Emergency Preparedness

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CMS CORE EP RULE ELEMENTS	70
Appendix A: TJC STANDARDS - E.C.01.01.01-E.C. 03.01.03	71
Appendix B: EMERGENCY MANAGEMENT ACRONYMS	92
LIST OF POSITIONS	140
Demonstrations	276
Drills	276
Exercises	277
EMERGENCY PROGRAM MAINTENANCE SCHEDULE	282
EM .02.02.05 (5) the plan identifies means for radioactive, biological, and chemical isolation and decontamination: Facilities for decontamination are maintained and coordinated through the Engineering Department, Emergency Department (ED), Security, ...	294
PURPOSE:	305
To standardize the risk assessment, triage, transportation, and management of patients with any highly infectious disease throughout Kern Medical and its clinics. It is the policy of Kern Medical to take care of those in need regardless of their illne...	305
DEFINITIONS:	305
 Standard Precautions: Work practices that require that blood, all body fluids (except sweat), secretions and excretions, mucous membranes and non-intact skin of all patients be treated as potentially infectious. The precautions are designed to reduc...	305
 Contact Precautions: In addition to Standard Precautions, for patients who are suspected or known to be infected with organisms that can be transmitted by direct contact with the patient (hand or skin-to-skin contact that occurs while performing pat...	305
 Droplet Precautions: In addition to Standard Precautions, for patients known or suspected to be infected with microorganisms transmitted by droplets (large-particle droplets larger than 5 micrometer in size) that can be generated by the patient duri...	305
 Airborne Precautions: In addition to Standard Precautions, for patients known or suspected to be infected with microorganisms transmitted by airborne droplet nuclei [small-particle residue (5 micrometer or smaller in size) of evaporated droplets con...	305
 Ebola Virus Disease (EVD): formerly known as Ebola hemorrhagic fever, is a severe, often fatal illness in humans. The virus is transmitted to people from wild animals and spreads in the human population through human-to-human transmission. The avera...	305
 Centers for Disease Control and Prevention (CDC): CDC is a federal agency that conducts and supports health promotion, prevention and preparedness activities in the United States with the goal of improving overall public health.	305
 Environmental Protection Agency (EPA): The EPA was established in December 1970 under United States President Richard Nixon. The EPA is an agency of the United States federal government whose mission is to protect human and environmental health.	305
 Emergency Department (ED): is a medical treatment area specializing in emergency medicine, the acute care of patients who present without prior appointment; either by their own means or by that of an ambulance.	306
 Personal Protective Equipment (PPE): refers to protective clothing, helmets, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection.	306
 Patient Under Investigation (PUI): A person who has both clinical features and an epidemiologic risk should be considered a patient under investigation.	306
 Kern County Public Health Department (KCPHD): the science of protecting and improving the health of families and communities through promotion of healthy lifestyles, research for disease and injury prevention and detection and control of infectious...	306
 Emergency Medical Services (EMS): A system of services organized to provide rapid response to serious medical emergencies, including immediate medical care and patient transport to definitive care in an appropriate hospital setting.	306
 Hospital Incident Command System (HICS): An incident command system (ICS) designed for hospitals and intended for use in both emergency and non-emergency situations. Is this the definition of HICS?	306
 Highly Infectious Disease (HID): Infectious diseases are caused by pathogenic microorganisms, such as bacteria, viruses, parasites or fungi; the diseases can be spread, directly or indirectly, from one person to another.	306
 Association for the Advancement of Medical Instrumentation (AAMI): The AAMI standards program consists of over 100 technical committees and working groups that produce Standards, Recommended Practices, and Technical Information Reports for medical d...	306
 Powered Air Purifying Respirator (PAPR): a device equipped with a face piece, hood or helmet, breathing tube, canister, cartridge, filter, canister with filter or cartridge with filter and a powered blower.	306
Equipment:	306
 All equipment contaminated with blood or body fluids shall be decontaminated, if possible, or labeled as contaminated, prior to internal or external disposal/repair/maintenance release from the unit to minimize environmental contamination and the ri...	306
 Procedure	306
 Examine equipment for contamination prior to handling, servicing and shipping. It can be cleaned with hospital disinfectant wipes used for equipment decontamination.	306
 Decontaminate as necessary unless decontamination of equipment, or portions of such equipment, is not feasible (defer to infection control policy and manufacturer recommendations for cleaning and sterilization).	307
 When possible, soiled portions of equipment that do not require repair/ maintenance are to be removed and retained in the Unit	307
 Pre-cleaning/decontamination of equipment can be accomplished with a variety of agents after removal of visible soil. Only EPA-registered agents approved by the Infection Control Committee will be used.	307
Procedure:	307
 Risk Assessment	307
 Travel to high-risk areas is one of the risk factors for transmission; these guidelines address patients who are considered at high risk for a highly infectious disease who meet travel criteria as determined by the CDC. Exposure to a known highly in...	307
 Emergency Department Walk-Ins	307
 Upon patient arrival at the Emergency Department, the Quick look nurse or triage nurse will ask patients if they have a travel history or have been in contact with someone who has traveled to any area of concern as determined by the CDC in the last ...	307
 If the patient states that they have any symptoms (ie. fever,rash, cough), the nurse will notify the charge nurse who will notify security to help with transport. During this time the charge nurse will help ready the room for the patient.	307
 The quick look nurse will then escort the patient to room #1512 (while keeping a distance of at least 3 feet away).	307
 The designated room will have a disposable digital thermometer and access to a translator phone to allow for further screening without entering the isolation room.	307
 If the patient has signs or symptoms (ie. fever, rash, cough) after having a medical screening exam and further investigation, and has traveled to or been in contact with someone who has traveled to an area of concern, the nurse will immediately not...	307
 Appropriate signs will be posted on the designated room doors.	307
 At this point the door will be closed and the staff member must immediately perform hand hygiene	307
 Once isolated, use the Emergency Department Assessment Tool	308
 If the patient screens out, remove the isolation sign as appropriate and complete the patients visit.	308
 Clinics	308
 If the patient presenting to the front desk (or subsequently) reports they have a fever or symptoms and that they have traveled to or been in contact with someone who has traveled to an area of concern, the front desk employee will provide a face ma...	308
 The patient should be seated in the designated room, asked to keep their mask on and told that either a nurse or PCT will be with him/her shortly. At this point the door should be closed and the staff member must immediately perform hand hygiene and...	308
 Appropriate signs shall be posted on the isolation room door.	308
 Once isolated, bring the Regulated Medical Waste container (RMW) into the Isolation Room and use the Ambulatory Secondary highly infectious disease Screening Tool and Triage form.	308
 The required PPE is located in an isolation cart _____.	308
 If an interpreter phone is needed for the initial triage, the phone will be set on the speaker phone setting.	308
 If the patient screens in, follow the protocol for activation of Code 300	308
 If the patient screens out, remove the isolation sign as appropriate and complete the patients visit.	308
 Labor and Delivery	308
 If the patient presenting to the front desk (or subsequently) reports they have a fever or any other symptoms and that they have traveled to or been in contact with someone who has traveled to an area of concern, the front desk employee will provide...	308
 The patient should be seated in an isolation room and told that either a nurse will be with her shortly. At this point the door should be closed and the staff member must immediately perform hand hygiene and alert the charge nurse.	308
 Appropriate signs shall be posted on the isolation room door.	308
 Once isolated, bring the RMW Bio Hazard Waste container into the isolation room and use the Ambulatory Secondary Ebola Screening Tool and Triage Form.	308
 Appropriate PPE is located in Central supply.	308
 If the patient is excreting bodily fluids (incontinent of urine, feces, blood, or vomiting) use the appropriate level of PPE required.	308
 If an interpreter phone is needed for the initial triage, the phone should be set on the speaker setting.	308
 If the patient screens in, move to section ___ of this policy.	309
 If the patient screens out, remove the isolation sign as appropriate and complete the patient’s visit.	309
 Activation of Code 300	309
 Upon determining that a patient is a PUI, Kern County Public Health Department (KCPHD) or EMS will contact Kern Medical.	309
 The initial call from KCPH or EMS will be directed to the Emergency Department.	309
o Upon receipt of a PUI Transfer or transport call from KCPHD or EMS, the Emergency Department will immediately contact the operator with notification of a Code 300.	309
o The operator will notify the Administrator on call, Emergency Management Coordinator, Infection Prevention and Medical Director.	309
 The Emergency Management Coordinator, Administrator on call, or Medical Director will activate the HICS incident command center.	309
 Alert the Highly Infectious disease team.	309
o The HICS Medical Branch Director will activate the HID team by contacting the operator.	309
o The Kern Medical operator will have a list with names and contact information for:	309
 Infectious Disease physician on call	309
 HID team members	309
 Administration	309
 Emergency Management Coordinator	309
1. The Incident Commander will notify:	309
2. Hospital Security	309
3. Environmental Services (EVS)	309
4. Hospital Leadership	309
 PUI’s coming to Kern Medical via EMS transfer/transports will enter via designated route.	309
 The transported vehicle will be parked on the North West side of the Emergency Department (Hot Zone).	309
 EVS will bring drums to the Hot Zone	309
 During an HICS activation for a PUI, an appropriately trained Hospital Security Officer will tape off the Fire Lane and act as the Hot Zone commander and will coordinate all Hot Zone activity.	309
 EMS staff will hand off the patient to Kern Medical staff while staying in the Hot Zone.	309
 Security will escort the transport of the patient to ensure safe travel and crowd control.	309
 Transport routes are available as addendum ___.	309
 An EVS designee shall walk behind the gurney during transport to assure no possible contamination occurs	309
 When necessary, EVS shall clean the elevator used to transport the patient, as well as the entire transport route per their normal cleaning protocols.	309
 If the EVS designee notes a possible point of contamination, a higher level of cleaning/PPE may be required.	310
 Hospital Security shall be responsible for monitoring EMS decontamination of the Hot Zone.	310
 EMS staff will doff outside in the “Hot Zone” and will dispose of PPE and/or items in the drums places behind the yellow tape.	310
 EVS will cover the drums without crossing the yellow tape	310
 EVS will take the drums to a designated location. Kern Medical will properly dispose of said waste per waste removal protocol.	310
 EMS will return to the ambulance and follow their protocol.	310
 Activation of the Direct Observation Unit via internal Point of Entry	310
 The Nursing supervisor or designee will activate HICS by initiating a CODE 300 to activate the Highly Infectious Disease Team.	310
 The HICS medical Branch Director activates the HID Team by contacting the Kern Medical Operator.	310
 The Kern Medical Operator has names and contact information for the HID team which includes:	310
o On call Physician(s)	310
o Nursing	310
o Respiratory therapist	310
o Administration/ Site managers	310
o HICS Incident Commander	310
 The Incident Commander will notify:	310
- Hospital Security	310
- Hospital Leadership	310
 Hospital security will recall the D-wing cargo elevators necessary to the ground floor.	310
 The security officer will remain on the floor with the elevator to await staff and patient’s arrival.	310
 Additional security officers will be assigned on the ground floor level for crowd control.	310
 Transport routes are available as addendum ___.	310
 An EVS designee shall walk behind the gurney during transport to assure no possible contamination occurs	310
 When necessary, EVS shall clean the elevator used to transport the patient, as well as the entire transport route per their normal cleaning protocols.	310
 If the EVS designee notes a possible point of contamination, a higher level of cleaning/PPE may be required.	310
 Care Rendered on the Direct Observation Unit	310
 Floor Layout	310
 Room 2428- Dirty/Doffing	310
 Room 2430- Patient care	310
 Room 2432- Clean/Donning	310
 Room 2436- Lab	311
 HID Team	311
 Physician	311
 Primary RN	311
 Observation RN	311
 Third RN	311
 Respiratory Therapist	311
 Site Manager	311
 HID team responsibilities on the Direct observation Unit before patient arrival	311
 HID Activation Checklist-Addendum____	311
 The Site manager will review the checklist to ensure all necessary equipment is in the patient room and the supply/Donning and Doffing rooms	311
 A Physician will be on the unit when the patient arrives.	311
 The Primary RN, Observation RN, and Third RN will don PPE in room 2432 with guidance from the Site Manager.	311
o The three RN’s will pick up the PUI from the designated Hot Zone outside of the Emergency Department or Decontamination room and transport the patient to the Direct Observation Unit.	311
o Refresher training will be provided by the Infection Prevention or Site manager to all staff (when Necessary) on the shift receiving the patient and the beginning of following shifts.	311
 HID Team members responsibility upon patient arrival	311
 Consents must be obtained from a PUI/EVD patient prior to treatment whenever possible, per hospital policy	311
 A HIPAA Privacy statement must be signed at the earliest possible juncture.	311
o Consents will be obtained by the RN/MD verbally. Any paper charts will be kept at the nurse’s station and will not be brought into the patient’s room.	311
o Blood Pressure will be accessed through the monitor in room 2430 ( a stethoscope is not required)	311
 HID Team members responsibilities during treatment	311
 Primary RN uses a check-off list to ensure she/he has all needed supplies to provide care to patient, including supplies for medication administration	311
o All supplies and medications are brought into the patient room in a see-through bag	311
o If additional supplies or medications are required, they will be handed to the primary RN by the Observation RN (who will remain in the cold zone during the handoff.	311
 There will be a small table that can be pushed inside of the warm zone for the Primary RN to pick up additional supplies, if needed. (RN should not enter or touch anything in the warm zone while outfitted in PPE)	311
 Observation RN stays in the cold zone of room 2432	312
o If the Primary RN in Room 2430 needs help, the Observation RN will go into the hot zone as appropriate	312
o The table will be wiped down with hospital approved bleach wipes after each use.	312
o Other HID team members will watch room 2430 from the nurses station	312
 Prior to entering the patient room the Physician:	312
o Will don the required PPE with guidance from the Site Manager and the posters posted in the donning area.	312
o Will be briefed by a member of the Nursing staff on the Lab testing and the patient’s condition	312
 Clinical documentation will be completed at the nurses station (cold Zone) by the third RN. Primary RN will communicate with the Observation RN through the glass door (others will communicate with both nurses via intercom and video)	312
 RN’s, Physicians, and RT’s will doff per policy, following the posters posted in each zone with guidance from the Observation RN and Site Manager.	312
 Other caregivers(e.g. respiratory therapist) will only be permitted access if trained in appropriate PPE and approved by Infection Preventionist along with the HID team	312
 All personnel will be logged into and out of Hot Zone by a site Manager	312
 Carts and equipment that have entered the isolation room should remain in isolation. Should equipment need to be removed it shall be wiped down (including wheels) with a 10% bleach solution before leaving the hot zone (when possible) then covered by...	312
 Unused patient medications will be disposed of in the patients room	312
 Observation and monitoring of activity on the designated unit	312
 The CDC recommends the use of a designated onsite manager, whose sole responsibility is to ensure the safe and effective delivery of HID treatment. This individual is responsible for all aspects of observing the donning and doffing process to ensure...	312
 Site Manager	312
o Oversee donning and doffing	312
o Observe and record issues with environmental processes	312
o Provide guidance and address issues related to infection control	312
o Ensure that any person entering the “hot” zone is donned appropriately	312
o When not otherwise occupied, record person, time, and activities of the person(s) entering the “hot” or “warm” zones only.	312
o Ensure the designated unit doors are locked upon activation	312
o Ensure staff and hospital security knows to redirect any possible traffic around the locked unit.	312
o Monitor access to the Unit	313
o Request supplies	313
o Communicate with command center as necessary	313
o Coordinate activities between clinical staff and personnel	313
 Nurse Leader	313
o Coordinate Primary and Observation RN schedules	313
o Assist in acquiring materials and supplies from other areas as needed	313
o Assist the site manager to oversee donning and doffing process	313
o Performs all documentation as necessary.	313
 Observation RN	313
o Observe the care being provided by the Primary RN	313
o Observe and talk to the Primary RN through doffing (with assistance of the Site Manager- (who will remain in the cold zone at all times.)	313
 In the interest of ensuring the safest and most effective delivery to HID treatment, Kern Medical Observation RN’s, Nurse Leaders, Site Managers, and Primary RN’s are cross trained in certain functions otherwise served by the Site Manager (i.e., any...	313
 Respiratory Services	313
 In the event that and HID patient is intubated, a respiratory Therapist will be available on the unit to provide guidance and support	313
 HID respiratory Equipment	313
 A standard Avea ventilator will be brought to the unit upon initiation of mechanical ventilation.	313
 A V60 bipap machine will also be available	313
 A single patient use disposable transport ventilator will be used in the event of transportation.	313
 Cleaning of equipment: follow all current manufacturers’ recommendations	313
o Circuits and filters are all single patient use	313
o Disposable circuits are to be removed in hot zone	313
o The Respiratory staff responsible for cleaning and respiratory equipment must don appropriate PPE	313
 If patient is on oxygen, an E cylinder can move with the patient, and will remain segregated from other cylinders by signage.	313
 Radiology Services	313
 Testing should be limited (i.e., use portable ultra sound or plain films in the patient room when possible)	313
 X Rays	313
o Heavy plastic sheets, will accompany the machine	313
 One plastic sheet shall be laid to provide access from the doorway to the bed	314
o The machine will be covered, as much as possible, with a plastic bag over the machine and a C-arm bag over the tube and arm to avoid contamination. The RN will roll the portable x-ray into the isolation room	314
o The cassette will be placed in a triple bag by the technologist and handed to the RN in the room who will put it in position under the patient	314
o The X-ray tech will remain in the cold zone and will instruct the RN remotely via communication device. The tech will expose the x-ray from as far away as the cord allows.	314
o Radiology equipment will be wiped down in room and again outside the room with a 10% bleach solution.	314
o Probes (e.g., Vaginal probes) shall be covered with a condom and the condom cover should be discarded as regulated medical waste. Used probes shall remain in the room until treatment is completed.	314
 Pharmacy Services	314
 Once brought into the patient room, all single and multi-dose medication (whole or partial) not administered shall be discarded	314
 Once brought into the patient room, any multi-dose vials, inhalers, creams, ointments, liquids, etc, must be stored in the patients room in a secure location until the medication is discontinued, or the patient, wrappers and containers shall also b...	314
 For all medications administered to the patient, wrappers and containers shall also be disposed	314
 Controlled Substances: Once brought into the patient room all controlled medications (Schedule II-V) not administered (whole or partial) shall be wasted in the isolation room. Any container or wrapper that remains must also be disposed	314
 All IV solutions and IV tubing brought into the patients room should be discarded in a red container when no longer needed	314
 Any medication brought into the patient room can NOT be returned to the pharmacy	314
 Property	314
 All property that a suspected HID patient brings with him/her into the facility will go into the room with the patient	314
 No property will be reimbursed	314
 Any patient property that the patient had contact with prior to admission and is subsequently brought into the facility will be considered on a case by case basis	314
 Subsequent to treating a confirmed HID patient, all property in the room will be treated as waste. Valuable items will be considered on a case-by-case basis	314
 Mail/Deliveries	315
 Hospital Security shall be informed of all mail/packages addressed to patients in special isolation.	315
 No items shall be delivered into a patients room that would hinder or obstruct patient care or safety	315
 Approved list for mail/packages	315
 Nursing staff shall request from the patient, a list of family and friends who may forward mail and/or packages to the patient.	315
 Approved mail/packages shall be forwarded to the patient but shall not interfere or obstruct patient care	315
 Patients shall be advised that suspicious mail/packages will be screened to ensure patient and staff safety and may be discarded	315
 The patient/patient family shall be informed that mail/packages that enter the isolation room of a PUI will be discarded at the end of the patient stay	315
 Patient’s wishes regarding mail/package acceptance shall be documented in the patients’ medical record	315
o Letters, cards, etc. shall be scanned or photographed and delivered electronically by patient advocacy	315
 Original mail/packages will be held until patient discharge	315
 If patient prefers accepting original mail/package, the mail will be delivered to the patient using the process for delivering supplies/equipment in an isolation room	315
 Patient shall be informed that original mail/packages delivered into the isolation room will be discarded at the end of the patient’s stay	315
 Delivery of written mail/packages from individuals NOT on the patients approved list	315
o Letters and packages that are not on the isolation patient’s approved list shall be screened prior to delivery	315
 Psychiatry Considerations	315
 PUI or confirmed HID patients will NOT be treated in the Comprehensive Psychiatric Emergency Program (CPEP) or inpatient Psychiatry. A psychiatric patient presenting as a PUI or confirmed HID patient will be screened and assessed in the designated r...	315
 A patient will only be restrained if a determination is made that the patient is at risk of harming him/herself or others	315
 The treating clinician will determine the need for physical restraints. A psychiatry consult will be obtained.	315
 Rationale for and duration of use of restraints will be documented in the patients’ medical record	315
 Hospital security will provide emergency assistance if the HID team cannot successfully restrain the PUI or HID patient. Hospital security must:	315
o Don appropriate PPE	315
o Follow the direction of the clinical staff	315
o Hospital security shall doff under the supervision of a trained observer	315
 Psychology Services	316
 Support groups are available to all staff	316
 Psychiatry, social work, and psychology led support groups will be made available	316
 Specific times are dependent on the unit’s needs, with the goal of reaching all HID team members. These groups follow principals of Psychological First Aid and Critical Incident Stress Debriefing	316
 Individual Psychiatry check-ins will occur on the unit with individual nurses and ancillary staff on duty.	316
 Psychiatry is available to contact members of the HID team on days off to check in telephonically, in coordination with Leadership.	316
 The Kern Medical Employee Assistance Program (EAP) will be made available on-site for individual and group interventions 5 days a week, depending on need	316
 Pastoral care is available for interested staff	316
 Media/Communication	316
 All media and internal communications shall first be approved by Kern Medical Leadership and the Chief Executive Officer or their designee	316
 Lab Services	316
 Lab Procedure	316
 EVD is detected in blood only after the onset of symptoms, usually fever. It may take up to 3 days after symptoms appear for EVD to reach detectable levels. EVD is generally detectable by real-time RT-PCR from 3-10 days after symptoms appear.	316
 Specimens ideally should be taken when a symptomatic patient reports to a healthcare facility and is suspected of having an EVD exposure. However, if the onset of symptoms is <3 days, a later specimen may be needed to completely rule-out EVD virus, ...	316
 The decision to send specimens for confirmation Ebola testing will be made by the on-call infectious disease physician or the Laboratory Medical Director or designee.	316
 Laboratory Notification:	316
 In cases of suspected EVD or other HID infections, Emergency Room personnel or the on-call infectious disease physician will alert the Lab by phone (661-326-2442) of a suspected Ebola patient ("Code 300"), including patient name, date-of-birth, MRN ...	316
 Once notification is received in the Lab, Lab personnel on duty will initiate notification of key lab personnel.	316
 Lab Test Availability for EVD Patients:	316
 Due to the hazardous nature of EVD infections, the Laboratory will offer a limited menu of tests available for suspected patients:	316
o Sendout for Los Angeles County Public Health Department:	316
Ebola Real-Time RT-PCR (Sendout)	317
o Performed in-house:	317
Complete Blood Count (CBC)	317
Basic Metabolic Panel (BMP)	317
Liver Function Test (LFT)	317
UA w/o microscopic (UA)	317
Arterial Blood Gas Critical Care Panel (ABG)	317
BionaxNOW Malaria Kit	317
BD Directigen EZ Influenza A+B	317
 Specimen Collection:	317
 General Guidelines	317
o NO SPECIMENS ARE TO BE SENT DIRECTLY TO THE LABORATORY FOR ANY SUSPECTED OR CONFIRMED EVD PATIENTS.	317
o Specimen collections for patients suspected of EVD or HID infections will be only performed by designated Physician or Nursing personnel inside of the designated EBV patient room in the Direct Observation Unit.	317
o Contact and Droplet precautions are to be utilized, and specimen collection personnel are to adhere to Ebola/HID PPE requirements.	317
o No specimen collections for suspected EVD patients will be performed by Laboratory phlebotomy staff.	317
o Designated laboratory personnel will bring the required transport supplies directly to the designated EVP patient room in DOU (room 2436).	317
o All phlebotomy procedures will be followed as usual, including donning of PPE, patient identification and phlebotomy, and then removal of PPE. There should always be a second health care provider available to assist the staff member collecting speci...	317
o Limit the use of sharps, and use only plastic vacutainer tubes for all blood specimens.	317
o Following specimen collection and prior to labeling, liberally disinfect all sample tubes and containers with a hospital approved disinfectant (e.g. CaviCide or PDI Super Sani-Cloth Germicidal Disposable wipes). Remove any blood residues from outsid...	317
o All specimens must be properly labeled with patient name, MRN, DOB, date and time of collection and ID of the person collecting the samples.	317
o Completed manual requisitions for tests to be performed should be given to Lab testing personnel prior to specimen transport. Requisitions should be completed by physician or nursing personnel who are not directly attending to EVD patient to avoid p...	317
 Specimen Containers:	318
o For each test, use the corresponding containers listed in the table below:	318
 Specimen Transport	318
 General Guidelines:	318
o no specimens are to be sent directly to the laboratory for any suspected or confirmed evd patients.	318
o Specimens that are significantly contaminated or leaking should not be transported or used for lab testing and should not leave the patient’s room until properly disinfected and disposed of by EVS.	318
o Prior to transport of any Lab specimens, disinfect exterior of sealed plastic biohazard bag(s) prior to transfer to specimen transport container using a hospital approved disinfectant.	318
o Once specimens are placed in secondary containers, secondary containers should be disinfected with a hospital approved disinfectant.	318
 Transport of Specimens for Ebola RT-PCR Confirmation Testing:	319
o Prior to transport, all blood samples will be contained in plastic collection tubes, sealed inside a leak-proof sealed plastic bag, then enclosed within a secondary durable leak-proof plastic container containing absorbent material, and finally plac...	319
o Prior to closure, place shipping manifest and completed test requisition inside of cardboard box.	319
o No samples will leave the HID Containment area until they are fully sealed, disinfected, packaged and ready for shipment.	319
o Packages ready for shipment will be hand-delivered to the Lab Client Services area using the secured stairwell next to DOU room 2428 (the stairwell directly connects to the Lab and is free of patient traffic). No specimens will be transported via th...	319
o PPE is to be worn during transport of packages between patient room and Laboratory Client Service area.	319
o Once sealed, no packages will be opened outside of HID containment area.	319
o Personnel and foot traffic in area between patient room and Laboratory area should be minimized during times of package transport.	319
o Any specimen spills or exposures during transport of specimens between patient room and lab area will immediately be reported to HID Incident Command Team and EVS.	319
o Once courier picks up package, a Lab employee will escort courier personnel to their vehicle to ensure that no incidents with package occur. Any incident will immediately be reported to HID Incident Command Team and EVS.	319
o Specimens for Ebola RT-PCR testing will be sent to the Los Angeles County Public Health Department (LAC) for testing – please see Addendum A in Lab Policy LAB-EC-100 for instructions on sending specimens to LAC.	319
o Confirmation testing of positive specimens for EVD will be sent to the Center for Disease Control and Prevention (CDC) for further evaluation – please see Addendum B in Lab Policy LAB-EC-100 for instruction on sending specimens to the CDC.	319
 Transport of Specimens for In-house Performed Lab Testing:	319
o All samples will be transported in a clearly labelled biohazard bag, enclosed within a secondary durable leak-proof container prior to transport to Lab testing room.	319
o Specimens and containers for in-house testing will be hand-delivered to the HID Lab testing room (2428), which is in close proximity of the HID patient room, and no specimens will be transported via the pneumatic tube system.	319
o PPE is to be worn during transport of specimen containers between patient room and lab testing room.	320
o Personnel and foot traffic in area between patient room and Lab testing room should be minimized during times of specimen transport.	320
o Any specimen spills or exposures during transport of specimens between rooms will immediately be reported to HID Incident Command Team and EVS.	320
o For further instructions regarding Lab test collections, specimen transport and handling, please refer to Laboratory Policy LAB-EC-501.00 - Collection, Transport, Handling and Disposal of Specimens for Patients Suspected of Ebola Virus Disease or Ot...	320
 Waste Management/Cleaning & Terminal Cleaning	320
 Waste Management	320
 Pathway Cleaning	320
 EVS shall clean the transport pathway and elevators per their usual protocols	320
o A higher level of cleaning/PPE is only required if contamination is observed (Said cleanings shall be conducted after consulting with Infection Control and Prevention).	320
 Patient Generated Waste	320
 ***NOTE: prior to disposing of any liquids, a quantity of our designated disinfectant will be poured into sed bio bag in order to disinfect any liquid placed in the bottom of the bag.	320
 Waste Container setup	320
 The primary container shall be red, impervious to moisture, and of strength sufficient to resist ripping, tearing, or bursting under normal conditions of use	320
 The primary container shall be marked “biohazard”	320
 The primary container shall be lined with 2 “ Biohazard” Red bags	320
 Sharps shall not be placed in the primary containers	320
 Sharps	320
o Sharps shall be discarded into a dedicated, rigid, leak-resistant, puncture-resistant and closeable container	320
 Removal of waste from patient room:	320
o The Nurse shall spray designated disinfectant into the primary bag and shall securely tie the bag	320
o The nurse shall then spray gesignated disinfectant into the secondary bag	320
o The Nurse shall then tie closed the second bag	320
o Upon removal of the primary waste bag from the container in the room the Nurse shall spray the exterior of the primary bag with SED designated disinfectant	320
o The primary bag shall be placed into a secondary bag located within a secondary container outside of the patient room.	321
o EVS personnel will then place SED Drum into waiting covered Bio hazardous Transport container	321
o EVS personnel will then transport SED waste via pre-appointed route to Autoclave area for proper disposal *NOTE** Security will lock down transport route prior to transport of waste	321
o Upon Arrival to autoclave area transport container exterior will be sprayed down with designated disinfectant	321
 Autoclave Process	321
o Autoclave Cart lined with Autoclave bag will be setup for placement of Primary Waste Bag(s)	321
o Transport Container will be opened and primary waste bag will be removed and placed into awaiting auto clave bag lined cart	321
o Autoclave bag on cart will then be securely closed and autoclave indicator tape will be placed on SED bag in a X pattern on the top of SED bag	321
o Autoclave cart will then be placed into autoclave for treatment of waste.	321
o Transport container interior will then be decontaminated with designated Disinfectant through Kai-Vac system.	321
o Container will then be reset for next Waste Removal cycle.	321
o When Autoclave cycle is completed indicator tape and temperature is checked to verify sterilization is completed *NOTE* 121 C/ 250 F for 15 mins for sterilization to occur	321
o Please see Addendum XXX for Autoclave process and Calibration form	321
o Once sterilization is verified waste is removed and placed into regular waste stream.	321
o *For Sharps:* the sharp container shall be sprayed (on the wall) with SED designated disinfectant, shall be removed from the wall and sprayed again.	321
o A cap will be placed onto SED sharps container and then placed into Category A DOT Waste drum.	321
o Sharps Waste drum will be transported down to Predetermined Secure Hazardous Waste holding area until pickup from Stericycle occurs.	321
o EVS Personnel will secure lid to barrel with Duct Tape placed from top of lid to barrel in a double X Pattern	321
o EVS Personnel shall ensure that said drum is labeled “Category A DOT SHARPS Waste”	321
o Labeling on all drums in the secure storage area shall be checked and logged	321
o Upon Stericyles’ arrival, all Labeled drums shall be Package per DOT Standards of Category A Waste by Stericycle and then loaded onto Stericyles’ trucks, a manifest shall be completed	322
 Laboratory Waste	322
o Lab Personnel place waste in 20 gallon step-on container which is lined with a Red Biohazard Bag.	322
o Lab Personnel will notify Site manager that waste will need to be removed upon next Waste Removal Cycle	322
o Waste removal process will be followed by Laboratory Personnel *NOTE* All glass will be placed within wall mounted Sharps Container for proper Disposal	322
 Patient Room Cleanings	322
o High touch surfaces and equipment shall be wiped down by the primary care providers	322
o When thorough cleanings are necessary, said cleanings shall be conducted by nursing staff with designated disinfectant	322
o Disposable cleaning products will be used for SED cleaning of room	322
 Terminal Cleaning	322
o Any room that was occupied by a confirmed EVD patient shall undergo an initial terminal cleaning by EVS	322
o Terminal cleaning will encompass the use of a designated disinfectant and the Kai-Vac System.	322
o Approximately 4-6 hours after the initial terminal cleaning has been completed, a second terminal cleaning shall take place	322
o 24 hours after the completion of the second terminal cleaning, the room may be used again	322
 Personal Protective Equipment	322
 All staff members treating a PUI of confirmed HID patient will don Level C PPE	322
 Hospital scrubs tops and pants	322
 Tyvek coverall	322
 Blue impermeable gown (worn over Tyvek Jumpsuit)	322
 Plastic boots	322
 1 pair of 12” Nitrile exam gloves	322
 1 pair of gloves	322
 Knee high booties	322
 PAPR (respirator)(battery, Belt, Hood)	322
 Educational/Awareness/Training/recertification	322
 All staff are educated to heighten their awareness of emerging infectious diseases and are cognizant of the geography of the current epidemic.	322
 Kern Medical staff are also educated as follows:	322
o Refrain from touching the patients such as shaking hands or other greetings that involve person-to-person contact	322
 Staff is educated to understand that HID’s can be a very stigmatizing illness. Suspected and confirmed patients may need psychosocial support. At every encounter, staff will be mindful of how the patient is feeling, will communicate clearly, and wil...	323
 Only staff members who received training from Infection Prevention and Control are directly or indirectly involved in the care of PUI’s and confirmed HID patients.	323
 Staff members directly involved in direct patient care or handling of patient specimens receive initial certification training for donning/doffing appropriate PPE and are recertified thereafter.	323
 Management of exposures	323
 Monitoring Exposure Incidents: All employees with potential or definite exposure to a pathogen infecting a patient being cared for in the hospital will be immediately evaluated on the unit by the on-call Infectious Disease physician. Employee health...	323
 Immediate Steps for Symptomatic Employees: HCP who develop sudden onset of fever, fatigue, intense weakness or muscle pains, vomiting, diarrhea, or any signs of hemorrhage should Not report to work or should be instructed to:	323
 Immediately stop working	323
 Notify their supervisor.	323
 Seek prompt medical evaluation and testing	323
 Comply with work exclusion until they are deemed no longer infectious to others.	323
 Immediate Steps for Asymptomatic Employees: HCP who had an unprotected exposure (not wearing recommended PPE at the time of patient contact or through direct contact to blood or body fluids) to a patient with any HID and is not experiencing any sym...	323
 Notify their supervisor	323
 Seek prompt medical evaluation and testing	323
 Complete symptom and fever monitoring for 30 days after the last known exposure.	323
 Report any onset of symptoms or fevers to employee health nurse and PMD	323
 Symptom Tracking: All employees involved in direct or indirect patient care or waste management are required to complete symptom surveys twice daily for 30 days.	323
 Monitoring for Acute Illness: All employees who have recently cared for a patient in the unit and experience symptoms of an acute infectious disease (e.g., fever, cough, new rash, nausea, vomiting, diarrhea, night sweats) will be immediately referre...	323
 Notification: Local and state health departments will be notified of any highly infectious disease exposure.	324
 Discharge Process	324
 Prior to the patient’s discharge, a family member or friend will be asked to bring clean clothing to the hospital, which will be placed in ____.	324
 Clean surgical scrubs and socks/slippers will be placed in a sealed bag and will be brought into the patient room.	324
 On the day of Patient’s discharge, the following will occur in the Hot Zone	324
 Patient takes a shower	324
 After shower, patient will stand on clean towel in bathroom and don clean surgical scrubs	324
 After drying feet, patient dons hospital socks/slippers	324
 Patient dons long surgical booties over shoe covers	324
 Patient dons one pair of gloves	324
 Patient will then walk to door of patient room and carefully remove surgical booties and discard them in the regulated medical waste container	324
 Patient will open door with bleach SaniWipe (in glove hand)	324
 The following will occur in the Warm Zone	324
 Patient will remove gloves, clean hands with alcohol gel then don clean gloves	324
 Patient will sit on stool and carefully remove one shoe cover and sock and discard into regulated medical waste container	324
 Patient will then don clean sock and (without placing foot on the floor in the warm zone), put clean foot into the cold zone	324
 Patient will carefully remove second shoe cover and sock and discard into the regulated medical waste container	324
 Patient will don second clean sock (without placing second foot on the floor in the warm zone) stand in the cold zone	324
 The following will occur in the Cold Zone	324
 Patient will carefully stand in the cold zone, doff gloves and clean hands with alcohol gel	324
 Patient will walk to the donning room	324
 The following will occur in the donning room	324
 Patient will take another shower	324
 Patient will put on personal clothing	324
 Room Recovery Process	324
 Deactivation of the HICS due to a PUI rule out	324
 The command Center will facilitate an “ Code 300 All Clear” HICS alert	324
 The Command Center shall coordinate the following	324
o EVS will clean the DOU unit	324
o EVS shall restock Bleach SaniWipes	324
o Central Supply shall immediately restock HID units to par levels of supplies/PPE	324
 Deactivation of the HICS due to the discharge of an EVD patient	325
 The Command Center will facilitate a “Code 300 all clear” alert	325
 Terminal cleaning shall occur as follows	325
o Any room that was occupied by confined EVD patient or any lab used to process specimens shall undergo an initial terminal cleaning by EVS	325
o Approximately 4-6 hours after the initial terminal cleaning has been completed, a second terminal cleaning shall take place	325
o 24 hours after the completion of the second terminal cleaning, the room may be used again	325
 The command center shall coordinate the following	325
o Central supply shall immediately restock HID carts to par level of supplies	325
o EVS shall restock Bleach SaniWipes and shall change bed linens, etc. 24 hours after the second terminal cleaning	325
 Post Mortem Care	325
 To be handled by the Kern County Public Health Department	325
 SPECIAL CONSIDERATIONS:	325
o Pediatric Considerations	325
 Treatment	325
(1) Patients up to the age of 18 will be treated as pediatric patients	325
i) A Pediatric Physician will be the first responder and initially triage and treat a pediatric PUI	325
ii) The following equipment/supplies may be necessary:	325
-Bed, Crib, incubator, or warmer	325
-Broselow or neonatal Crash Cart	325
-Pediatric/Neonatal Vent(Avea) / supplies / Oscillator / VDR	325
-Ambu-bags with age appropriate face masks	325
-IV pump(s) with pediatric face masks	325
-Pediatric and infant IV insertion supplies (i.e., IV catheters and butterflies)	325
- Portable suction	325
- Diapers/Wipes	325
-Formula and oral rehydration solutions	325
o Adults accompanying pediatric patients	325
 Generally, Kern Medical will not allow anyone other than a PUI or confirmed HID patient into the “Hot” zone of the isolation unit.	325
 The need to allow a parent, guardian, caretaker, etc. into the “Hot Zone” to calm and/or comfort a child shall be determined on a case-by-case basis by the clinical team, Infection Prevention, and Hospital leadership	325
 If a parent/caretaker is permitted to enter an isolation room with the patient, the parent/caretaker will have the risks associated with entering the room explained to him/her.	325
 Just-in-time training on donning/doffing PPE will be provided to the patient/caretaker (the level of PPE shall be determined by the Kern Medical Infection Prevention Department)	325
 Any Parent, guardian, caretaker permitted into the Isolation Room will have their temperatures monitored twice daily by the Kern County Public Health Department (KCDPH) for symptoms until 30 days after last exposure to the pediatric HID patient.	326
o Considerations for women of child bearing age	326
 For any PUI, for whom there is the possibility of pregnancy (sexually active female of child bearing age), a urine pregnancy test will be completed immediately following isolation.	326
o Considerations for a Pregnant PUI	326
 L&D HID card, will be available from Central Supply	326
 The following Labor and Deliver procedures shall be followed:	326
1. An OBGYN consult is required to assess status and fetal well-being	326
2. If the patient is not in labor, Fetal-maternal surveillance/ management will be provided by OB and Maternal Fetal Medicine	326
3. If the patient is in active labor, or goes into labor during isolation, management will be provided by OB and preparations for delivery will commence.	326
4. Assessment by OB will be on-going. If a complication develops, the Providers (OB and Anesthesia) will collaborate about the safest mode of delivery.	326
5. Those patients who identify themselves as pregnant with known gestational age will be triaged according to gestational age and clinical status. These patients will be transported and treated in room 2430.	326
 Those patients who identify themselves as pregnant or who are obviously clinically pregnant but of unknown gestational age:	326
1. Will be transported and treated in room 2430.	326
2. Fetal-maternal consult will be provided by OB and Maternal Fetal Medicine.	326
o Other considerations	326
 Immediate access to Blood Bank shall be available as hemorrhage is more common even in NSVD’s	326
 NICU care may be needed for the infant	326
 Surgical and invasive Procedures	326
 If suspected or confirmed EVD patient requires surgery or any other invasive procedure is required, the locations of said procedures shall be determined on a case-by-case basis.	326
 Nutrition Services	326
 Assessment	326
o If nutritional assessment is needed, communication will be coordinated through nursing, via phone system.	326
o If a translator is required from nursing station, the dietician will call the translator line and have the translator call the patient’s room for nutritional assessment.	327
 Food orders	327
 Nursing staff will communicate order to Dietary	327
 Tray ticket will specify Isolation/Disposable Tray Only	327
 Tray will be delivered to the designated unit	327
 Nursing will deliver tray to patient.	327
POLICY	337
PROCEDURE	337
EM .02.02.05 (5) the plan identifies means for radioactive, biological, and chemical isolation and decontamination:	350
EM .02.02.05 (7-9) Kern Medical establishes processes for controlling entrance into and out of the health care facility during emergencies:	350
Part B: Decision to Shelter-in-Place	380
Part C: Decision to Evacuate	381
Form B: Transportation Log for Evacuated Patients	392
 General Recommendations for Hospitals	412
II. Chemical Decontamination	414
 Algorithm for Chemical Decontamination in a Hospital Setting	414
III. Radiological Decontamination	421
 Treatment of Radiological Contamination	421
 or	423
 Expert radiological consultation may include the following:	424
IV. Biological Decontamination	427
 Decontamination of Patients and Environment2	427
 Preferred Staff Protection in Biological Decontamination	427
 Gloves	427
 Facial Protection	428
 Gowns	428
V. Water Containment and Run-Off	429
 Addressing Water Containment and Run-Off During Decontamination Operations	429
VI. Evidence Collection – Recommended Procedure	432
 Collection of Belongings - Valuables	432
 Collection of Belongings - Clothing	432
 Other Considerations in Evidence Collection	433
 Decontamination of Valuables and Belongings	433
Purpose: The Incident Action Plan (IAP) Quick Start is a short form combining HICS Forms 201, 202, 203, 204 and 215A. It can be used in place of the full forms to document initial actions taken or during a short incident. Incident management can expa...	439
 The 14 essential ICS features are listed below:	508
Professionalism:	509
 Accountability: Effective accountability at all jurisdictional levels and within individual functional areas during incident operations is essential. To that end, the following principles must be adhered to:	509
 Unity of Command: Each individual involved in incident operations will be assigned to only one supervisor.	509
 Span of Control: Supervisors must be able to adequately supervise and control their subordinates, as well as communicate with and manage all resources under their supervision.	509
 Dispatch/Deployment: Personnel and equipment should respond only when requested or when dispatched by an appropriate authority.	509
 Flexibility does not mean that the ICS feature of common terminology is superseded. Note that flexibility is allowed within the standard ICS organizational structure and position titles.	511
 The collection, analysis, and sharing of incident-related intelligence are important elements of ICS.	519
 Typically, operational information and situational intelligence are management functions located in the Planning Section, with a focus on three incident intelligence areas: situation status, resource status, and anticipated incident status or escala...	519
 Regardless of how the Intelligence/Investigations Function is organized, a close liaison will be maintained and information will be transmitted to Command, Operations, and Planning. However, classified information requiring a security clearance, sen...	520
 The Unified Command organization consists of the Incident Commanders from the various jurisdictions or agencies operating together to form a single command structure.	521
 Authority	522
 Advantages of Using Unified Command	522
 The Planning “P”	525
 The ICS uses a series of standard forms and supporting documents that convey directions for the accomplishment of the objectives and distributing information. Listed below are the standard ICS form titles and descriptions of each form:	531
BIOTERRORISM RESPONSE OVERVIEW	543
What is Bioterrorism?	543
Recognizing a Bioterrorist Event	543
Federal Response to Bioterrorism	544
Role of the California Department of Health Services (CDHS)	545
SECTION 2 – BIOTERRORISM AGENTS BY CDC RECOMMENDATIONS FOR ISOLATION	546
STANDARD PRECAUTIONS	546
OSHA Bloodborne Pathogens Standard	546
Patient Placement	546
Visitors	547
Personal Protective Equipment (PPE)	547
Handwashing	548
Transporting Patients	548
Laboratory Specimens	548
Dietary Trays	548
Patient Care Equipment	548
Housekeeping	548
Soiled Linen	548
Patient’s Clothing	549
Biohazard waste	549
Deceased Patient	549
CONTACT PRECAUTIONS	549
Patient Placement	549
Visitors	549
ANTHRAX (BACILLUS ANTHRACIS) OVERVIEW	550
Naturally Occurring Anthrax	550
Bioterrorism Epidemiology	550
1. Incubation Period	551
Clinical Presentation	551
Diagnosis	552
Treatment (See tables 1 and 2)	552
Vaccination	552
Isolation	553
Table 1: Anthrax – Antibiotic Therapy for Contained Casualty Settings	554
Table 2: Anthrax – Antibiotic Therapy for Mass Casualty Settings or Post- Exposure Prophylaxis	555
ANTHRAX – QUICK REFERENCE	556
Bioterrorism Epidemiology:	556
Incubation Period:	556
Clinical Disease:	556
Diagnosis:	556
Treatment: (See overview)	556
Prophylaxis: (See overview)	556
Isolation:	556
ANTHRAX – FREQUENTLY ASKED QUESTIONS (FAQ)	557
What is anthrax?	557
Is anthrax spread from person to person?	557
How will I know if I was exposed to the bacteria?	557
How soon will symptoms develop (incubation period)?	557
What are the symptoms of infection?	557
How is the infection treated?	557
How is the infection prevented?	557
How long should I take the antibiotic?	558
What should I do if I do not have symptoms?	558
How can I get more information?	558
ANTHRAX – HOME CARE INSTRUCTIONS	559
ANTHRAX – SCREENING FORM	560
Over the past 6 weeks, have you had any of the following symptoms or ailments? (Check all that apply).	560
Naturally Occurring Brucellosis	561
Bioterrorism Epidemiology	561
Incubation Period	561
Clinical Manifestations	561
Complications	562
Diagnosis	562
Treatment	562
Prophylaxis	563
Isolation	563
BRUCELLOSIS – QUICK REFERENCE	564
Bioterrorism Epidemiology:	564
2. Incubation Period:	564
Clinical Disease:	564
Diagnosis:	564
Treatment: (See overview)	564
Prophylaxis: (See overview) Isolation:	564
BRUCELLOSIS – FREQUENTLY ASKED QUESTIONS (FAQ)	565
What is Brucellosis?	565
How soon will the symptoms develop (incubation period)?	565
What are the symptoms of infection?	565
How is the infection treated?	565
How is the infection prevented?	565
How long should I take the antibiotic?	565
What should I do if I do not have symptoms?	566
How can I get more information?	566
BRUCELLOSIS – HOME CARE INSTRUCTIONS	567
BRUCELLOSIS – SCREENING FORM	568
Over the past 3 weeks, have you had any of the following symptoms or ailments? (Check all that apply).	568
Naturally Occurring Botulism	569
Bioterrorism Epidemiology	569
Incubation Period	569
Clinical Presentation	570
Diagnosis	571
Treatment	571
Isolation	572
BOTULISM – QUICK REFERENCE	573
Bioterrorism Epidemiology:	573
Incubation Period:	573
Clinical Disease:	573
Diagnosis:	573
Treatment: (See overview)	573
Isolation:	573
BOTULISM – FREQUENTLY ASKED QUESTIONS (FAQ)	574
What is botulism?	574
Is botulism spread from person-to-person?	574
How will I know if I was exposed to the toxin that causes botulism?	574
How soon will symptoms of botulism develop (incubation period)?	574
What are the symptoms of botulism?	574
How is botulism treated?	574
How is botulism prevented?	574
What should I do if I have symptoms of botulism?	575
How can I get more information?	575
BOTULISM – HOME CARE INSTRUCTIONS	576
BOTULISM - SCREENING FORM	577
Over the past 2 weeks, have you had any of the following symptoms or ailments? (Check all that apply).	577
Q FEVER (COXIELLA BURNETII) OVERVIEW	578
Naturally Occurring Q Fever	578
Bioterrorism Epidemiology	578
Incubation Period	578
Clinical Manifestations	578
Complications	578
Differential Diagnosis	579
Diagnosis	579
Treatment	579
Prophylaxis	579
Isolation	579
Q FEVER – QUICK REFERENCE	580
Bioterrorism Epidemiology:	580
Incubation Period:	580
Clinical Disease:	580
Diagnosis:	580
Treatment: (See overview)	580
Prophylaxis: (See overview)	580
Isolation:	580
Q FEVER – FREQUENTLY ASKED QUESTIONS (FAQ)	581
What is Q fever?	581
Is Q fever spread from person to person?	581
How will I know if I was exposed to the bacteria?	581
How soon will the symptoms develop (incubation period)?	581
What are the symptoms of infection?	581
How is the infection treated?	581
How is the infection prevented?	581
How long should I take the antibiotic?	582
What should I do if I do not have symptoms?	582
How can I get more information?	582
Q FEVER – HOME CARE INSTRUCTIONS	583
Q FEVER – SCREENING	584
Over the past 2 weeks, have you had any of the following symptoms or ailments? (Check all that apply).	584
TULAREMIA (FRANCISELLA TULARENSIS) OVERVIEW	585
Naturally Occurring Tularemia	585
Laboratory	586
Complications	587
Differential Diagnosis	587
Treatment (See Tables 1 and 2) Prophylaxis	587
Isolation	587
Table 2: Tularemia – Antibiotic Therapy for Mass Casualty Settings and Post- exposure Prophylaxis	588
TULAREMIA – QUICK REFERENCE	590
Bioterrorism Epidemiology:	590
Incubation Period:	590
Clinical Disease: (Six classic forms of tularemia that may overlap)	590
Diagnosis:	590
Treatment: (See overview)	590
Prophylaxis: (See overview)	590
Isolation:	590
TULAREMIA – FREQUENTLY ASKED QUESTIONS (FAQ)	591
What is tularemia?	591
Is tularemia spread from person-to -person?	591
How will I know if I was exposed to the bacteria?	591
How soon will symptoms develop (incubation period)?	591
What are the symptoms of infection?	591
How is the infection treated?	591
How is the infection prevented?	591
How long should I take the antibiotic?	592
What should I do if I do not have symptoms?	592
How can I get more information?	592
TULAREMIA – HOME CARE INSTRUCTIONS	593
TULAREMIA – SCREENING FORM	594
Over the past 3 weeks, have you had any of the following symptoms or ailments? (Check all that apply).	594
DROPLET PRECAUTIONS	595
Patient Placement	595
Respiratory Protection	595
Transporting Patients	595
Visitors	595
PLAGUE (YERSINIA PESTIS) – OVERVIEW	596
Naturally Occurring Plague	596
Bioterrorism Epidemiology	596
Incubation Period	596
Clinical Presentation	596
Complications	596
Diagnosis	597
Treatment (See Tables 1 and 2)	597
Isolation	597
Table 1: Plague – Antibiotic Therapy for Contained Casualty Settings	598
Table 2: Plague – Antibiotic Therapy for Mass Casualty Settings and Post- exposure Prophylaxis	598
PLAGUE – QUICK REFERENCE	600
Bioterrorism Epidemiology:	600
Transmission:	600
Incubation Period:	600
Clinical Disease:	600
Diagnosis:	600
Treatment: (see overview)	600
Prophylaxis: (see overview)	600
Isolation:	600
PLAGUE – FREQUENTLY ASKED QUESTIO NS (FAQ)	601
What is plague?	601
Is plague spread from person-to-person?	601
How will I know if I was exposed to the bacteria?	601
How soon will symptoms develop (incubation period)?	601
What are the symptoms of infection?	601
How is the infection treated?	601
How is the infection prevented?	601
How long should I take the antibiotic?	602
What should I do if I develop symptoms of infection while I am taking the antibiotic?	602
What should I do if I do not have symptoms?	602
How can I get more information?	602
PLAGUE – HOME CARE INSTRUCTIONS	603
PLAGUE – SCREENING FORM	604
Over the past 3 weeks, have you had any of the following symptoms or ailments? (Check all that apply).	604
OSHA Bloodborne Pathogens Standard	605
Training	605
Vaccination	605
Isolation Recommendations	606
Room Placement	606
Visitors	607
Personal Protective Equipment (PPE)	607
Handwashing	608
Transporting Patients	608
Laboratory Specimens	608
Patient Care Equipment	608
Environmental Services	608
Soiled Linen	609
Biohazard Waste	610
Deceased Patient	610
SMALLPOX (VARIOLA) – OVERVIEW	611
Naturally Occurring Smallpox	611
Bioterrorism Epidemiology	611
Incubation Period	611
Transmission	611
Clinical Presentation	612
Diagnosis	613
Differential Diagnosis	613
Treatment	613
Vaccination	615
Isolation	616
SMALLPOX – QUICK REFERENCE	617
Incubation Period:	617
Clinical Disease:	617
Diagnosis:	617
Differential Diagnosis:	617
Treatment:	617
Prophylaxis:	617
Isolation:	617
SMALLPOX – FREQUENTLY ASKED QUESTIONS (FAQ)	618
What is smallpox?	618
Is smallpox spread from person-to-person?	618
How will I know if I was exposed to the virus?	618
How soon will the symptoms develop (incubation period)?	618
What are the symptoms of the infection?	618
How is the infection treated?	618
How is the infection prevented?	618
How will I know if I need to be vaccinated?	619
How will I know where to go to get the vaccination?	619
Do people get sick from the vaccination?	619
What can I do to keep from getting infected?	619
SMALLPOX - HOME CARE INSTRUCTIONS	620
SMALLPOX – SCREENING FORM	621
Over the past 3 weeks, have you had any of the following symptoms or ailments? (Check "yes" to all that apply).	621
SMALLPOX – SPECIMEN COLLECTION	622
Safety Recommendations	622
Pustule/Vesicle Specimens	622
Scabs Specimens	622
Biopsy Specimens	622
Blood Specimens	623
Autopsy Specimens	623
Labeling	623
SMALLPOX – INFORMATION ABOUT VACCINATION	624
Vaccine Effectiveness	624
Target Populations	624
Previous Vaccination	624
Vaccine Contraindications	625
Vaccine Administration	625
Vaccine Response	625
Vaccination Site Care	626
Complications:	627
SMALLPOX VACCINATION CONSENT FORM	628
I have had the opportunity to read and I understand that complications can occur after receiving the vaccination. I understand the instructions for caring for the vaccination site. I have had the opportunity to ask questions related to smallpox vaccin...	628
Lot Number: Expiration Date:	628
SMALLPOX VACCINATION INSTRUCTIONS	629
Supplies	629
Administrative Requirements	629
Reconstitution of Vaccine with Commercially Packaged Diluent	629
Administration of Reconstituted Vaccine	630
Reprocessing Bifurcated Needles	631
Frequency of Reuse	631
Multi-dose Vials	631
VIRAL HEMORRHAGIC FEVER (VHF): RECOMMENDATIONS FOR ISOLATION	632
Introduction	632
OSHA Bloodborne Pathogens Standard	632
Training	633
Isolation Recommendations	633
Room Placement	633
Visitors	634
Personal Protective Equipment (PPE)	634
Handwashing	635
Transporting Patients	635
Laboratory Specimens	635
Patient Care Equipment	635
Environmental Services	635
Management of Blood and Body Fluids	636
Soiled Linen	636
Biohazard Waste	637
Deceased Patient	637
VIRAL HEMORRHAGIC FEVER (VHF) – OVERVIEW	638
Bioterrorism Epidemiology	639
Incubation Period	639
Clinical Presentation	639
Diagnosis	639
Differential Diagnoses	640
Medical Management	640
Isolation	641
Table 1: VHF Differential Diagnostic Variables	642
VIRAL HEMORRHAGIC FEVER (VHF) - QUICK REFERENCE	643
Incubation Period:	643
Clinical Disease:	643
Diagnosis:	643
Treatment:	643
Prophylaxis: None Isolation:	643
VIRAL HEMORRHAGIC FEVER (VHF) – FREQUENTLY ASKED QUESTIONS (FAQ)	644
What are viral hemorrhagic fevers?	644
Is VHF spread from person-to-person?	644
How soon will symptoms develop (incubation period)?	644
What are the symptoms of infection?	644
How is the infection treated?	644
What should I do if I DO NOT have symptoms?	644
How can I get more information?	644
VIRAL HEMORRHAGIC FEVERS (VHF) – HOME CARE INSTRUCTIONS	645
VIRAL HEMORRHAGIC FEVERS (VHF) – SCREENING FORM	646
Over the past 3 weeks, have you had any of the following symptoms or ailments? (Check all that apply).	646
INTERNAL BT RESPONSE TEAM NOTIFICATION MATRIX	648
SUMMARY OF POTENTIAL BT DISEASE SYNDROMES	650
LABORATORY PACKAGING AND TRANSPORTING REQUIREMENTS	656
Precautions	656
Packaging	656
Transporting	656
1. Purpose:	668
2. Assumptions:	668
3. Definitions:	669
4. Surge Level Activation:	670
2. Activation:	671
3. Determine Size and Scope:	671
4. Internal Alert:	671
I. Staffing	671
Acknowledgements	2
Plan Authorization	2
Plan Maintenance	3
Table of Contents	4
General	6
Purpose	6
Policy	6
Scope	7
Key Terms	8
ALTERNATE SITES/FACILITIES	8
CONTINUITY OF OPERATIONS (COOP)	8
EMERGENCY OPERATIONS CENTER (EOC)	8
EMERGENCY PREPAREDNESS COORDINATOR (EPC)	8
EMERGENCY MANAGEMENT GROUP (EMG)	8
Kern County Health Care Coalition (KCHCC)	8
ESSENTIAL FUNCTIONS (EF)	8
HAZARD MITIGATION	8
HAZARD VULNERABILITY ANALYSIS (HVA)	10
HOMELAND SECURITY EXERCISE AND EVALUTION PROGRAM (HSEEP)	10
HOSPITAL INCIDENT COMMAND SYSTEM (HICS)	10
MULTI-HAZARD APPROACH	10
NATIONAL INCIDENT MANAGEMENT SYSTEM (NIMS)	10
PHASES OF EMERGENCY MANAGEMENT	10
STANDARD OPERATING PROCEDURES (SOP)	10
1 MITIGATION	11
1.1 Introduction	11
1.2 Hazard Vulnerability Analysis	11
1.2.1 Hazard and Vulnerability Analysis	11
1.3 Hazard Mitigation	12
1.4 Risk Assessment	12
1.5 Insurance Coverage	13
2 PREPAREDNESS	13
2.1 Introduction	13
2.2 Emergency Operations Plan	14
2.3 National Incident Management System (NIMS)	15
2.4 Integration with Community-wide Response	16
2.4.1 Coordination with Government Response Agencies	17
2.4.2 Coordination with Emergency Responders	17
2.4.3 Mutual Aid	18
2.4.4 Relationship to Hospital Coordination System	19
2.5 Roles / Responsibilities – Disaster Recall list (HR) EM.02.01.01(1)/EM02.01.01(2)	20
2.6 Initial Communications and Notifications	22
K.1 – Communications Equipment Inventory for Communication Resource List.	23
e. Refer to Appendix P.4 – Incident Command System.	23
2.7 Continuity of Operations	24
L.1 – Health Care Alternate and Referral Facilities.	24
2.8 Hospital Patient Surge Preparedness	26
2.9 Incident Medical Resources	28
2.10 Incident Mental Health	29
2.11 Public Information / Risk Communications	30
2.12 Training, Exercises and Plan Maintenance	30
2.12.4 Plan Development and Maintenance	33
Appendix H.18 – Emergency Codes.	33
3 RESPONSE	33
3.1 Introduction	33
3.2 Response Priorities	33
3.3 Alert, Warning and Notification	33
3.4 Response Activation and Initial Actions	34
3.5 Emergency Management Organization	35
3.6 Emergency Operations Center (EOC) Operations	38
3.7 Medical Care	38
1.	40
3.8 Acquiring Response Resources	42
3.9 Communications	43
3.9 Public Information / Crisis Communications	44
3.10 Security	51
3.11 Mental Health Response	52
3.13 Volunteer / Donation Management	53
3.14 Response to Internal Emergencies	54
3.15 Response to External Emergencies	59
4 RECOVERY	62
4.1 Introduction	62
4.2 Documentation	63
4.3 Inventory Damage and Loss	63
4.4 Lost Revenue through Disruption of Services	63
4.5 Cost / Loss Recovery Sources	63
4.6 Psychological Needs of Staff and Patients	64
4.7 Restoration of Services	64
4.8 After-Action Report	64
4.9 Staff Support	64
4.10 Psychological Needs of Staff and Patients	64
4.11 Restoration of Services	64
4.12 After-Action Report	64
4.13 Staff Support	65
List of Appendices	66
Appendix A TJC Standards	66
Appendix F Organizational Tools	66
Appendix J.1 Staff Call Back	67
Appendix M	67
Appendix P.9 After Action Report	68
Appendix S Post Incident Assessment	68
Appendix S.1 Damage Assessment Form	68
Appendix Q Volunteer and Donations Procedures	68
Appendix Q.1 Volunteer Management Policies and Procedures	68
Purpose 3	675
Assumptions 3	675
Definitions 4-6	675
Surge Capacity and Rationale 7	675
Surge Level Activation 8-9	675
1. Purpose:	676
2. Assumptions:	676
3. Definitions:	677
4. Surge Level Activation:	679
2. Activation:	679
3. Determine Size and Scope:	679
4. Internal Alert:	679
Staffing	679
B. LEVEL II SURGE (Local):	680
2. Activation:	680
3. Determine Size and Scope:	680
4. Internal Alert	680
5. Staffing	680
6. Bed Capacity	680
7. Communicate Status	681
8. Communicate Resource Needs	681
C. LEVEL III SURGE (regional):	681
2. Activation:	681
d. Incident Management Team Requirements:	681
3. Determine Size and Scope	681
4. Internal Alert	682
5. Staffing	682
D. LEVEL IV SURGE (REGION/STATE):	682
2. Activation	682
3. Determine Size and Scope	682
4. Internal Alert	682
5. Staffing	683
6. Bed Capacity	683
7. Communicate ED/Hospital Status	683
8. Communicate Resource Needs	683
9. Participate in Operational Area/regional/statewide Planning Sessions	683
Surge Configuration Table for Inpatient Care:	685
Surge Configuration Table for Triage Care:	686
NOTE:	686
1. Mass Casualty Incidents (Five or more patients).	687
c. Support requirements:	687
d. Set-Up expectations:	687
2. Small Casualty system (	687
For Personnel, Supplies, Equipment, Pharmaceuticals	689
Kern County MHOAC	689
XXXXX or XXXXXXXX	689
Personnel:	689
Specialty Quantity	689
Kern Medical Emergency Communication Strategies	691
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