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Emergency Codes


Hazard Vulnerability Analysis
Dupont Hospital identifies potential hazards, threats, and adverse events and assesses the impact on the care, treatment, and services sustained during an emergency. The assessment is a Hazard Vulnerability Analysis (HVA) that is designed to assist in gaining a realistic understanding of the vulnerabilities and to help focus on resources and planning efforts. The community and region’s HVA assessments assist in the assessment of the facility. A list of priority concerns is developed from the HVA and is evaluated annually. The HVA includes the ability to provide services, the likelihood of those events occurring, and the consequences of those events.  The EC Committee reviews the hospital’s HVA annually.

The Safety Committee develops specific emergency response plans based on priorities established as part of the Hazard Vulnerability Analysis. Each emergency response plan addresses the four phases of emergency management activities: 

MITIGATION Activities designed to reduce the risk of and potential damage due to an emergency (i. e., the installation of stand-by or redundant equipment, training).

PREPAREDNESS Activities that organize and mobilize essential resources (i. e., plan-writing, team member education, preparation with outside agencies, acquiring and maintaining critical supplies).

RESPONSE Activities the hospital undertakes to respond to disruptive events. The actions are designed with strategies and actions to be activated during the emergency (i. e., control, warnings, and evacuations).

RECOVERY Activities the hospital undertakes to return the facility to complete business operations.  Short-term actions assess damage and return vital life-support operations to minimum operating standards.  Recovery is long-term focus on returning all hospital operations back to normal or an improved state of affairs.

Community Involvement
Dupont Hospital has established a relationship with the community.  In conjunction with the community, priorities have been set among the potential emergencies identified in the Hazard Vulnerability Analysis.   Communication has been established on the needs and vulnerabilities for Dupont Hospital.  The capabilities that the community can contribute to aid in meeting the needs of the facility have been identified. Dupont Hospital is a major healthcare facility in the community.  During a disaster, the hospital’s role within the community is to care for sick and/or wounded individuals who may present for treatment.  The facility and community are involved through local emergency management meetings, regional hospital council meetings, and state meetings.

Inventory & Monitoring of Assets & Resources
The Dupont Hospital has identified and documented the assets and resources that are available on-site and/or elsewhere prior to an incident.  Assets and resources included are: 

Personal protective equipment (PPE)
Medical, surgical, & pharmaceutical supplies.

The Corporate Disaster Plan provides processes for the support of assets and resources in an emergency.  This Plan is located in the Command Center.

Par Level
Par levels have been set for this inventory to assure availability during an emergency. A par level is a quantity that represents a midpoint between extremes on a scale of valuation. A separate inventory of stocked additional supplies, stored at the Network Warehouse, is kept in the Logistics packet (NIMS Element 15).  

During the emergency, a process has been put into place under the Logistics Chief that will monitor the quantities of assets and resources. This information will be communicated through the HICS within the facility and to those within the community who need to know. 


Plan Initiation
To facilitate the orderly initiation of the response to an emergency, the following steps of the Emergency Operations Plan will be initiated.

1.Information received by the Emergency Department/designee concerning an external emergency facing the community or an internal emergency involving the function of the hospital will be passed directly to the Administrator on Call (AOC) or the House Coordinator (Administration 3023 or House Coordinator 3198).  

2.When notified of a potential disaster, the AOC/House Coordinator, Emergency Department Physician, and Emergency Department Charge Nurse will:

Evaluate the issues, such as location of incident (internal/external), the distance from Dupont Hospital, the scope of the incident (single individual, mass casualty, or malicious attack), and weather conditions (seasonal and current).

Discuss the operations pertaining to the conversion of the hospital to disaster status.

Plan care of casualty and non-casualty guests arriving in the Emergency Department during a disaster.

Evaluate the information concerning this emergency and determine if initiation of the Emergency Operation Plan (EOP) is warranted.  Two of the three are required to initiate the EOP.

3.Once it has been determined to activate the EOP, the ER will call Security to announce “Code D1” overhead that will initiate Incident Command and the notification of leadership and each department will initiate their call tree.

Incident Phases

Phase I
When notified by EMS and/or other sources of an incident with multiple casualties or a small incident with no casualties that occurred within the facility.

Situation that most likely can be managed with the team members already on duty. 

Team members will remain on duty and review their department specific procedures to be prepared to respond to the next level if the situation requires and upgrade.

The AOC/House Coordinator will complete a bed count with number of expected discharges.

The Hospital Command Center (HCC) may be set up and only selected departments notified.

Phase II 
Once victims are received, some support from the Emergency Department will be required, and/or the affected area may need some support.

Situation may require additional team members to be called into the hospital.

All team members will remain on duty and follow their procedures.  

The HCC will be set up to coordinate disaster operations.   

Phase III 
Large numbers of guests are received and/or significant issues have occurred and the need for extensive support will be addressed.  

The HCC will be set up to coordinate disaster operations.  

This major event requires mobilization of most aspects of the Hospital Incident Command System in the EOP, including department callback procedure and planning for team member relief over an extended period of time.  

The plan may be called “all clear” for the disaster situation while the recovery efforts continue until the hospital is back to normal operations. 

Hospital Command Center

1.The HCC will be set up immediately in the Conference Room for Phase II and III situations and may be set up at the discretion of the Incident Commander for Phase I of a disaster.  The phone number for the Command Center is 260-416-5870.  If the Conference Room is not available, an alternate site has been designated as the Boardroom.  The phone number for the alternate Command Center is 260-416-3025.  This decision will be made by the Incident Commander and the location will be announced overhead. 

2.The Incident Commander will establish the HCC. The following is the order of authority in the role of Incident Commander:

Administrator-On-Call (AOC)
House Coordinator
Team Leaders

3.The Command Center staff report to the Command Center and includes the Public Information Officer, the Safety Officer, the Liaison Officer, and administrative support for phones and documentation. 

Note: The Infection Control Coordinator responds only if needed in a specific disaster event such as infectious disease (i.e., smallpox, etc.). 

4.Deployment of supplies and materials for use in the Command Center will be deployed upon the decision to implement the Command Center.  The table below shows locations of supplies and the positions responsible for bringing the supplies to the Command Center.  Each position category has a binder with all needed information with required forms and job description.

Incident Commander
Incident Commander will organize and direct the HCC and give overall direction for hospital operations and, if needed, authorize evacuation.   The command function manages the incident, which includes establishing the strategic objectives of the operation, including the ordering and releasing of resources. During normal business hours, the Incident Commander is the CEO, COO, CQO/CMO and/or the CNO. During non-business hours, the House Coordinator/designee will serve as Incident Commander until the CEO/COO/CNO/CQO, Administrator-on-Call or a Team Leader relieves them.

Hospital administrative staff and other assigned personnel will support the Incident Commander.

Role of the Incident Commander:
Direct overall emergency operations for the hospital
Activate the HCC and initiate the appropriate emergency operating procedures
Appoint HCC staff in the HICS configuration and supervise their activities
Appoint team member to scribe and another to monitor 800 radios, WebEOC, or other forms of communication.  This may be added to the Liaison Officers position.
Act upon information received from any source in a timely and effective fashion 
Communicate internally and externally.
Determine need for lockdown and order through Security if necessary.
Complete documentation as indicated.

Safety and Security Officer
The Safety & Security Officer is responsible for the coordination of all security measures. The Safety & Security Officer assists and ensures that the emergency management plan is implemented and identifies 
any hazards and/or unsafe conditions.  This person determines need of lockdown with Incident Commander.

The Incident Commander will assign the position of Safety & Security Officer. It is recommended that the Support Services Team Leader, Safety Officer, or another individual familiar with the hospital Security Management Plan fill the position.

Public Information Officer
The Public Information Officer is responsible for the coordination of all outside media communications. The Public Information Officer (PIO) will provide information to the news media. The PIO will also oversee the facility Media Center.  The Incident Commander will assign the position of Public Information Officer.  It is recommended that a team member from Public Relations or another individual experienced in communications fill the position.  Should the incident involve more than one hospital in the Lutheran Health Network, the PIO may be at a central location managing the incident with input from all hospitals.  The Incident Commander will remain in constant contact with the PIO and determine the information to be released.  The Public Information Officer will release any/all information to the press. During a mass casualty event involving more than one hospital, the facility Public Information Officer, as agreed upon in the Memorandum of Understanding (MOU) agreement, communicates with the Public Information Officer at the scene or other agreed upon facility to ensure only one person is designated to speak with the media concerning the medical response.  Information will be provided to the Joint Public Information Officer who will speak on behalf of participating hospitals to assure consistent messages and flow of information. 

Administrative support will provide phone and documentation support along with receiving various information/tracking lists and messages.

The Section Chiefs for Operations, Planning, Finance, and Logistics will establish their functions as indicated by the Incident Commander. They will then report to their designated meeting place to receive further instructions.

The Incident Commander or Liaison Officer initiates communication with local emergency response groups as needed.  The Liaison Officer may be asked by the Incident Commander to monitor radio communication in the command center.

The proper Incident Command Structure identification apparel is issued to the Command Center Staff and Section Chiefs. 

The Support Services Team Leader deploys the Dupont Hospital Security Team to the appropriate location as designated in preparation for securing the facility (lock-down), if necessary.  Should additional security assistance be required, staff may be deputized as security officers or a security service may be employed. 

The proper identification is worn by the Security Team to distinguish the team from local law enforcement officials. 

The Public Information Officer communicates to local media needed information concerning the emergency, including instruction for walk-in victims and route for emergency vehicles and services.

Once the type of the emergency is determined, the appropriate Emergency Response Plan will be initiated.

Emergency Initiation Process

Hospital Incident Command System (HICS)
The hospital has implemented the Hospital Incident Command Structure (HICS) developed by the Emergency Medical Services Authority (EMSA) of California as a revision from the previous Hospital Emergency Incident Command System (HEICS). 

HICS is an incident management system based on the Incident Command System (ICS) that assists hospitals in improving their emergency management planning, response, and recovery capabilities for unplanned and planned events.  HICS is consistent with ICS and the National Incident Management System (NIMS) principles.  The new HICS has been restructured to be consistent with ICS and NIMS principles and will provide greater flexibility/adaptability for the hospital setting (NIMS Element 2).

The Operations Section conducts the tactical operations (i.e., guest care, clean up) to carry out the plan using defined objectives and directing all needed resources. Many incidents that are likely to occur involve injured or ill guests. The Operations Section is responsible for managing the tactical objectives outlined by the Incident Commander. A subject level expert in health care emergency services will be required for this position. A potential individual for this role may be the CNO or Clinical Team Leaders (or someone familiar with the hospital disaster policy).  The Operations Chief will expand this area as needed for type of disaster.

The Operations section is typically the largest in terms of resources to coordinate. To maintain a manageable span of control and streamline the organizational management, Branches, Divisions, and Units are implemented as needed. The degree to which command positions are activated depends on the situational needs and the availability of qualified command officers.  

Planning Section
The Planning Section collects and evaluates information for decision support, maintains resource status information, prepares documents, and maintains documentation for incident reports. It will also be responsible for preparing status reports, displaying various types of information, and developing the Incident Action Plan (IAP). The effectiveness of the Planning Section has a direct impact on the availability of information needed for the critical, strategic decision-making done by the Incident Commander and the other general staff positions.  This department will expand into all managers as needed for type of disaster.
The Incident Commander will assign the position of Planning Section Chief, which can be filled by the Chief Medical/Chief Quality Officer, VP of HR, or Administrator On-Call, etc. A senior representative from the Medical Staff, Information Systems, and Admitting Departments will support the Planning Sector Chief. 

Logistics Section
The Logistics Section provides support, resources, and other essential services to meet the operational objectives set by Incident Command.  The Support Services Team Leader, the Hospitality Team Leader or an individual with knowledge of the building structure, utilities, and material resources would be appropriate for this role.  This department will expand into needed directors and unit leaders as needed for type of disaster.

For the hospital to respond effectively to the demands associated with a disaster, the Logistics Section coordinates support requirements. These responsibilities include acquiring resources from internal and external sources using standard and emergency acquisition procedures and requests to the local EOC or District 3. Each resource request from an area in the hospital will be reported to the Logistics Section using pre-identified ordering procedures outlined in the EOP. When requesting resources from outside sources, it will be important that the hospital specify exactly what its need is and not try to identify how that need will be met, as that will be done at the local EOC or District 3 ICC. In addition, it is important for the hospital to know how the requests are to be made (electronically, fax, phone).

Finance Section
The Finance/Administration Section monitors costs related to the incident while providing accounting, procurement, time recording, and cost analyses. The Incident Commander will assign the position of Finance Sector Chief. It is recommended that the position be filled by the CFO, Controller or another individual experienced in fiscal operations.  

The costs associated with the response must be accounted for from the outset of the incident. These costs can come from multiple sources such as overtime; loss of revenue-generating activities; and repair, replacement, and/or rebuild expenses. Daily financial reporting requirements are likely to be modified and, in select situations, new requirements outlined by state and federal officials.

Preplanning efforts will identify what state and federal financial aid documents must be completed for receiving reimbursement. In addition to guest costs being tracked, vendor expenses, mutual aid financial remuneration, and personnel claims must also be accounted for and processed. The Finance/ Administration Section coordinate’s personnel time (Time Unit), orders items and initiates contracts (Procurement Unit), arranges personnel-related payments and Workers’ Compensation (Compensation/Claims Unit), and tracks response and recovery costs and payment of invoices (Cost Unit).

Team Response
All team members on duty will report to their departments and STAND-BY (i. e., being ready, willing and able to perform assigned duties) for further instruction.

Team members away from their department or duty station, who cannot report physically to the department, will communicate with the department and identify their current location and status of activity.

1.Guest care activities being conducted away from the department, such as radiology, surgery, etc., will continue until a point of completion is reached.

2.The guest and team members will return to the appropriate area as soon as possible or receive instructions to secure the guest in an ancillary location if necessary.  

3.The team members will notify their departmental Team Leader/Specialists of the location of the guest and team member.

4.Team members will continue their designated guest care activities in preparation for response to the directions provided by the Command Center. 

5.All team members requesting to go off duty must obtain the approval of their departmental Team Leader/Specialist.  The Team Leader/Specialist may not give this approval without prior clearance from the Incident Commander.  Team members must not leave their workstations until relief has arrived or until dismissed by the departmental Team Leader/Specialist.

Departmental Response

1.Each departmental Team Leader/Specialist, for both clinical and non-clinical operations, will assess the status of their team to maintain normal operation.

2.Each departmental Team Leader/Specialist/designee will identify available resources, such as beds, personnel, and equipment, which could be allocated to the emergency response.

3.The departmental Team Leader/Specialist will STAND-BY with information on status of department.

4.The departmental Team Leader/Specialist will provide information to the Command Center team or Incident Command Section Leader when requested.

5.When the departments receive the notification of the specific emergency, the departmental Team Leader/Specialist will initiate the appropriate departmental response plan for the emergency.

6.The departmental Team Leader/Specialist will report any problems or concerns to the appropriate Section Leader or the Command Center team.

7.No department will reduce its hours of operation without prior approval from the CEO/COO/CNO.

Ongoing Communication with Staff
During the event, the team members and departmental heads will receive instructions and information from the Section Chiefs or Command Staff. This information may be relayed via a meeting, a written form sent by email, or by a runner. Additional meetings will be setup to disseminate information throughout the emergency until the “All Clear.” 


Internal & Staff Notification Levels

During an emergency:

1.The Incident Commander will notify the Dupont Hospital Security to alert the team members of the emergency by announcing a code, via overhead page.  

2.The team is also notified through alternate announcements including intra-net messages and personal communication devices (i. e., pagers, walkie-talkies, and cellular telephones) as well as Call Lists and overhead paging conducted by Security.

3.Alternate communication to team members may include notification through the Public Information Officer by radio or television, dependent on procedures required. 

4.Communications systems may include the following:
Internal telephone system:  Internal communications will be limited to disaster-related issues once the emergency process has been initiated.  THE SECURITY OPERATOR WILL NOT BE CALLED FOR INFORMATION.

Radios: Communications Unit Leader/designee will make sure all departments have their radios on and are able to use them, reporting it to the Logistics Chief.
Alpha-numeric pagers, e-mail, public address system, inter-departmental radios, inter-hospital radio network, fax, cellular telephones, runners, and Ham Radio operators.


HICS Form 258 will be completed prior to the emergency to ensure all contacts and phone numbers are available when needed.  The list of contacts below includes primary contacts.  


Notification & Communication with External Authorities

1.All appropriate external authorities will be notified to facilitate effective response, continue operations, and recover from an emergency that disrupts the normal guest care and/or business operations of the organization.

2.When an emergency plan is initiated, the appropriate external authorities and community resources will be notified.

3.External authorities include, but are not limited to: 

Office of Emergency Management (OEM) - 911
Fire Department - 911
Law enforcement agencies - 911
EMS - 911
Emergency Management Agency - 449-7684
Centers for Disease Control - 1-800-232-4636
Red Cross of America - 480-8254
Community Relations - 435-7119

4.   The Public Information Officer (PIO) has the responsibility for media and public information as it     pertains to an event that involves the hospital.  The PIO has established working relationships with local media, emergency management office, and public health prior to an event.  The PIO regularly attends meetings with the systems that would establish a joint information center (JIC).  The information that will go out to the community will come from the JIC as a unified message to the area (NIMS Element 4).

5. If the hospital is involved solely during an event, the PIO in the Hospital Command Center will communicate with the community or local media. 

Communication with Guests (Patients) & Family
A Family Support Center/Family Information Center will be established to coordinate needs and information to family members of guests, to coordinate the information of the location of guests, and to provide critical incident stress debriefings. 

The Family Support Center/Family Information Center will be located in the Resource Center.   Representation within the hospital will be in Room 1 of Surgical Waiting.  This room will serve as the location for relatives and friends of guests that have arrived at the hospital for treatment. 

1.Under the Logistics Section, with the Support Branch, the Family Unit Leader establishes procedures for the guest’s families. 

2.The availability of medical, logistic and mental health and day care for the families of staff members should be ensured.  Mass prophylaxis / vaccination / immunization of family members should be coordinated, if required.

3.There is direct communication with the Guest Tracking Manager.

4.The immediate emergency contact family member that is not present with the guest will be contacted regarding the location of the guest once they are moved. 

Backup Communications
The Dupont Hospital will maintain a current listing of backup communication systems or devices.  The communication devices or systems will be tested monthly and be included in exercises. 

A listing of all primary and/or secondary communication systems and devices are listed below: 

1.Alphanumeric or digital pagers may be considered as backup communications. 

2.E-mail will only be available if the infrastructure is working. 

3.The overhead address or paging system cannot be tied into the telephone or fire system only.  These systems will work independently in case of infrastructure damage. 

4.Inter-departmental radios or inter-hospital radio networks may be used as backup communication. Training must be achieved along with an instruction card attached for those that do not use the equipment often. 

5.Fax machines may be used as backup as long as some are on the emergency power. 

6.Ham radios may be used either with internal or external operators.

7.Cellular telephones and blackberries have proven to shut down quickly during a natural or large-scale disaster.  The facility must be under the G.E.T.S. program for their hospital issued cell phones or blackberries.  This ensures priority of connection during a disaster. 

8.Runners may be used, as appropriate.    

The HICS form, HICS 205 – INCIDENT COMMUNICATIONS LOG (INTERNAL AND EXTERNAL), may be used prior to an event for a listing of internal and external phone numbers.  This form is also used during an event to determine what communications are available at the time.

Communications with Purveyors
Dupont Hospital has developed a list of purveyors, including vendors, contractors, and consultants that can provide specific services before, during, and after an emergency event.  The list will be maintained by the Support Services Team Leader, Engineering, and Maintenance Departments and will be updated annually or as appropriate to identify changes in purveyors.  Where appropriate, Memoranda of Understandings (MOUs) are developed to facilitate services during the time of a community event. (HICS form 258)

Communication with Other Healthcare Organizations
Other healthcare organizations and alternative care sites, located within Fort Wayne/Allen County, have a working relationship with Dupont Hospital before an event occurs.  This occurs through a direct Mutual Aid Agreement (MAA) with each individual hospital or town, borough, parish, county, and/or regional hospital group (NIMS Element 8).  

The key information to share with the other healthcare organization(s) is:

Command structures & other command center information
Names & roles of command center structure
Resources & assets to be potentially shared
Process for the dissemination of guest & deceased individual names for tracking purposes.

In order for the District 3 and/or other healthcare organizations to establish communications, they have existing systems in place for interoperability since an event may disable one or more communication methods, resulting in limited communication resources.  The District has established a web-based system to ensure that secondary communication is accessible during an event.  This will ensure inter-operability with other organizations (NIMS Element 16).

Information, including names and location of both guests and the deceased, may be shared with other healthcare organizations, local or state health departments, or law enforcement authorities during an emergency.  The information shared will be in accordance with applicable laws and regulations.  


Obtaining & Replenishing Medical & Non-Medical Supplies
The amounts, locations, processes for obtaining and replenishing of medical and non-medical pharmaceutical supplies, including personal protective equipment, will be established before an event.  The process goes from mitigation to recovery stages.  Medical supplies include anything used in the care of guests.  Non-medical supplies include food, linen, water, fuel, and transportation vehicles. 

Dupont Hospital will obtain and replenish medications and related supplies, non-medical supplies and personal protective equipment from the Lutheran Health Network Warehouse, if access is available.  The hospital leadership team has access to the Network supply system to find needed supplies throughout the hospital and purchasing system for ordering equipment not supplied at the Warehouse.

Dupont Hospital has fifteen mini chem pack located in the pharmacy.  The host hospital for the large ChemPack is Lutheran Hospital.  The ED physician may request the items from the large ChemPack once the hospital stock and the mini ChemPack have been depleted.  The ED physician will notify the pharmacist on duty that will notify the Lutheran Hospital pharmacy.  Lutheran Hospital will facilitate the transportation of the ChemPack medication to Dupont Hospital pharmacy for distribution.

For those items that usage exceeds par levels as a result of a large scale incident or items exceed expiration dates (i. e., additional antibiotics, vaccines, PPE), a Mutual Aid Agreement has been developed to expedite receipt of items when needed.  Dupont Hospital participates in the Statewide Indiana Hospital Mutual Aid Memorandum of Understanding, which is a voluntary agreement that addresses the loan of medical personnel, pharmaceuticals, supplies, equipment, or assistance with emergency hospital evacuation, including accepting transferred guests. The hospital also works closely with District 3 hospitals in the sharing of equipment and assistance. 
(NIMS Element 15).

The amounts and locations of current supplies have been evaluated to determine how many hours the facility can sustain before replenishing.  This has given the facility a par level on supplies and the projection of sustainability before terminating services or evacuating, if supplies are unable to reach the facility.  

The planning of the sustainability of Dupont Hospital, without the support of the community within the first 96 hours, is a coordinated and ongoing effort of the Emergency Management Committee and the departments over the six critical areas.  Where supplies and alternative means are required to sustain 96 hours, resources and assets, alternative sources, and the sustainability at that point have been identified.  If near or around 96 hours cannot be sustained, policies and procedures indicate that the facility may conceivably evacuate or temporarily close.  The Sustainability Worksheet has identified those resources and assets and the sustainability indicated in hours.

Managing Staff Support Activities
During activations of the EOP, various modifications and accommodations are made for hospital staff to assist them in coming to the hospital and providing needed services.  

The following accommodations are authorized:
1.   Where travel is difficult or impossible because of weather conditions, the hospital works with groups with appropriate vehicles to assist staff in getting to and from the hospital.

2.   Where necessary because of conditions, the hospital accommodates staff that need to sleep, eat, and/or other services in order to be at the hospital to provide needed services.

3.   The Logistics Chief along with the Service Branch Staff Food and Water Leader handles the needs of staff during the emergency.  The Logistics Chief is authorized to modify the normal use of hospital space and/or to work with local hotels and motels to provide accommodations for staff.  Meal service for staff is authorized where approved by the Logistics Chief. 

4.   Dupont Hospital will be prepared for incident stress debriefings.  Hospital teams, consisting of staff from St Joe Behavioral Health, clergy, and others trained in stress debriefing, will provide incident       stress debriefing.  As part of planning for mass casualty and similar incidents, staffing/alternatives will be identified, determining facilities and processes to be used.

5.Communication to team members’ family members will also be arranged through the Staff Food and Water Leader. 

Managing Staff Family Support Activities
During activations of the EOP, various accommodations may be made for team members’ families to assist staff availability for providing their services.  

These include:

1.Family accommodations are made available in those unusual situations where entire families must       come to enable team member to be present for emergency services coverage.  These will be arranged prior to families arriving at the hospital.

2.The team members that need accommodation(s) for their dependent(s), such as a child or adult, will give this information to their contact/caller.  The caller will then notify the Staff Food and Water Leader that accommodations will need to be established.  A daycare center will be established if needed.  The location of the day care center will be in the Building 2514 or area designated by the Incident Commander.  The team member will need to bring the following items: 
ID badge/name tag
Change of clothes and toiletries (for everyone).
The team member’s dependent child/adult will need the following items:

All prescriptions in their original containers 
Immunization Records (under 4 yrs) if available
Emergency contact other than parent
Diapers, if applicable
Baby food & bottles
Child’s/Adult’s favorite item.

3.Team members that need accommodation(s) for their pets will give this information to their contact/caller.  The caller will then notify the Staff Food and Water Leader that accommodations will be needed.  A local kennel or shelter will be established to accept the animal(s) for the team member.  Phone numbers for the local kennel or shelters are listed below:

Canyon Kennels - 260-637-3140 
Happy Tails - 260-637-0798
Dupont Animal Care Center - 260-489-7100

The team member will need to bring the following items for teach animal:

ID tag
Shot records
Favorite bedding, toy, etc. 
Food & any prescriptions

4.Location of the Team Family Support Center:

A team member, who reports for assignment with immediate family in attendance, will be appropriately identified and family members will be assisted to the assigned area in MOB 2514 or area designated by Incident Command to be housed during their family team member’s disaster assignment. 

Sharing of Resources
The process of sharing resources with other healthcare organizations outside of the community during regional events is coordinated through the county Emergency Operation Center, where the Chairman of the District Hospital Corporation will be stationed.  The number for the Chairman is 260-920-9512.  Those resources will be tracked by the Fast Command District III system, created by the state, county, or district.  The community EOC will be responsible for delivery of the needed resources. 

Involvement of the Community 
A multi-agency coordination system (MAC) has been put into place and involves the District III Hospital Corporation and works in conjunction with the Indiana State Department of Health.  A MAC is a combination of facilities, equipment, personnel, procedures, and communications integrated into a common system with responsibility for coordinating and supporting incident management activities.  

The primary function of the MAC is to: 

Support incident management policies & priorities
Facilitate logistics support & resource tracking
Provide information regarding resource allocation decisions to incident management personnel in concert with incident management priorities
Coordinate incident-related information
Coordinate interagency & intergovernmental issues regarding incident management policies, priorities, & strategies. 

Prior to an incident, the potential emergency needs and areas of priority will be defined: 

Team member staffing, roles & authority
Decontamination of guests, team members and/or equipment 
Equipment & supplies
Ancillary services.

The Emergency Program Manager will attend the meetings with the District 3 Bioterrorism Corporation and maintain those relationships established with the other healthcare organizations.  The MAC will be updated as needed post-event or exercise (NIMS Element 3).

Evacuation Activities 

1.The Incident Commander in conjunction with the hospital CEO will direct an evacuation of the hospital for a situation that renders the facility no longer capable of providing necessary guest care.  The evacuation will be handled in cooperation with local police or fire and/or local EOC.

2.The local police or fire and/or the EOC will be notified as soon as the potential for evacuation is considered and will be kept updated on an ongoing basis in order to begin the process for identification of the availability of vehicles to relocate guests.  

3.Transporting guests, their medications, equipment, team members, and pertinent information to alternate care sites when the environment cannot support care, treatment, and services is managed through the Transportation Unit Leader.  


Security Including Local Support
When the community is overwhelmed and local support is unavailable, Dupont Hospital will notify Fort Wayne Police/Allen County Police Department, as predetermined, for security and safety support.  The information will be located on the HICS-258 directory located in the HCC.

The facility meets regularly with local law enforcement agencies, Fort Wayne and Allen County Police Departments, to share the hospital’s needs and to understand law enforcement’s capabilities and limitations in providing support to the hospital during an emergency.   

Dupont Hospital coordinates security activities with community security agencies (i.e., police, sheriff, National Guard) by communicating on a regular basis with these agencies.

Managing Hazardous Waste
The hazardous waste discussed here is the biological, chemical, and radioactive waste after decontamination and during isolation procedures.  This also includes the waste that accumulates if pick up by vendors is not available due to the disaster.  A current list of vendors/back-up vendors is maintained. 

Dupont Hospital manages hazardous materials and waste through Premier Wastes.  The MOU is located in the Maintenance/Security Office.  In addition, Dupont Hospital provides for radioactive, biological and chemical isolation and decontamination by the current Decontamination Plan.

Access & Egress Control
Due to the limited amount of security in the facility at any given time, there may be a time when the facility may be locked down.  Secure Operations or a “lock down” refers to the locking of all entrance and exit doors to buildings and the posting of personnel at these doors to assure that only authorized persons enter or exit. In the event of a Security Lockdown, the only entrance(s) available to enter the facility is the Team Member entrance.  

Traffic Control
Based on the characteristics of the event, the Incident Commander initiates the organization’s Traffic Control Plan to manage the movement of personnel, vehicles, and guests, both inside and on the grounds of the facility.  The Dupont Hospital Security team will manage the movement of guests and team members inside the facility.  If advisable, the Security team will also assist in the movement of vehicles, both emergency and commercial, on the grounds.  If the main route to the facility is rendered inaccessible, the alternate route to the hospital is via Dupont Road to the back access between 2514 and the back of the hospital.  

When appropriate, local law enforcement will assist in the management of traffic on the grounds of the facility. In the event a vehicle needs to be towed to allow access to services, Kelley Wrecker Service at 260-483-4913 will be contacted.  


Staffing Critical Areas:  Responsibilities & Identification
The Dupont Hospital assures that critical staff functions will be performed for the rapid, effective implementation of any emergency response.  In addition, it is the policy of Dupont Hospital to assure adequate staffing is available to perform these critical functions at any time of the day or night.  The team identified in the critical areas will receive the appropriate training in HICS and NIMS prior to an event.  This training will also include the licensed practitioners.

When the Incident Command System (ICS) is established, the Dupont Hospital ICS Organizational Chart and Job Action Sheets are used to assure critical task positions are filled first, and as other team members become available, they are assigned to the most critical jobs remaining. These team members are assigned and report to the Operations Chief of the command team.

The Incident Command Team is responsible for assuring that the critical tasks they manage are filled by the most appropriate available team members and to assure that the tasks are performed as quickly and effectively as possible. The command team will assess needs continually and use the support of their administrative team to provide input into decision making for housing of team members during the incident.  The Security team will continue to provide internal transportation.  The hospital will continue to use ambulances (MICU/TRAA) for external transport of guests.  Pastoral Care and representatives from St Joe Behavioral Health will assist in incident stress debriefing.  The hospital will use Network resources when available.

If team members are not available for handling critical tasks defined by the Job Action Sheets, team members will be drawn from the appropriate departments.  

As team members are called, they will replace personnel at tasks they are better qualified to perform.  If questions arise, the ICS Section Leaders will determine who will perform the task.  The tasks are evaluated frequently to assure the most appropriate team members available are being used, burnout or incident stress problems are identified, and team members in these jobs are rotated as soon as possible. The hospital will use its own resources as well as Network resources to provide the family support needs of staff (i.e., child care, elder care, communication).  The MOB 2514 has been identified as the area to house families if needed.

The hospital communicates in writing to licensed independent practitioners (LIP) their roles in emergency response and to whom they report in an emergency. LIPs are managed through the HCC and specifically under control of the Personnel Tracking Manager.



Alternative Utilities
During an emergency, Dupont Hospital provides alternate means for providing essential utility systems as identified in the Utilities Management Plan.  These utility systems will be identified, as well as, alternate means for providing services.  The organization assesses the requirements needed to support each system, including fuel, water, and supplies.  This assessment includes the requirements for 96 hours without community support and the alternative means for these sources.    

The alternative utility systems and supplies include, but are not limited to the following:

1.Emergency power supply system
Alternate source: Hospital generator  
Alternate source: CHS Mobile generators –Whayne Power Systems
(See Corporate Disaster Plan located in ICC).

2.Water supplies for equipment, consumption, & sanitary usage
Alternate source: Prairie Farms
3.Fuel supplies for operations, generators and essential transport services.
Alternate source: Ag Plus

4.Ventilation systems
Alternate source: Havel Brothers/Portable fans

5.Medical gas systems
Alternate source: Praxair for canisters 

6.Medical Vacuum systems  
Alternate source: Praxair for canisters 

7.Other essential utilities that the hospital defines as essential (i.e., vertical and horizontal transport, heating and cooling systems, steam for sterilization)
Alternate source: Havel Brothers and Shambaugh


Caring for Mass Casualties
Dupont Hospital has designated treatment areas for mass casualty triage, decontamination, and other major emergency situations. 

Treatment areas are identified below:

Guest Tracking:  Internal & External
For the departments that will be receiving disaster guests, such as the Emergency Department and guest care units, guest trackers will be assigned to track the guests entering and leaving the areas.  That information will be given to the Guest Tracking Manager who will track all the guests within the facility during the disaster.  The form to use for guest tracking will be the HICS 254 – Disaster Victim Patient Tracking Form. 

If guests are evacuated, the process will be the same except for the forms.  The individual guest tracking for evacuation will be the HICS 260 – Patient Evacuation Tracking Form.  When more than two guests are being evacuated, the HICS 255 – Master Patient Evacuation Tracking Form will be used to facilitate a master copy of all those that were evacuated. 

According to the facilities MOU, MAC, or third-party information (i.e., Web EOC, American Red Cross database, or faxed tracking information), information will be maintained for regional tracking methods.  In some of these methods, there may be the possibility of families gaining access to this information to find their loved ones. 

Business Continuity/Disaster Recovery Plan
Lutheran Health Network has a Business Continuity/Disaster Recovery Plan for information systems.  This plan includes:

Instructions for handling unscheduled interruptions, including end user training with downtime instruction

Contingency plans for operational interruptions

Plans for minimal interruptions/scheduled downtime

An emergency service plan

A backup system for data retrieval, including retrieval from storage and information presently in the operating system

Retrieval of data in the event of a system interruption
Backup of data. 

The plan is tested periodically to ensure the business interruption backup techniques are effective and is implemented when information systems are interrupted.  Lutheran Health Network Information Systems department has specific policies and procedures to support the Business Continuity and Disaster Recovery Plan.  Administration reviews and approves the policies that support the plan. 

Influx & Management of Infectious Guests
Dupont Hospital prepares for and determines responses to an influx, or the risk of an influx, of infectious guests.  Dupont Hospital has a plan for managing an ongoing influx of potentially infectious guests over an extended period.  Under the direction of the Infection Control Coordinator, the hospital performs the following functions:  1) how long it will keep abreast of current information about the emergence of epidemics or new infections that may result in the hospital activating its response, 2) how it will disseminate critical information to team members and other key practitioners, 3) how the facility will identify resources for additional information in the community through local, state, and/or federal public health systems.  The Infection Control Coordinator manages the functions described through the Infection Control Plan and the policy: Managing an Influx of Infectious Patients.  Dupont Hospital administration and the medical staff review the Infection Control Plan annually. 

Guest Flow
Leadership, including medical staff, identifies and mitigates impediments to efficient guest flow throughout the hospital. Leadership assesses guest flow issues within the hospital, the impact on guest safety, and plans to mitigate that impact.  Planning encompasses the delivery of appropriate and adequate care to admitted guests who must be held in temporary bed locations.  Leadership and the medical staff share accountability to develop processes that support efficient guest flow.  Planning includes the delivery of adequate care, treatment, and services to non-admitted guests that are placed in overflow locations.  Specific indicators are used to measure components of the guest flow process and address available guest bed space, efficiency of guest care, treatment and service areas, safety of guest care, and support service processes that impact guest flow.  Indicator results are available to those individuals who are accountable for processes that support guest flow. Indicators are reported to Leadership on a regular basis to support planning. The hospital improves inefficient or unsafe processes identified by Leadership as essential to the efficient movement of guests through the hospital.  Dupont Hospital has not approved and will not implement diversion processes.   Dupont Hospital Leadership reviews all guest flow processes regularly with clinical department heads and medical staff.     

Granting Disaster Privileges for Volunteer Licensed Practitioners
Disaster privileges may be granted only when the Emergency Operations Plan has been activated in response to a disaster and the hospital is unable to handle the immediate patient needs.  The medical staff identifies in its bylaws the individuals responsible for granting disaster privileges to volunteer licensed independent practitioners. 











During disasters, Dupont Hospital may assign disaster responsibilities to volunteer practitioners who are not licensed independent practitioners, but who are required by law and regulation to have a license, certification, or registration.  Disaster privileges may be granted only when the Emergency Operations Plan has been activated in response to a disaster and the hospital is unable to handle the immediate patient needs.  The same standards apply to volunteer practitioners who are not licensed independent practitioners as those who are volunteer licensed independent practitioner. See policies EM.02.02.13 and EM.02.02.15.

This applies to employees of other institutions and volunteers in the medical profession who are called to or volunteer for work at a CHS facility during times of a declared disaster.  This process assumes that all loaning institutions are JCAHO accredited (or equivalent) without HR contingencies.  Worker’s Compensation and Professional Liability Insurance are the responsibility of the loaned employee or volunteer’s institution.  If permitted in the state of the receiving hospital, volunteers will be covered under the volunteer accident policy associated with the receiving hospital.  This process assumes that all loaned employees or volunteers have undergone appropriate primary source verification for professional licenses or certifications, background checks and drug screenings to the satisfaction of the loaning institution. 










In the event a declared disaster requires a CHS facility to use additional personnel, the following process will be used:

A. Approval of the CEO or other individual assigned disaster responsibility should be obtained prior to requesting additional personnel from other institutions. The CEO, CNO, or other responsible individual will determine the number and type of needed positions.  The Human Resources Director or designee will request or assist in requesting personnel from other healthcare facilities as needed.  The Human Resources Department will assist with the transportation needs of loaned employees or volunteer practitioners.  (See CHS Disaster Preparedness Plan dated 8/1/06 for Workgroup Planning and for CHS Facility Support List.)

B.Processing loaned employees or volunteer practitioners into a CHS institution:

1.Loaned employee or volunteer practitioner will:

(1) (If required by law and regulation to practice a profession) cannot be completed in 72 hours (for example, no means of communication or a lack of resources), it is expected that it be done as soon as possible.  In this extraordinary circumstance, there must be documentation of the following:

Why primary source verification could not be performed in the required time frame; 

Evidence of a demonstrated ability to continue to provide adequate care, treatment, and services;  and

An attempt to rectify the situation as soon as possible.

a. Primary source verification of licensure, certification, or registration (if required by law and regulation to practice a profession) would not be required if the loaned employee or volunteer practitioner has not provided care, treatment, and Report to Human Resources or other designated Disaster Staffing Registration Area.

b. Provide appropriate ID x 2

(1) At a minimum, valid government-issued photo identification issued by a state or federal agency (e.g., driver’s license or passport) and at least one of the following:

A current health care organization (such as a long term care, ambulatory care, laboratory, or hospital) picture identification card that clearly identifies professional designation.

A current license, certification, or registration.

The Model State E Emergency Health Powers Act authorizes license reciprocity during periods of declared emergencies.

The Interstate Civil Defense and Disaster Compact Act authorize volunteers who are licensed in one state to practice in another state during emergencies.

Primary source verification of licensure, certification, or registration (if required by law and regulation to practice a profession and should be obtained by the receiving HR department).

Identification indicating that the individual is a member of a Disaster Medical Assistance Team (DMAT8), or MRC, ESAR-VHP, or other recognized state or federal organization(s) or group(s).

Copy of license, CPR or other certification, if required and available.

3. The Receiving HR Department will:

a. Perform primary source verification of  applicable licensure or certification:

(1)In the extraordinary circumstance that primary source verification of licensure, certification, or registration services under the disaster responsibilities.

b. Contact loaned employee or volunteer practitioner’s Human Resources Department, if available, to:

(1) Validate that the loaned employee or volunteer practitioner is currently employed at loaning hospital in good standing.

(2) Validate the scope of the loaned employee or volunteer practitioner’s credentials and/or privileges.

(3)  Determine if there were any restrictions placed on loaned employee or volunteer practitioner.

(4)  Determine which institution pays the person and at what rate of pay.

(5)Determine how long the assignment will be, if possible.

a. Provide to loaned employees:

(1) Abbreviated orientation (Basic Competency Assessment) to the person before he/she begin work to ensure understanding of the essential safety requirements for that facility, local required policies, and understanding of various emergency codes (provide card with current codes).

(2)Temporary ID, so the staff will know they have been accepted by HR.

(3)Blank timesheets to loaned employee or volunteer.

(4)Introduction of the loaned employee or volunteer to his/her immediate supervisor for department safety orientation and job assignment. 
a. Develop a mechanism of assessment in writing (for example, direct observation, mentoring, and clinical record review) to oversee the professional performance of loaned employees or volunteer practitioners who are assigned disaster responsibilities.

b. Record the dates, identity, position, employer, and department assigned of the loaned employees or volunteer practitioners that have been assigned disaster responsibilities. (See CHS Disaster Preparedness Plan dated 8/1/06, page 220).

3. The Immediate Supervisor will:

a. Distribute appropriate position description or assignment to loaned employee or volunteer practitioner.  If this is unavailable, an abbreviated list of duties may be distributed to the loaned employee or volunteer practitioner.

b. Provide for any distinctive clothing or PPE required.

c. Verify weekly timesheets and return to HR Department.

d. Provide oversight of the care, treatment, and services provided by the loaned employee or volunteer practitioner.

e. Oversee the provision of meals and other services to loaned employees or volunteer practitioner.

B. Out-Processing of loaned employees or volunteer practitioners:

2. Immediate Supervisor or Department Head will:

a. Obtain for return any items issued to loaned employee or volunteer practitioner.

b. Notify HR Department date of departure.

c. Submit remaining completed and verified time sheets to Human Resources Department.  (Please see CHS Disaster Preparedness Plan dated 8/1/06, page 222).

3. The Receiving Human Resources Department will:

a. Notify the loaning Human Resources Department that the loaned employee or volunteer practitioner is no longer working at the facility.

b. Provide time/attendance sheets to the individual’s HR Department.

c. Submit appropriate financial documents and previously agreed upon arrangements to the Finance department if applicable.


Evaluation of Events & Exercises
Within 72 hours of the “All Clear” of the event or exercise, an “after actions” debriefing for those involved in the incident command structure will occur. The template for the after actions report and critique is located in the Emergency Management Manual.


Health Information Systems Policy: Electronic Medical Record Downtime Procedure.

EM.  – Mitigation, Preparedness, Response and Recovery Chart 
EM. - Hazard Vulnerability Analysis (HVA)
EM. - Priorities for Emergencies Matrix
Alternate Care Site Assessment Form – Utilities EM.
Alternate Care Site Assessment Form - EM.
Alternate Care Site Selection and Matrix - EM.
HICS Forms - EM.
HICS Job Action Sheets - EM.
Other Healthcare Organizations Matrix Form I - EM.
Backup of Internal and External Communications Matrix - EM.
Sustainability Worksheet - EM.
Evacuation Plan - EM.
Attachment I - Routes and Exits for Evacuation - EM.
Attachment II - Staging Areas - EM.
Attachment III: Additional Equipment - EM.
Attachment IV: Patient Evacuation Equipment - EM.
Attachment V: Patient Medical Equipment and Transportation - EM.

Emergency Response Plans are polices and procedures Dupont Hospital has developed to respond to specific emergencies.  The EOP is not intended to include all processes for responding to emergencies such as fire, epidemic, or severe weather.  Emergency Response Plans contain specific instructions for responding to each of these events.