Welcome to ZZ Cape Fear Valley Health System

Functional Annexes

The Functional Annexes provide guidance relative to the delivery of a service or performance of a broad task.  The functional annexes are oriented towards operations and are targeted toward those most likely to perform the tasks.

Hospital Incident Command System (HICS)
Cape Fear Valley Healthcare System (CFVHS) adopted the Hospital Incident Command System (HICS) / National Incident Management System (NIMS) models for its EOP to provide for a scalable response to different types of incidents.   These models along with department specific plans define how each department, as well as the Health Care System as a whole, responds to incidents.  When possible, CFVHS uses pre-identified Incident Management Teams (IMT) to quickly fill Incident Commander, Command Staff, and General Staff positions.

Although integrated into the community response, the Health Care System's response to an incident will most likely be in the form of a single incident command (Example structure below).  The HICS fits seamlessly into either an Area or Unified command structure as well.

Click Here to View the Incident Command Structure for Cape Fear Valley Health System

Incident Command (IC) utilizes one incident commander and is usually sufficient for incidents that involve only one agency or jurisdiction.

Incident management takes place in the Hospital Command Center (HCC).  The primary location of the HCC is the Skylight Room in the cafeteria.  This area is located centrally to the functions of the Health System, is pre-wired for emergency power, lighting, and phones, and provides natural access control points for security.  The secondary location is the Administrative Board Room.  The IC may establish the HCC at his or her discretion.  Labor pools and/or other staging areas shall also be established to deploy personnel as needed throughout the healthcare system.

Members of the Incident Management Team:

One of the many strengths of HICS is the ability for a skilled leader from the organization to assume an incident management role with little-to-no training.  The IC will select personnel on-duty at the time of the incident to fill activated HICS positions.  These leaders will conduct the initial response until properly relieved under the principles of ICS.  Trained members of the Incident Management Team (IMT) are, for the most part, pre-identified for specific HICS positions.  Staff understands that any one person might find themselves in any position during an emergency.

Communication –
Communication is key to the success of any incident response.  Effective communication between the health system and patients, visitors, and staff can, literally, save lives.  The elements of the communication plan include internal, external, notification, media relations, and operational communication (with the County EOC, with vendors, with physicians, etc).  While every situation is different, the health system will utilize any and every means of communication that is effective given the specific circumstances.

The Incident Commander is ultimately responsible for communications during an incident.  The Public Information Officer (PIO) manages all communications during an incident.

Media Relations -
The PIO coordinates all releases to the media regarding any emergency incident.  The PIO will schedule periodic briefs to the media to keep the public informed.  The health system will make every effort to accommodate the media as long as their presence does not impact patient care.

Internal -
Staff is notified that emergency response procedures are initiated by:

The overhead paging system called Code Triage or Code Triage: Standby;

A departmental phone tree initiated by the Vice Presidents;

A CFVHS Information line (See Resources)

The HCC maintains communication with all internal portions of CFVHS.  During an emergency the health system will communicate with its staff, its licensed independent practitioners and any established alternate care sites by any and all means available.  Depending on the situation, communication means may include telephone, e-mail, fax/faxination or overhead page as the primary means of communicating.  Cell phones serve as backup communication.

CFVHS has a backup “Power Failure Phone” system.  These phones will function when the regular phone system will not.  These phones are strategically placed throughout the health system.  The most up-to-date list of phone numbers and locations is located on the Infoweb or in the HCC.

The IC will hold periodic briefings to update staff.  The IC, through the PIO, will program general staff information on the electronic display systems located throughout the health system.

Several organizations throughout CFVHS, Engineering, Security and EMS have organic two-way radio capability.  Upon activation of the HCC, all users will clear the HCC channels for response use only.  The IC, through the Log Chief, will issue the HCC radios to appropriate individuals as required.  These radios must be returned to the HCC after the incident is cleared.

The HCC will be prepared to dispatch couriers (runners) with information to any unit / facility.

Employees can receive information at any time on the Employee Communication Hotline. This hotline can be accessed by employees outside of CFVHS at 615-7511 or internally at CFVHS at 7511.  Instructions to update the information on this line are located in the HCC alert book.

Employees or the public can receive information through the CFVHS website at www.capefearvalley.com. The information on the website will be updated by the HCC as required.

External -
Likewise, the health system will notify and communicate with external agencies by any and all means available.  The health system maintains a close relationship with the Cumberland County Office of Emergency Management and is the first agency to contact.

Establishing communication with Cumberland County EOC will be a priority as the HCC is being established.  Contact telephone numbers are located in the HCC and in the AOC and NS instructions. The IC will communicate the health system's status (current capabilities and limitations) to the County EOC as soon as possible.

Certain responses may require a CFV Liaison Officer to report to the County EOC.  The Liaison will be knowledgeable in all areas of CFVHS operations, is empowered to make decisions on behalf of the health system and will actively monitor the health system's status.

The Liaison Officer will use county telephone systems with cell phone backup.  The liaison and the IC will be prepared to use couriers if required.  Radio capability may be established through a combination of CFVHS EMS on UHF and 800mz radio systems. These systems are capable of 24/7 operations.

The HCC will maintain contact with other county agencies, such as local law enforcement and fire departments, as required.  Locations and contact numbers are in the HCC.  Telephones will be the primary means of communication. Radio will be used as back up.

For regional and larger events, Cumberland County Office of Emergency Management established a “view-only” account for Cape Fear Valley Health System on their Web-EOC software.  For access to this management tool, contact the County EOC for login information.

Patient Relations, in coordination with the PIO, has responsibility for communicating with our patients and their families.  Patient Relations will use normal operating policies and procedures as much as possible.  They will communicate any situational modifications or specific changes to the patients as soon as practicable.  Patient Relations will coordinate with the HCC for information relative to any established alternate care sites.

The Incident Commander is responsible for communications with the media.  The PIO will draft press releases for the IC's approval.  The PIO will manage routine media requests and other duties related to the media as assigned by the IC.

The health system establishes support relationships with vendors, suppliers, and the like.  Pre-planned procedures for advance deliveries, pushed-packages, and stat orders in case of an emergency situation are discussed with all established vendors.  CFV contracts include a stipulation that the health system, a critical piece of regional infrastructure, be considered a top priority during emergencies.

The health system maintains both formal and informal mutual-aid partnerships with regional healthcare organizations.  During an emergency the healthcare system would communicate:

A situational status report regarding its response, organization, and contact information;

Information on the specific HICS staff sections activated and their contact info;

A list of assets or resources that could be shared within the region.

Although “drastic times call for drastic measures, Cape Fear Valley Health System prides itself on supporting patients' rights and will make every effort to protect the privacy of ill or injured victims and their families during an emergency.  Any patient information situations or requests from outside agencies will be handled on a case-by-case basis within the guidelines of the law.  Deceased victims will be afforded the same consideration of privacy.

Resource Management
The Director, Central Supply is responsible for Resources and Asset Management.  The areas within the health system conducting supply chain operations are the Distribution Storeroom, Central Supply, and Purchasing.

Supply Chain Management maintains a minimum of 96 hours of medical and non-medical supplies on hand at Cape Fear Valley Health System.  In situations that offer advance warning, such as weather emergencies, Supply Chain Management personnel make arrangements with its Prime Vendors (PV) to have additional supplies delivered in advance of the event.  Emergencies that arise without advance warning which are anticipated to exceed 96 hours will be reacted to as follows:  Supply Chain Management personnel will contact the PV for immediate delivery.  PV has multiple alternate distribution locations identified to support Cape Fear Valley Health System in the event that the primary distribution center is unable to deliver due to the event.

The healthcare system maintains a stock of emergency preparedness supplies.  These items are stored in strategic locations throughout the health system and are inventoried on a semi-annual basis.  The health system conducts an annual review of the inventory process and documents the findings of the review.

Cape Fear Valley works closely with its partnering hospitals within the area and has agreements for assistance if necessary.  Cape Fear Valley Health System will assess resource and asset needs at Cape Fear Valley Health System and Highsmith-Rainey Specialty Hospital and will allocate as needed.  Other health care organizations in the community include Fort Bragg's Womack Army Medical Center and the VA Medical Center (both Federal facilities) on Ramsey Street.  These facilities will be contacted to assess their needs and their availability to provide support.

In accordance with the standing NCHA Memorandum of Agreement, Cape Fear Valley Health System will make every effort to support requesting hospitals outside of our community with supplies.  Central Supply will catalog all supplies shipped in order to request reimbursement at some point in time during the recovery phase.

During incidents, the health system will continue to monitor inventory levels using the real-time inventory control database.  In the event these systems are not operational, manual downtime processes will be followed.  Identification of critical supplies needed for specific events will be coordinated with clinical staff through the Hospital Command Center.  Once identified, Central Supply will place stat orders with the appropriate PV.

In the event the environment cannot support care, treatment, and services, Supply Chain Management will arrange transportation arrangements for medications, supplies, and equipment in collaboration with the Pharmacy Department and Clinical Technology Services.  Lifelink will coordinate transportation of patients and staff members.

Inventories – The healthcare system maintains a database for real-time accountability of assets.  Supply Management personnel conduct inventories as needed or as directed for specific requirements.

Emergency Management Supplies.  The healthcare system maintains a stock of emergency supplies purchased some years ago through an emergency preparedness grant.  These items are stored in strategic locations throughout the health system and are inventoried on a semi-annual basis.  The health system conducts an annual review of the inventory process and documents the findings of the review.

Safety
The safety of patients, staff and visitors cannot be compromised, especially during times of emergency.  If anything, emergency conditions require staff to be more aware of their surroundings and the potential hazards associated with them.  The Health System maintains a robust safety program, but reemphasizes these items for the EOP.

The Health System utilizes the following methods to manage risk and to mitigate safety issues in the event of an emergency:

Appointment of a Safety Officer in the HICS structure;

Provision of safety equipment, training and procedures to staff and visitors;

Use of engineering controls to remove or mitigate any hazards;

Use of warning devices and alarms;

Development and implementation administrative controls or procedures.

Safety reaches across all activities during an incident.  As such, there are safety activities throughout this plan in numerous annexes and appendices.

Security
The security of our patients, staff, and facility is paramount to any response provided under this plan.  Security planning is constant and ongoing as circumstances and situations change around the organization and the community.

CFVHS contracts for the security services provided the Health System.  The senior contract representative on-site serves as the CFV Security Director.

The Security Director conducts Advanced Contingency Planning, which includes:

Pre-identification of staff to incorporate into the organization on short notice;

Meeting periodically with local law enforcement officials to review plans' roles;

Available Resources.  Security operational plans are also reviewed and updated as needed.

1.The security contractor has access to normal shift personnel, off duty security officers, flex officers, company police (law enforcement) officers, and the Allied Barton (NC) Special Response Team, which draws resources from other AlliedBarton sites.  All have been trained and certified as require by the State of North Carolina and have been provided familiarization training for the Health System and its facilities and operations.

2.Community Security/Law Enforcement Resources.  The Cumberland County Sheriff and police chiefs of the cities of Fayetteville, Spring Lake and Hope Mills have committed to provide a certain number of law enforcement officers.  Additionally, resources of the NC National Guard could be available.  Requests for assistance from each of these agencies is made through the Cumberland County Emergency Operations Center or, if it has not been activated, the Cumberland County Office of Emergency Services.  After this initial contact, communication would be directly with the watch commander of each agency.  Staff provided by these external agencies would be used specifically to facilitate campus and/or facility lockdown support by being stationed at campus or facility entrances.  They would be directed to report to Security Base Operations, where they would team up with a regular security officer who would staff a special post with them.  The intent is to place them at those posts where law enforcement capabilities would be needed.  If required or requested, CFV IC would accept a liaison officer from participating departments.

3.Depending on the nature of the incident and threat, staff from Engineering, Environmental Services, and administrative staff (Patient Financial Services, Administration, etc.) could be called upon to assist Security staff.

4.Internal Staffing.  Security has an established staffing roster each week.  It may be supplemented with flex officers if additional officers were needed or an officer was not able to report to work.  Post orders are established and are available in Security Base Operations.

5.Campus and Facility Access Control.  If it became necessary to secure either the campus or any CFV facilities, Marketing would be directed to provide information to the media notifying the public.

a.Campus.  If directed by the Incident Commander to restrict access to the campus, the Security Chief/Security Director could arrange for personnel to man each of the entrances to the CFVMC campus.  Staff could be drawn from the resources listed above.  Depending on the circumstances, these posts might be directed to screen everyone approaching an entrance to the campus and grant entry only to certain people—i.e., staff, credentialed volunteers, etc.—or they may not permit anyone to enter the campus.  Emergency response vehicles will be granted access in all cases, unless improper use of the vehicle or subversion is suspected.  Vendors displaying proper CFVHS identification would likewise be granted access.

b.Facility.  If directed by the Incident Commander to restrict access to the campus, the Security Chief/Security Director could arrange for personnel to man each of the entrances to facilities on the CFVMC campus.  Staff could be drawn from the resources listed above.  Depending on the circumstances, these posts might be directed to screen everyone approaching an entrance to the facility and grant entry and exit only to certain people—i.e., staff, credentialed volunteers, etc.—or not to permit anyone to enter or leave the facility.  In a normal restricted entry situation, entrances would be reduce to those at the main lobby, Cancer Center lobby, Melrose, Occupational Health, Rehab lobby, employee entrance near Security Base, Pharmacy, Peds ED and Main ED.  These would be staffed while all others would be locked from the outside.  Employees would be instructed to direct people to these entrances and not to use other entrances, except for emergency egress.

6.Control of Patients and Visitors.  To better control the free movement of patients and visitors during lockdown periods, the Visitation Policy would be expanded to 24-hour application.  This would require that all visitors be registered and wearing visitors badges.  Regular vendors are registered and credentialed in advance and wear CFVHS badges when they enter the facility.  Staff would be instructed to challenge anyone they see inside the facility without a badge displayed.  Unauthorized personnel would be reported to Security Base Operations and security officers dispatched to investigate.

Personnel Management -
CFVHS will maintain as many Human Resource policies and procedures as possible in times of emergency management.  Staff are expected to make every effort to get to their place of duty.  In extreme situations and for key specialties, the health system may arrange for transportation.

Staff
All CFVHS staff have roles and responsibilities in performing, as a minimum, the key functions required in an emergency response (below).  Ultimately, the Incident Commander is responsible for these functions, but members of the Command and General Staff are responsible for the operational management of:

Communications
The Public Information Officer (PIO) has primary responsibility for communications in an incident.  (See the Communications Annex).  The Director of Marketing has primary planning responsibility.

Resources and Assets
The Logistics Branch Chief has primary responsibility for management, accountability, and resupply of resources and assets in an incident.  (See the Resource Management Annex).  The Director of Central Supply has primary planning responsibility.

Safety and Security
The Operations Branch Chief has primary responsibility for Safety and Security during an incident.

The Safety Officer on the Command Staff advises the staff on safety issues that arise during the response.

Planning responsibility falls to the Corporate Safety Officer and to the Director of Security respectively.

Utilities Management
The Operations Branch Chief has primary responsibility for Utility Management during an incident.

The Director of Maintenance Engineering has primary planning responsibility.

Patient Management
The Operations Branch Chief has primary responsibility for Patient Management during an incident.

The Chief Nursing Officer has primary planning responsibility.

During an incident, the majority of personnel will perform in their normal staff functions.  The IC has the authority to reassign staff, through the Operations Branch, as the situation dictates.  Staff will report to the appropriate section utilizing the established HICS command structure.
CFVHS requires all personnel in a supervisory position to take Independent Study (IS) courses 100 and 200.  Those that supervise several staff members or that may be assigned HICS positions are required to take IS 700 as well.

Service Line Directors and Department Managers are responsible for training staff members in their emergency response roles specific to their units.  Managers have numerous resources available to them online, during unit-level drills, or through the Training and Education Department.

Clinician Volunteers
Licensed Independent Practitioners (LIPs).

During an activation of the EOP, CFV Human Resources will issue orange name tags and a checklist to ensure that volunteer practitioners are competent to provide safe and adequate care, treatment and services.

Other Licensed, Certified or Registered Providers.

Same as above

Staff Support
In order to be most effective caring for patients, staff must know that they and their families are safe.  CFV encourages every staff member to maintain a Personal Preparedness Kit for themselves and their families.  Information is available at www.ready.gov.

Transportation
CFV will transport staff and their families as situation and resources allow.  The IC will make all decisions regarding transportation based on the criticality of the employee and the safety of the situation.

Housing
Staff- Circumstances may require staff to remain on site for several days at a time.  Temporary quarters will be set up as time and space allow.  Should a large number of CFV employees find themselves without shelter, the Healthplex will serve as temporary family housing.

Dependents - Circumstances may also require staff to bring dependent children or adults to CFV property.  The health system will make every effort to ensure the safety and comfort of family members to allow staff to focus on their healthcare duties.

Employees bringing family should be prepared to bring:

Identification

Bed linens, blankets, towels, pillows

Personal medications

Personal supply of food and water, especially if family have special dietary needs.

Simple light weight clothing

Infant formula, diapers, etc.

Personal hygiene items

Flashlight, battery powered radio, clock with extra batteries

Cards and other simple recreational items.

The Senior Vice President for HR is the executive agent for emergency housing.

The Director of the First Adventures day care will:

Provide for enrolled dependents according to the department's plan

Ensure staffing is available to provide adequate dependent care

Be prepared to move to Rehab area for an alternate site

Establish emergency procedures for staff not already enrolled

Coordinate meals for dependents

Ensure dependents are released to parent providing picture ID

Pets - The Healthplex will be set up to accept house pets. Owners must provide a carrier, food, and proof of vaccinations.

Utility Management
The following systems and required actions in the event of a loss or failure are included in the Utility Management Plan:

Electrical Systems

Emergency Power Systems

Water

Sewer

Boilers

Air Handlers

Chilled Water

Energy Management

Medical Gas systems: Oxygen, Nitrous Oxide and Nitrogen

Medical Air

Medical Vacuum

Natural Gas

Elevators

PEVCO Pneumatic Tube System

Fire Alarm System

Communications:  Telephone and Computer

Emergency Fuel and Power -
CFVHS maintains resources to provide emergency fuel and power to support operations.

I.  Boilers and Boiler Fuel Supply
Cape Fear Valley Health System has four (4) 400 horsepower boilers.  The primary source of fuel for all boilers is natural gas, with No. 2 oil as an alternate fuel supply.  Maintenance Engineering maintains this supply and resupply contacts.

The CFVMC boilers have a dedicated 25,000 gallon reserve tank of No. 2 fuel oil at all times.

Highsmith-Rainey Specialty Hospital has two (2) 150 horsepower boilers.  The fuel sources are the same as above

The HRSH boilers have a dedicated 10,000 gallon reserve tank of No. 2 fuel oil at all times.

II.  Emergency Generators and Fuel Supply
Cape Fear Valley Health System has the following generator support:

a.Four (4) 2,500 kW generators serve the essential emergency power needs for the Valley Pavilion, Patient Services Tower (PST) and the Central Energy Plant.  Fuel for these generators is stored in two (2) 30,000 underground storage tanks.  Under normal load conditions, these generators will operate for 114 hours.  These generators will enable the Valley Pavilion and the Patient Services Tower to remain fully operational in the event of a loss of normal utility service.

b.Three (3) 500 kW generators serve the essential emergency power needs for the North Tower, South Tower and West Tower.  Fuel for these generators is stored in one (1) 4,000-gallon underground storage tank.  Under normal load conditions, these generators will operate for 53 hours.

c. One 225 kW generator serves the essential emergency power needs for the Central Energy Plant.  Fuel for this generator is stored in one (1) 2,500gallon underground storage tank.   Under normal load conditions, these generators will operate for 420 hours.

d.One 500 kW generator serves the essential emergency power needs for the Cape Fear Valley Rehabilitation Center.  Fuel for this generator is stored in one (1) 1,000-gallon sub-base tank.  Under normal load conditions, these generators will operate for 66 hours.

Highsmith-Rainey Specialty Hospital has the following generator support:

Two (2) 900 kW generators serve the essential emergency power needs for HRSH.   Fuel for these generators is stored in one (1) 10,000-gallon underground storage tank.  Under normal load conditions, these generators will operate for 200 hours.  These generators will enable HRSH to remain fully operational in the event of a loss of normal utility service

Behavioral Health Care (Melrose Annex) has the following generator support:

One (1) 155 kW generator serves BHC (Melrose Annex).  Fuel for this generator is stored in one (1) 500gallon sub-base tank.  Under normal load conditions, these generators will operate for 72 hours.

Melrose Center (IST and Financial Planning) has the following generator support:

One (1) 150 kW generator serves the essential emergency power needs for the Melrose Center.  Fuel for this generator is stored in one (1) 500 gallon underground storage tank.  Under normal load conditions, these generators will operate for 72 hours.

Maintenance Engineering has the capability to transfer fuel from one tank to another to maintain each generator's operating capability beyond than 96 hours.

Medical Gas Management
The Health System is built with systems to provide all the medical gases necessary for the services we provide.  Systems are in place to assure that gas is delivered in a safe manner.

The following are considered under medical gases:

1.Oxygen – Bulk Oxygen is stored on site.  The bulk primary and reserve oxygen tanks will provide a minimum 7 to 10 day supply, depending upon overall use.  Oxygen supply readings are taken on a daily basis to ensure an adequate supply is on hand.  Oxygen alarms are located in the Security office and Central Energy Plant.  Oxygen gas and the required alarms are installed and tested in accordance with NPFA 99 standards by an outside contractor.   Purchasing maintains a supply of oxygen cylinders in the storage room.

2.Nitrous Oxide – Nitrous Oxide is stored on site, and has a backup system that provides for automatic transfer when the pressure in the primary system drops below 150 PSIG.  A medical gas alarm sounds in the Security Office and in the Central Energy Plant when the pressure is above or below the standard pressure.  Inspections of the system are made on both a quarterly and annual basis.

3.Nitrogen – Nitrogen is stored on site, with a redundant bank of tanks that automatically transfer supply should the pressure drop below 200 PSIG.  Alarms are monitored in the Security Office with a second alarm in the Central Energy Plant.  Back up tanks are ordered by Purchasing and maintained in the tank storage area in Central Shipping and Receiving.  Preventative testing of the system occurs on a monthly basis.  In addition, an independent testing agency conducts annual maintenance.

4.Medical Air – The medical air system has a back up dryer-purifier as well as a series of 3 back up compressors.  If the lead compressor fails, the lag compressor will activate and initiate an alarm in the Security office and Engineering department.  Inspections of the system occur weekly.

5.Medical Vacuum – The medical vacuum system has a back-up rotary system, which will start automatically if the primary pump fails.  Portable vacuum pumps are available in Central Supply. There are alarms in the Security Office and Engineering as well as local alarms.  The system is inspected on a daily basis.

Patient Care Services -
The health system will utilize normal procedures for patient scheduling, triage, assessment, treatment, admission, transfers, and discharge to the maximum extent possible.  The health system maintains several programs that track patient information and document care to include Seimens and ValleyLink.  Downtime Procedures are in place to conduct these patient care services during utility or computer failures.

As the situation dictates during periods of increased clinical demand, specifically from special needs populations, the health system will:

Evaluate all in-patients for immediate discharge;

Open emergency or expansion beds;

Increase nurse to patient ratios;

Cross-level staff according to skills and specialties;

Double-up patients with like diagnoses.

Assigned nursing staff will be responsible for patient hygiene and sanitation needs. If waste disposal becomes an issue, staff will follow the health system's Hazardous Waste Disposal protocols.

The health system recognizes that being hospitalized during an emergency incident may exacerbate a patient's condition. Nursing staff will specifically consider the mental health needs of their patients during these times. The following resources are available to complement the nursing reassurance provided by inpatient staff:

Coordination of Care

Social Workers

Patient Relations

Clergy

In situations involving fatalities that exceed the capabilities of the morgue, the health system will make every effort to maintain the dignity of the remains as well as the safety and well being of both patients and staff. Depending on the time of the year, Purchasing will contract for refrigeration trailers; arrangements will be made with the state's Disaster Mortuary Assistance Teams; and, at the very least, remains will be moved to a location downwind from the campus and placed under observation.

Emergency Department
During EOP activation, the Emergency Department will:

Be supervised by on-site personnel only using the following chain of succession:

The Medical Director, Emergency Services or his or her designee.

The Vice President of Emergency Services or his or her designee.

The Service Line Director, Emergency Services or his or her designee.

The Emergency Department Nursing Supervisor on duty.

The Lead Charge Nurse on duty.

Follow Incident Response procedures as outlined in this plan.

Surgical Services
During EOP activations Surgical Services will:

Be supervised by on site personnel only. The following is the chain of succession for SurgiCare:

The Medical Director – Surgical Services; or in his or her absence,

the Service Line Director – Surgical Services; or in his or her absence,

the Patient Care Manager- SurgiCare, or in his or her absence,

the Lead Charge Nurse or Senior RN on shift

Follow immediate Incident Response procedures,

Evaluate the incident's affect on Surgical Services

Coordinate with Incident Command the need to halt, delay or cancel procedures

Be prepared to transfer or discharge patients, as necessary, as directed by the Anesthesiologist

Release personnel or equipment to support other services or areas.

Prepare for and conduct evacuation, if required

Anesthesiologist-in-charge will triage patients for evacuation

Evaluate the use of oxygen in transport (per Fire Department instructions)

Be prepared to use bag-valve-masks for ventilation assistance.

Maintain IV infusions whenever possible.

Remove traction and position limbs as comfortably as possible.

The charge nurse/patient care nurse transports emergency drugs.

Patient charts are transported with patients as they are evacuated.

Evaluate continuation of Invasive lines

Keep patients, families, and staff informed

Position a volunteer in family waiting area as a liaison

Gastro-Intestinal (GI) Lab
The GI lab consists of 3 rooms at Cape Fear Valley Hospital and 2 rooms at Highsmith Rainey Specialty Hospital.

During EOP activations the GI Lab will:

Be supervised by on site personnel only. The following is the chain of succession for the GI Lab:

The Medical Director – Surgical Services; or in his or her absence,

the Service Line Director – Surgical Services; or in his or her absence,

the Patient Care Manager- GI Lab, or in his or her absence,

the Lead Charge Nurse or Senior RN on shift

Conduct immediate Code Triage activities,

Evaluate the incident's affect on Surgical Services

Coordinate with Incident Command the need to halt, delay or cancel procedures

Be prepared to transfer or discharge patients, as necessary, as directed by the procedural physician

Release personnel or equipment to support other services or areas.

Prepare for and conduct evacuation, if required

The PCM/Lead Charge Nurse will triage patients for evacuation

Evaluate the use of oxygen in transport (per Fire Department instructions)

Be prepared to use bag-valve-masks for ventilation assistance.

Maintain IV infusions whenever possible.

Remove traction and position limbs as comfortably as possible.

The charge nurse/patient care nurse transports emergency drugs.

Patient charts are transported with patients as they are evacuated.

Evaluate continuation of Invasive lines

Keep patients, families, and staff informed

Position a volunteer in family waiting area as a liaison

Laboratory Services
During EOP activations the Laboratory will:

Trigger the Lab manager or senior Med Tech to assess the situation for severity, duration and possible affect on laboratory services;

Consider if the incident will require more staff;

Contact the HCC to offer phlebotomy assistance to the ED or other department as required;)

Determine if any instrumentation needs to be calibrated or brought into service.

Determine the amount of reagent and supplies in stock.

Ensure staffing rotations are adequate to cover the expected duration of the incident;

Implement downtime procedures as necessary.

Highsmith-Rainey Specialty Hospital
Highsmith-Rainey Specialty Hospital (HRSH) is a satellite hospital of Cape Fear Valley Health System, and works in collaboration with the parent organization towards the safety and well-being of all components of the organization.

HRSH is licensed for 112 Long Term Acute Care (LTAC) beds, and provides outpatient surgery.  In addition, an Express Care operates 7 days per week located on the second floor at the back entrance to the hospital.

The LTAC patients are medically complex; many require ventilators, oxygen, dialysis, and IVs.   The Express Care treats ambulatory care patients who require attention for minor illnesses such as cuts, sprains, non-severe asthma attacks, colds and urinary tract infections.  Finally, HRSH provides Outpatient Surgery; occasionally these patients require an overnight stay.

Although EOP activation may happen in one of three ways, the corresponding activities are relatively the same.  If either CFVMC or HSRH experience an incident that affects only one of the hospitals (such as an internal incident), the other hospital will serve in a support role to assist response.  If the incident involves both facilities, support provided will be as available.  If the incident is in the community, the activation of the CFV Health System plan will supersede the HRSH plan.

During EOP activations Highsmith-Rainey Specialty Hospital will:

Maintain a chain of succession from the Vice President of Post-Acute Services to the LTAC Service-Line Director to the Director of Clinical Support;

Understand that requests from the CFVHS Incident Commander supersede decisions by the HRSH Incident Commander.

Establish a liaison to the CFVHS Incident Command, if applicable.

Quickly review specific plans or policies relative to the incident

Coordinate with the CFV HCC for incident resources;

Maintain communication with the CFV HCC.

Complete and maintain a hospital capacity and census report IAW the HRSH plan.

Ensure adequate staffing in collaboration between the nursing supervisor and administration considering which staff have been vaccinated against certain agents, general staff safety and any preventive measures available.

Highsmith-Rainey Specialty Hospital maintains hazard specific plans for:

Hazardous Spills. HRSH is subject to both operational spills facing all facilities and the additional concern of nearby rail traffic.  In the event of a spill or derailment and release of a hazardous material:
Engineering will turn off the air handling system;
Security and Engineering personnel will man doorways to minimize building access and egress;
Staff and patients will be alerted.

Evacuation.  Cumberland County EMS provides transportation during an evacuation.  Mutual Aid Agreements will be invoked in the event the volume of patients exceeds their ability to transport.

Sheltering.  Be prepared to use administrative areas (meeting rooms, waiting areas, etc.) as potential patient care areas.  IC will consider the additional logistics required when sheltering patients.

Outreach Clinics
During EOP activations, the community Outreach Clinics will:

First and foremost ensure the safety of all patients and staff;

Conduct immediate Incident Response procedures;

Assess the situation for impact on clinic operations;

Notify the HCC, patients, and staff regarding any changes to clinic operations;

Cancer Center
CFVHS provides oncology services at both the main campus and the Health Pavilion North (HPN) locations. While some situations will dictate differing responses, the plan calls for, at a minimum, a like response to be modified according to circumstances.

During EOP activations, the Cancer Center will:

First and foremost ensure the safety of all patients and staff;

Complete all treatments underway at the time of the activation;

Conduct immediate Incident Response procedures;

Ensure both main campus and HPN are appropriately notified and respond;

Notify patients, staff, and physicians regarding any changes to clinic operations;

Utilize phone trees and the media to contact personnel.

Blood Donor Center
During EOP activations, the Blood Donor Center will:

First and foremost ensure the safety of all patients and staff;

Complete all donations underway at the time of the activation;

Conduct immediate Incident Response procedures;

Assess the situation for its impact on operations;

Notify patients, staff, and physicians regarding any changes;

If notified of a sudden increase in blood product needs, blood inventory will be assessed in accordance with Blood Services procedures. Based on projected increases in blood needs, the AABB Task Force may be contacted. This task force will work with Cape Fear Valley Health System to balance demand with available supply in the market.

Blood Services staff will maintain contact with the Emergency Department, Operating Room, and ICUs to ensure that physicians and nursing staff are aware of the amount of blood products available.

Donor Center staff will assess the volume of donors presenting to donate. Based on that information, we may cancel blood drives and ask all donors to come to the center.

Blood Service staff will follow departmental policy BB-106:  Blood Services Disaster Plan for specifics.

Food and Nutrition
The Food and Nutrition Department is made up of several components including production, catering, retail, Valley Perks, patient services, dish room, diet office, dietitians, and management.

Production prepares food for seven days per week; Catering provides food and services for special events; Retail staff provides food Skylight Cafeteria seven days a week; Valley Perks operates the kiosk in the main lobby; Patient services staff (including BHC and daycare) provide food and ensure satisfaction to patients admitted to CFVMC, the Dish Room ensures the sanitation of the kitchen and utensils used; the Dietary Office inputs diet orders in the dietary computer system and obtains patients' food preferences seven days a week; the Dietitians ensure patients receive proper nutrition;  and Management staff completes day-to-day operations and is on call seven days per week.
Food suppliers provide food to storeroom on Mondays and Thursdays and maintenance continuously monitors the operations for any issues that arise.

Food and Nutritional Services has at least seven (7) days of food and water on hand to provide for patients, dependants, and staff during an Emergency Incident.

During EOP activations, the Food and Nutrition Department will:

Follow immediate Incident Response procedures;

Maintain normal patient and staff feeding operations as much as possible;

At the direction of the Incident Command, be prepared to deliver food and nourishment to departments unable to leave;

Be prepared to offer non-select and Disaster Menu meals as required;

Maintain a record of all items dispensed or used during the activation;

Alert suppliers of the condition and the need for replacement items;

Organize to utilize volunteer help in serving meals and nourishment;

Periodically report status to and maintain communication with the HCC;

Post customer information;

Use downtime procedures if required;

Make alternate dining area available for staff if required;.

Coordinate and cooperate with maintenance personnel to maintain operation of equipment, priority for electrical power being given to the patient care departments.

Upon announcement of the “ALL CLEAR”, release or reassign staff involved in the disaster.

Engineering
During EOP activations, the Engineering Department will:

If required, designate an individual to serve as the Facility Unit Leader;

If required, designate a Damage Assessment & Control Officer;

Follow immediate Incident Response procedures;

Assess all facilities for damage or impact from the incident

Provide personnel to assist the HCC as the situation permits.

Environmental Services
During EOP activations the Environmental Services Department will:

Be led by the Director of Environmental Services or his/her representative;

Maintain on-duty staff until adequate replacements arrive and/or they are notified officially that they may leave.

Use two-way radio communication for the leadership team; * The department maintains four (4) radios

Use pagers for all employees; Pages are restricted to incident support

Maintain normal functioning of the department as much as possible.

Instruct EVS personnel positioned on inpatient units to report to the nurses' station for instruction. Nursing leaders' instructions supersede instructions from shift supervisor as the immediate need to support existing patients needs are prioritized.

Be ready to assist in the evacuation of patients, as necessary.

Instruct project and trash/linen personnel to report to the EVS office for instructions.

Hazardous Waste Management
Detailed policies for selecting, storing, using, transporting and disposing of hazardous materials and wastes are contained in the CFVHS Hazardous Materials Manual, which includes some departmental policies and procedures by reference.  The following supplemental information is provided for assistance during times of emergency:

Unplanned releases.  In the event of a spill or other unplanned release of some hazardous material, the Safety Officer should be contacted through the Hospital Command Center.  The Safety Officer collects information about the release to determine how to handle the release area.  The release may require in-house resources, the fire department's HazMat Team or a contractor for containment, clean-up and disposal.  NOTE:  The HazMat Team will contain a spill, but will neither clean it up nor dispose of it.  The Health System Safety Officer has required training and credentials to clean up most hazardous materials spills.

Hazardous Materials Brought On Site by Patient/Family.  When a patient has been exposed to some hazardous material, it is not unusual for the patient or a family member to bring a sample of the material with them to the hospital to assist medical staff in treating the patient.  Often, they leave the container/substance behind or, at least, the patient's contaminated clothing is left behind and both must be disposed of as hazardous material.  In such a case, Emergency Department staff contact Environmental Services for pick-up.  Containers of hazardous materials should be packaged to prevent accidental release and marked in indelible marker with the name of the substance, if known.  Contaminated clothing or other personal articles should be packed in a double bag or other container suitable to prevent accidental release and marked as hazardous.  RED BAGS SHOULD NOT BE USED UNLESS THE ITEM CONTAINS 20cc OR MORE OF BODY FLUID.  EVS place the container inside the hazardous waste holding building on the west side of the Energy Center, where it is held pending investigation by the Health System Safety Officer to determine the most suitable method of decontamination or disposal.  Items exposed to radiation are turned over to the Radiation Safety Officer for proper packaging and half-life decay in the appropriate location, as determined by the RSO.

ED Patient Decon Room.  Patients presenting with biological, chemical, or radioactive contamination will be decontaminated in the ED Decontamination Room.  Runoff from this area is held in a 500-gallon underground tank near the Emergency Department decontamination room.  The tank is equipped with an indicator that alarms when it is nearing its capacity.  Contents of the tank are tested, pumped out and disposed of by a qualified pre-identified contractor.

Environmental Services will follow the guidelines below:

For Medical Waste

Transport/remove medical waste

Follow procedures listed in “Unit Activities”

Assign “attendants” areas of responsibility to transport medical waste

Continue to follow proper sealing procedures and transport separately.

Transport to refrigerated truck for storage and security.

For General Waste

Follow procedures listed in “Unit Activities”

Office areas will not be serviced during emergency incidents. Staff should seal trash and place in designated containers.

Clinical areas will receive as normal service as is possible.

Recovery Operations -
Recovery is often described as the longest phase of emergency management. Recovery begins almost immediately after an incident, even during response activities, and continues until operations return to a pre-incident state.

The health system prioritizes its recovery operations to more effectively meet the needs of our patients and the community. Priorities for recovery operations are:

Emergency Services

In-Patient Care

Ancillary Services

Out-patient Care

Outreach Clinics

Support Services

Administrative areas

Alternative Care Sites -
Although patient safety and the continuity of quality care remain the health system's top priorities, CFV maintains the ability to expand patient holding capacity or to relocate patients during an emergency.  The IC may utilize as many resources as are available at the time to maintain these priorities.

Underutilized or alternate spaces in the facility may be used to hold or monitor patients provided staff and equipment are available.

The hospital maintains emergency cots to expand the system's bed capacity.

Patient records, confidentiality and family communication are maintained as outlined in the respective portions of this plan.

Patients are to be returned to the appropriate facilities as soon as possible during the recovery phase of any incident.

US Patent Numbers 7,720,998 B2, 7,836,207