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Sheridan Memorial Hospital Evacuation Plan

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STATEMENT OF PURPOSE
To outline a plan, whereas patients, visitors, staff and vital hospital functional components can be safely relocated out of harms way, whenever part or all of the physical building and/or its infrastructure is threatened or rendered uninhabitable.

SCOPE
This evacuation plan is to be applied to all evacuation scenarios.

OVERVIEW
Sheridan Memorial Hospital recognizes the possibility that internal/external emergency situations may force the evacuation of part or all of the building.  The extent of the evacuation would be governed by the scope of the threat to the health and well being of our patients and staff.  Successful evacuation may be accomplished internally by moving patients/staff laterally from one department/wing to another or vertically from one floor to the floor(s) below.  Evacuation of the entire building to an alternate care site may be warranted due to extreme conditions, as well.  This plan will address both scenarios and define the procedures to be followed to ensure an efficient and safe evacuation and minimize the disruption in care provided to patients.


INTERNAL EVACUATION

AUTHORITY/RESPONSIBILITIES UTILIZING HICS (Hospital Incident Command System)

I.Chief Executive Officer or Designee
A.Assumes the role of Incident Commander and initiates Code Yellow if this has not already been done.

B.Determines the need for evacuation from endangered area and gives the order to evacuate part of the building.  This may be accomplished for a variety of reasons in one or more of the following ways:

1.Evacuation laterally, from one department only.
2.Evacuation laterally, from one wing to another.
3.Evacuation of an entire floor to the floor(s) below.

II.Nursing Service Director or Designee 
A.Assumes the role of Operations Sections Chief 

1.Directs the patient evacuation, depending on the severity and type of situation.
2.Maintains information about patient relocation.
3.Initiates staff call list, if sufficient manpower is not available in-house.

III.Facilities Services Manager or Designee
A.Secures designated evacuation route(s).

B.Acts as traffic flow officer, as needed.

C.Secures affected area(s) and prevents unauthorized re-entry.

D.Assigns personnel to take control of elevators, if they are safe to use.

1.If they are not safe, they are to be shut off at their main control panel and all elevator doors marked with an out-of-service sign.

E.Provide support services, as needed:

1.Distributes food, water, stretchers, and wheelchairs in coordination with Nursing Services.
2.Provides available personnel to assist Nursing Services in the evacuation of patients.

IV.Business Office Manager/Admissions Personnel
A.Maintains patient location

V.Material Management Manager/Material Personnel
A.Provide additional supplies to patient care area(s), as requested.

VI.Non-clinical Personnel
A.Provide assistance in evacuation of patients.

PROCEDURES

I.Notification
A.If sufficient personnel are not on-site to complete a timely evacuation, the staff call list shall be initiated.

II.Evacuation from one room or a block of rooms
A.If an emergency situation arises that precipitates the evacuation of a single room or block of rooms, any staff member may order the removal of anyone in immediate danger.  The Operations Section Chief shall be notified immediately.  Admissions personnel shall be notified if patient relocation results.

III.Evacuation laterally from one department/wing to another
A.If evacuation from one room to another will not guarantee the safety of patients, visitors and staff during an emergency situation, it may become necessary to vacate an entire department or wing of the hospital.

B.The Incident Commander or his designee will be notified immediately of the emergency, and will give the order to evacuate, if necessary.

1.In the case of imminent danger to patients or personnel, the order to evacuate may come from the person having authority over the area in question.  The Incident Commander, or designee, will be notified as soon as possible of the situation.

C.Patient care areas

1.Upon determining that an internal evacuation is potentially warranted, Code Yellow will be initiated immediately.  
2.Facilities Services staff will secure possible evacuation routes.
3.Patients in immediate danger will be evacuated first, followed by ambulatory patients, non-ambulatory patients, then visitors and employees.
4.Methods for evacuating patients are outlined in External Evacuation Plan.
5.All available hospital staff will assist with patient evacuation and directing visitors to safe areas.
6.If an entire floor of the building is in danger; patients, visitors and staff will be evacuated to the floor(s) below.
7.Elevators should be used to evacuate non-ambulatory patients only, provided they are deemed safe by Facilities Services.
8.Facilities Services staff will be responsible for assuring that there is no unauthorized entry to the affected area(s).
9.Re-occupation of the affected area(s) will be at the discretion of the person having authority at the scene.


EXTERNAL EVACUATION

AUTHORITY/RESPONSIBILITIES UTILIZING HEICS (Hospital Emergency Incident Command System)

I.Evacuation Planning
A.Chief Executive Officer or Designee

1.Assumes the role of Incident Commander and initiates Code Yellow if this has not already been done.
2.Determines the need and is responsible for ordering and directing the evacuation of the hospital.

B.Nursing Service Director or Designee

1.Assumes the role of Operations Sections Chief
2.Directs patient evacuation, maintains information about patient relocation, initiates staff call list, and coordinates activities/nursing personnel at the alternate care sites, as needed.

II.Authority/Direction of Personnel
A.HICS

1.Chief Executive Officer-Incident Commander or designee: in charge of the Incident Command Center.
2.Nursing Service Director-Operations Sections Chief or designee: directs patient evacuation, maintains information about patient relocation, initiates staff call list, and coordinates activities/nursing personnel at the alternate care sites, as needed.
3.Human Resource Director-Logistics Section Chief or designee: in charge of the Labor Pool.
4.Logistics Chief or designee:  secures designated evacuation route(s), maintains control of the elevators, and provides support services, as needed, and coordinates security in and out of the hospital during the evacuation process.
5.Chief Financial Officer-Finance Section Chief or designee:  Oversees the acquisition of supplies and services necessary for evacuation and continued patient care at the alternate care site(s) and documentation of expenses.
6.Department Managers-responsible for determining what needs to be taken to the new site.  

PROCEDURES

I.Notification
A.The Chief Executive Officer, or designee, will be notified immediately of any emergency situation that may indicate the need for an evacuation.

B.Upon determination that a total building evacuation is warranted, the Chief Executive Officer will contact:

1.The operator to have it paged overhead:  Implement Evacuation Plan six times at 15-second intervals.  
2.The Local Emergency Planning Office
675-2569 - work (Dave Coleman)
752-2174 - cell
674-534 - home

3.Request transportation support from the Local Emergency Planning Office
4.Request law enforcement support

C.An Incident Command Center will be established

1.All external communication regarding evacuation activities will go through the Incident Command Center.

a.Phone number 674-5327 ext. 1053
Use of 2-way radios may be utilized, as needed.

b.Location: Basement LL11 or an alternate outside site from the building.

II.Evacuation of Patients 
A.Ambulatory patients should be moved first

1.The ambulatory patients should be instructed to line up in the corridor and follow a lead nurse to the staging area.  The rooms should than be checked for stragglers.
2.Ambulatory patients should use stairwells for vertical evacuation routes.
3.Staff member(s) are to accompany patients at all times.  NEVER LEAVE A PATIENT ALONE.

B.Non-ambulatory patients should be moved second.

1.Elevators should be used, provided they are deemed safe by Facilities Services, to evacuate non-ambulatory patients, if using the basement as the evacuation route.

C.Patients are to be escorted to other buildings associated with the hospital which will be used as the primary staging area (prior to relocation to the alternate care site(s), unless that area is unsafe).

III.Transportation
D.Per Local Emergency Planning Center
E.Sheridan Fire and Rescue Ambulance Service
F.Rocky Mountain Ambulance Service

IV.Evacuation Responsibilities
G.Nursing Services and All Other Departments

1.If an order for evacuation is received, make sure all patients are accounted for. 
2.Direct removal of patients when authorized.
3.Never leave a group of patients alone.  Always have a nurse or other attendant with them.  This will help lessen the possibility of panic. Avoid using the term fire, bomb, etc.
4.Avoid giving orders in a hurried manner.  Direct patients in such a way that they will know evacuations are under control.
5.Direct/assist outpatients to the staging area.
6.All departments should have an evacuation plan for their specific department that should include, at minimum, roles and responsibilities for staff, as well as equipment/supplies that would be needed to support patient care activities at the alternate site.

V.Alternate care location(s)
A.Primary site:  

1.VAMC
2.Sheridan, Wy

B.Secondary site: 

1.Other medical facilities outside the area.

a.Campbell County Memorial Hospital
Gillette, Wy
(307) 688-1000

b.Johnson County Hospital
Buffalo, Wy
(307) 684-6188

2.Nursing homes, when appropriate