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Code Yellow - Emergency Management Plan

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HICS 201
HICS 202
HICS 203
HICS 204
HICS 205
HICS 206
HICS 207
HICS 251
HICS 261

A.The purpose of the Emergency Management Plan at Sheridan Memorial Hospital is to establish a practical and workable program for providing patient care to injured persons in the event of a disaster or emergency situation.

A.This plan is organized to describe the duties and responsibilities of available manpower and to maintain equipment, material, and supplies necessary to cope with any emergency, which may occur.  The plan further addresses the possibility of discharging patients, or in the worst case, to evacuate the hospital.  It is also the purpose of this plan to recognize the importance of flexibility to meet the medical needs of disaster victims and patients in the hospital.  The plan addresses four key components to emergency preparedness: mitigation, preparedness, response, and recovery.  Staff will participate in various drills throughout the year to test overall readiness and responsiveness to this plan.

B.Authority and Organization:

1.The hospital’s Emergency Management Plan is an integral part of the Sheridan County Municipal Emergency Operations Plan.  The countywide plan is documented in writing in the Emergency Department and updated through the Emergency Management Coordinator of Sheridan County.  As such, hospital staff participates in community wide planning for emergency preparedness activities, to include assessment of services and resources available for a variety of preparedness scenarios, to include bioterrorism threats, haz-mat incidents, vehicular accidents, disruption in utilities, explosions, weather related incidents, and other incidents that may arise.  This plan covers “All Hazards” via activation of the Code Yellow, with the exception of Severe Weather Warnings, Code Gray (see Policy EPP 1100, which can in turn activate the Code Yellow alarm, if required.

2.The decision to activate the plan will be made by the Emergency Department Physician or Hospital Administration depending on the nature of the disaster.  Additionally, an assessment will be made regarding the extent of activation of staff and the plan, based on anticipated impact from the impending disaster.

3.The hospital’s Emergency Management Coordinator is responsible for developing, implementing, and monitoring the Emergency Management Plan according to NIMS / HICS, and providing periodic reports to the Safety Committee.

C.Additional Procedures: The following procedures will supplement this plan:

1.Triage and treatment of disaster victims.

2.Duties and responsibilities of various departments during disasters.  Departments will develop department specific Emergency Management plans, describing functions and duties of the department, consistent with the Hospital plan.

D.Communication and Notification of Personnel:

1.Notification of an external disaster will normally be received by the Emergency Department through the EMS radio system.  The Emergency Department personnel will immediately inform the Emergency Department physician and Nursing Administration (Director of Nurses or the Nursing Supervisor).

2.The Administrator and other designated key personnel will be immediately notified of the impending disaster.  A member of Administration or the Nursing Supervisor will staff the Command Center until the Incident Commander arrives.  The Command Center will be located in the 3rd Floor administrative Board Room, Ext. 5327 or Ext.1313.  The hospital Command Center staff will determine need to be in contact with the community-wide Incident Command Officer, depending on the nature of the disaster and the severity of the incident.  Communication will be maintained via the hospital telephone system, two-way radio, or cellular phones, as required and based on the availability of the systems being used.  The Command Center will also determine the need to call back Social Service personnel and/or chaplains in the event that additional support will be required to address friends and family of incoming casualties.

3.The Emergency Department physician will determine the need for additional medical staff support and identified physicians will be called.

4.Nursing Administration with the Emergency Department physician will determine additional hospital staff needs and begin to contact these departments.  The individual departments will then mobilize the necessary personnel within their respective departments, consistent with the Department Plans.  Staff called in will report to the Labor Pool (see sub-paragraph G (Labor Pool) below in Procedures section) to be assigned a duty.  All Surgical Staff will report directly to Surgery.


A.Once the decision has been made to activate the Emergency Management Plan by the Emergency Department physician or a member of the Hospital Administration, the telephone operator will be contacted to announce “Code Yellow”.  This announcement will be made three separate times.

B.Triage – When the Code Yellow has been activated and announced; Emergency Department staff will prepare the Emergency Department for acceptance and triage of casualties/patients.  The Emergency Department will serve as the primary “triage” area with the Family Consultation Room next to the Surgery Waiting Room receiving other patients to be triaged as an alternate site. The Outpatient Surgery Area on first floor will serve as a treatment area, in addition to the Emergency Department.  Emergency Department staff will be reassigned to this alternate site to assist in the acceptance, triage, and treatment of casualties, with the Surgery Waiting Room used as an overflow/patient waiting area, if needed.  Additional staff will be summoned from other departments and/or the labor pool (see sub-paragraph G below) as needed, to assist in the set-up, triage, and treatment of the casualties.  The initial assessment and triage will be made by the physician.  Facilities Services staff will assist in insuring that the entrance areas are cleared for emergency vehicles only, and that all other vehicular traffic is redirected so that the entrance areas to the triage unit is assessable to the ambulance services.  Additionally, all pedestrian traffic will be redirected to avoid congestion into the triage area.

C.Identification of Victims – 

1.During an external disaster, the patients will be identified with pre-hospitalization tags used by emergency technicians in the field, who will be responsible for attaching the tags to victims.  All information transmitted to the hospital will reference the number on this identification card.  A hospital identification bracelet will be prepared with the disaster card number and the patient’s name if possible.

2.Business Office personnel will be prepared as soon as possible to assist in the collection and development of a medical record, which will be used to track the patient during the course of treatment/hospitalization.  The disaster card number will be referenced in the medical record for continued coordination of information.  In addition, an updated listing of all casualties will be compiled by clerical personnel, and will be made available to the Command Center and/or the Public Information Officer, to respond to family/media inquiries.  All efforts will be made to maintain the strictest level of patient confidentiality; yet provide timely and compassionate responses to external inquires.

D.Discharge of Hospital Patients - 

1.Depending on the severity of the disaster, a decision to discharge patients already in the hospital may be necessary.  It is the responsibility of the Department Manager/Nursing Supervisor or designee to identify the number of beds available for patients and from nursing assessment information, identify possible patients who might be discharged if a shortage of beds is imminent.  This information should be communicated to the Emergency Department physician and the Command Center.  Periodic updates are to be furnished, depending on the anticipated number of casualties to be expected.

2.The attending physician will be contacted to discuss the need to discharge specific patients identified.  Patients able to be discharged will be moved to the Inpatient Waiting Area on First Floor and observed by assigned nursing personnel until transportation is made available to take the patient to their home or other suitable housing.

E.Processing Dead on Arrivals - 

1.Patients arriving at the triage area who are dead on arrival (DOA) will be transported to the Storage Area in the basement, adjacent to the rear main entrance.  The County Coroner will be notified.  Security will be assigned to the area, if necessary by the Command Center.  The County Mass Fatality Plan will be activated. 

2.All efforts will be made to secure all personal belongings of any DOA brought into the facility, which will be made available to the Coroner.

F.Hospital Access and Public Information - 

1.During a disaster, entrance and access to the hospital will be restricted.  Facilities Services staff will have primary responsibility for control of traffic.  With the help of law enforcement an attempt will be made to utilize the Cafeteria in the basement for family of victims and Room 221 on Second Floor for news media.  Law enforcement will restrict entrance to the hospital by all other persons. 

2.The Public Information Officer or his/her designee will have primary responsibility for release of information relative to the disaster activities and for release of information to the news media.  He/she will consult with the Command Center on issues, as the need arises.  No other staff or parties are to engage in any release of information to the news media.  Release of patient information will be made in conformance to the Hospital’s release of information policy.

G.Labor Pool – 

1.A labor pool will be established to be able to mobilize staff that is not assigned specific tasks and duties.  This labor pool will be available for assigned duties, to mobilize staff for use as runners, to assist in transport of casualties to assigned treatment areas, assist in controlling traffic into various areas such as the triage/command center, news media room, etc.

2.The labor pool will be designated as the Meeting Rooms A and B in the basement.  Staff assigned to the labor pool will be required to check in with the designated coordinator who will periodically advise the Command Center of staff available for mobilization.

H.Hospital Evacuation – If the disaster severely compromises the hospital’s ability to safely care for patients, the decision to evacuate patients will be made by the Administrator on duty.  Refer to the Evacuation Plan - Attachment A.

I.Department and Individual Responsibilities - 

1.All Department Managers will develop departmental Emergency Management plans, which will be approved by the Safety Committee.   Departmental plans will augment the overall Emergency Management Plan and will be reviewed at least annually.  Department staff will be instructed on the Departmental duties and assignments and where the plans are located.  Plans will address at the minimum, several key components to include:

a.Departmental Callback system.

b.Staff assignments and roles.  If staff are not assigned to specific roles and responsibilities, departments are to designate staff to the labor pool for other assigned duties, as required by the Command Center, to include serving as messenger/runner, transport of casualties from one location to another, if required (see sub-paragraph G above).

c.Management of Patients and Patient Care During Emergencies (i.e. scheduling, modification or discontinuance of services, control of patient information, etc.)

d.Management of Space, Supplies, and Security during the disaster event.

2.Human Resources under Logistics Section Chief will design systems to address the following concerns in event of prolonged activation of the Emergency Management Plan:

a.Housing/Lodging needs
b.Transportation needs
c.Family Support needs, as necessary
d.Incident debriefing and counseling 

J.Safety Committee/Risk Manager – The Emergency Management Coordinator will provide a semi-annual report to the Safety Committee regarding the overall readiness of staff regarding Emergency Management activities.  In collaboration with the Safety Committee, Emergency Management plans will be revised, adjusted, and training provided as required to meet the ongoing needs of the community as well as the employees, patients, and others that the hospital serves. 

A.Evacuation Plan - Attachment A

A.All Departments

A.Joint Commission Standards  
B.Policy Code Gray – Severe Weather Warning, EPP 1100

A.Safety Committee, February 17, 2010

A.All Departments