Johns Hopkins Safety Manual

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Emergency Response At JHH

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POLICY
It is the policy of The Johns Hopkins Hospital (JHH) to be ready to respond to and recover from internal or external
emergency or disaster and to ensure that patient care and essential hospital operations are maintained throughout the
response and recovery period.
An Emergency Management Committee and Incident Command Team shall be maintained to ensure that the
designated policy is implemented. These two groups shall consist of members representing clinical, administrative
and ancillary departments critical to efficient and effective planning and response to disaster-related incidents.
REFERENCES
The JHH Emergency Operations Plan
The JHH Corporate and Administrative Manual, Operational Policy Section
Joint Commission for Accreditation of Healthcare Organizations, Emergency Management Standards EM.01.01,
.02.02 and.03.01
JHH Disaster Plan
42 CFR Part 73
ATTACHMENTS
JHH & JHU SoM Staff Emergency /Response Reference
JHH Disaster Report Form: Functional Unit and Nursing Unit Summary Forms
JHH Disaster/Exercise Evaluation Form
JHH Emergency Preparedness Policies & Procedures (located in the JHH Corporate & Administrative Manual).
RESPONSIBILITIES
Emergency Management Committee

Meet as often as necessary to ensure an effective emergency

management process (e.g., mitigation,
preparedness, response and recovery) via incident command system
Coordinate, conduct and evaluate four emergency educational
sessions or exercises per 12 month period (plan exercises to meet
Joint Commission standards).
Develop the necessary hospital and School of Medicine wide
disaster response and recovery plans.
Plan and coordinate hospital-wide drills, exercises and training.
Ensure that all departments have a plan for internal and external
response.
Define expectations for departmental disaster planning, training, and
performance.
Provide consultation to departments when requested.
Evaluate the effectiveness of the JHH EOP, Plans and Policies
Keep departments informed on changing needs in the area of
emergency management.

All Staff

Participate in preparedness exercises and actual response and

recovery procedures.

Departmental Management

Provide training for all staff regarding roles in emergency situations.

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Implement established duties and responsibilities in response to and

recovery from disaster-related incidents.
COMMUNICATION
The JHH Disaster Plan is available on Hopkikns Policy On-Line and link to The Johns Hopkins Institutions
Telephone Directory to provide an overview of the responsibilities for faculty and house staff to respond to patient
influx disaster events. Seven specific patient influx policies and the Emergency Operations Plan are stored or
filed on line at the following web sites:
www.insidehopkinsmedicine.org/operations_integration or
www.hopkinsonalert.org and Hopkins Policy On-Line. Activation of the specific emergency policies will normally
be initiated by the Disaster Control Administrator or a Disaster Team Member (unless otherwise specified).
ADMINISTRATIVE ALERT - Requires members of the Disaster Team to be notified by the hospitals web based
communication system or through the Telecommunications Service operator whenever a local or regional
catastrophe has occurred to implement pre-requisites when indicated
CODE YELLOW ED - Requires partial mobilization of personnel and resources to the Main Emergency
Department as required to manage up to 10 patients from a single event.
CODE YELLOW HOSPITAL - Requires full mobilization of all personnel and hospital-wide resources as
required for management of more than 10 patients from a single event.
CODE YELLOW BIO - Requires activation of partial to the complete bioterrorism policy. Activation of
departmental plans via the Incident Command Center should not be implemented unless these plans are preapproved.
CODE YELLOW CHEMICAL - Requires mobilization of all personnel and hospital-wide resources due to a large
number of casualties from a chemical related catastrophe. Do not report to the Main ED unless assignments are preapproved.
CODE YELLOW RADIATION - Requires mobilization of all personnel and hospital-wide resources due to a
large number of casualties from a radioactive exposure catastrophe. Do not report to the Main ED unless
assignments are pre-approved.
Pandemic Influenza Plan Requires activation in appropriate phases of the pandemic influenza plan. Activation
of departmental plans via the Incident Command Center should not be implemented unless these plans are preapproved.
REVIEW CYCLE
Every 3 years

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The Johns Hopkins Hospital

Nursing Unit Summary Disaster Report Form
Department ______________________
Nursing Unit ______________________

Date ______
Time ______

Instructions
Charge Nurse shall complete all requested information, utilizing a separate form for each reporting period.
Submit this form to Dept. Control Center so that Functional Unit Form may be completed.

Name of RNs or Staff Available for

Reassignment to Other Areas

Total Number of Beds

Total Number of
Occupied Beds
Total Number of Empty
Beds
Total Number of
Potential Discharges

Type of Staff

# On-Duty
Staff

# On-Duty Staff That is

Available for Reassignment

# Off-Duty
Staff &
Reporting In

RNs
LPNs
Clinical Associates
Clerical Associates
Support Associates
Other Staff

Equipment Available in Dept for Use Elsewhere

- White Copy for Nursing Unit

- Yellow Copy for Department Control Center

# Of Stretchers
# Of Wheelchairs
# Of Monitors

- Pink Copy for Nursing Director

15-810200 11/93

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The Johns Hopkins Hospital

Functional Unit Summary Disaster Report Form
Department ______________________
Nursing Unit ______________________

Date ______
Time ______

Instructions
Department Control Center shall complete all requested information, utilizing a separate form for each
reporting period. Summarize data from Nursing Unit Summary Forms onto this form.

Total Number of Critical

Care Beds
Total Number of Critical
Care Beds Occupied
Total Number of Empty
Critical Care Beds
Total Number of
Potential Discharges

Total Number of Beds

Total Number of
Occupied Beds
Total Number of Empty
Beds
Total Number of
Potential Discharges
Type of Staff

# On-Duty
Staff

RNs
LPNs
Clinical Associates
Clerical Associates
Support Associates
Other Staff

# On-Duty Staff That is

Available for Reassignment

# Off-Duty
Staff And
Reporting In

Equipment Available in Dept for Use Elsewhere

# Of Stretchers
# Of Wheelchairs
# Of Monitors
- White Copy for Hospital Incident Command Center (Zayed Arcade Conference Room: 2117)
- Yellow Copy Remains in Department Control Center

15-810300

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Emergency Response At JHH

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Johns Hopkins Hospital Disaster/Exercise Evaluation Form

Please scan and email this completed form to HICC.SmithRoom@jhmi.edu within 24 hours after completion of any
disaster related exercise or as directed during an actual event.
Prepared by:

Job Title

Notification & Activation Parameters

Date & Time Notified
Notified that Event Has Ended
Primary Dept Control Center Activated
Alternate Dept Control Center Activated
Physician Squads Activated
Did Squad Physicians Respond
Dept Disaster Plan Readily Available

Reply

Call Roster Parameters

Initiated Call Roster
Administrative Staff Names Current
Admin Staff Phone Numbers Current
Clinical Staff Names Current
Clinical Staff Phone Numbers Current
Call Roster Completed

Y
Y
Y
Y
Y
Y

NA
NA
NA

Were Forms Available

Functional Unit Summary Form Scan & Email

to HIC.SmithRoom@jhmi.edu or faxed to (27144) as instructed

N
N

Y
Y
Y
Y
Y

N
N
N
N
N

Call Roster Comments?

Time Started:

Time Completed:
Disaster Forms: Functional Unit Summary,
Nursing Unit Summary &/or Evaluation Form

NA

Reply
Y
N

Communication Parameters
Problems Interfacing with Other Departments

Any Problems with Communication to

Administrative Staff
Nursing Staff
Faculty / Residents
Support Services Staff
Smith Room Staff

NA
NA
NA
NA
NA
NA

Reply

Activated by Whom (Job Title):

Any Activation Comments?

N
Reply
N
N
N
N
N
N

Disaster Forms and Supplies

Problems Obtaining Any Supplies

Any Notification Comments?

Notified by Whom?

N
N
N
N
N

Y
Y
Y
Y
Y
Y

Department or Unit

Describe Problem:
Communication Comments?

NA
NA
NA
NA
NA

Describe Any Impact to Normal Operations

Issues to be Investigated
General Impressions of Dept Performance (e.g., Timely Response, Leadership and Staff Performance)

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Emergency Response At JHH

JHH Emergency Management

Policy & Procedure Index

JHH Emergency Management Policy

Biohazardous Material Spills
Bioterrorism (Code Yellow Bio)
Bomb Threat
Chemical Plan: Code Yellow Chemical
Civil Disturbance
Code Yellow ED
Code Yellow Hospital
Computer Outage
Contingency Planning (In The Event of A
Strike)
Credentialling of Clinical Workers
Disaster Plan -- JHH
Electric Power Outage
Evacuation
Emergency Operations Plan
Fire Emergencies
Gas (Natural) Outage
Hazardous Chemical Spills
High Winds Policy
Inclement Weather
Medical Air / Vacuum Outage
Oxygen Outage
Pandemic Influenza Plan
Radiation Plan: Code Yellow Radiation
Radioactive Spills
Steam, Chilled Water and Ventilation
Outage
Structural Failure
Unknown Substances
Workplace Violence: Shooters / Hostages

Policy #
EP015
IFC038
(#22)
EP003
EP023
EP002
EP019
EP018
EP020
EP004
EP031
EP017
EP005
EP021
N/A
EP013
EP007
EP014
EP026
EP001
EP009
EP010
#EPS029

EP24
EP016
EP006
EP008
EP030
EP032

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Johns Hopkins Safety Manual

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Emergency Response At JHH

Outage or
System Failure

Characteristics/
Symptoms

JHH
Locate Problem
And Call

MAINFRAME
COMPUTER,
SOFTWARE OR
NETWORK
OUTAGE

System or software
unavailable.
Intra/intranet network
connection not
accessible

IT Data Center
(5-2571)

JHH
Action to be Taken

Use backup system and/or manual

procedures to complete duties
Input any manual reports into
computer system once mainframe
software is operational

HSE 028

JHU/SOM
Locate Problem
And Call

JHU/SOM
Action to be Taken

ISO Data Center

(5-2571)

Same as JHH Actions

Facilities Mgt.

Electrical
Power Outage

HVAC
TEMPERATURE
+ VENTILATION

MEDICAL AIR /
VACUUM

Facilities Engineering
Failure of electrical
(5-5770)

systems

If emergency power
Many lights are out
Patient equipment not does not activate within
10 seconds, call
functional
(5-4444)

Critical change in
temperature

No vacuum

Outage

Facilities Engineering

(5-5770)
If no answer, call

(5-4444)
Respiratory Therapy
(5-5303) and
Facilities Engineering
(5-5770)
If no answer, call
(5-4444)

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- Notify Facilities Mgt Customer

Notify shift coordinator; use flashlights Customer Svc Center

RN Staff: Identify impact to patients
Check life support equipment, call
(5-3323)
Resp Therapy if needed (5-5303)
Hand ventilate patients; manually
regulate IVs
If emergency power
Do not start new OR cases
does not activate within
10 seconds, call
(5-3323)

Svc Center.

Notify department shift coordinator

RN Staff: Determine impact to
patients
Check equipment that is dependent
upon temperature regulation

RAR Staff: Determine impact to

vivarium areas and coordinate

- Determine critical equipment

that needs to be manually
restarted. Minimize use of
refrigerators and freezers.
Transfer contents to another
freezer if indicated

Facilities Mgt.
activities with Facilities Mgt.
Customer Svc Center Other Areas: Notify Dept Super(5-3323)
visor and implement dept plan

Notify department shift coordinator

RN Staff: Determine impact to patients
Facilities Mgt.
Check backup systems and other
Customer Svc Center
equipment that is dependent upon air
(5-3323)
Use portable suction equipment from
Code Cart when indicated

RAR Staff: Determine impact to

vivarium areas and coordinate
activities with Facilities Mgt.
Other Areas: Notify Dept Supervisor and implement dept plan
Turn off gas valve in use.

NATURAL GAS
OUTAGE

Little remaining gas

Facilities Engineering
(5-5770)

If no answer, call

(5-4444)

OXYGEN
OUTAGE

STRUCTURAL
FAILURE

Oxygen alarm will

sound on clinical
units

Breach in structural
integrity

Telecommunications
Operators
Marburg B-101
(5-4444)
and Oxygen Therapy
(3-7913)

Facilities Engineering
(5-5770)

If no answer, call
(5-4444)

Notify department shift coordinator

Implement backup system

Facilities Mgt.
Customer Svc Center If a gas leak is detected, call
Facilities Mgt Customer Svc
(5-3323)
Center (5-3323) and give
location. Evacuate area.

Notify Department Shift Coordinator

RN Staff: Determine if O2 pressure is
really low. Make overhead
announcement to all rooms
Facilities Mgt.
Repressurize area by turning off O2
zone valve
Customer Svc Center
Attach H cylinder to nearest O2 out(5-3323)
let + open valve to repressurize area
If unit does not have H cylinder,
place patients on E cylinders
(transport tanks)

If an oxygen outage or loss in

pressure results, call Facilities
Mgt Customer Svc Center (53323) and give location.

Notify department shift coordinator

RN Staff: Identify impact to patients
Evacuate any patients, family or staff
from immediate danger

Facilities Mgt.
Customer Svc.
Center
(5-3323)

Evacuate faculty, staff or

students.
RAR Staff: Determine
impact to vivarium areas
and coordinate activities
with Facilities Mgt

Johns Hopkins Safety Manual

Policy Number

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Emergency Response At JHH

Telecommunications
TELEPHONE OR
PAGER
OUTAGE

No telephone or
pager service

Operators
Marburg B-101
(5-5277)
or
(4-3921)

WATER LOSS
PRESSURE
REDUCTION OR
FLOOD

Little or no water or
flood

Facilities Engineering

(5-5770)
If no answer, call
(5-4444)

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Determine if pager outage affects 1or 2-way models. Access CEPAR

web site for cell phone numbers
Telecommunications
Notify Shift Coord (inform other
Operators
units)
Marburg B-101
Inform patients, families + employees
(5-5277)
Establish runner system
or
Identify nearest payphones
(4-3921)
Collect all available cellular phones
and pagers and distribute as indicated
Open DICC if requested
Notify Department Shift Coordinator
RN Staff: Check equipment dependent upon water or temperature
regulation.
Obtain water / ice from CSD/nutrition

Same as JHH Actions

Facilities Mgt
Customer Svc Center
(5-3323)

RAR Staff: Determine

impact to vivarium areas
and coordinate activities
with Facilities Mgt.
Contain flood to the extent
possible until help arrives

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Emergency Response At JHH

Emergency
Event

BIOHAZARD
MATERIAL
(HSE 703)
OR RADIATION
SPILL OR
RELEASE
(HSE 909)

Characteristics/
Symptoms

JHH
Locate Problem
And Call

Release of potentially
HSE (5-5918) or
infectious materials,
Radiation Control Unit
hazardous chemical or
(5-3712)
radiation has spilled or
released in unit or
If no answer, call
employees appear in
(5-4444)
ED

BOMB THREAT
(Code Gold)

Code Yellow
Hosp, Chemical or
Radiation

DCA notifies Shift

Mgrs. Notifind &
possible overhead
announcement

ED Charge Nurse or
Attending In-Charge
Calls Telecom at 5-4444
to activate Disaster Plan

Earthquake

Experience Tremor,
Items Falling or
Structural Damage

Facilities Engineering
(5-5770)
If no answer, call
(5-4444)

EVACUATION
(HSE 041)

Dept mgt + Security

Mgr notify staff to
evacuate the area in
the event of
uncontained smoke,
fire, suspected bomb

Contact Security, Safety

or DCA dependent on
type of incident causing
evacuation through
Telecom (5-4444)

FIRE
EMERGENCY

Fire alarms sound

and/or
Smoke seen

Telecom Operators
(5-4444)
Indicate where the fire is,
What kind of fire it is,
your name and extn.

High Wind
warning

Alert to High Wind

Warning is now in
effect. All staff are to
report to their duty
stations

Use Disaster Call Tree

(443-287-7000) and
Press #4 for updates

Patient(s) or staff
PANDEMIC FLU,
experiencing
SARS or Code
symptoms from virus
Yellow Bio
or ID outbreak

UNIDENTIFIED
SUBSTANCE
OR PACKAGE

JHU/SOM
Locate Problem
And Call

09/20/13
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JHU/SOM
Action to be Taken

You receive a
call about an explosive
device on premises or
have a suspicious
package

SHOOTER OR
HOSTAGE
INCIDENT

JHH
Action to be Taken

HSE 028

Patients or staff aware

or experiencing
incident

You notice an
unidentified and/or
receive or notice a
suspicious package

Security
(5-5585)

HEIC (5-8384) or
Emergency Pager
(3-3855)
Security
(5-5585)

Security
(5-5585)

Notify department shift coordinator

Attempt to identify the source, nature,
+location of spill. Implement HAZMAT
HSE (5-5918) or
response plan +contain spill w plastic
Radiation Control Unit
backed absorbent pads (Chux).
(5-3712)
Evacuate any patients, visitors, and/or
staff in immediate danger. Restrict
access to affected area(s).
If no answer, call
Contact ED at 5-2280 if potential
(5-4444)
casualties will need tx (inform supervisor, dept leaders and DCA (5-4444)
of any injuries)
Record as much information as possible on
Security
the Bomb Threat Telephone Checklist then
call Security Office. Shift Mgr and Security
(5-5585)
Mgr will decide the need to evacuate once
an inspection is conducted
All employees are to report to their
duty stations
Dept representative report to Smith
N/A
Room (Admin 212) when requested
Implement DICC & departmental plans
Do not evacuate unless evacuation
order given by on-site official. Protect
Facilities Mgt.
patients & yourself from falling items
Customer Svc.
If evacuate, go to open area to avoid
falling debris
Center
Do not use elevators unless cleared
(5-3323)
by Facilities
Report structural damage to Facilities
Implement unit-specific disaster plan
Initiate dept call rosters
Review possible evacuation sites with Contact DCA through
highest ranking on-site official
Telecom (5-4444)
Evacuate under direction of on-site
official (BCFD, VPs, DCA, HSE,
Security) or delegated authority
Notify dept shift coordinator and pull
Telecom Operator
nearest fire alarm box. Evacuate any
(5-4444)
Indicate where the fire
patients, visitors, and/or staff in
immediate danger. Close all doors. Know is, What kind of fire it is,
your name and extn.
your evacuation routes
RN Staff: Move patients, visitors and staff
Use Disaster Call Tree
away from glass windows or provide
barriers between window and patients and
(443-287-7000) and
staff. Implement unit-specific disaster plan. Press #4 for updates
Evacuate unit if unit or building unusable

Implement instructions provided by

Hospital Epidemiologist and/or Infection
Control Practitioner. Do not implement
disaster plans until instructed to do so

Secure immediate area; remain calm

Notify Security (STAT) & dept leaders
Take protective actions
Protect patients, staff, et al
Contain unidentified substance or pkg
RN Staff or Staff: Notify supervisor
Keep patients, visitors and staff away
from package. Do not move package
Ask staff if they saw who dropped off
package or unidentified substance
Identify anyone that was exposed
Evacuate patients, visitors and/or staff
if package is suspected to be an
explosive device

HEIC (5-8384) or
Emergency Pager
(3-3855)
Security
(5-5585)

Security
(5-5585)

Same as JHH actions

Same as JHH Actions

Same as JHH Action for
Clinical Enterprise. No action
required for SoM Basic
Sciences except become
familiar with safety procedures

Same as JHH actions

Same as JHH actions

Same as JHH Actions

Move patients, visitors +staff

away from glass windows or
provide barriers between window
and patients and staff. Implement dept disaster plan

Same as JHH Actions

Same as JHH Actions

Same as JHH Actions

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Emergency Response At JHH

INCLEMENT
WEATHER
(SNOW)

ANIMAL
FACILITIES

Hospital or University
Position on Current
Weather Situation

Use Disaster Call Tree

(443-287-7000) and
Press #4 for updates

1) Escape or malicious
1) Research Animal
release of laboratory
Resources (RAR)
animals.
(5-3273 or 5-3275)
2) Environmental
2) RAR (5-3273) +
emergency or catastroFacilities Engineering
phic failure of animal
(5-5770)
facility physical plant.

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Comply with essential staff

Do not leave at the end of shift unless Use Disaster Call Tree
immediate supervisor releases you
(443-287-7000) and
procedure for your respective
Open DICC when requested
Press #4 for updates
area, division and/or dept

1) Close doors or cordon off area to contain

animal. Do not attempt to capture
physically. Contact RAR.
2) Determine If conditions place animals at
risk and require the relocation of animals to
other areas.

1) Research Animal
Resources (RAR)
(5-3273 or 5-3275)
2) RAR (5-3273) +
Facilities Engineering
(5-5770)

1) Alert JHU Security and

Admin if animal rights mischief is
suspected.
2) RAR to work w Facilities and
JHU Admin to explore short term
housing prospects for displaced
animals.