESIDENT OPERATIONS
       6.     INTERIM VICE PRESIDENT NURSING
       7.     EXECUTIVE DIRECTOR NURSING
       8.     ADMINISTRATOR ON-CALL
       9.     DIRECTORS OF PATIENT CARE SERVICES
       10.    PATIENT CARE COORDINATOR

This integrated approach to incident management recognizes the clinical expertise as well as the
administrative and operational resources, which are required to adequately manage an emergency
situation affecting a major University teaching hospital. Depending on the type of emergency and the
need for expert resources, the unified command will request additional members as required. Whenever
the Emergency Operations Plan is activated, the responsible command representatives, or their
designee, must respond to the hospital command post to assume command and control responsibilities.

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Emergency Operations Plan
University Hospital



The Administrator On-Call is responsible to operationalize decisions made by the Unified Command
representatives and is the overall responsible administrative person in charge of command post
operations and incident follow-up procedures.

C.     DISASTER SITUATION COMMAND POST PERSONNEL

       Depending upon the incident the following personnel should be present:
             Unified Command as listed above
             Disaster Coordinator
             Director Marketing and Media Relations
             Public Safety Representative
             REMCS/EMS Representative
             Nursing Operations Center Representative
             Scribe(s)/Others

D.     COMMAND POST OPERATIONS

The primary responsibility of the command post is to assume command and control of all
hospital operations during a disaster scenario until the facility is returned to normal operations.
Therefore, all decisions regarding the operations of University Hospital and patient management
as well as resources will be presented to the command post for determination.

Depending on the nature of the emergency and the status of hospital operation, the following
actions should be considered by the unified command:

               hold over of current staff;
               recall of additional staff;
               discontinue patient visiting privileges;
               discontinue outpatient clinic visits;
               discharge eligible patients;
               transfer appropriate inpatients to other facilities;
               accept appropriate transfer patients;

               authorize the procurement of emergency supplies and resources;
               authorize emergency expenditures;
               request Emergency Management resources;
               notification of status to Central Administration;
               notification of status to regulatory authorities if required;
               notification of patient status to family members;
               conclusion of disaster situation; and
               any other required actions deemed necessary by the unified command.



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University Hospital



E.     COMMAND POST LOCATION

The primary Hospital Command Post location is the Administrative Conference Room UH D-215. This
command post will be utilized unless affected by the disaster at which point the secondary Command
Post located in conference room UH C-455 will be used. The Nursing Operations Center is located in
the Nursing Office in room D-202. The alternate location for the Nursing Operations Center
is E-406.

Upon notification of a disaster, the command post will set up for operation. Telephone equipment is
stored in the credenza on the left side of the conference room and the Emergency Operations Plan
Manual is located in cabinet #1. Keys to the conference room D-215 and the cabinets are available in
the Nursing Office, Room D-202. Conference Room C-455 has been designated as the alternate
command post. Keys to this conference room and credenzas are also located in the Nursing Office,
Room D-202 and Hospital Support Services Room A-216.


F.     COMMAND POST COMMUNICATIONS

There are six (6) unrestricted telephone lines available and one fax/modem line in the command post.
The Public Safety representative and EMS representative assigned to the command post will bring
portable radios. If additional communications capabilities are required, a request can be made to the
Newark Office of Emergency Management for a mutual aid response of a communications mobile
vehicle.

       Hospital Command Post Telephone Numbers

       In-Coming Calls Only:                                 Out-going Calls Only:

              972-5800                                               972-3640
              972-5801                       -


IV.    EXTERNAL DISASTER

       An external disaster is an event which may involve a disaster in the surrounding community that
       would require University Hospital to provide supplemental emergency medical care at the
       disaster site or may precipitate an influx of patients. Examples of external disasters are: large
       fire in the community, plane crash, major snow storm, gas line explosions, building collapse,
       extensive or prolonged utility failure, major public event (sporting event, arrival of public figure
       in community or on campus), civil disturbance, strike or labor action.



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University Hospital
A.   NOTIFICATION PROCESS

     1.    Phase I: Disaster Alert
           Notification from external sources regarding a disaster or impending danger may be
           received by:

                  a. Department of Public Safety
                  b. REMCS
                  c. Telephone Operators

           If notified from external sources, REMCS and Telephone Operators will notify the
           department of Public Safety and vice versa.

           Upon notification by external source(s) or the Department of Public Safety:

              REMCS will notify:

                  a. Administrator On-Call (AOC) ( 856-719-3963)
                  b. Emergency Department (2-5123)
                  c. Director of Trauma, Surgical/Trauma Attending (In-House) and Trauma Team
                      (2-6000)
                  d. Newark Office of Emergency Management (OEM) (973) 733-3660
                     and Essex County (OEM) when applicable at (973) 621-4160/4105

              Upon notification of a disaster or impending danger, Phase I: Disaster Alert will
              be activated by the Administrator On-Call (AOC). This will enable the hospital to
              a state of readiness to respond to any situation prior to knowing the impact of the
              situation on University Hospital’s resources.

              Administrator On-Call (AOC) will notify:

                  a.   Telephone Operators (2-6000)
                  b.   Nursing Office (2-5671/5672)
                  c.   Disaster Coordinator (2-3337) Beeper (973-421-0676)
                  d.   Chief of Staff (2-0440) Beeper (973-312-6310)

              Telephone Operators will notify:

                  a. Department of Physical Plant/Environmental Services
                                                  24 HOURS (2-5400)
                  b. Central Supply Services      24 HOURS (2-3438/3437)
                  c. Admitting Department         24 HOURS (2-4045)
                  d. Laboratory                   24 HOURS (2-4080)
                  e. Patient Transport            7 AM - 12 MIDNIGHT (2-7433)


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Emergency Operations Plan
University Hospital


     2.       Phase II: Disaster Situation (External)

              Upon notification from Public Safety and/or REMCS, the Administrator On-Call or the
              Surgical Trauma Attending will activate Phase II Disaster Situation.

              Activation of Phase II: Disaster Situation

              The following will occur:

              1. Administrator On-Call or the Surgical Trauma Attending will notify:

                 a. The Senior Surgical Trauma Attending/AOC

                 b. Advise Nursing Office to activate Nursing Operations Center and proceed with
                    their notification list.

                 c. Notify the Department of Public Safety (2-4491)

                 d. Advise the Telephone Operators to announce the Disaster Situation over the
                    Public Address System: (2-6000)




          “Code Triage in the Emergency Department.” (Repeat three (3) Times)


              2. The Telephone Operators will notify the following to advise them that Phase II:
                 Disaster Situation has been activated: (Initiate home phone tree if no response to
                 pager within 5 minutes).

                     Executive Committee consisting of:
                     - Chief Executive Officer
                     - Vice President for Finance
                     - Chief of Staff
                     - Vice President Ambulatory Care
                     - Vice President Operations
                     - Interim Vice President Nursing
                     - Executive Director Nursing
                     - Administrator On-Call
                     - Physical Plant/Environmental Services
                     - Central Supply Services
                     - Admitting
                     - Pathology & Laboratory Medicine
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      Emergency Operations Plan
      University Hospital
                         -   Telecommunication Operator Services Supervisor

NOTE: AFTER PHASE II NOTIFICATION, OPERATOR(S) MUST HAND DELIVER THE PHASE I DISASTER ALERT
NOTIFICATION SHEET/FORM TO THE COMMAND POST.




                  3. The Disaster Coordinator will notify the following:

                                                    8a.m.- 5p.m.     5p.m. - 8a.m.

                   Physical Plant                       2-5400       2-5400

                   Materials Management                 2-3597       2-3438/6515
                                                                     Pager 973-318-4377

                   EOC Coordinator                      2-3358       Pager 973-421-0208

                   EOHSS                                2-4812       2-4491

                  4. The Chief of Staff will notify medical staff.

                  5. The designated departments will provide support to the Emergency/Trauma
                     Department and prepare for additional resources accordingly.

                  6. The Medical Staff, Nursing Unit and each Department will activate their respective
                     Disaster Plans and recall lists.

         B. DESIGNATED DEPARTMENT SUPPORT



        THE DESIGNATED DEPARTMENTS WILL PROVIDE SUPPORT TO THE
        EMERGENCY/TRAUMA DEPARTMENT AND PREPARE FOR ADDITIONAL
        RESOURCES ACCORDINGLY:


       NURSING OFFICE WILL DISPATCH 3 R.N.’s TO THE EMERGENCY DEPARTMENT

       DEPARTMENT OF PHYSICAL PLANT/ENVIRONMENTAL SERVICES –
        HOUSEKEEPING SERVICE WORKER

       CENTRAL SERVICES - 1 CENTRAL SERVICES TECHNICIAN TO BRING AND
        REMAIN WITH EMERGENCY CART

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Emergency Operations Plan
University Hospital


 ADMITTING DEPARTMENT - 1 ADMITTING/REGISTRATION CLERK

 DEPARTMENT OF LABORATORY MEDICINE AND PATHOLOGY - ENSURE THAT
  ADEQUATE STAFFING IS IN PLACE.

 PATIENT TRANSPORT SHOULD MAKE SURE THAT ADEQUATE WHEEL CHAIRS
  AND STRETCHERS ARE AVAILABLE. DISPATCH ONE (1) CUSTOMER SERVICE
  TECHNICIAN II (LOGISTICS)




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  Emergency Operations Plan
  University Hospital


  V.   INTERNAL DISASTER

       An internal disaster is an event which impacts University Hospital’s physical plant or ability to
       provide adequate staffing and which could require patient relocation or evacuation. Examples of
       internal disasters are fire, chemical release, power outage, bomb explosions, building damage,
       massive failure of a utility system, severe staff shortage, biological contamination

       In the event of an internal disaster, the Department of Public Safety will notify REMCS and if
       necessary, the Newark Fire Department.

  A.   DISASTER SITUATION: NOTIFICATION PROCESS

       1. Upon notification by the Department of Public Safety, REMCS will notify:
          a. Administrator On-Call (AOC) (Beeper: 856-719-3963)
          b. Emergency Department (Direct Line 2-5123) - speak to Charge Nurse.
          c. Director of Trauma, Surgical/Trauma Attending (In-House) & Trauma
             Team (972-6000)
          d. Newark Office of Emergency Management (OEM) (973) 733-3660
          e. Essex County (OEM) when applicable (973) 621-4160/4105

       2. Administrator On-Call will:
          a. Advise Nursing Office to activate Nursing Operations Center and if AOC not in-house,
             activate the Hospital Command Post.
          b. Advise the Telephone Operators to announce the Disaster Situation over the Public
             Address System:


“D Code Triage in the Command Post Ext. 5800/5801” (Repeat Three (3) Times)



       3. The Telephone Operators will notify the following to advise them of the Internal Disaster:
             Disaster Coordinator
             Administrator On-Call
             Chief Executive Officer
             Vice President Finance
             Chief of Staff
             Vice President Ambulatory Care
             Vice President Operations
             Interim Vice President Nursing
             Executive Director Nursing
             Executive Director, Perioperative Services
             Physical Plant/Environmental Services
             Central Supply Services
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                 Admitting
                 Laboratory
                 Director, Marketing and Media Relations
                 Telecommunications; Operator Supervisor


NOTE: OPERATOR(S) MUST HAND DELIVER IMMEDIATELY AFTER NOTIFICATION
THE “DISASTER ALERT NOTIFICATION” TO COMMAND POST.


           4. The Disaster Coordinator will notify the following:
              a. Physical Plant                  (2-5400)
              b. Materials Management            (2-3597/6828/3438/6515)
              c. EOC Coordinator                 (2-3358) Beeper: 973-421-0208
              d. EOHSS                           (2-4812/4490/4491)

B.     LOGISTICAL SUPPORT

SPD has developed a local hospital network of Material Managers who routinely borrow and lend
supplies to hospitals in the network. St. Michaels, Beth Israel and East Orange General Hospital are
participating Essex County facilities. Hospital Materials Management Managers, Assistant Managers
and Supervisors are authorized to execute a loan from an area hospital. The SPD Emergency Operating
Procedures Plan outlines the capabilities and resources available to support University Hospital in the
event of an incident.

An agreement is in place with Tuscan Dairies to provide potable water to University Hospital in a
disaster situation (see Attachment). Lighting will be supplied by power from the emergency generator.
Newark Emergency Management will provide lighting upon notification of the type of emergency.


C.     TRIAGE: RECEIVING AND SORTING

1. All casualties are to be transported through the Emergency Ambulance Entrance.

2. Admitting staff will provide disaster tag packets prior to casualty arrivals. Disaster tags will be pre-
   stamped with a unit number. Admitting personnel will complete the disaster tag patient information
   with a minimum of name, date of birth and sex after the hospital triage team makes patient
   disposition. All patients will be tagged. Medical Records acts as the first back-up to Admitting.

3. The Emergency Triage Officer, in conjunction with the Emergency Department Nurse Manager, will
   receive incoming casualties. Based upon the field triage tag, the team will reassess, prioritize and
   make patient dispositions.




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University Hospital



4. The team will use the Universal Disaster Tag Categories. These categories are:

           Priority
           Disposition    Symbol          Color          Interpretation             Destination

               0                          Black          Death                      Morgue

               I          Rabbit          Red            Life Threatening-          Trauma
                                                         Rapid Transport

               II         Turtle          Yellow         Urgent - Slow              C385 (ER)

               III        Ambulance       Green          Delayed                    Ambulatory
                                                                                    Care Unit # 6 & 7

5. Emergency Admitting data will be taken from their disaster tag by the admitting clerk. At no time
   will this cover tag be removed from the patient.

6. Before patients leave the Emergency Department, all basic information concerning the patient will
   be placed in the Disaster log, including disaster tag# and location of patient assignment for further
   care. Copies will be sent to the Hospital Command Post, Admitting, Media Relations and Pastoral
   Care.

7. Upon notification of a disaster situation, Environmental Services personnel will inventory the
   institution for all available stretchers and wheelchairs and will bring them to the Emergency
   Department - Holding Area. (Refer to #4 on page 15).



D.     TREATMENT AREAS

Priority I Red Surgical or Severe Trauma Cases (Life Threatening)

 Patients requiring surgery or immediate life saving intervention will be given any necessary
  treatment in the Emergency Department, Shock Trauma or Critical Care areas.

 Patients requiring specialized treatment not available at University Hospital (i.e., burns) will be
  transferred to the appropriate facilities.




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Emergency Operations Plan
University Hospital



Priority II Yellow Stretcher Cases (Urgent)

 Treatment to stretcher patients will be given in the Emergency Department. (Refer to #4 on page 15)

 Patients then will be transported to C-385 (ER) for further treatment or observation as required.

Priority III Green Minor First Aid - Ambulatory (Delayed)

 Patient from the Triage Area requiring only minor first aid treatment will receive the needed
  treatment in the Ambulatory Care area (Unit # 6 & 7). (Refer to #4 on page 15).

 Patients will then be escorted to the outpatient waiting area to wait for transportation to their homes.


E.     X-Ray

 Patients requiring diagnostic X-Ray procedures will be transported from the ER (C-385) to the X-
  Ray station. (C-305) extension 2-4907. (Refer to #12 on page 15). In the event that the number of
  casualties exceeds the capabilities of the Emergency Department, other departments can be opened
  to support minor and urgent care patients. The opening and staffing of these areas are authorized
  only by the Administrator On-Call.

 a. Ambulatory Care Area will serve as the treatment facility for minor first aid - ambulatory. The
     Doctors Office complex will serve as the overflow ambulatory care area. (Refer to #4 on page 15).

 b. The Holding Area will provide immediate supportive medical care to patients categorized as urgent.
     (Refer to #4 on page 15).


Priority 0 Black - Death (Morgue)


F.     DISASTER STATIONS & LOCATIONS

            STATION                                  LOCATION/EXTENSION

       1.   Admitting:                               Emergency Reception Area, Admitting
                                                     Office (2-4045)

       2.   Discharge:                               Outpatient Reception Area (2-3331)

       3.   Employee Entrance:                       Medical Science Building - Main Entrance
                                                     South Orange Avenue
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     4.   Holding:                                 Emergency Department (Urgent care, if needed)
                                                   (2-5464)
                                                   Ambulatory Care (minor cases, if needed)
                                                   (2-5027/4993)
                                                   Community Mental Health Gym (excess holding)

     5.   Hospital Command Post:                   D-215 (5800/5801) C-455

     6.   Morgue:                                  (Forensic Lab) MSB A-521 (2-5234/4794)

     7.   Nursing Operations Center:               D-202 Extensions (2-5671/5676/5677/8750/8754)

     8.   Patient Receiving:                       Emergency Department Ambulance Entrance

     9.   Receiving:                               Supply SPD Loading Dock/A-119 (2-4175)

     10. Surgery:                                  Operating Room (2-6901)

     11. Triage:                                   Emergency Department Triage Area

     12. X-Ray:                                    Radiology Department C-305 (2-4907)


G.   CENSUS MANAGEMENT

     During a major disaster with a large number of in-coming casualties, the Chief of Staff will
     contact the Chief Resident of the appropriate in-patient services arrange for the discharge of
     appropriate patients to home or for transfer to another hospital. Transfer arrangements must be
     established prior to discharge. Approval of the primary physician must be obtained prior to
     discharge. The Directors of the in-patient Surgical and Medical Service will cancel all elective
     admissions in order to free appropriate beds. The ICU Director will designate patients for
     transfer to the Step-Down Units for consolidation on units other than the SICU or the Trauma
     Step-Down Unit. All elective surgical procedures will be suspended and the appropriate
     complement of operating rooms and critical care nurses will be called in by the Nursing Director
     of the O.R.

     Upon notification of an emergency condition, the surgical and medical attendings in charge will
     assign a senior resident with the charge nurse to survey the floors of each service. They will list
     patients, in order of increasing severity of illness, appropriate for transfer to a general staging
     area.




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University Hospital



     Upon completion of the survey, the residents will report back to their respective attendings. The
     attendings or physician in charge will then order the transfer of these patients as warranted by the
     number of casualties expected.

     Upon notification of an emergency condition, Environmental Services will assign personnel to
     set-up cots or litters in the designated staging area(s). Simultaneously, nursing personnel will be
     assigned to the staging area to prepare for the arrival of patients.


H.   OPERATIONS AND CONTROL

     Dissemination of Emergency Information to Hearing Impaired or Non-English Speaking
     Persons

     The Inpatient Units, Public Safety stations, Emergency Department, Information Desk and
     Admitting Department will be equipped with signage (bilingual as well as symbols) indicating
     that the hospital is in the midst of an emergency and that patients and visitors should not panic.
     The signage will also direct the individuals to the Department/Nurse Manager and await further
     instruction.

     If any evacuation is necessary, the Department/Nurse Manager or designee will accompany
     hearing-impaired and/or non-English speaking individuals to the appropriate area.



      Each In-patient Unit and Department is to report to their respective Command Posts that
      they require assistance for hearing impaired and/or non-English speaking persons. The
      information provided must include name(s) and location.


     The Command Post is to maintain the list of hearing-impaired and/or non-English speaking
     individuals and monitor their status.

     The Department of Social Work Services at extension (2-5727) will also be responsible for
     assisting all hearing impaired and non-English speaking persons by identifying any available
     interpreters (Interpreter’s Roster Attachment 11). The Department will maintain a listing of
     the names and location of those individuals needing assistance.




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University Hospital


I.     CONTROL OF MEDIA, FAMILIES, VISITORS AND OTHER

CROWD CONTROL

The University Public Safety Department provides crowd control as specified in the Public Safety policy
and procedures. In the event that visitors and/or crowd control presents a problem, and upon notification
from a Public Safety Supervisor or designee, the Newark Police Department will be called to assist.
Direct police contact phones can be found in the Emergency Room area by the hospital police desk.

MEDIA RECEPTION

The University Hospital Department of Marketing & Media Relations will be responsible for release of
all casualty information to the press. Members of the press are not to be admitted into the hospital.
The press will be stationed in the Medical School, Medical Science Building Room B-515 (The
Rosemary Gellene Room). The Department of Marketing & Media Relations will be in charge of this
operation. Internal security will be necessary to maintain and control the media.

FAMILIES OF VICTIMS

The Dental Student Lounge Area B-Level, Dental School will be designated for the families of D.O.A.
victims. Family members of all other victims will be directed to Rooms B-721 and/or B-723 located in
the Dental School. This area will be controlled by the Chaplain, crisis personnel and Public Safety. The
Chaplain will act as a spokesperson to the families. Periodic updates will be provided to the families by
Social Work Services or the Chaplain.

HOSPITAL VISITORS

During emergency operating conditions, it is critical for University Hospital to limit access to the
facility. The Command Post will determine if it is necessary to cancel visiting hours and clinic sessions
and any non-essential activity scheduled at University Hospital.

In any emergency condition, the presence of visitors in the hospital may interfere with care of the
injured. Visitors will be asked to leave as rapidly as possible for the areas involved. All visitors will be
removed from the Emergency Room, Out-Patient department, etc. UMDNJ Police Officers, with an
Administrator, will be responsible for coordinating visitor control.




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J.     INTERNAL & EXTERNAL DISASTER


TERMINATION DISASTER SITUATION

The Administrator On-Call, upon notification from the appropriate emergency officials and Disaster
Coordinator, will terminate the Disaster Situation. Once the decision has been made, the following will
occur:

       1. Administrator On-Call will:

           a. Advise the Nursing Office to terminate Nursing Operations Center.
              The Nursing Office will proceed with their notification list (2-5671/5676)
           b. Notify Public Safety (2-4490)
           c. Close the Command Post and advise the Telephone Operators to announce the
              termination of the Disaster Situation over the Public Address System:


                 “Code Triage ALL CLEAR” (Repeat Three (3) Times)

       2. Operator will notify:

           a. Executive Management

       3. The Disaster Coordinator will notify the following:

               a. Physical Plant (2-5400)
               b. Materials Management - Supply, Process and Distribution (2-3437/3597)
               c. EOC Coordinator (2-3358)
                  EOHSS (2-4812)


K.     RECOVERY

Since the type and nature of disasters as well as the size and magnitude of them will vary tremendously,
there is no prescriptive recovery procedure that “fits all sizes”. It is therefore the responsibility of the
Command Center, and specifically the Incident Commander, to ensure a systematic and organized
recovery effort. In much the same way the incident command structure will be used to respond to an
incident, the same structure and unified command will be used to re-open services and return the
hospital to normal operations. The Incident Command Center will remain open until the Hospital has
fully recovered from the disaster.



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University Hospital




L.     EMERGENCY PREPAREDNESS DRILLS

Emergency Preparedness and/or disaster drills will be conducted at least twice a year; with one
drill simulating a natural disaster with an influx of patients from outside of the hospital. Other
drills may involve patient evacuation and will include all working shifts. Each drill will be
followed by a critique and a report written by the Administrator On-Call and reviewed by the
Environment of Car Management Committee. The report will include problems identified
during implementation, corrective actions taken staff participation, type of disaster, outside
agencies involved, and the time factors will also be included.




                                                                                                     19
Emergency Operations Plan
University Hospital




APPENDICES




                            20
Emergency Operations Plan
University Hospital




                   APPENDIX A

         EVACUATION PLAN




                                21
Emergency Operations Plan
University Hospital


APPENDIX A
EVACUATION PLAN

In the event that an emergency situation occurs in a particular department or nursing unit of the
hospital, the Department/Nurse Manager or designee will identify the need to evacuate the
affected area. This decision will be based upon the extent of immediate threat to patients,
visitors and staff. The Department Nurse Manager or designee will immediately contact the
Department of Public Safety and communicate the decision to evacuate.

The Department of Public Safety will be responsible for notifying the following:

    REMCS
    Fire Department, if necessary
    Operator 111

The Internal Disaster Plan will be activated in accordance with the established procedures.

The AOC, in conjunction with the Department of Public Safety, the Disaster Coordinator and the
Hospital Safety Coordinator will oversee the evacuation. Public Safety will assist by directing
the evacuation throughout University Hospital.

Each Department and Nursing Unit will follow their respective evacuation plans to manage the
safe removal of patients, visitors and staff.

I. Levels of Evacuation

   Depending on the nature and extent of the emergency there are four (4) different levels of
   evacuation that may be utilized.

   1. Partial Evacuation

       An isolated area, for example, a patient room is the site of the emergency and requires
       that the individuals in the area be removed to another location.

   2. Lateral/Horizontal Evacuation

       An entire department or nursing unit is affected by the emergency and requires all
       individuals in the area to be removed to another location on the same floor.

       a. Move patients, visitors and staff beyond the nearest fire doors in the department
          area/nursing unit.




                                                                                                 22
Emergency Operations Plan
University Hospital



     b. If moving patients from one nursing unit to another, the protocol is as follow:
             Blue Unit to Green Unit
             Yellow Unit to Green Unit
             Green Unit to Blue Unit

     c. For those patients that are non-ambulatory patients, the patient’s bed or stretcher is to
        be pushed to the designated area.

     d. The Nurse/Department Manager or designee must ensure that the patient’s Medical
        Chart is collected and transported with the patient.

     e. The Nurse/Department Manager or designee and if appropriate, the Director of
        Pharmacy, is responsible for securing all medications and drugs prior to evacuation.

  3. Vertical Evacuation

     An entire floor is affected buy the emergency and requires that all individuals on the floor
     be removed to another floor. Generally, individuals should be moved downward to the
     floor below. However, in the event that the emergency situation affects C-level or the
     floors beneath it, the evacuation may include the use of exit doors to the adjacent building
     (Medical Science Building and/or University Behavioral HealthCare Center) or outside of
     the building.

     a. Only stairways and the “Link” to the Medical Science Building are to be used to
        move patients to floors below.

     b. Ambulatory patients are to be moved as follows:
           Wrap patients in blankets.
           Lead patients using a Daisy Chain (single file, each patient maintaining close
             contact with person in front). A staff member should be at the front end of the
             line and another staff member is to be at the end of the line.

     c. Wheelchair patients are to be transported by Blanket Slide or Carry.

     d. Whenever possible, infants and children are to be moved by cribs. Infants can be
        moved, if necessary, by placing wrapped infants side by side on a blanket and using a
        Blanket Pull.

     e. The Nurse/Department Manager or designee must ensure that the patient’s Medical
        Chart is collected and transported with the patient.




                                                                                               23
Emergency Operations Plan
University Hospital



         f. A list of all evacuated patients must be maintained. The listing should identify the
            following:
                 Name of Patient
                 Name of Staff Accompanying Patient
                 Destination of Patient

         g. A list of all employees and their disposition must be maintained to account for all
            personnel.

      4. Facility Evaluation

         The entire facility or building is affected by the emergency and necessitates the removal
         of ALL occupants. This will require an organized approach including a sequence of
         dismissal based upon immediate threat of danger.

         Any facility evacuation will be based on the following priority situation:
             Immediate Location of Emergency
             Intensive Care Units (From I-Level down to E-Level)
             Emergency Department

II.      Transporting Evacuated Patients

         1. Emergency Medical Services (EMS) will coordinate and direct all transportation of
            evacuated patients.

            If local resources are not readily available, EMS will request assistance form other
            emergency service entities including the New York City EMS and the Health and
            Hospitals Corporation. In addition, EMS can activate the Medical Transportation
            Association of New Jersey for the emergency response of licensed ambulances and
            invalid coaches to assist the hospital in the event of an evacuation.

         2. The Receiving facility or facilities may operationalize their own Disaster Plans in
            preparation for the incoming patients.




                                                                                                   24
Emergency Operations Plan
University Hospital



III.   Responsibilities

       1. The Group Manager for Physical Plant & Executive Director for Hospital Support
          Services is responsible for ensuring that evacuation routes (including safety and
          emergency lighting in corridors and stairways) are clearly marked throughout the
          facility.

       2. As part of the orientation process, all staff will participate in training sessions
          regarding the Hospital Fire Safety and Emergency Evacuation Plan.

       3. The Disaster Coordinator is responsible for scheduling and conducting periodic
          evacuation drills and exercises.

       4. In the event of an emergency situation requiring an evacuation, the Unified Command
          is responsible for notifying the local government and alternate facilities of the
          evacuation.




                                                                                                25
Emergency Operations Plan
University Hospital




                   APPENDIX B


        HOSPITAL SUPPORT
         STAFF HOURS OF
           OPERATION




                                26
Emergency Operations Plan
University Hospital


APPENDIX B
HOSPITAL SUPPORT STAFF HOURS OF OPERATION

1. University Hospital, 150 Bergen Street, Newark, N.J. is a 890,081 square foot hospital
   building located on 64 acres of the UMDNJ Campus. The hospital houses approximately
   466 in-patients and 553 ambulatory care units. Additional outpatient facilities are located on
   GA and GB level of the Stanley S. Bergen Jr. Building, 65 Bergen Street, Newark, N.J.,
   utilizing approximately 50,000 square feet of area.

DEPARTMENT                                      HOURS OF OPERATION

Nursing                                             24 Hour
ER                                                  24 Hour
Admitting                                           24 Hour
Infection Control                                   24 Hour
Central Supply                                      24 Hour
Material Management – SPD                           7:30 a.m. – 5:00 p.m.
Pastoral Care                                       8:00 a.m. – 5:00 p.m. (On-Call)
Food & Nutrition                                    6:30 a.m. - 9:00 p.m.
Public Safety                                       24 Hour
Nuclear Medicine                                    7:30 a.m. – 5:00 p.m.
Pharmacy                                            24 Hour
Environmental Services                              24 Hour
Radiology                                           24 Hour
Radiation Oncology                                  7:30 a.m. – 4:30 p.m. (On-Call)
Quality Assurance                                   7:30 a.m. – 5:00 p.m.
Physical Medicine & Rehabilitation                  8:00 a.m. - 5:00 p.m. (On-Call)
Cardiorespiratory                                   7:00 a.m. – 5:00 p.m. (On-Call)
Pathology & Laboratory Medicine                     24 Hour
Medical Records                                     7:30 a.m. – 5:30 p.m.
Social Work Services                                8:00 a.m. – 5:00 p.m. (On-Call)
Physical Plant                                      24 Hour
HMIS                                                24 Hour
IS&T                                                24 Hour
Clinical Engineering                                7:00 a.m. – 6:00 p.m. (On-Call)
Volunteer Services                                  9:00 a.m. – 5:00 p.m.
Transport Services                                  7:00 a.m. – 12:00 midnight


*Nursing staff work twelve hour work shifts - 7am to 7pm and 7pm to 7am




                                                                                               27
Emergency Operations Plan
University Hospital




                   APPENDIX C



          RESPONSIBILITIES




                                28
Emergency Operations Plan
University Hospital


APPENDIX C
RESPONSIBILITIES

  A. By designation of the Chief Executive Officer, the Administrator-On-Call is responsible
     for directing the Emergency Response.

  B. The respective Department Managers and the Executive Director of Nursing will initiate
     directives to implement call-in of personnel to augment the Personnel Pool.

     The designated individual in each department and the Nursing Operations Center will be
     responsible to recall staff. Each Department and Nursing Division will maintain a
     telephone tree for recall purposes.

  C. The Director of Medical Records will be responsible for safeguarding essential records.
     The respective Department Managers will be responsible to safeguard the essential
     records for their department. All medications and essential records are maintained by the
     Director of Pharmacy.

  D. The Department of EOHSS and all Department Managers are responsible for the
     provision of the necessary information on the emergency operations plan. A copy will be
     maintained in each department and in all patient care areas. Each department must
     have developed and established individual emergency plans.

  E. These plans are introduced to all new employees with the guidance of the respective
     department manager. Staff is responsible to direct patients and visitors as to the proper
     procedures during an emergency situation.

  F. Training in safety measures is provided to all employees by the individuals designated in
     the areas of the Office of Environmental and Occupational Health and Safety Services
     (EOHSS), the Environment of Care (EOC) Management Committee or designee, and
     their respective Departments.

     It is the Manager’s responsibility to ensure their staff is familiar with their
     respective department’s Emergency Operation Plan.

  G. The Disaster Coordinator is responsible for the development and maintenance of
     logistical preparations for emergency situations. The Administrator-On-Call is
     responsible for records, reports and expenditures during an emergency.




                                                                                            29
Emergency Operations Plan
University Hospital




                   APPENDIX D



                  CONTINUITY

                            OF

                  LEADERSHIP




                                 30
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University Hospital



APPENDIX D
CONTINUITY OF LEADERSHIP


    A. The line of succession to assure continuous leadership is as follows
       CHIEF EXECUTIVE OFFICER; In the absence of the CEO, the
       CHIEF OF STAFF; In the absence of the COS, the
       VICE PRESIDENT FOR AMBULATORY CARE; In the absence of the Assistant Vice
       President, the
       VICE PRESIDENT FOR FINANCE; In the absence of the
       Vice President of Finance, the
       INTERIM VICE PRESIDENT OF NURSING; In the absence of the Interim Vice President of
                 Nursing, the
       EXECUTIVE DIRECTOR NURSING; In the absence of the Executive Director, the
.      ADMINISTRATOR ON-CALL; In the absence of the Administrator On-Call, the
       DIRECTORS OF PATIENT CARE SERVICES; In the absence of the Director of
       Patient Care Services, the
       PATIENT CARE COORDINATOR


    B. Resources and information are requested from Operations Departments through contact
       between the respective Department Managers and the Command Post. Nursing Managers
       communicate directly with the Nursing Operations Center.


    C. Medical Records are essential and are kept with the patient during all transport
       operations.




                                                                                             31
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University Hospital




                   APPENDIX E



           ADMINISTRATION

                            AND

                     LOGISTICS




                                  32
Emergency Operations Plan
University Hospital


APPENDIX E
ADMINISTRATION AND LOGISTICS


  A. The Hospital Administrator On Call (AOC) directing the activities of the command post
     will review and approve requests for extraordinary expenses incurred during an
     emergency. The department requesting the approval will include a record of the expenses
     incurred as well as a justification of necessity in the evaluation report due to the AOC
     within one week of the event. The finance department will assist the AOC in preparing
     financial reports regarding total incident expenses.

  B. If the resources of University Hospital are not sufficient enough to mitigate the
     emergency, the Command Post can request the Newark Office of Emergency
     Management (OEM) to facilitate support from voluntary agencies or government
     agencies. If local resources are not available, Newark OEM can forward the request to
     Essex County OEM for assistance. If Essex County OEM is unable to provide assistance
     from within the county, the State Police Office of Emergency Management Region I, will
     be activated upon request of the Essex County OEM Coordinator.

     1. University Hospital Emergency Medical Service (EMS) will coordinate the mutual
        aid response of ambulances and mobile intensive care units (MICU) in accordance
        with the Department of Health (DOH) statewide emergency operating procedures and
        the New Jersey State First Aid Council Mobilization Plan. If local resources are not
        readily available, EMS can request assistance from New York City EMS and the
        Health and Hospitals Corporation.

     2. University EMS can also activate the Medical Transportation Association of New
        Jersey for emergency response of licensed ambulances and invalid coaches to assist
        the hospital in the event of an evacuation. Private ambulance companies will activate
        their staff recall rosters and divert resources from nonessential assignments to provide
        emergency support to health care facilities. Each private provider has an established
        emergency rate which will be charged to the hospital.

     3. UMDNJ and University Hospital are members of the National Disaster Medical
        System (NDMS) which upon activation by the President of the United States or upon
        request of the Governor of New Jersey, can mobilize national resources from both the
        military and private sector.

  C. Medical/surgical supplies, laboratory supplies, and linen will be provided by the
     department of Materials Management. Materials Management has agreements for
     emergency delivery of critical supplies in the event of an emergency within four hours of
     notification.



                                                                                              33
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University Hospital




                    APPENDIX F



     PLAN DEVELOPMENT

                            AND

               MAINTENANCE




                                  34
Emergency Operations Plan
University Hospital




APPENDIX F
PLAN DEVELOPMENT AND MAINTENANCE

University Hospital participates in all emergency management exercises sponsored by the City of
Newark as well as actively providing support and receiving patients from the Annual Newark
International Airport Exercises.

Additionally, as the designated Level I Trauma Center servicing Northern New Jersey,
University Hospital participates in several local and regional disaster exercises, accepting the
specialty care patients transported by ground or medevac helicopter.

University Hospital will annually submit copies of the emergency plan to the Newark Office of
Emergency Management and the Essex County Office of Emergency Management.

University Hospital Disaster Committee and the Environment of Care Management Committee
will ensure the emergency plan is reviewed and deficiencies are corrected each time the
emergency plan is activated for an actual event or simulated exercise. University Hospital’s
Environment of Care Management Committee will actively participate in reviewing and
modifying the Emergency Operations Plan.




                                                                                                   35
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University Hospital




                   APPENDIX G

   UNIVERSITY HOSPITAL
    CONTINGENCY PLAN
            &
    GUIDE FOR UTILITY
      INTERRUPTIONS




                                36
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University Hospital




                   APPENDIX H

 NUCLEAR BIOLOGICAL
 CHEMICAL (NBC) ANNEX




                                37
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University Hospital




              ATTACHMENTS




                            38
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University Hospital



ATTACHMENTS


#1    Map of the Greater Newark Area will identify major roadways, railways, Newark
      International Airport, Seaports of Newark and Elizabeth. (Located in the Command
      Post)

#2    Map of the Newark UMDNJ Campus will identify the facilities roads, parking areas and
      main access points. (Located in the Command Post)

#3    Map of Greater Newark Area Hospitals and their locations. Brief summary of hospital
      specialty care capability or service. (Located in the Command Post)

#4    Map of University Hospital facility floor plan will be supplied indicating the buildings,
      heat plants, boilers, generators flammable liquid storage and hazardous material storage.
      (Located in the Command Post)

#5    Map of the fire fighting equipment and stations in Appendix A

#6    Command Post Response List and the Administrative Notification Response List

#7    External Disaster Phase I: Alert Notification Response List

#8    External Disaster Phase II: Disaster Notification Response List

#9    Internal Disaster Notification

#10   Medical Staff Disaster Plan

#11   Interpreter’s Roster

#12   Tuscan Dairy Agreement




                                                                                              39
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University Hospital




S1                    PERSONNEL

                 MANNED BY: THE COMMAND POST


     1. OBTAIN INFORMATION CONCERNING INCIDENT FROM S2 AND
        IMPLEMENT PERSONNEL SUPPORT. THIS INFORMATION MUST
        INCLUDE AT A MINIMUM THE FOLLOWING:

       A. CURRENT AVAILABLE STAFF AT UNIVERSITY HOSPITAL IN
          THE CRITICAL AREAS. I.E., (ER, TRAUMA, OR) AND OTHER
          PATIENT CARE AREAS IF NEEDED.

       B. DETERMINE THE NUMBER OF BEDS AND THEIR LOCATIONS
          AVAILABLE AND CONSISTENTLY UPDATE THIS
          INFORMATION. FAX FROM ADMITTING EVERY HOUR AFTER
          INCIDENT. THIS INFORMATION WILL BE POSTED ON THE
          INCIDENT BOARD LOCATED IN THE COMMAND POST.

       C. IDENTIFY THE NUMBER AND TYPE OF STAFF THAT WILL BE
          AVAILABLE TO REPORT TO DUTY. IDENTIFY APPROXIMATE
          ETA AFTER NOTIFICATION.

       D. AT COMPLETION OF INCIDENT, OBTAIN ACCOUNT NUMBER
          TO RECORD LABOR HOURS FROM EACH DEPARTMENT
          INVOLVED WITH THE INCIDENT.

       E. PREPARE AFTER ACTION REPORT AND SUBMIT TO HOSPITAL
          DISASTER COORDINATOR WITHIN 72 HOURS AFTER
          INCIDENT.

       F. ENSURE PROPER COMPLETION OF COMMAND POST
          CHECKLIST.




                                                                 40
Emergency Operations Plan
University Hospital




S2                    INTELLIGENCE

               MANNED BY: PUBLIC SAFETY OR EMS


     1. GATHER INFORMATION AND MAKE SAID INFORMATION
        AVAILABLE AS NEEDED TO COMMAND POST (CP) . THIS
        INFORMATION MUST INCLUDE AT A MINIMUM THE
        FOLLOWING:

       A. LOCATION OF INCIDENT


       B. TYPE OF INCIDENT - I.E., AIRPLANE CRASH, FIRE, BOMB
          THREAT

       C. NUMBER AND TYPE OF CASUALTIES EXPECTED

       D. ANTICIPATED ETA TO UNIVERSITY HOSPITAL

       E. PREPARE AFTER ACTION REPORT AND SUBMIT TO HOSPITAL
          DISASTER COORDINATOR WITHIN 72 HOURS AFTER THE
          INCIDENT.




                                                                41
Emergency Operations Plan
University Hospital



S3                          OPERATIONS

     MANNED BY: NURSE MANAGER/DEPARTMENT MANAGER

1. COORDINATE THE ACTIVITIES OF ALL THE SUPPORT SERVICES TO
   ENSURE SUCCESSFUL COMPLETION OF THE MISSION. THIS
   FUNCTION WILL DIRECT THE RESOURCES TO THE AREA WITH THE
   MOST IMMEDIATE NEED INCLUDING:
                                      8:00 am - 5:00 pm    5:00 pm - 8:00 am
NEWARK OFFICE OF EMERGENCY
  MANAGEMENT (OEM)                          733-3660             973-578-3906

HOSPITAL FINANCE                            2-3721               973-421-0748

FOOD SERVICES - (PATIENT FAMILY SUPPORT)    2-4026/4021          2-4021

ENV. SVCS.(CONF. RMS/WAITING AREAS)         2-5400               2-5400

MEDIA – PUBLIC RELATIONS                    2-8007               973-318-4866

MEDICAL/CLINICAL REQUIREMENT                2-0440               973-312-6310
(CHIF OF STAFF OFFICE)

MEDICAL EQUIPMENT (CLINICAL ENGINEERING) 2-6661                  2-6661
                                         973-312-6394            973-312-6394

MEDICAL GAS (RESPIRATORY)                   973-421-0893         973-421-0893

NURSING ADMINISTRATION                      2-5676               2-5677

PASTORAL CARE                               2-5668               973-312-3966

PATIENT/FAMILY ASSISTANCE (ADMITTING)       2-4050/4051          2-4050/4051

PATIENT TRANSPORT                           2-5803               2-7433

PHARMACY                                    2-5118/5121          2-5118/5121

PHYSICAL PLANT (EMERGENCY POWER/HVAC)       2-5400               2-5400
          UTILITIES/ELEVATOR OPERATIONS

RADIOLOGY                                   2-4907               2-4907
                                                                               42
Emergency Operations Plan
University Hospital



S3                          OPERATIONS (CONT’D)


1. COORDINATE THE ACTIVITIES OF ALL THE SUPPORT SERVICES TO
   ENSURE SUCCESSFUL COMPLETION OF THE MISSION. THIS
   FUNCTION WILL DIRECT THE RESOURCES TO THE AREA WITH THE
   MOST IMMEDIATE NEED INCLUDING

                                    8:00 am - 5:00 pm    5:00 pm - 8:00 am

QUALITY ASSURANCE                      2-7623/7059       See Attachment 11

HEARING IMPAIRED/BILINGUAL             2-5727            800-643-2255/210019
                                                         800-523-1786-911

EOC COORDINATOR                        2-3358            973-421-0208

EOHSS                                  2-4812            2-4490

SECURITY (PUBLIC SAFETY)               2-4491            2-4491/4492

SPACE ALLOCATION                       2-5400            2-5400
(CP/PHYSICAL PLANT)

CITY/COMMUNITY LIAISON (REMCS)         2-7000 (24 Hrs)   2-7000 (24 Hrs)


VEHICLE TRANSPORTATION                 2-4315            973-421-0664

WASTE REMOVAL                          2-7019            2-5400

WATER (PHYSICAL PLANT)                 2-5400            2-5400




                                                                             43
Emergency Operations Plan
University Hospital



S4                          SUPPORT SERVICES


                  PHONE NUMBER: 972-3597 (973-318-4377)


     UPON NOTIFICATION, GATHER INFORMATION REGARDING THE
     AVAILABILITY OF ESSENTIAL SUPPLIES REQUIRED TO SUPPORT
     THE INCIDENT.

     A. MEDICAL - PATIENT

     B. NON-MEDICAL - PATIENT

     C. SHIPPING/RECEIVING

     D. LAUNDRY

     E. VENDOR SERVICES

           1.   WATER
           2.   FOOD
           3.   EQUIPMENT
           4.   GENERAL SUPPLIES

     F. OTHER SUPPORT (HOSPITALS, CITY, STATE)




                                                          44
Emergency Operations Plan
University Hospital



S5                  PUBLIC RELATIONS


               PHONE NUMBER: 972-8007 (973-318-4866)


        DIRECT AND CONTROL THE FLOW OF INFORMATION
        REGARDING THE INCIDENT AND THE ACTIVITIES OF
        UNIVERSITY HOSPITAL AS IT RELATES TO THE INCIDENT.


        1. PROVIDE INFORMATION TO THE PUBLIC VIA VARIOUS
           MEDIA FORMS.



        2. PROVIDE INFORMATION TO HOSPITAL COMMAND POST




        3. COMMUNITY ISSUES/CONCERNS




        4. INFORMATION FOR PATIENT FAMILIES




                                                             45
Emergency Operations Plan
University Hospital
                                                        ATTACHMENT 7
TELEPHONE OPERATORS/TELECOMMUNICATIONS

                                   EXTERNAL DISASTER
                     PHASE I: ALERT NOTIFICATION RESPONSE CHECKLIST
                       CALL METROCALL 1 866-208-6365 COMMAND POST # 972-5800/5801

                                                                                   Date _________ Time

                                EXTENSION        BEEPER NUMBER         RESPONSE                     COMMENTS
                                                                         TIME
Environmental Services              2-5400
                                  (24 Hours)
Central Supply Services          2-3438/6515
                                  (24 Hours)
Admitting Department                2-4045
                                  (24 Hours)
Laboratory                          2-4080
                                  (24 Hours)
Infection Control                   2-5790
                                  (24 Hours)
Patient Transport                   2-7433       973-312-5654
                                (7 am - 12 am)   973-421-0339


                                                 Name of person completing form:_________________________________




                                                                                         46
Emergency Operations Plan
University Hospital
                                                               ATTACHMENT 8

                                     EXTERNAL DISASTER
                    PHASE II: DISASTER NOTIFICATION RESPONSE CHECKLIST
    CALL METROCALL 1- 866-208-6365                                                                 COMMAND POST # 972-5800/5801
                                          Date___________ Time ____________ Date _____________ Time _____________
                                            EXTENSION BEEPER NUMBER RESPONSE                  HOME #         RESPONSE   COMMENTS
                                                                                 TIME                           TIME
Administrator On-Call (AOC)                 N/A            856-719-3963                        N/A
Chief of Staff, - Suresh Raina, MD          2-0440        973-699-4721                  973-535-2660

Disaster Coordinator - Steven L. Mosser     2-3337        973-421-0676                  973-886-4192
Surgical Attending/Trauma Team              SEE DOCTOR ON CALL SCHEDULE
Public Safety – Glen E. Crawford            2-4491        609-481-8345 (C)              757-382-9232
Chief Executive Officer-
   Sidney Mitchell                          2-5658        973-566-8752                  201-239-1861
Vice President Ambulatory Care -            2-4968        973-566-4949                  973-477-6296(C)
   Adam Henick/Ed Jimenez                   2-3109        973-281-9353                  201-785-9660
Vice President Finance –
    James Lawler                            2-3721        973-421-0748                  908-604-4918
Vice President Operations –                 2-0874        973-281-4389                  201-363-0124
    Derrick Johnson/Steven Mosser           2-3337        973-421-0676                  973-886-4192
Interim Vice President Nursing -
   Patricia Wrobbel                         2-1787        973-318-4392                  973-838-3577
Marketing & Media Relations
   Director, Robin Preisler                 2-6273        973-318-4866                  908-233-8529
   Assistant, Roger Ramsey                  2-6273        973-318-4978                  973-673-2481



                                                                                                       47
Emergency Operations Plan
University Hospital
Patient Care Services

Executive Director, Nursing
    Patricia Wrobbel                     2-1787   973-318-4392           973-838-3577


Executive Director, Perioperative Svcs   2-5730
    Nancy Berger                                  973-312-4945           908-276-7269

Family Health Services                   2-5837
   Ferne Bell-Woodley                             973-312-5286           732-827-0250

Division Psychiatry                      2-6127
   Chris McCallion                                973-312-6193           732-842-9118

Division of Critical Care                2-7012
   Linda McGinnis                                 973-566-7483           973-471-4416

Cardiac Services & Education &           2-6824
Professional Development                          973-566-2766           845-365-2818
   Fabienne Ryan

Emergency Department                     2-1624
  James Henry                                     973-566-7508           908-531-6735

Medical/Surgical                         2-6652
  Judy Colorado                                   973-566-8111           908-832-6641

Telecommunications - Lois Gibbs-Reid     2-4052   973-421-0305           973-371-1842



                                                  Name of person completing form:_________________________________


                                                                                        48
Emergency Operations Plan
University Hospital


                                                                ATTACHMENT 9

                   INTERNAL DISASTER NOTIFICATION RESPONSE CHECKLIST

CALL METROCALL 1- 866-208-6365                                                                      COMMAND POST # 972-5800-1
                                                                               Date________ Time ________   Date _________ Time ______________


                                          EXTENSION   BEEPER NUMBER RESPONSE      HOME #        RESPONSE              COMMENTS
                                                                      TIME                        TIME
Administrator On-Call                     AOC         856-719-3963                   N/A
Chief of Staff, - Suresh Raina, MD        2-0440      973-699-4721             973-535-2660
Disaster Coordinator - Steven L. Mosser   2-3337      973-421-0676             973-886-4192
Surgical Attending/Trauma Team            SEE DOCTOR ON CALL SCHEDULE
Public Safety – Glen E. Crawford          2-4491      609-481-8345 (C)

Chief Executive Officer –
   Sidney Mitchell                        2-5658      973-566-8752             201-239-1861
Vice President Ambulatory Care-           2-4968      973-566-4949             973-467-3468
   Adam Henick/Ed Jimenez                 2-3109      973-281-9353             201-785-9660
Vice President Finance –
   James Lawler                           2-3721      973-421-0748             908-604-4918
Vice President Operations -               2-0874      973-281-4389             201-363-0124
   Derrick Johnson/Steven Mosser          2-3337      973-412-0676             973-886-4192
Interim Vice President Nursing
   Patricia Wrobbel                       2-1787      973-318-4392             973-838-3577
Marketing & Media Relations
   Director, Robin Preisler               2-6273      973-318-4866             908-233-8529
   Assistant, Rogers Ramsey               2-6273      973-318-4978             973-673-2481
                                                                                               49
Emergency Operations Plan
University Hospital
Directors of Patient Care Services

 Executive Director, Nursing
    Patricia Wrobbel                     2-1787         973-318-4392           973-838-3577
Executive Director, Perioperative Svcs
     Nancy Berger                        2-5730         973-312-4945           908-276-7269
Family Health Services
    Ferne Bell-Woodley                   2-5837         973-312-5286           732-827-0250
Division of Psychiatry
   Chris McCallion                       2-6127         973-312-6193           732-842-9118
Division of Critical Care
   Linda McGinnis                        2-7012         973-566-7483           973-471-4416
Cardiac Services/Education &
 Professional Development                2-6824         973-566-2766           845-365-2818
   Fabienne Ryan


Telecommunications - Lois Gibbs-Reid     2-4052         973-421-0259
Physical Plant
   Frank Watts                           2-3413                                973-865-2288
  James Campoli                          2-5175/7770                           973-214-8797
   Paul Crawford                         2-4858                                973-202-9258

Environmental Services                   2-5400
Central Supply Services                  2-3438/6515
Admitting Department                     2-4045
Laboratory                               2-4080
Patient Transport                        2-7433         973-312-5654
                                         (7am -12 am)   973-421-0339

                                                       Name of person completing form: _________________________________



                                                                                              50
Emergency Operations Plan
University Hospital
                                           ATTACHMENT 6
                                  COMMAND POST CHECK LIST


 Name of person completing form:                         Activation Date:   Time:
  TASK                                                                        TIME
  S1 (Personnel) conducted by:
  S2 (Intelligence) conducted by:
  S3 (Operations) conducted by:
  S4 (Support Services) conducted by:
  S5 (Public Relations) conducted by:
  AOC called command post
  “Code Triage ” announced
  Public Safety arrived to command post
  PCC arrived to command post
  AOC arrived to command post
  AOC terminates disaster mode
  “Code Triage ALL CLEAR” announced
  Command post closed
  Operator report received in command post

 PATIENT INFORMATION
 TASK                                                                        TIME
  Command post notified that patients are being transferred to UH
  ER notified command post that all patients have been received
  Patients arrive to UH – ER
  Stretchers transported to ER
  Patient tag types/number of patients
        RED
        YELLOW
        GREEN
        BLACK



                                                                                 51
Emergency Operations Plan
University Hospital

                                           ATTACHMENT 10

                               MEDICAL STAFF DISASTER PLAN

Disasters are events which would quickly overwhelm the routine staffing patterns and supplies of the
hospital. The Emergency Operating Plan will be activated depending on: 1.) magnitude of event
2.) the number or the acuity of the victims 3.) type of disaster.

The following are the mechanisms by which physicians will be recruited to assist in a disaster:

DISPATCH OF PHYSICIANS TO THE SCENE

It is the first priority of the University Hospital medical staff to provide service within the hospital.
Therefore, the Trauma Center Director will determine whether or not the EMS Medical Director or his
designee will be sent to the scene, after ascertaining that there are sufficient medical staff in the hospital to
care for the expected number of emergency admissions and provide care for patients already in-house.
Assuming that the in-house demands are at least minimally covered, it is the responsibility of the EMS
Medical Director to dispatch at least one physician to the scene if requested. If medical staff personnel are
dispatched to the scene, radio communication will be maintained with them through the Emergency
Medical Service and they will be recalled to the hospital at the discretion of the Surgical/Trauma Attending
in charge.

The Senior Surgical Attending will proceed to the Hospital Triage Area and will direct the Triage Function.

KEY PERSONNEL WILL ASSUME DUTIES AS INDICATED

Upon notification that the Emergency Operations Plan has been activated, the following medical staff will
report to the designated areas:

SURGERY/TRIAGE

UH Medical Director or designee
Director, NorthStar Air Medical Program
Section Chief, Trauma Surgery
ER Attending

SURGICAL ICU

Director of Surgical ICU

TRAUMA

Chief of Trauma Surgery


                                                                                                    52
Emergency Operations Plan
University Hospital




                            MEDICAL STAFF DISASTER PLAN (Cont’d)



NEURO ICU

Chief of Neuro ICU

OPERATING ROOM

Chairman, Department of Surgery
Medical Director, Operating Room
Chairman, Department of Orthopedics
Chief, Section of Neurosurgery
Chairman, Department of OB/GYN

All other Attending Surgical personnel will report to the Chief of General Surgery on E-Yellow (Rm E-
349) for assignments.

MEDICAL EMERGENCY AREA (ER)

Medical Director, Emergency Room Nurse Manager, Emergency Medical Director

All other Medical Attending personnel will report to the Medical Critical Care Unit for assignment - I-
Yellow 1 & I-Yellow 2

PEDIATRIC EMERGENCY AREA

Director, Emergency Room Nurse Manager, Pediatrics
If the Emergency Alert predicates, the following areas will be named:

OUTPATIENT DEPARTMENT

Chairman, Oral Maxillofacial Surgery Nursing Director Ambulatory Care
Chief, Section of ENT
Designated ENT Attending
Director of Medical Clinics




                                                                                               53
Emergency Operations Plan
University Hospital


                             ESSENTIAL PHONE NUMBERS
Command Post Phone Lines: 972-5800/5801 & 972-3640/3641 Fax Line: 972-7609

Emergency - 222                                 Medical Emergency - 111
Census                                                4050/4051
Central/General Stores/Linen                          3437/6515
Clinical Engineering                                  6661
EMS                                                   4850
Emergency Room                                        5123/5124
Food & Nutrition                                      4021/4025/4026
Nursing Operations Center                             5671/5672
Operating Room                                        6901
Page Operator                                         6000
Patient Transport Services                            7433
PCC (after 3 PM)                                      5676/5677
Pharmacy                                              5118/5121
Physical Plant/Environmental Services                 5400
Public Relations (Marketing & Media)                  8007
Public Safety                                         4491
Radiology                                             6907
REMCS                                                 7000
Same Day Surgery                                      2929
Vehicle Transportation                                4573

NURSING UNITS
Level               Yellow          Green          Blue
D                   0543            5617/5618      N/A
E                   5622            5754           2364
F                   5626            5624/5625      5633
G                   6128            5882           6476
H                   5636            5638           5634
I #1                6072            N/A            N/A
I #2                6068            N/A            N/A
I                   N/A             N/A            5640
Renal                                              6080
Labor & Delivery                                   5813/5814/5815
FICN                                               5610
PICU                                               3784
SICU                                               5755
NICU                                               5882




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