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emergency operationsquick reference

Vanderbilt HealthOne Hundred Oaks

Copyright, Vanderbilt Medical Center, 2009. All Rights Reserved.

Vanderbilt Emergency Operations Quick Reference Flip Chart 100 Oaks.indd 1 6/25/09 4:23:23 PM

Introduction

It is imperative that Vanderbilt Health One Hundred Oaks faculty and staff familiarize themselves with the basic causes of accidents and be continuously alert to safety requirements in their area. We all share responsibility for reporting, eliminating, and preventing unsafe conditions and practices. Prevention of accidents is accomplished through the use of proper equipment, the elimination of hazards, and safe work habit training. Similarly, we are all responsible for reacting to internal and external emergencies or a disruption of services as a cohesive organization to insure a smooth transition from normal to emergency operations. Meeting this challenge requires thoughtful planning and practice involving all areas of the Vanderbilt Health One Hundred Oaks campus. This Emergency Operations Quick Reference Guide is designed to provide faculty, staff, and students with an immediate source of reference relating to safety and emergency preparedness and response on this campus.


Emergency Operations Quick ReferenceDept. of Emergency Preparedness

Vanderbilt University Medical Facility 615-322-0242

Emergency Operations Center

100 Oaks Emergency Operations Center (EOC) for incident management • Vanderbilt100Oaksfirstfloorconferenceroom(936-8880)

Labor Poolformanagerstosendnon-utilizedstafftobere-assigned• Vanderbilt100OaksConferenceRoomsA/B/C

Family Media Center where visitors of patients gather for information

Media Coordination Center where the news media gather to obtain information • ParkingLot–Southwestsideofmainbuilding


Emergency First Response

EmergencyFirst Response

Medical Emergency (911 from an in-house phone) AdditionalEmergencyContacts:• 100OaksChiefAdministrativeOfficer(CAO)–(835-0242)• Fire–ActivateNearestFireAlarmPullStation• VPD(911fromanin-housephone)• EnvironmentalHealthandSafety(322-2057)orOn-CallSafetyOfficer(pager835-4965)• PlantServices(322-2041)• ClinicalEngineering(322-3440orhospitaloperator)• RiskManagement(936-0660)• 100OaksEnvironmentalServices(343-9350)• VUH/VCHAdministratorOnCall–(VUHpager–835-1018/VCHpager–835-8284)• OfficeofEmergencyPreparedness–(322-0242)• PoisonControlHotline–(936-2034)


Mass CasualtyPlan Activation

Area Specific Information

Duties Person Responsible

Triage Patients for Discharge

Activate Staff Stand-By or Recall

Assess Supplies/Resources


Mass Casualty Plan Activation (Also see Incident Command Flow Chart)

Mass CasualtyPlan Activation

Refer to Emergency Preparedness website home page @ http://www.mc.vanderbilt.edu/ep and select the Emergency Operations Resource needed from the list on right side of this page

1. Activateunit/departmentsub-plan,assessstaffinglevels,sendnon-utilizedstafftotheLaborPool, andcontactoff-dutystaffasnecessary.

2. AllstaffarerequiredtoremainondutyuntilreleasedbytheIncidentCommander.

3. ContactEmergencyOperationsCenter(EOC)ifadditionalresourcesarerequired(936-8880).

4. Assureallvisitorshaveappropriateidentification.

5. Securefacilityifnecessary.

6. Waitforannouncementthatthesituationiscancelledbeforereturningtonormaloperations.

7. CompletetheelectronicEmergencyOperationsCritiqueForm.


Evacuation

Conduct Patient/Staff Head Count at Evacuation Destination



Place Medical Record with Patient

Final Unit Search

Evacuation Destination


Evacuation

Evacuation


1. Moveanypatientorvisitorfromimmediatedanger.Donotwaitforinstruction.2. Preparetoevacuatethosewhoarenotinimmediatedanger.3. Activatedepartmentsubplan.4. Evacuationprioritywillbe:

1. AmbulatoryPatients2. Non-AmbulatoryPatientsandVisitors3. FacultyandStaff

5. Allfacilitieswillbeevacuatedfromthetopfloordownunlessimmediatedangerdictatesotherwise.6. Staffareresponsibleforclearingallroomsanddirectingvisitorsandpatientstonearestexit.7. Donotuseelevatorsunlessdirectedtodoso.8. Usevisitorstoassistinevacuation.9. Waitfortheannouncementthatthesituationiscancelledbeforereturningtonormaloperations.10. CompletetheelectronicEmergencyOperationsCritiqueForm.


Fire


Locations of Fire Pull Stations

Locations of Fire Extinguishers

Pull the pin in the neck of the extinguisher.Aimthespraynozzleatthebaseofthefire.Stand8-10feetawayfromthefire.Squeeze the handles together.Sweepthespraynozzlefromsidetoside,coveringthefire.


Fire

Fire

Ifthereisafireorfirealarminyourzone:1. Remaincalmandrescueanyoneinimmediatedanger.2. Activatethenearestfirealarm.3. Alertanyco-workersintheimmediatevicinityofthefire.4. Confinethefirebyclosingalldoors.5. Extinguishthefirebysmotheringwithblanketorusingafireextinguisher.6. Evacuatetotheoutside.

Whenyouhearthefirealarm:1. Prepareforevacuationby:•Alertingallstaffandpatientsoftheemergencyandevacuationplan•Terminatingprocedures

•Directingpatientsandstafftothenearestexit•Supervisor/designeeassessesareaforpresenceofvisiblesmokeorfire

2. Evacuatetotheoutside3. ContactCAO/AC(835-0242)ifadditionalresourcesarerequired.4. Waitforannouncementthatthesituationiscancelledbeforereturningto

normal operations. 5. CallRiskmanagement(936-0660)toreporttheincident anddocumenttheincidentusingtheon-lineincident reportingsystem@https://veritas.mc.vanderbilt.edu

OverheadannouncementforFireis:Red Alert

TheVanderbiltbusinessofficesandclinicsatOneHundredOaksareconsideredonesmokezone,butareseparatefromthecommercialestablishments.AnyalarmorfiresituationwillimpactalloftheVanderbiltfacilitiesatOHO.

Fire alarm pull stations are located at all major exits from the building and may NOT be located within your immediate work area.


Earthquake



Earthquake

Earthquake


1. Remaincalm.2. Remaininsideandawayfromwindowsanddoors.3. Getunderanysturdyfurniture.Sitdownandcoveryourheadandneck.4. Preparetoevacuatepatientsinimmediatedanger.5. Activateunit/departmentsubplan.6. ContactCAO(835-0242)forimmediateassistance.7. WhenEmergencyOperationsCenter(EOC)isactivated,

callEOC(936-8880)ifadditionalresourcesarerequired.8. Waitforannouncementthatthesituationiscancelledbeforereturningtonormaloperations.9. CompletetheelectronicEmergencyOperationsCritiqueForm.


Tornado


Safe Refuge Areas


Tornado

Tornado


1. Tornadoalertswillgothroughthefirepanelandbeautomaticbasedoninformationfromthecontractedweatherservice.

2. Staffareresponsiblefordirectingallpatients,visitorsandstafftointeriorareasawayfromexteriorwalls,windowsand skylights.

3. ContactCAOforimmediateassistance(835-0242)

4. WhenEmergencyOperationsCenter(EOC)isactivated,callEOCifadditionalresourcesarerequired(936-8880)

5. Waitforannouncementthatthesituationiscancelledbeforereturningtonormaloperations.



Code Silver


Duties

Do not attempt to negotiate, apprehend, or intervene with the suspect

Remove yourself from the situation immediately if possible

Identify and note possible witnesses to the incident and refer them to Police.

Call 911. Tell them:• Your Location• Location of subject(s)• Description of subject(s)• Types of weapons• Description of event / Additional information related to the incident if known

Person Responsible


Code Silver (Active Shooter)

Code Silver

1. Ifthishappens:• Aviolentassaultandaweaponisinvolved• Someonefiringgunshots• CodeSilverand(Location)isannouncedoverthepublicaddresssystem;“Location”isthesiteoftheCodeSilver

2. Donotattempttonegotiate,apprehend,orintervenewiththesuspect3. Removeyourselffromthesituationimmediatelyifpossible4. CalltheVanderbiltPoliceDepartment(VPD)at911fromanin-house

phone.Tellthem:• Yourlocation• Locationofsubject(s)• Descriptionofsubject(s)• Typesofweapon(s)• Descriptionofevent/Additionalinformationrelatedtotheincidentif

known• Numberofvictimsandanyknowninjuries

5. Isolatethesuspectfrompatients,visitors,andstaffifpossiblebyaddingdistanceand/orabarrier

6. Whenpossible,securepatientcareareasbyclosing,lockingand/orbarricadingalldoorsleadingtotheCodeSilverarea.Useavailableitemssuchasfilecabinetsandfurnituretoblockaccessfromsuspectif necessary.

7. Whenpossible,closeblinds,blockwindows,turnoffradiosandcellphones, and keep quiet to reduce your vulnerability.

8. AwaitinstructionsfromVPD.9. IdentifyandnotepossiblewitnessestotheincidentandrefertoVPD.10. ContinueresponseuntilyouhearaCodeSilveriscancelled

announcement over the public address system.11. Waitforannouncementthatsituationiscancelledbeforereturningto

normal operations.12. CompletetheelectronicEmergencyOperationsCritiqueForm.13. CallRiskManagement(6-0660)toreporttheincidentanddocument

the incident using the online incident reporting system @ http://veritas.mc.vanderbilt.edu

Overheadannouncementforanactiveshooteris:Code SilverAn announcement for a CODE SILVER must be authorized and announced by VPD.



Person with Firearm or Dangerous Weapon


Duties

Call 911 and arrange to meet with a Police Officer away from the person suspected of having a weapon.

Do not attempt to negotiate, apprehend, or intervene with the suspect

Tell them:• Your Location• Location of subject(s)• Description of subject(s)• Types of weapons• Threats – whether threats have been made and whether weapon is being used in

a threatening manner• Description of event / circumstances that led to the belief that a firearm or other

weapon may be present• Number of victims and any known injuries

Person Responsible





1. Ifthishappens:• Youreceiveinformationthatafirearmorotherdangerousweaponmaybepresentinthe100Oakscomplex,followVMC PolicySA30-10.04

2. CalltheVanderbiltPoliceDepartment(VPD)froma100Oaksphoneat911,andarrangetomeetwithanofficerawayfromthepersonsuspectedofhavingaweapon.Advisethepoliceofthefollowing:• Yourlocation• Locationofsubject(s)• Descriptionofsubject(s)• Typesofweapon(s)• Threats–whetherthreatshavebeenmadeandwhetherweaponisbeingusedinathreateningmanner• Descriptionofevent/circumstancesthatledtothebeliefthatafirearmorotherweaponmaybepresent• Numberofvictimsandanyknowninjuries

3. Donotattempttonegotiate,apprehend,orintervenewiththesuspect.4. Identifyanon-publicareawhereofficersmayspeakwiththeindividualawayfromotherpatients,visitors,andstaff.5. ContactCAOforimmediateassistance(835-0242).6. CallRiskManagement(936-0660)toreporttheincidentanddocumenttheincidentusingtheonlineincidentreporting

system@https://veritas.mc.vanderbilt.edu


Security Emergency



Security Emergency

Security Emergency

Refer to Emergency Preparedness website home page @ http://www.mc.vanderbilt.edu/ep and select the Emergency Operations Resource needed from the list on right side of this page1. Ifyouencounter: •Acombativepatient •Adisruptive,hostileorthreateningindividual •Someonemakingthreats •Amissingpatient(SeepurpleMissingPerson/Abduction tab.) •Asuspiciousperson •Harassingorthreateningphonecalls2. CallVPDat911fromanin-housephone3. Tellthem: •Yourlocation •Descriptionofsubjects •Descriptionofevents •Typesofweaponsandthreats4. Stayonthephoneuntilinstructedotherwise.5. Activateunit/departmentsubplan.6. ContactCAOforimmediateassistance(835-0242)7. WhenEmergencyOperationsCenter(EOC)isactivated,callEOC(936-8880)ifadditionalresourcesarerequired8. TerminateresponsewhendirectedbyVPD.9. CallRiskmanagement(936-0660)toreporttheincidentanddocumenttheincidentusingtheonlineincidentreportingsystem@https://veritas.mc.vanderbilt.edu


Bomb Threat

Date______________________________ TimeCallReceived_____________________________________________

CallerIDMalenFemalen PhoneNumberdisplayedifusingD-TermPhone______________________

ApproximateAge __________________________________________________________________________________

VoiceCharacteristics _______________________________________________________________________________

SoundsBelievable__________________________________________________________________________________

BackgroundNoise__________________________________________________________________________________

Bomb Information to Ask Caller

TimeScheduledtoExplode____________ LocationofBomb __________________________________________

TypeofBomb_______________________ NumberofBombs__________________________________________


Bomb Threat (Code Black)

Bomb Threat

Refer to Emergency Preparedness website home page @ http://www.mc.vanderbilt.edu/ep and select the Emergency Operations Resource needed from the list on right side of this page1. Remaincalm.DoNOThangupthephone(EVENIFthecaller

hangsup).2. Makedetailednotes.(Seetheformabove.)3. HavesomeonecontactVPD(911)onanotherin-housephone.4. Notethetime.5. ReportthecalltoCAO(835-0242)6. Ifthecallerstatesthebombisinyourarea,scantheareafor

suspicious packages or devices. 7. Donotmoveorhandlesuspiciouspackagesordevices.8. Turnoffcellphones,pagers,andradiosifthecallerstatesthe

bomb is in your work area. 9. Ondutystaffmembersassignedtotheworkareawherethe

bomb is reported are to report to their work area for further instructions.

10. Reviewtheworkareaevacuationplan.11. Preparetoevacuatetheworkarea,butwaituntildirected.12. Awaitfurtherinstructionsfromyoursupervisor.13. WhenEmergencyOperationsCenter(EOC)isactivated,callEOC

(936-8880)ifadditionalresourcesarerequired.14. TerminatetheresponsewhendirectedbyVPD,orwhenan

overhead announcement is made that the situation is cancelled, before returning to normal operations.

15. CallRiskmanagement(936-0660)toreporttheincidentanddocument the incident using the online incident reporting system@https://veritas.mc.vanderbilt.edu/

Overhead announcement for a bomb threat is CODE BLACK AnannouncementforaCODE BLACKmustbeauthorizedandannouncedbyVPD.


Suspicious Caller

Date______________________________ TimeCallReceived_____________________________________________

CallerIDMalenFemalen PhoneNumberdisplayedifusingD-TermPhone______________________

ApproximateAge __________________________________________________________________________________

VoiceCharacteristics _______________________________________________________________________________

SoundsBelievable__________________________________________________________________________________

BackgroundNoise__________________________________________________________________________________


Suspicious Caller

Suspicious Caller


1. Intheeventyoureceiveasuspiciousphonecall,collectandreportthefollowinginformation:•Takecarefulnoteofwhatisbeingasked•Requesttheidentityofthecaller•Requestwithwhomthecallerisaffiliated•Notethecaller’sphonenumber•Noteanyspecificinformationaboutthecall(backgroundnoise,voicecharacteristics)

2. DONOThangupthephone(evenifthecallerhangsup).

3. Remaincalm.

4. Makedetailednotesastheyareoutlinedabove.

5. HavesomeonecontactVPD(911)fromanotherin-housephone.

6. Notethetimeofthecall.

7. ReportthecalltotheCAO(835-0242)

8. TerminatetheresponsewhendirectedbyVPD.


Suspicious Letter or Pkg



Suspicious Letter or Package

Suspicious Letter or Pkg


1. Ifthesuspiciousletterorpackagehasnotbeenopened:• Donotopen,shakeordisturbthecontents.Donotpasstoothersortransportcontentsoutofthearea.• CallVPD(911fromanin-housephone)andprovidethelocationofthepackage,adescriptionincludingsize,andyour

location and contact number. 2. Ifthesuspiciousletterorpackagehasbeenopenedorisleaking:

• Donotshake,disturboremptyitscontents.Donotpasstheletterornotetoothersortransportoutofarea.Donottrytocleanuppowdersorfluids.Placetheenvelopeorpackageinaplasticbagorsomeothertypeofcontainertocontainleakageof contents.

• Ifnothingisavailable,covertheitemandleaveitundisturbed.Turnofffans,closedoor,orsectionofftheareatominimizeexposure to others.

• Washyourhandswithsoapandwater,andmovetoanareathatminimizesyourexposure.CallVPD(911fromanin-housephone)andprovidethelocationofthepackage,adescriptionincludingsize,andyourlocationandcontactnumber.RemainintheareaandrestrictothersfromenteringuntilthearrivalofVPD.

3. TerminateresponsewhendirectedbyVPD.4. Completea“FirstReportofInjury”reportandcontactOccupationalHealth(936-0955)

or,duringoffhours,calltheEmergencyDepartment(322-0145)ifexposureoccurred.5. CallRiskmanagement(936-0660)toreporttheincidentanddocumenttheincidentusingtheonlineincident

reportingsystem@https://veritas.mc.vanderbilt.edu/


Hostage Crisis



Notify Security

Clear Nonessential Persons From Area

Conduct Head Count At Assembly Point

Keep Possible Witnesses In Area


Hostage Crisis

Hostage Crisis


1. NotifyVPDimmediately(911fromanin-housephone).2. Tellthem:

•Yourlocation•Descriptionofsubjects•Descriptionofevents•Typesofweaponsandthreat

3. Clearnon-essentialpersonsfromsurroundingareasassoonaspossible.4. DONOTactuponrequestsfromhostagetakeruntilVPDarrives,unlessdangerouscircumstancesarepresent.5. KeeppossiblewitnessesintheareaandidentifythemtoVPD.6. Activateunit/departmentsubplan.7. ContactCAO(835-0242)8. IfEmergencyOperationsCenter(EOC)isactivated,callEOC(936-8880)

if additional resources are required. 9. TerminateresponsewhendirectedtodosobyVPD.10. CallRiskManagement(936-0660)toreporttheincidentanddocumenttheincidentusingtheonline

incidentreportingsystem@https://veritas.mc.vanderbilt.edu/


Electrical Failure


Location of Flashlights


Electrical Failure

Electrical Failure


1. Checkallelectronicallyoperatedpatientcareequipment.Useredemergencyoutletsforvitalorcriticalfunctionsonly.Confirmproperoperationofbatteryoperatedequipment.

2. Emergencyoutletsandlightsrequire10secondsforactivation.3. ReportoutagetoPlantServices(322-2041)4. Ifemergencypowerisnotavailable:

•CallPlantServices(322-2041)•Useflashlightsasnecessary

5. Activateunit/departmentsubplananddowntimecampusprocedures.6. NotifyCAO(835-0242)ifadditionalhelpisrequired.7. Reassurepatients.8. IfEmergencyOperationsCenter(EOC)isactivated,callEOC(936-8880)ifadditionalresourcesarerequired.9. Waitforannouncementthatsituationiscancelledbeforereturningtonormaloperations.10. CompletetheOnlineEmergencyOperationsCritiqueForm.11. CallRiskManagement(936-0660)toreporttheincidentanddocumenttheincidentusingtheonline



Critical FuelShortage



Critical Fuel Shortage

Critical FuelShortage


Naturalandmanmadedisastershavethepotentialforcausinganinterruptioninfuelresourceswhichcouldimpactnormaloperationsatthemedicalcenteraswellasitsoffsiteclinics.ForthisreasonaCriticalFuelShortagePlanhasbeendevelopedto ensure business continuity when this situation is encountered.TheCriticalFuelShortagePlanisdividedintofourtiers.ThedecisionforrespondingtoaspecificTIERLeveloradvancingtosubsequentTIERSistheresponsibilityoftheVU/VMCExecutiveLeadershipTeaminconcertwiththeFuelShortageEmergency Response Team.TIER 0: Nocriticalfuelshortageexists,normaloperations.FocusofthisTIERisonpreparedness/mitigationactivities.TIER 1: Threat of a critical fuel shortage exists. The focus of this TIER is operational readiness for a potential fuel shortage.TIER 2: PotentialCriticalFuelshortageexists.YellowalertStand-ByforFuelShortageisannouncedoverthepublicaddresssystem and this message is sent via the alphanumeric paging system. Shuttle service may be reduced.TIER 3: Criticalfuelshortageexists.OrangealertFuelShortageisannouncedoverthepublicaddresssystemandthismessageissentviathealphanumericpagingsystem.DesignatedEmergencyOperationsCenter(EOC)isopenedandEmergencyOperationsPlanisactivated.Shuttleserviceisdiscontinued.Accommodationsmaybeavailableforfacultyandstaff.TIER 4: CriticalFuelshortagenolongerexists.Returntonormaloperations.OrangeAlertforFuelShortageiscancelledanddesignedEmergencyOperationsCenterisclosed.

OverheadannouncementforPotentialCriticalFuelShortageis:Yellow Alert Stand-By for Fuel ShortageOverheadannouncementforCriticalFuelShortageis:Orange Alert Fuel Shortage


Facility Damage



Facility Damage

Facility Damage


Note:Thisresponseappliestosituationswherethereisfacilitydamage(i.e.:damagefromsmoke,water,orfireresultingincompromisedemployeeand/orstaffsafetyandbusinessdisruption).

1. CallPlantServices(322-2041).

2. Activatedepartmentsub-plan.

3. NotifyCAO(835-0242)ifadditionalhelpisrequired.

4. Incollaborationwithclinicmanagement,awaitinstructionsregardingtemporaryre-locationorclosureofclinic.

5. IfEmergencyOperationsCenter(EOC)isactivated,callEOC(936-8880)ifadditionalhelpisneeded.

6. CompletetheonlineEmergencyOperationsCritiqueForm.

7. CallRiskManagement(936-0660)toreporttheincidentanddocumenttheincidentusingtheonlineincidentreportingsystem@https://veritas.mc.vanderbilt.edu/

Dependent on severity, consider terminating clinic operations or providing alternate hand-washing and toileting facilities.


Water Failure



Water Failure

Water Failure


1. Donotflushtoiletorusetapwater,drinkingfountain,oricemachine.

2. Assureallfaucetsareturnedoff.

3. Conservewaterforpatientuse.BottledwaterwillbedistributedbyPlantServices.

4. CallPlantServices(322-2041)ifproblemsarefound.

5. Activateunit/departmentsubplan.


7. IfEmergencyOperationsCenter(EOC)isactivated,callEOC(936-8880)ifadditionalresourcesarerequired.

8. CompletetheonlineEmergencyOperationsCritiqueForm.

9. CallRiskManagement(936-0660)toreporttheincidentanddocumenttheincidentusingtheonline incidentreportingsystem@https://veritas.mc.vanderbilt.edu/

Dependent on severity, consider terminating clinic operations or providing alternate hand-washing and toileting facilities.


Computer System Failure






1. NotifytheVMCHelpDesk(343-4357)and100OaksITSmanager(pager835-9246)

2. Standbyforfurtherinstructions.

3. Bepreparedtoprovideinformationrequiredtodiagnosetheproblem,suchasyourname,UserID,theworkstationand/orprinterID,thenameoftheapplicationinwhichyouhadaproblem,etc.

4. Youmaybetoldtousedowntimeproceduresforabriefperiodwhilesupportpersonneldetermineifsystemdowntime is needed. In such cases, you may try to use another device if the problem seems to be isolated to one workstation or printer.

5. Donotuseanycomputerizedsystemsuntildirectedtodoso.

6. Waitforannouncementthatsituationiscancelledbeforereturningtonormaloperations.

7. CompletetheOnlineEmergencyOperationsCritiqueForm.



Laboratory Computer System Failure


Standby for further instructions

Check for messages about the failure in STAR Panel

Assign a staff member to check the computer in your work area on an hourly basis

to obtain updates sent out through the Vanderbilt e-mail system.






1. Standbyforfurtherinstructions.

2. EmergencyDepartmentsandCriticalCareAreasreceivedirectphonenotificationaboutthesystemfailurefromtheLaboratoryDowntimeCallCenter.

3. Checkthefollowingcommunicationsystemsforadditionalinformationregardingtheoutage:

• MessagesinSTARPanel

• MessagesviaVanderbilte-mailsystem(assignastaffmembertocheckthecomputerinyourworkareaonanhourlybasistoobtainupdatesviatheVanderbilte-mailsystem.Thedesignatedstaffmemberisresponsibleforprovidingupdatestothesupervisor/chargenurseinyourworkareaastheybecomeavailable).

4. STATlabresultsduringtheoutagearecalledtotheorderingdepartments.

5. Notifythelaboratorydowntimecallcenterat322-1164forassistanceasneeded





Phone System Failure



Phone System Failure (Also see black tab Emergency Radio System)

Phone System Failure


1. Determineifnearbyphonesareoperational.

2. ReportoutagetoTelephoneRepairat421-1611.

3. Useacellphoneifpossible.

4. CallVPDoncellphone(322-2745)ifassistanceisneeded.

5. Usebeepersystemfortextpagingasanalternatewaytocommunicateforemergencypages.

6. NotifyCAO(835-0242)forimmediateassistance.

7. WhenEmergencyOperationsCenter(EOC)isactivated,callEOC(936-8880)ifadditionalresourcesarerequired.



10. CallRiskManagement(936-0660)toreporttheincidentanddocumenttheincidentusingthe onlineincidentreportingsystem@https://veritas.mc.vanderbilt.edu/


Beeper System Failure






1. Usein-housephoneorcellphone.

2. NotifyCAO(835-0242)ofbeepersystemfailure.




Blood/Body Fluid Spill

Immediate First Aid• Washskinsurfacesimmediatelyandthoroughlywithsoapandwater.• Flushmucousmembranesoftheeye,mouth,ornoseimmediatelyandthoroughlywithwaterfor

10-15minutes.Removecontactlenses. DONOT use bleach as a skin disinfectant.

ImportantMake sure the exposed employee goes to Occupational Health or the ED, regardless of the source patient HIV results.

Reporting –Completea“FirstReportofWorkInjury”ThisreportmustbetakenwiththeemployeetotheOccupationalHealthClinicormaileddirectlytoOfficeofRiskandInsuranceManagementSuite#610OxfordHouse

Refer to Exposure Control Policy SA 60.10.01





Refer to ExposureControlPolicySA60-10.01

1. Weartheappropriatepersonalprotectiveequipment. DONOTPICKUPBROKENGLASSWITHYOURHANDS!

2. Cleanupbloodwithanabsorbentmaterial.

3. Discardbloodandcleanupmaterialinabiohazardbag.

4. Cleanspillareawithanapproveddisinfectant.

5. IfnecessaryisolateareaandcontactEnvironmentalServices(343-9350)

6. Completea“FirstReportofInjury”reportandcontactOccupationalHealth(936-0955) or,duringoffhours,theEmergencyDepartment(322-0145)ifexposureoccurred.


Chemical Spill



Chemical Spill

Chemical Spill


Refer to policy SA20-10.02HazardousMaterialSpill

1. Evacuateanyoneinimmediatedanger.

2. Isolatethearea,closingdoorsasyouleave.

3. Notifythefollowing:

•VPD(911fromanin-housephone)

•On-CallSafetyOfficer(835-4965)

•PlantServices(322-2041)

•CAO(835-0242)

4. KeeppeopleawayfromthespilluntilVPDarrives.

5. ObtainMaterialSafetyDataSheets(MSDS)onchemical,ifknown. FindMSDSinformationontheInternetatwww.safety.vanderbilt.edu/msds/


7. TerminateresponsewhendirectedbyOn-CallSafetyOfficer(835-4965)




Chemotherapeutic Spill


Location of spill kit





RefertoVUMCPolicyCL30-06.09Cytotoxic(Chemotherapy)AdministrationandManagement. 1. Removepatient,family,visitorsandstafffromimmediatearea.2. Weartheappropriatepersonalprotectiveequipment.

DO NOT PICK UP BROKEN GLASS WITH YOUR HANDS! 3. Useappropriatespillkit.4. Smallspillslessthan5ml.

•Wearpersonalprotectiveequipment•Wipewithabsorbentmaterial•Placeinproperdisposalbag

5. Largespillsgreaterthan5ml.•Markareatobecleanedandpreventothersfromentering.•NotifyPharmacyon-siteandobtainspillkit.Followinstructionsonspillkitforclean-up.•NotifyOn-CallSafetyOfficer(835-4965)

6. Placewastefromclean-upofchemospillsinchemotherapeuticwastecontainers.7. Activateunit/departmentsubplan.8. NotifyCAO(835-0242)ifadditionalhelpisrequired.9. Terminateresponsewhenareaclean-upiscomplete,or,forlargespills,

whentheOn-CallSafetyOfficer(835-4965)directsyou.10. Completea“FirstReportofInjury”reportandcontactOccupationalHealth(936-0955)

or,duringoffhours,theEmergencyDepartment(322-0145)ifexposureoccurred.11. CallRiskManagement(936-0660)toreporttheincidentanddocumenttheincidentusingtheonline



Radioactive Material Spill






Refer to policy SA20-10.02HazardousMaterialSpill and policy SA40-10.08RadiationSafety.

1. Confinethespill.

2. Isolatearea,closingdoorsasyouleave.

3. Preventothersfromenteringthearea.

4. Quarantineallstaffinvolvedinspill.

5. Notify:

•VPD(911)

•On-callSafetyOfficer(835-4965)

•CAO(835-0242)

6. Onlytrainedradiationworkersshouldcleanthearea.

7. TerminateresponsewhentheOn-CallSafetyOfficer(835-4965)directsyou.




Mercury Spill



Mercury Spill

Mercury Spill


Refer to policy SA20-10.01MercurySafety

1. Reportallmercuryspills,nomatterhowsmall,to:

•On-CallSafetyOfficer(835-4965)

•VPD(911)

2. Onlytrainedstaffshouldcleanupamercuryspillusingtheappropriatematerials.

3. Evacuatetheimmediateareaandisolatethespill.


5. TerminateresponsewhenyouaredirectedbyOn-CallSafetyOfficer(835-4965)




Medical Equipment Failure






Ifmedicalequipmentfailsduringuseoramalfunctionissuspectedyoushould:

1. Assesspatientforinjury.

2. Discontinueuse.

3. Leaveallselectorknobs,switchesandpushbuttonsinsamepositionastheywereatthetimeoftheincident. Takeequipmentoutofservice.SaveforClinicalEngineeringServices.

4. ContactClinicalEngineeringServices(322-3440) Afterhours,callhospitaloperatorforanon-calltechnician(322-5000).

5. ObtainapprovalofClinicalEngineering(322-3440)orRisk&InsuranceManagement(936-0660) before notifying the equipment vendor.





Missing Person/ Abduction



All staff hearing the announcement should watch for the person described.

Report information to VPD.


Missing Person/Abduction

Missing Person/ Abduction


Refer to Policy SA30-10.01MissingPerson/AbductionResponse

Code Pink -MissingInfant(youngerthan12monthsold) Code Purple -MissingChild(age1-12years) Code Walker Adolescent (age13-17years) Code Walker Adult (18yearsorolder)Ifastaffmembersuspectsaninfant,child,adolescent,oradultpersonismissing:

1. TheChargeNurse/Manager/DesigneenotifiesVPDat911fromanin-housephoneandprovidesthedispatcherwiththefollowinginformation:•Race •Build(slender,medium,heavy) •Gender•Haircolor •Age •Clothingdescription•Height •Weight •Medicaldevice

2. TheChargeNurse/Manager/DesigneenotifiestheCAO(835-0242).CAO/ACisresponsibleforoverheadannouncement.3. StaffoftheareaforwhichtheMissingPersonorAbductionoccurredmustreturntothearea.4. ReferallquestionstoNewsandPublicAffairs(322-4747)5. Activatetheclinicspecificsecurityplan.6. Staffinareaslocatedatoraroundexits/accesspointsofthecentershouldmonitorthoseareasandreportanypossible

sightingsofthemissingorabductedpersonimmediatelytoVPD(911).7. Allclinicalstaffintheclinicareashouldsearchtheirrespectiveclinicsandalladjacentcommonareasforthemissingor

abducted person. 8. Supportandadministrativestaffnotassignedtotheincidentshouldsearchcommonareasofthemedicalfacilitytoinclude

hallways,corridors,garageconnectors,cafeteriasandbreakareas,basementandsub-basementconnectors.9. Waitforannouncementthatthesituationiscancelledbeforereturningtonormaloperations.10. CallRiskManagement(936-0660)toreporttheincidentanddocumenttheincidentusingtheonlineincidentreporting

system@https://veritas.mc.vanderbilt.edu/

Overhead announcement for activation is Code Pink, Code Purple,CodeWalkerAdolescentorCodeWalkerAdult (dependingupontheageofthemissingperson),followedbyunitidentificationandadescriptionofthemissingperson.

Note:AnyoverheadannouncementforMissingPersonorAbductionisauthorizedandannouncedbyCAOordesignee.


Emergency Ops Plan Overview

Elements of Emergency Operations Plan Overview

1. Emergency Response Team

2. Department Sub-Plan Activation

3. Emergency Operations Center

Internal Disasters Include: Fire, Flood, Earthquake, Tornado, and Utility Systems Shutdown

External Disasters Resulting in Mass Casualties Include: Transportation Related Accidents,

Chemical, Biological or Radioactive Terrorist Threats, Natural Disasters, and Manufacturing

Plant Accidents

4. Recovery Operations


Emergency Operations Plan Overview

Emergency Ops Plan Overview


TheEmergencyOperationsPlanisdesignedtooutlinetheresponsibilitiesofVanderbiltMedicalfacility(VMC)personnel intheeventofaninternaland/orexternal(MassCasualty)Disastertoprovideforanorderlytransitionofoperations. TheVMCEmergencyOperationsPlanismodeledaftertheIncidentCommandProtocolusedbylocal,state, andfederalemergencyresponseagencies.ThroughtheEmergencyOperationsPlan,VMCwill:

1. EstablishanEmergencyResponseTeam2. Assesstheimpactoftheeventonnormalbusinessactivities3. Continuetoprovidenormalserviceunlesstheeventprecludesthatability4. EstablishanEmergencyOperationsCenter(EOC)toimplementnecessaryelementsoftheIncidentCommand

System 5. PrepareforamodificationofnormaloperationstoincludeAreaSpecificSub-PlanActivationifnecessary

The Chief Administrative Officer on Call, when notified of an event, will assume the role of the Incident Commander and contact the following:

DOES THE EVENT PREVENT MAINTAINING NORMAL OPERATIONS?

YES NO

Activate necessary elements of Resolve with Available Resources Emergency Operations Center

ChiefAdministrativeOfficer/AdministratoronCall

VPDShiftCommander SafetyOfficeronCall PlantServicesOn-Site MedicalDirector


Activation Announcements


ANNouNCemeNT BASiC ReSPoNSe

Red Alert, Location Follow Fire Plan (RACe), Close Doors,

Evacuate the Building

Yellow Alert Standby For (Situation) Prepare to Activate Response

orange Alert For (Situation) Activate Response

Code Pink missing infant (younger than 12 months old)

Code Purple missing Child (age 1-12 years)

Code Walker Adolescent (age 13-17 years)

Code Walker Adult (age 18 years and over)

Code Black Bomb Threat

Code Silver Active Shooter




STAT -MedicalEmergency

Red Alert (Location) -PotentialFireCondition

Code Black (Location) -BombThreat

CodePink–MissingInfant(youngerthan12monthsold)

CodePurple–MissingChild(age1-12years)

CodeWalkerAdolescent–(age13–17years)

CodeWalkerAdult–(18yearsorolder)

CodeSilver–ActiveShooter

Yellow Alert Standby for (Situation) -PreparetoactivateEmergencyOperationsPlanfor(Situation) Orange Alert (Situation) -ActivateEmergencyOperationsPlanfor(Situation)

Applicable Situations

• Tornado


Unannounced Survey

ElementsofUnannouncedSurvey:EmergencyOperationsPlan

1. Emergency Response Team

2. Emergency Operations Center (EOC)

3. Activation Announcement

ApproveduseofEOCforUnannouncedSurvey:

The Joint Commission (TJC) unannounced triennial survey, TJC Focus survey, CMS complaint survey, CMS validation survey,

State licensure survey.


Unannounced Survey

Unannounced Survey


TheUnannouncedsurveyplanisdesignedtooutlinetheresponsibilitiesofVMCpersonnelintheeventofanunannouncedsurvey(TJCorStateetc)toprovidefororganizationofoperationsduringthesurveyandpreparationofmaterialsforsurveyor review.

TheplanisbasedonthenationallyrecognizedIncidentCommandSystemusedduringdisasters.

ThroughtheUnannouncedSurvey:EmergencyOperationsPlan,VMCwill:

1. EstablishEmergencyResponseTeam

2. EstablishEmergencyOperationsCenter(EOC)toimplementnecessaryelementsoftheIncidentCommandSystem.

3. Continuetoprovidenormalservice.


Early Warning Weather Alert



Early Warning Weather Alert

Early WarningWeather Alert

Aweathermonitoringandearlywarningsystemwillgivefaculty,staff,students,patients,andvisitorstimetoprepareforpotentialsevereweather.ThisweathermonitoringsystemisexclusivelyfortheVanderbiltand100Oakscampuses.

“YELLOW ALERT STANDBY FOR TORNADO” will be announced over the public address system when a Tornado Warning isissuedforDavidsonCountyoratthediscretionoftheCAO/ACbasedonweatherconditions.Staffshouldassesstheambulatorystatusofallpatients.Curtainsshouldbeclosed.Whenthethreathaspassed,“YELLOWALERTSTANDBYFORTORNADOHASBEENCANCELLED”willbeannouncedoverthepublicaddresssystem.

“ORANGE ALERT TORNADO WARNING” will be broadcast over the public address system when a tornado has been identifiedapproachingtheOneHundredOaksCampus.Non-ambulatorypatientsshouldbeturnedawayfromwindows.Patients, visitors, and staff are moved into an interior part of the building, away from doors and windows. Once the danger haspassed,“ORANGEALERTTORNADOWARNINGHASBEENCANCELLED”willbeannouncedoverthepublicaddresssystem.


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