Nurse

PICU

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Complete and drop off Disaster Information Form to the Labor Pool located in the Medical Imaging/ Lab Waiting Area (Room A – 0501)
  • Work with Charge Nurse and Attending Physician to assess potential discharges or transfers
  • Assess that essential equipment is available
  • Assess stock of supplies
  • Reassure families only if prompted
  • Be prepared to initiate call trees if instructed by Incident Command

NICU

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Complete and drop off Disaster Information Form to the Labor Pool located in the Medical Imaging/ Lab Waiting Area (Room A – 0501)
  • Work with Charge Nurse and Attending Physician to assess potential discharges or transfers
  • Assess that essential equipment is available
  • Assess stock of supplies
  • Reassure families only if prompted
  • Be prepared to initiate call trees if instructed by Incident Command

Surgical Services

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • All Surgical Service procedures in progress should be completed without delay
  • Validate with Incident Command if safe to proceed with surgical and procedural schedule prior to starting new case
  • If Incident Command recognizes a potential impact to the OR:
    • Review surgical and procedural schedule. Prioritize any high risk surgeries or procedures and notify Incident Command
    • Await approval from Incident Command to cancel elective and non-high risk surgeries and procedures
    • Notify patient and family of cancellations
    • If and when appropriate, reschedule procedures and surgeries
  • Complete and drop off Disaster Information Form to the Labor Pool located in the Medical Imaging/ Lab Waiting Area (Room A – 0501)
  • Work with Charge Nurse and Attending Physician to assess potential discharges or transfers
  • Assess that essential equipment is available
  • Assess stock of supplies
  • Reassure families only if prompted
  • Be prepared to initiate call trees if instructed by Incident Command

Emergency Department

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Complete and drop off Disaster Information Form to the Labor Pool located in the Medical Imaging/ Lab Waiting Area (Room A – 0501)
  • Work with Charge Nurse and Attending Physician to assess potential discharges or transfers
  • Assess that essential equipment is available
  • Assess stock of supplies
  • Reassure families only if prompted
  • Be prepared to initiate call trees if instructed by Incident Command

4S Med Surg

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Complete and drop off Disaster Information Form to the Labor Pool located in the Medical Imaging/ Lab Waiting Area (Room A – 0501)
  • Work with Charge Nurse and Attending Physician to assess potential discharges or transfers
  • Assess that essential equipment is available
  • Assess stock of supplies
  • Reassure families only if prompted
  • Be prepared to initiate call trees if instructed by Incident Command

5S Med Surg

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Complete and drop off Disaster Information Form to the Labor Pool located in the Medical Imaging/ Lab Waiting Area (Room A – 0501)
  • Work with Charge Nurse and Attending Physician to assess potential discharges or transfers
  • Assess that essential equipment is available
  • Assess stock of supplies
  • Reassure families only if prompted
  • Be prepared to initiate call trees if instructed by Incident Command

Hematology Oncology

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Complete and drop off Disaster Information Form to the Labor Pool located in the Medical Imaging/ Lab Waiting Area (Room A – 0501)
  • Work with Charge Nurse and Attending Physician to assess potential discharges or transfers
  • Assess that essential equipment is available
  • Assess stock of supplies
  • Reassure families only if prompted
  • Be prepared to initiate call trees if instructed by Incident Command

Outpatient

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Complete and drop off Disaster Information Form to the Labor Pool located in the Medical Imaging/ Lab Waiting Area (Room A – 0501)
  • Review clinic schedule and assess for critical patient visits and patients traveling long distances for appointments
  • Await Incident Command decision for appointment cancellation. Notify families of cancelled appointments
  • Assess that essential equipment is available
  • Assess stock of supplies
  • Reassure families only if prompted
  • Be prepared to initiate call trees if instructed by Incident Command
  • Prepare for possible reassignment of nursing staff

Patient Flow Supervisor

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

During 8 am to 5PM:

  • Code GREEN DELTA 3 situation: Notify Security Command, Admin on-call and Environmental Safety Manager through a 4 way call.

After hours, 5PM to 7AM:

  • In the absence of an onsite Administrator on Call, the Patient Flow Supervisor assumes the Incident Commander responsibilities until the Incident Commander arrives
  • Follow day time supervisor responsibilities
  • Refer to Incident Command Checklist
  • Be prepared to brief Incident Command upon arrival of team

Specialty Nurses

Code GREEN DELTA Level 3

Specialty Nursing Includes But Is Not Limited To: Clinical Nurse Educators, Advanced Practice Nurses, Nursing Advancement, IV Therapy Nurses, Nursing Informatics

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Complete and drop off Disaster Information Form to the Labor Pool located in the Medical Imaging/ Lab Waiting Area (Room A – 0501)
  • Work with Charge Nurse and Attending Physician to assess potential discharges or transfers
  • Assess that essential equipment is available
  • Assess stock of supplies
  • Reassure families only if prompted
  • Be prepared to initiate call trees if instructed by Incident Command

Critical Care Transport

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Provide support as requested by Incident Command

Respiratory

PICU

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Continue with regular patient care unless directed otherwise by Incident Command
  • Additional therapists may be requested by Incident Command through the Therapist In Charge
  • Assess that essential equipment is available
  • Assess stock of supplies

NICU

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Continue with regular patient care unless directed otherwise by Incident Command
  • Additional therapists may be requested by Incident Command through the Therapist In Charge
  • Assess that essential equipment is available
  • Assess stock of supplies

Surgical Services

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Continue with regular patient care unless directed otherwise by Incident Command
  • Additional therapists may be requested by Incident Command through the Therapist In Charge
  • Assess that essential equipment is available
  • Assess stock of supplies

Emergency Department

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Continue with regular patient care unless directed otherwise by Incident Command
  • Additional therapists may be requested by Incident Command through the Therapist In Charge
  • Assess that essential equipment is available
  • Assess stock of supplies

4S Med Surg

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Continue with regular patient care unless directed otherwise by Incident Command
  • Additional therapists may be requested by Incident Command through the Therapist In Charge
  • Assess that essential equipment is available
  • Assess stock of supplies

5S Med Surg

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Continue with regular patient care unless directed otherwise by Incident Command
  • Additional therapists may be requested by Incident Command through the Therapist In Charge
  • Assess that essential equipment is available
  • Assess stock of supplies

Hematology Oncology

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Continue with regular patient care unless directed otherwise by Incident Command
  • Additional therapists may be requested by Incident Command through the Therapist In Charge
  • Assess that essential equipment is available
  • Assess stock of supplies

Outpatient

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Continue with regular patient care unless directed otherwise by Incident Command
  • Additional therapists may be requested by Incident Command through the Therapist In Charge
  • Assess that essential equipment is available
  • Assess stock of supplies

Critical Care Transport

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Continue with regular patient care unless directed otherwise by Incident Command
  • Additional therapists may be requested by Incident Command through the Therapist In Charge
  • Assess that essential equipment is available
  • Assess stock of supplies

Physician

PICU

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Administrator or designee send current list of departmental physicians in house at the time of the Code Green Delta announcement to the Labor Pool
  • Assess for potential transfers and discharges
  • Prepare to activate call tree
  • Await specific instructions from Incident Command

NICU

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Administrator or designee send current list of departmental physicians in house at the time of the Code Green Delta announcement to the Labor Pool
  • Assess for potential transfers and discharges
  • Prepare to activate call tree
  • Await specific instructions from Incident Command

Emergency Department

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Administrator or designee send current list of departmental physicians in house at the time of the Code Green Delta announcement to the Labor Pool
  • Assess for potential transfers and discharges
  • Prepare to activate call tree
  • Await specific instructions from Incident Command

General Pediatrics

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Administrator or designee send current list of departmental physicians in house at the time of the Code Green Delta announcement to the Labor Pool
  • Assess for potential transfers and discharges
  • Prepare to activate call tree
  • Await specific instructions from Incident Command

Hospitalists

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Administrator or designee send current list of departmental physicians in house at the time of the Code Green Delta announcement to the Labor Pool
  • Assess for potential transfers and discharges
  • Prepare to activate call tree
  • Await specific instructions from Incident Command

Surgical Services

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Administrator or designee send current list of departmental physicians in house at the time of the Code Green Delta announcement to the Labor Pool
  • Assess for potential transfers and discharges
  • Prepare to activate call tree
  • Await specific instructions from Incident Command

Anesthesiology

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Administrator or designee send current list of departmental physicians in house at the time of the Code Delta announcement to the Labor Pool
  • Assess for potential transfers and discharges
  • Prepare to activate call tree
  • Await specific instructions from Incident Command

Hematology Oncology

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Administrator or designee send current list of departmental physicians in house at the time of the Code Green Delta announcement to the Labor Pool
  • Assess for potential transfers and discharges
  • Prepare to activate call tree
  • Await specific instructions from Incident Command

All Other Physicians

Code GREEN DELTA Level 3

All Other Physicians Including But Not Limited To: Orthopedics, Diagnostic Referral, Pathology, Primary Care, Developmental Medicine, Genetics, Immunology, Behavioral Health, Endocrinology, Hematology/Oncology, Neurology, Nephrology, Pulmonology, Rheumatology, Weight Management, Rehabilitation, Otolaryngology, Transition Team, Dentistry, Ophthalmology, Urology

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Administrator or designee send current list of departmental physicians in house at the time of the Code Green Delta announcement to the Labor Pool
  • Assess for potential transfers and discharges
  • Prepare to activate call tree
  • Await specific instructions from Incident Command

The Logistics Center

Emergency Logistic Technician

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • If a Code GREEN DELTA 3 is requested, take down the following information
    • Name of caller
    • Location/department impacted
    • Description of events
    • Extent of impact
    • Potential impact on daily operation
  • Announce twice that there is a Code Green Delta 3 on the Fire P.A. “Attention Please… Code Green Delta 3 (location or any other information).”
  • Notify PFS (57-2364)
  • Send out Voalte Blast notification

Security Command Center Dispatch

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • If a Code GREEN DELTA is requested, take down the following information
    • Name of caller
    • Location of the incident
    • Description of events
    • Extent of impact
    • Potential impact on daily operation
  • Immediately contact the PFS (57-2364), who will contact the administrator on call.
  • The acting incident Commander will direct Security when to announce the Code Delta Green
  • Announce twice that there is a Code Green Delta 3 on the Fire P.A. “Attention Please… Code Green Delta 3 (location or any other information).”
  • Incident Commander is established (initial default is Patient Flow Supervisor until Administrator on Call or Incident Commander arrives)
  • NCH’s Logistics Center established (Administration Conference Room, 1st floor) and activates Code Green Delta page to all pre-determined Code Green Delta grouping.
  • Hospital Incident Command activated
  • The Security Officer Recall Roster will be in effect. It will be the Emergency Department Security Officer’s responsibility
  • If the situation warrants, the main Lobby entrance will be closed off using cones or barriers and placed in a lock-down status.
  • Security Officers Unit 34 will be stationed at the main entrance and will assist with access control and package
  • Security officer Unit 36 will assist with building sweeps.

Code Green Delta Room Assignments:

  • Incident Command Center: Administration Conference Room, 1st floor
  • Labor Pool: Medical Imaging/ Lab Waiting Area (Room A – 0501), Ground Floor
  • Discharge Holding Unit: 5th Floor Clinic
  • Family Gathering/Waiting Area: Occupational Therapy Rehab Gym, 4th floor
  • Family Support and Information Center: Auditorium
  • Pediatric Safe Area—“Kids Track” on Main Floor
  • Media Relations Room: Off the NCH campus across the street
  • Associate Sleeping Area: Clinic areas
  • Associate Child Care Area: 1st floor computer rooms 1721 (12 beds) & 1722 (12 beds)
  • Associate Elder Care Area: 1st floor computer room 1723 A (10 beds) & 1723B (10 beds)
  • Emergency Shelter location for associates pets: enclosed area by back loading dock

Mobilize, assign, and pre-position emergency response personnel

  • Security Patrol Unit 35 will initiate and operate an ID check post at the main vehicle entrance at Nemours Parkway and Lake Nona Blvd. All vehicles and pedestrians are to be stopped at this location and Employee badges verified. A Nemours vehicle and traffic cones will be utilized to block lanes and divert traffic in this effort. Unit 35 will be tasked with boarding all delivery trucks and performing a vehicle inspection prior to granting access. A phone call should be made to all receiving parties to verify delivery (this includes Materials Management deliveries). The security patrol will escort any responding police/ fire department personnel to the loading dock area. An interior security unit or manager will respond to the loading dock and provide escort for the emergency personnel to the incident scene.
  • Notify Engineering Managers and request assistance with access control, building sweeps, and package inspections by staff.
  • Contact the Incident Command Center to notify of severe threat status. Ask that each department conduct area sweeps. They will be tasked with conducting a department sweep once per shift and calling into the Command Center with results.

Close high risk and/or vulnerable facilities, if applicable

  • The Nemours vehicle is to be parked at the main entrance creating a physical barrier. It will remain until the severe threat level is lifted
  • Loading dock will not be accessed without a Materials Management representative present to verify delivery personnel and perform vehicle inspection.
  • All site construction projects will be reviewed by Facilities and Security Management to determine whether the project will be suspended until the severe threat level is lifted.
  • All special events will be cancelled during the severe threat event.
  • Exterior door inspections and exterior sweeps to all properties are to be performed once per shift.
  • Look for unattended packages, suspicious person(s) or unauthorized vehicles. Be sure to take down the vehicle tag number immediately upon identifying suspicious activity. Increased visibility of our patrols is the goal during such an event.
  • Patrol should report all exterior light and access failures immediately.
  • Do not allow vehicles to park alongside any of the buildings. Approach all illegally parked Vehicles and direct the driver to move immediately.
  • All exterior property fencing must be inspected every 12-hours.

Immediate protocol alterations

  • The Incident Command Center will be the central contact for all appointments by contractors, Vendors and/or visitors requiring escort. Department contacts and/or escorts will be required to give 24 hours notice for scheduled visits. A daily list will be generated by the Incident Command Center and distributed to all posts including patrol. Only those visitors and vendors on the list will be admitted onto the site.
  • No personal deliveries will be permitted on site. This includes but is not limited to food and floral deliveries, etc.
  • Package inspections will be performed on all packages entering the buildings.
  • Badge spot inspections should be conducted on a continuous basis. Ensure all associates are wearing their identification badge in the building and advise those who are not that it is mandatory to do so.
  • Building exterior sweeps will be conducted each shift.

Guidelines

In the event of a severe threat, and as directed by NCH Executive Management, the following protective measures shall be implemented only at those facilities that may be at risk during a period of heightened alert.

Initiate notification procedures and communicate as required

  1. Notification to the following people and/or designee should take place during the first phase after Severe threat status is declared.
    1. Director of Facilities
    2. Administrator On Call
  2. The Incident Command Center will be responsible for notifying the following entities.
    1. Emergency Response Group
    2. Security Administrator
    3. Safety Administrator
  3. The Healthcare Emergency Incident Command System (HEICS) will be implemented and the Code Delta Command Center (Facilities Conference Room) will be staffed 24/7 during a severe threat affecting any AIDHC Facility. All satellite status updates will be communicated through The Command Center.

Level 1 - Criteria

Mass Casualty Incident with the anticipation of 25 or more patients.

  • Notification as per Emergency Management Plan
  • Staff pre-designated for Emergency Room report as directed.
  • Follow Emergency Management Plan
  • Establish Command Post and open Incident Command Center
  • Commence with documentation.

Level 2 - Criteria

Local or Regional Emergency with the anticipation of fewer than 25 patients.

  • Notification of Emergency Department Physician in Charge and Administrator on-call.
  • Request for additional personnel made by the Emergency Department Staff.
  • Follow Emergency Management Plan.
  • Establish Command Post and open Incident Command Center.
  • Commence with documentation.

Level 3 - Criteria

Operations Systems Failure

  • Notification to all personnel by email, pager, and overhead announcement.
  • Request for needed personnel, management and labor pool.
  • Establish Command Post and open Incident Command Center.
  • Commence with documentation.

Security

Security Supervisor

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Incident Commander is established (initial default is Patient Flow Coordinator until Administrator on Call or Incident Commander arrives)
  • NCH’s Logistics Center established (Administration Conference Room, 1st floor) and activates Code Green Delta page to all pre-determined Code Green Delta grouping.
  • Hospital Incident Command activated
  • Incident Commander is established (initial default is Patient Flow Coordinator until Administrator on Call or Incident Commander arrives)
  • NCH’s Logistics Center established (Administration Conference Room, 1st floor) and activates Code Green Delta page to all pre-determined Code Green Delta grouping.
  • Hospital Incident Command activated
  • The Security Officer Recall Roster will be in effect. It will be the Emergency Department Security Officer’s responsibility for notifying all Security personnel of the threat status and advising them when/where to report for duty.
  • If the situation warrants, the main Lobby entrance will be closed off using cones or barriers and placed in a lock-down status.
  • Security Officers Unit 34 will be stationed at the main entrance and will assist with access control and package inspections
  • Security officer Unit 36 will assist with building sweeps.

Code Green Delta Room Assignments:

  • Incident Command Center: Administration Conference Room, 1st floor
  • Labor Pool: Medical Imaging/ Lab Waiting Area (Room A – 0501), Ground Floor
  • Discharge Holding Unit: 5th Floor Clinic
  • Family Gathering/Waiting Area: Occupational Therapy Rehab Gym, 4th floor
  • Family Support and Information Center: Auditorium
  • Pediatric Safe Area—“Kids Track” on Main Floor
  • Media Relations Room: Off the NCH campus across the street
  • Associate Sleeping Area: Clinic areas
  • Associate Child Care Area: 1st floor computer rooms 1721 (12 beds) & 1722 (12 beds)
  • Associate Elder Care Area: 1st floor computer room 1723 A (10 beds) & 1723B (10 beds)
  • Emergency Shelter location for associates pets: enclosed area by back loading dock

Mobilize, assign, and pre-position emergency response personnel

  • Security Patrol Unit 35 will initiate and operate an ID check post at the main vehicle entrance at Nemours Parkway and Lake Nona Blvd. All vehicles and pedestrians are to be stopped at this location and Employee badges verified. A Nemours vehicle and traffic cones will be utilized to block lanes and divert traffic in this effort. Unit 35 will be tasked with boarding all delivery trucks and performing a vehicle inspection prior to granting access. A phone call should be made to all receiving parties to verify delivery (this includes Materials Management deliveries). The security patrol will escort any responding police/ fire department personnel to the loading dock area. An interior security unit or manager will respond to the loading dock and provide escort for the emergency personnel to the incident scene.
  • Notify Engineering Managers and request assistance with access control, building sweeps, and package inspections by staff.
  • Contact the Incident Command Center to notify of severe threat status. Ask that each department conduct area sweeps. They will be tasked with conducting a department sweep once per shift and calling into the Command Center with results.

Close high risk and/or vulnerable facilities, if applicable

  • The Nemours vehicle is to be parked at the main entrance creating a physical barrier. It will remain until the severe threat level is lifted
  • Loading dock will not be accessed without a Materials Management representative present to verify delivery personnel and perform vehicle inspection.
  • All site construction projects will be reviewed by Facilities and Security Management to determine whether the project will be suspended until the severe threat level is lifted.
  • All special events will be cancelled during the severe threat event.
  • Exterior door inspections and exterior sweeps to all properties are to be performed once per shift.
  • Look for unattended packages, suspicious person(s) or unauthorized vehicles. Be sure to take down the vehicle tag number immediately upon identifying suspicious activity. Increased visibility of our patrols is the goal during such an event.
  • Patrol should report all exterior light and access failures immediately.
  • Do not allow vehicles to park alongside any of the buildings. Approach all illegally parked Vehicles and direct the driver to move immediately.
  • All exterior property fencing must be inspected every 12-hours.

Immediate protocol alterations

  • The Incident Command Center will be the central contact for all appointments by contractors, Vendors and/or visitorsrequiring escort. Department contacts and/or escorts will be required to give 24 hours notice for scheduled visits. A daily list will be generated by the Incident Command Center and distributed to all posts including patrol. Only those visitors and vendors on the list will be admitted onto the site.
  • No personal deliveries will be permitted on site. This includes but is not limited to food and floral deliveries, etc.
  • Package inspections will be performed on all packages entering the buildings.
  • Badge spot inspections should be conducted on a continuous basis. Ensure all associates are wearing their identification badge in the building and advise those who are not that it is mandatory to do so.
  • Building exterior sweeps will be conducted each shift.

Guidelines

In the event of a severe threat, and as directed by NCH Executive Management, the following protective measures shall be implemented only at those facilities that may be at risk during a period of heightened alert.

Initiate notification procedures and communicate as required

  1. Notification to the following people and/or designee should take place during the first phase after Severe threat status is declared.
    1. Director of Facilities
    2. Administrator On Call
  2. The Incident Command Center will be responsible for notifying the following entities.
    1. Emergency Response Group
    2. Security Administrator
    3. Safety Administrator
  3. The Healthcare Emergency Incident Command System (HEICS) will be implemented and the Code Delta Command Center (Facilities Conference Room) will be staffed 24/7 during a severe threat affecting any NCH Facility. All satellite status updates will be communicated through The Command Center.

Level 1 - Criteria

Mass Casualty Incident with the anticipation of 25 or more patients.

  • Notification as per Emergency Management Plan
  • Staff pre-designated for Emergency Room report as directed.
  • Follow Emergency Management Plan
  • Establish Command Post and open Incident Command Center
  • Commence with documentation.

Level 2 - Criteria

Local or Regional Emergency with the anticipation of fewer than 25 patients.

  • Notification of Emergency Department Physician in Charge and Administrator on-call.
  • Request for additional personnel made by the Emergency Department Staff.
  • Follow Emergency Management Plan.
  • Establish Command Post and open Incident Command Center.
  • Commence with documentation.

Level 3 - Criteria

Operations Systems Failure

  • Notification to all personnel by email, pager, and overhead announcement.
  • Request for needed personnel, management and labor pool.
  • Establish Command Post and open Incident Command Center.
  • Commence with documentation.

Administration

Incident Command Executives

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

Special note Code Delta 3: Due to the various potentials scenarios, Administrator on Call/Incident Command identifies the specific subject matter expert involved in that scenario (i.e. loss of computers: immediate notification to the director of IS) and identify plan to resolve issue. Identify immediate potential risk to patient population and implement strategies to address this work.

Administrator on Call for Code Delta 1, 2, 3 or special "Disaster Code"

  • Activation of a Code Delta 1, 2 or 3 occurs when the Nursing Supervisor contacts the Administrator on Call and reports a detailed scenario of what is occurring:
    • Estimated arrival of 25 or more patients to the Emergency Department (Code Delta 1)
    • Estimated arrival of 24 or less patients to the Emergency Department (Code Delta 2)
    • An infrastructure/operations failure directly impacting the delivery safe patient care i.e., power loss, fire. (Code Delta 3)

Note: Emergency Physician, in collaboration with the Patient Flow Coordinator, is empowered to make Code Green Delta activation if ETA of incoming patient influx is imminent and then notify the Administrator On Call

  • If this notification occurs during routine business hours, the Administrator on Call confers with the Incident Commander, COO, as to the activation of a Code Green Delta.
  • If this notification occurs after hours, the Administrator On Call is empowered to activate a Code Delta
  • After hours, the Administrator on Call assumes the responsibility as acting Incident Commander in the Incident Command Center

"Disaster Alert"

  • Some disaster situations may not require the immediate, full manpower response resulting from activating a Code Delta 1, 2, or 3. Yet, key stakeholders should be alerted to the actual or potential disaster situation and further discussion occurs whether to activate an actual Code Delta.
  • The Administrator on Call would then ask the Command Center to notify the following Leaderships personnel for further discussion:
    • Incident Commander
    • Safety Officer
    • Operations Chief
    • Planning Chief
    • Logistics Chief
    • Chief Medical Officer
    • Chief Nursing Executive
    • Any specific departmental/division leader directly impacted by that specific situation. i.e. , loss of HVAC, loss of computers

CLICK TO ACCESS INCIDENT COMMAND CHECK LIST

All Other Associates

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

Special note Code Delta 3: Due to the various potentials scenarios, Administrator on Call/Incident Command identifies the specific subject matter expert involved in that scenario (i.e. loss of computers: immediate notification to the director of IS) and identify plan to resolve issue. Identify immediate potential risk to patient population and implement strategies to address this work.

Administrator on Call for Code Delta 1, 2, 3 or special "Disaster Code"

  • Activation of a Code Delta 1, 2 or 3 occurs when the Nursing Supervisor contacts the Administrator on Call and reports a detailed scenario of what is occurring:
    • Estimated arrival of 25 or more patients to the Emergency Department (Code Delta 1)
    • Estimated arrival of 24 or less patients to the Emergency Department (Code Delta 2)
    • An infrastructure/operations failure directly impacting the delivery safe patient care i.e., power loss, fire. (Code Delta 3)

Note: Emergency Physician, in collaboration with the Patient Flow Coordinator, is empowered to make Code Green Delta activation if ETA of incoming patient influx is imminent and then notify the Administrator On Call

  • If this notification occurs during routine business hours, the Administrator on Call confers with the Incident Commander, COO, as to the activation of a Code Green Delta.
  • If this notification occurs after hours, the Administrator On Call is empowered to activate a Code Delta
  • After hours, the Administrator on Call assumes the responsibility as acting Incident Commander in the Incident Command Center

"Disaster Alert"

  • Some disaster situations may not require the immediate, full manpower response resulting from activating a Code Delta 1, 2, or 3. Yet, key stakeholders should be alerted to the actual or potential disaster situation and further discussion occurs whether to activate an actual Code Delta.
  • The Administrator on Call would then ask the Command Center to notify the following Leaderships personnel for further discussion:
    • Incident Commander
    • Safety Officer
    • Operations Chief
    • Planning Chief
    • Logistics Chief
    • Chief Medical Officer
    • Chief Nursing Executive
    • Any specific departmental/division leader directly impacted by that specific situation. i.e. , loss of HVAC, loss of computers

CLICK TO ACCESS INCIDENT COMMAND CHECK LIST

Pharmacy

Pharmacy

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Be available for support as requested by patient units and Incident Command
  • Prepare to initiate call tree

Clerk

Clerk/Aides

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Unless designated by Patient Flow Supervisor or Incident Command, remain in department and continue with tasks
  • Assist with assessing and/or calling to obtain additional supplies

Social Work

Social Worker

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • No specific required duties. Please be available if contacted by Incident Command

Pastoral Care

Pastoral Care

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • No specific required duties. Please be available if contacted by Incident Command

Rehab and Therapy Services

Rehab and Therapy Services

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • No specific required duties. Please be available if contacted by Incident Command

Facilities

Facilities Engineering

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Be available for support related to building systems management

Clinical Lab

Clinical Lab

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • No specific required duties. Please be available if contacted by Incident Command

Blood Bank

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • No specific required duties. Please be available if contacted by Incident Command

Information Systems

Information Systems

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • No specific required duties. Please be available if contacted by Incident Command

Nutrition Services

Nutrition Services

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • No specific required duties. Please be available if contacted by Incident Command

Radiology

X-Ray

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • No specific required duties. Please be available if contacted by Incident Command

MRI

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • No specific required duties. Please be available if contacted by Incident Command

CT

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • No specific required duties. Please be available if contacted by Incident Command

Interventional

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • No specific required duties. Please be available if contacted by Incident Command

Ultrasound

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • No specific required duties. Please be available if contacted by Incident Command

Health Information Management

Health Information Management

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • No specific required duties. Please be available if contacted by Incident Command

Human Resource

Human Resources

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • No specific required duties. Please be available if contacted by Incident Command

Environmental Services

Environmental Services

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Be available for additional support related to Environmental Services as requested by Incident Command

Materials Management

Materials Management

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Be available to assist with unit or Incident Command needs as instructed by Incident Command
  • Be aware of STAT supply requests

Volunteer Services

Volunteer Services

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Volunteers should immediately report to the Labor Pool located in the Medical Imaging/ Lab Waiting Area (Room A – 0501) and await instructions
  • Volunteers may be utilized as "runners"

Critical Care Transport

Critical Care Transport

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Provide support as requested by Incident Command

Child Life

Child Life

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Provide support as requested by Incident Command

Marketing and Public Relations

Marketing and Public Relations

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • The Public Relations Spokespersons will handle all questions from the public and media

All Other Associates

All Other Associates

Code GREEN DELTA Level 3

Code Green Delta 3: Infrastructure/operations failure impacting the delivery of safe patient care (i.e. loss of power, electricity, water, telephones, computers.)

  • Provide support as requested by Incident Command