*Section 6*

*Sample Standard Operating Procedures (SOPs)*

Table of Contents

6.1. Introduction 6 - 1

*Enclosures*

1\. Sample Standard Operating Procedure (SOP) Template 6 - 3

2\. Operations Section of ICS (Figure 6.1) 6 - 5

*The following documents are on the CD-ROM that accompanies this
Guidebook and at the CEOSH web site (vaww.ceosh.med.va.gov); those
documents marked with an asterisk (\*) are also provided in this printed
copy*

*at the page numbers indicated:*

**6.2. Hazards, Threats and Events Sample Standard Operating Procedures
(SOPs)**

6.2.1. ***Naturally Occurring Events***

6.2.1.1. Drought/Dust Storm CD

6.2.1.2. Earthquake CD

6.2.1.3. Fire Response CD

6.2.1.4. Flood CD

6.2.1.5. Hurricane CD

6.2.1.6. Thunderstorm/Lightning CD

6.2.1.7. Tornado CD

6.2.1.8. Tsunami CD

6.2.1.9. Volcanic Eruption CD

6.2.1.10. Winter Storm CD

6.2.2. ***Human Related Events***

6.2.2.1. Bomb Threat CD

6.2.2.2. Civil Disturbance CD

6.2.2.3. Cyber Attack CD

6.2.2.4. Hostage/Barricade Situation CD

6.2.2.5. Terrorist Threat CD

6.2.2.6. Violence in the Workplace CD

6.2.3. ***Hazardous Materials Events***

6.2.3.1. Biological Events

6.2.3.1.1. Generic Biological Agents CD

6.2.3.1.2. Anthrax Release in the Community or VA Medical Center CD

6.2.3.1.3. Smallpox Release in the Community or VA Medical Center CD

**\***6.2.3.1.4. Respiratory Viral Outbreak Event (e.g., SARS or
Pandemic Influenza) 6 - 7

6.2.3.2. Chemical Events

6.2.3.2.1. Chemical Event (External) CD

6.2.3.2.2. Chemical Event (Internal) CD

**\***6.2.3.3. Patients with Radiation Exposure or Radioactive
Contamination 6 - 25

6.2.3.4. Explosion - Internal VAMC Event (Engineering and Evacuation
Considerations) CD

**6.3. Key Operational Events Standard Operating Procedures (SOPs)**

6.3.1. ***Business Continuity***

6.3.1.1. Business Relocation CD

6.3.1.2. Communications CD

6.3.1.3. Critical Supplies Shortage CD

6.3.1.4. Patient Access to Services CD

6.3.1.5. Records Preservation CD

6.3.1.6. Staffing Shortages CD

6.3.1.7. VISTA and Other Computer Systems Disruptions CD

6.3.2. ***Equipment, Plant and Utilities***

6.3.2.1. Alarm Systems Failure CD

6.3.2.2. Electrical Power Failure CD

6.3.2.3. Elevators-Vertical Transport Failure CD

6.3.2.4. HVAC Failure CD

6.3.2.5. Room/Hood Exhaust Failure CD

6.3.2.6. Steam Distribution Failure CD

6.3.2.7. Internal Transport System Failure CD

6.3.2.8. Medical Gases System Failure CD

6.3.2.9. Roads and Grounds Blocked CD

6.3.2.10. Waste and Debris Removal CD

6.3.2.11. Water Delivery/Potability CD

6.3.3. ***Health and Medical***

6.3.3.1. Alternate Care Sites CD

**\***6.3.3.2. Healthcare First Receiver Decontamination 6 - 69

\*6.3.3.3. Trauma Management in a Mass Casualty Incident -
Blasts/Explosions 6 - 125

**\***6.3.3.4. Triage During a Mass Casualty Incident (MCI) 6 - 141

**\***6.3.3.5. Trauma Management in a Mass Casualty Event - All Hazards
Considerations 6 - 155

**\***6.3.3.6. VHA Pharmaceutical Cache 6 - 187

6.3.3.7. Evacuation (Total) CD

6.3.3.8. Fatality Management CD

6.3.3.9. Mass Casualty Incident CD

6.3.3.10. Outreach CD

6.3.4. ***Safety and Security***

6.3.4.1. Alerting and Warning System CD

6.3.4.2. Facility Access Contro1 CD

**\***6.3.4.3. Lockdown - Heightened Security Procedures 6 - 189

6.3.4.4. Fire Suppression System Failure CD

**\***6.3.4.5. Clinical Laboratory Biosafety and Biosecurity 6 - 197

*Section 6*

*Sample Standard Operating Procedures (SOPs)*

For Specific Incidents

6.1. ***Introduction***. Standard Operating Procedures (SOPs) have been
developed to serve as guides for VA Medical Center (VAMC) staff to use
in developing more detailed versions from the SOP sample template
described below. After the VAMCs develop their own SOPs, these become
part of the Emergency Operations Plan (EOP). Based upon the needs of the
emergency, the appropriate SOPs will be used to guide response and
recovery efforts. (A sample template is included as Enclosure 1.)

6.1.1. The SOPs for hazards, threats and events (Section 6.2) are the
outcome of the Hazards Vulnerability Analysis process described in
Section 3. Each of these describes mitigation, preparedness, response
and recovery strategies and resource issues appropriate to the hazard,
threat or event. Each SOP is accompanied by a worksheet and a diagram.
The worksheet, Key Activity Management Tool, provides additional advice
on what activities might need to be conducted. The diagram, Key Activity
Management Structure, illustrates which parts of the Incident Command
System (ICS) may be activated to manage the activities.

6.1.2. The SOPs in Section 6.3 describe in more detail how to conduct
the key activities in the Business Continuity; Equipment, Plant and
Utilities; Safety and Security; and Health and Medical Groups \[the
Operations Section of the VAMC's ICS (Figure 6.1, Enclosure 2)\].

> **Note:** Some of these cross over as hazards/threats/events and, as
> such, contain the same two worksheets as those in Section 6.2 (e.g.,
> communications disruption, VISTA/computer system disruption, fire
> suppression system failure and all of the activities found under the
> Equipment, Plant and Utilities Group).

6.1.3. Of particular interest in this issue are new sample SOPs directed
at decontamination procedures, CBRNE (Chemical,
Biological/Radiological/Nuclear/Explosive) events and Pharmacy Cache.
These new SOPs are contained in this hardcopy of the Guidebook and also
on the accompanying CD-ROM as sample documents \[Biological Events
(Respiratory Viral Outbreak Event, e.g., SARS or Pandemic Influenza),
6.2.3.1.4; Patients with Radiation Exposure or Radioactive
Contamination, 6.2.3.3; Healthcare First Receiver Decontamination,
6.3.3.2; Trauma Management, 6.3.3.3 and 6.3.3.5; Triage During an MCI,
6.3.3.4; VHA Pharmaceutical Cache, 6.3.3.6; and Lockdown/Heightened
Security, 6.3.4.3.\] Sample SOPs that were developed for the first
edition of the Guidebook (2002) have been updated as needed and are
contained on the CD-ROM only (see Section 6 Table of Contents).

6.1.4. The sample documents are not intended to be comprehensive or
cover all of the elements required for each particular VAMC. They
should, however, be used as a starting point and be used to document due
diligence. Some samples may address hazards found only in certain
geographical areas, while others may apply to facilities across the
country. These samples should be customized by Operating Unit Managers
to address conditions at your particular VAMC or Clinic. Development of
VAMC-specific SOPs will foster emergency management awareness and help
VAMC staff recognize the importance of their participation in emergency
management planning. SOPs should be "living" documents, revised as often
as necessary to include current information on the conditions addressed.
The effectiveness of emergency response actions outlined in the SOPs
should be evaluated as a part of drills and exercises.

6.1.5. Using the Key Activity Management Structure. To select and fill
in a key activity:

-   Make sure the drawing toolbar is viewable.

> 1\. Click on "View" on the menu bar.
>
> 2\. Highlight "Toolbars."
>
> 3\. Click on "Drawing."

-   Place the cursor on one of the circles to be selected. The cursor
    will change to cross arrows when over the subject.

-   Click once to select the object.

-   On the drawing toolbar, press the selection arrow to the right on
    the "fill color" tool.

-   Select the color to fill the object.

-   Repeat above steps for each selection.

Enclosures

1\. Sample Standard Operating Procedure (SOP) Template.

2\. Operations Section of ICS (Figure 6.1).

*Sample 6.2.1.1*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Drought/Dust Storm**

1\. ***Description of the Threat/Event.*** Droughts are caused by a
natural reduction in precipitation over an extended period of time. They
can occur in any climate and in any season; thus, the entire United
States is at risk. Dust storms are more likely and more severe during
droughts.

2\. ***Impact on Mission Critical Systems.* N/A**.

3\. ***Operating Units and Key Personnel with Responsibility to Manage
this Threat/Event.***

-   Medical Center Director's Office

-   Facilities Engineering

4\. ***Mitigation/Preparedness Activities for the Threat/Event.***

a.  *Hazard Reduction Strategies and Resource Issues.* An external
    supply connection for water tankers to the VA Medical Center's
    potable water and fire suppression system(s) can be added.

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a.  *Preparedness Strategies and Resource Issues.*

-   Water usage rates should be calculated and arrangements made with
    water suppliers in advance.

-   Waterless infection control techniques will require additional
    quantities of supplies.

-   Fire alarm systems should be re-inspected and monitored closely.

-   In cases of dust storms, ventilation systems, equipment and vehicles
    should be protected.

5\. ***Response/Recovery from the Threat/Event.***

a.  *Hazard Control Strategies.*

-   Remind employees about water conservation requirements.

-   Maintain regular contact with water suppliers for possible
    disruptions to their suppliers.

-   Contact home-based patients to check their status.

-   Maintain regular contact with other VA Medical Centers in the VISN.

a.  *Hazard Monitoring Strategies**.*** Safety Office will maintain
    regular contact with local water utilities and emergency management
    agency.

b.  *Recovery Strategies and Resource Issues.* Transition back to
    municipal water supplies may require water quality testing.

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d.  *See Attached Charts: Key Activity Management Tool/Structure.*

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4.  ***External Notification Procedures.***

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a.  *Within VA.* VISN will be notified when the VA Medical Center goes
    off and back on municipal water supplies.

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a.  *Other Federal Agencies.* Bulk purchasing of water should include
    other Federal agencies, as appropriate. Notify OSHA within eight (8)
    hours of one (1) employee fatality, or three (3) employee
    hospitalizations resulting from a single incident.

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c.  *Community Entities and Local Governments.*

-   Water Utility

-   Local Emergency Management Agency

-   Local Hospital Association

-   National Weather Service

6\. **Specialized Staff Training.** Staff and patient education should
address water conservation techniques.

7\. ***References and Further Assistance.*** N/A

8\. ***Review Date.***

(Name)

Chief, (Service)

Attachment:

A. Key Activity Management Tool

B. Key Activity Management Structure

*Sample 6.2.1.2*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Earthquakes**

1\. ***Description of the Threat/Event.*** An earthquake is a series of
waves or vibrations in the crust of the earth that are caused by the
sudden shifting of layers under great strain along geologic faults. A
fault is considered active if periodic movement or slow creepage occurs.
This movement is the result of energy forces deep within the earth.
Large crustal blocks that are separated by these faults are held in
place by friction. As pressure from the earth's core, which is in a
molten state, increases over time, a certain threshold is met in which
these frictional forces are overcome. The result is the sudden and
unpredictable shifting, slippage or readjustment along the fault lines.
That movement is known as an earthquake.

The earthquake's epicenter is a reference point located on the earth's
surface directly above the focus. The focus is the point of origin of
the quake and is sometimes called the hypocenter. Earthquakes are
measured in magnitude and intensity. Magnitude quantifies the energy
released at the earthquake's point of origin. The measurements are
recorded from seismographs and expressed on the Richter scale. Usually
the recordings will be recorded as a number between 0 and 10. Measuring
the duration and amount of seismic waves or vibrations determines the
intensity of an earthquake.

Several contributory factors are important in determining the amount of
damage and level of injuries that may be sustained from seismic
activity:

-   Intensity.

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-   Magnitude.

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-   Distance from the epicenter.

-   Depth of quake below the surface.

-   Type of slippage or movement along the fault.

-   Type of rock layer and soil transmitting the quake's energy.

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-   The type of structure, including design, age and construction
    material.

2\. ***Impact on Mission Critical Systems.*** Earthquakes may negatively
impact all mission critical systems:

-   Municipal utilities, including electrical power, water and natural
    gas.

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-   Medical Center normal and emergency electrical power distribution
    systems.

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-   Medical Center water distribution (potable and non-potable).

-   Sanitary sewer and storm drainage systems.

-   Natural gas supply and distribution system.

-   Steam generation and distribution systems (impacting heating,
    cooling, cooking and sterilization capabilities).

-   Medical gas (air, oxygen, nitrous oxide) and vacuum systems.

-   Diagnostic and therapeutic medical equipment.

-   Fire detection and suppression systems.

-   Voice and data communications (e.g. electronic patient records and
    images, cellular phones, telephones and paging systems).

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-   Heating, ventilating and air conditioning systems.

-   Vertical and horizontal transport systems (elevators, pneumatic
    tubes).

-   Refrigeration systems (e.g., blood bank, nutrition, laboratory,
    morgue, and research).

-   Liquid fuel systems (e.g., propane, diesel, gasoline).

-   Roadways and bridges.

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-   Waste handling and disposal (regular and bio-hazardous).

Secondary effects of an earthquake can be more disastrous than the quake
itself. The two primary causes of secondary damage are fires and floods.
Fires can be caused by the ignition of natural gas leaks or by short
circuits in the electrical power distribution system. Flooding is
typically caused by the rupture of major lines in potable and chilled
water distribution systems.

The damage that can be caused by earthquakes is not limited to the
physical or infrastructure domain. The psychological stress that is
caused to individuals can be significant. The sights and sounds of death
and destruction may render many individuals unable to cope for hours or
even days. Since human resources are the institution's most valuable and
critical assets, such potential problems arising from the earthquake
must be addressed.

3\. ***Operating Units with Responsibility to Manage this
Threat/Event.*** All Operating Units will have responsibilities to
manage mitigation/preparedness and response/recovery to an earthquake.
Since there may be multiple primary and secondary effects resulting from
earthquakes, it may be necessary to implement several of the Standard
Operating Procedures provided in the Emergency Management Plan.

4\. ***Mitigation/Preparedness Activities of the Threat/Event.***
Specific earthquake mitigation and preparedness activities are divided
into two general categories: 1) facility and 2) individual.

a\. *Hazard Reduction/Preparedness Strategies and Resource Issues.*

1\) **Mitigation.** \[The term *secure* means to anchor or brace in
accordance with applicable VA, American Institute of Architects (AIA),
state, municipal, National Fire Protection Association (NFPA), or other
directives and best practice engineering specifications or
recommendations.\]

a)  Secure all major power conditioners, uninterruptible power supplies
    and battery banks in Information Management Systems and telephone
    rooms.

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a)  Secure all electrical generator sets and associated battery systems,
    fuel systems and control panels.

b)  Secure all shelves, furniture, file cabinets, tool racks and the
    like firmly to wall studs.

c)  Secure water heaters by strapping to wall studs or on stands bolted
    to floor.

d)  Secure direct exchange, fan coils and window A/C units.

e)  Secure all major building service equipment, such as:

    -   Chillers and air handling units.

    -   Medical vacuum and air sources.

    -   Bulk oxygen storage tank and manifold.

    -   Sub-stations, transformers, switchgear, power conditioners.

    -   Fire suppression systems.

    -   Boilers.

    -   Water tanks.

    -   Nutrition and Food Service systems (e.g., re-therm, tray lines,
        freezers, dishwashers).

        g.  Secure all bulk or portable gas storage tanks (e.g.,
            propane, acetylene, carbon dioxide, nitrogen, nitrous oxide,
            and oxygen).

        h.  Hang heavy items such as artwork, displays, bulletin boards,
            calendar boards away from where people may sit, such as in a
            waiting room.

        i.  Brace all overhead light fixtures properly (see NFPA
            guidelines); brace all electrical conduit, pneumatic and
            water lines in accordance with NFPA or other applicable
            standards.

        j.  Anchor or brace indoor or outdoor fuel tanks.

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k)  Anchor all fixed medical equipment, including:

    -   Diagnostic and therapeutic radiographic equipment.

    -   Nuclear Medicine.

    -   Research.

    -   Laboratory.

    -   Dialysis (e.g., water purification system).

    -   Pulmonary (e.g., barometric chamber).

    -   Physical therapy.

    -   Urology.

        l.  Ensure electrical and gas distribution systems are
            maintained in good repair to minimize fire and explosion
            risks.

        m.  Ensure fire suppression systems are maintained in good
            condition.

        n.  Ensure potable, irrigation and chilled water distribution
            systems are maintained in good repair to minimize flooding.

        o.  Ensure adequate drainage capability for rooms at ground
            level or below which house patient records.

        p.  Store flammable materials in closed, rated cabinets with
            latches to minimize explosion risk and damage.

        q.  Store hazardous and radioactive materials securely with
            proper containment to minimize damage from spills and leaks.

        r.  Store breakable items such as glassware in closed cabinets
            with latches and secure items in display cases with
            "earthquake putty".

        s.  Place large or heavy objects on lower shelves whenever
            possible.

        t.  Repair deep or structural cracks in ceilings or foundations.

        u.  Install earthquake shutoff valves for water, gas and steam
            distribution systems.

2\) **Preparedness.**

a)  Ensure adequate as-built drawings.

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a)  Ensure adequate backup fuel storage capacity and supply.

b)  Ensure adequate battery powered emergency fixed lighting systems,
    particularly for operating rooms, intensive care units, emergency
    room, procedure rooms, and corridors and stairwells for safe egress.

c)  Ensure adequate, documented and tested back-up communication systems
    (e.g., point-to-point handheld radios, satellite phones, and
    runners).

d)  Ensure ready availability of portable toilets (e.g., vendor
    contract).

e)  Ensure availability of camp stoves or barbecues to cook outdoors for
    feeding staff and rescue workers during recovery.

f)  Ensure access to adequate potable water supplies, such as water
    tanker trucks from Army Corps of Engineers or local military base.

g)  Ensure presence of duplicate sets of keys for all vehicles in the
    event that keys are missing or inaccessible as a result of the
    earthquake.

h)  Ensure availability of up-to-date copies of drawings for key
    isolation shut-off valves for all major gas and water systems.

i)  Ensure all record drawings are current (e.g., architectural,
    electrical, mechanical and plumbing)

j)  Ensure availability of sufficient number of portable electric
    generators.

k)  Ensure availability of adequate number of portable lighting systems.

l)  Ensure availability of adequate fire extinguishers.

m)  Ensure that medical records are stored in an area with adequate
    drainage or ready availability of submersible pumps.

n)  Ensure dual site storage of research data.

o)  Ensure availability of hazardous and radioactive material
    inventories, including locations, and MSDSs.

p)  Ensure availability of alternative waste disposal means or temporary
    storage.

q)  Ensure Emergency Preparedness Plan includes alternate triage sites
    in case main site is unusable.

r)  Ensure capability to adequately maintain patient records during
    prolonged utility or VISTA outages.

s)  Prepare response plans for hazardous and radioactive leaks or
    spills.

t)  Prepare a back-up plan to relocate and secure patient records in the
    event of imminent flooding.

u)  Prepare patient evacuation plan.

v)  Prepare potable water testing protocols.

w)  Prepare evacuation plans for research animals.

x)  Prepare for inaccessibility of electronic patient records.

y)  Prepare and periodically update a list of multiple alternate
    suppliers for critical supplies (e.g., diesel fuel, electric
    generators, portable toilets, portable water, and gasoline).

z)  Identify seismic deficiencies (structural and non-structural);
    prepare abatement strategies and document in Capital Asset Plan.

a)  Retain licensed Professional Engineering (PE) structural team to be
    summoned on demand.

b)  Conduct and document earthquake preparedness drills.

c)  Document employee education on personal mitigation and preparation
    as described below in Section 4.b.

b\. *Individual Hazard Reduction Strategies and Resource Issues.*

1\) **During the Quake.**

a)  Duck or drop down to the floor.

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a)  Take cover under a desk or table; if this is not possible, seek out
    cover against an interior wall, and protect the head and neck with
    arms; hallways are safest; laboratory areas, canteen, kitchen and
    garage areas are most unsafe; avoid large windows, heavy hanging
    objects and tall furniture.

b)  Hold securely on to the furniture during the shaking; when the
    shaking stops immediately evacuate the building to nearest
    designated safe area.

c)  If outdoors, move to a clear area away from trees, buildings, signs
    or electrical wires (fallen or intact).

d)  If on a sidewalk, duck into a doorway protecting self from falling
    objects.

e)  If driving, pull to the side of the road and stop; avoid overpasses,
    power lines and trees; stay inside vehicle until shaking is over.

f)  If in a wheelchair, stay in it. Lock the wheels and protect head
    with arms.

h\) If in an auditorium, theatre or other large gathering place, stay in
seat and protect head with arms; and when the shaking is over exit in a
calm and orderly manner.

i\) If in parking structure, move near a column.

j\) Wait for the shaking to stop.

2\) **Immediately After the Quake.**

a)  Evaluate the immediate surroundings and move away from any immediate
    hazards.

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a)  If indoor, find a safe route to exit the building. Beware of:

    -   Fallen light fixtures.

    -   Flooded areas (electrocution risk).

    -   Broken glass and other sharp objects.

    -   Leaking gas (explosion and fire risk).

    -   Hazardous material releases.

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c)  If outdoors, find a safe area. Beware of:

    -   Fallen electrical lines

    -   Flooded areas

    -   Broken glass

    -   Leaking gas

    -   Hazardous materials releases

    -   Cracks/fissures in the ground

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d)  Follow the Emergency Management Plan. Remember to report all
    identified hazards up the chain of command.

5\. ***Response/Recovery from the Threat/Event.***

a\. *Hazard Control Strategies*. Primary hazard control comprises the
following four concurrent activities. Relative priorities of the four
activities are difficult to project and will be continually adjusted
dependent upon the individual situation.

1)  **Save Lives and Prevent Injury** - While it is important to set up
    the Emergency Operations Center as quickly as possible, it is urgent
    to address the safety of patients, particularly those who may be
    immobile or on life support. Clinical staff are the key in this
    effort. As the Emergency Operations Center is set up and
    communication lines are established, information must be routed to
    the Emergency Operations Center with all possible speed as to the
    assessment of the injury and safety status of all patients. A
    determination may have to be made as to whether evacuation is
    required from any or all damaged buildings at the Medical Center.

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1)  **Establish Communication Paths** - Effective and timely
    communication is essential to minimize the loss of life or property
    immediately following the earthquake. Back-up plans and Standard
    Operating Procedures to address severed communication paths must be
    deployed at once. The earthquake may disable normal routes of
    communication, including telephones (landline and mobile), two-way
    radio systems, PBX and localized intercom systems.

2)  **Activate the Standard Operating Procedure for Patient Evacuations
    if needed** - Special attention should be paid to begin the massive
    transportation needs and coordinate the safe transfer of patients.
    It is important to track and document patient movement and prepare
    patient records in advance of transport to other health care
    facilities.

3)  **Check and Secure Utility Systems** - Include all components of
    distribution systems (e.g., supply and return lines, risers,
    shut-off and isolation valves, manifolds, switchgear, transformers
    and sub-stations) for the following lifeline utilities:

    -   Normal and emergency electrical power distribution systems.

    -   Water distribution (potable, chilled and irrigation).

    -   Sanitary sewer and storm drainage systems.

    -   Natural gas supply and distribution system.

    -   Steam generation and distribution systems.

    -   Medical gas (air, oxygen, nitrous oxide) and vacuum systems.

    -   Fire detection and suppression systems.

    -   Voice and data communications (e.g., electronic patient records
        and images, cellular phones, telephones and paging systems).

    -   Heating, ventilating and air conditioning systems.

    -   Vertical and horizontal transport systems (e.g., elevators,
        pneumatic tubes).

    -   Refrigeration systems (e.g., blood bank, nutrition, laboratory,
        morgue, and research).

    -   Liquid fuel systems (e.g., propane, diesel, gasoline).

Secondary hazard control includes the following activities:

5.  **Assess Damage** - The Chief, Facilities Management Service should
    assign teams to gather information in accordance with the Emergency
    Management Program. This is critical information that may be
    required by coordinating agencies, such as police, fire and rescue
    and Veterans Health Administration hierarchy.

6.  **Determine Access Levels for all Areas and Structures** -
    (Appropriate signage should be placed to control the flow of staff,
    equipment and transport vehicles as quickly as possible.):

    -   Green - unrestricted access, building's original seismic
        integrity has not been compromised.

    -   Yellow - temporarily usable, or usable with caution (e.g.,
        hardhat entry).

    -   Orange - limited entry by authorized personnel only, no
        occupancy.

    -   Red - restricted, no access and no occupancy.

7\) **Check and Reset Systems after the Earthquake** - Examples include:

-   Fire detection and suppression systems (e.g., alarm panels, smoke
    and fire doors, pumps).

-   Dampers and traps.

-   Intrusion and panic alarms.

-   Central energy management computer system.

-   Line isolation monitors.

-   Security access systems.

-   Information management systems.

-   Elevator motor control centers.

-   Medical gas (air, oxygen, nitrous oxide) and vacuum systems.

    8.  **Check for Fires and Fire Hazards** - Fires ignited as the
        result of an earthquake cause significant damage and injury. The
        Safety Manager must take the lead to check the entire site for
        fires and fire hazards (e.g., gas leaks). Ensure the use of the
        proper type of extinguisher for any fires that may be
        encountered. Any findings should be immediately reported to the
        Chief, Facilities through the Emergency Operations Center for
        proper area clearance or restriction.

    9.  **Check for and Contain Asbestos Releases** - The Safety Manager
        must quickly ascertain whether the release of Asbestos
        Containing Material (ACM) may have occurred. Use the ACM
        assessment as a guide to locate potential problem areas. Some
        areas may have to be limited to controlled access for those with
        appropriate certification and personal protective equipment. In
        some cases, quick decisions will be needed to weigh standard
        safety precautions against serious injury or loss of life.

    10. **Find, Contain and Clean up Chemical Hazards and Spills** - The
        Safety Manager must take the lead to inspect the entire site for
        chemical hazards and spills. Use the existing hazardous
        materials inventory as a guide to locate likely problem areas
        and MSDS to determine appropriate actions (e.g., contain,
        evacuate, clean). Any findings should be immediately reported to
        the Chief, Facilities through the Emergency Operations Center
        for proper area clearance or restriction.

    11. **Find, Contain, and Clean up Radioactive Material Releases** -
        Nuclear Medicine, Radiology and Research Service Chiefs should
        work closely with the Radiation Safety Officer to check for
        radioactive spills. Use the existing radioactive materials
        inventory as a guide to locate and secure problem areas. The
        Radiation Safety Officer must determine the means and methods
        for cleanup. Any findings should be immediately reported to the
        Chief, Facilities through the Emergency Operations Center for
        proper area clearance or restriction.

    12. **Address Special Transportation Needs** - There may be an acute
        need for ambulance or lay-down transport for an unusually large
        number of patients within a small-time window. Check evacuation
        paths before beginning to ensure they are clear. It is important
        for clinical staff to prioritize the transportation sequence of
        patients. Remember to track patient movement.

    13. **Preserve Patient Records** - Ensure someone is assigned
        responsibility for the preservation and availability of patient
        records. Be aware of the possibility of damage from fire or
        flood. Paper medical records are usually stored at ground level
        or below. These areas may not have adequate drainage to
        withstand a massive introduction of water, which could damage or
        destroy the records. The responsible person may need to initiate
        the immediate removal for safe keeping of all patient records.

    14. **Preserve Perishable Foods and Supplies** - The Chief,
        Nutrition and Food Service must evaluate immediately the
        condition of perishable food and supplies and coordinate
        disposition with logistics (e.g., A&MM and Facilities Service).
        If refrigeration is lost, consume the most perishable foods
        first.

    15. **Address Matters of Public Interest** - The Public Affairs
        Officer must monitor and control all contacts with the media.
        Every effort must be made to maintain the public trust in a time
        of crisis. The Public Affairs Officer anticipates high-level
        contact from VISN and VACO, and it is entirely possible that
        coordinated responses to media inquiries may be necessary.

    16. **Preserve Research Specimens, Materials and Data** - The ACOS
        for Research must take action to minimize the immediate loss of
        research materials and data from fire, flood or electrical power
        outages. Be prepared to activate the research animal evacuation
        plan.

17\) **Assess Damage to Quarters.**

18. **Prepare for Aftershocks** - All staff should be prepared for the
    expected aftershocks that follow the major shake. It is important to
    remain calm and follow the individual hazard reduction strategies
    described in section 4.b above.

19. **Beware of Electrical Hazards** - Fallen power lines and light
    fixtures, exposed electrical wiring and submerged electrical
    distribution equipment (e.g., transformers, wall outlets, cables)
    are common following an earthquake. The increased presence of wet
    areas poses a higher risk of electrical shock or electrocution.
    Rescuing any person in contact with a live electrical line is
    extremely dangerous and must only be attempted as a last resort. If
    necessary, use a dry, non-conductive pole like a wooden broom handle
    to flip the wire away from the trapped person.

20. **Verify Potable Water Sources** - No one should drink any tap water
    until a determination is made on whether sewer lines are intact.
    Contamination could occur, and only bottled or otherwise contained;
    safe or treated water should be used until that determination is
    made. Use bottled water in interim and activate pre-arranged testing
    protocols.

21\) **Activate the Medical Center's water conversation plan as
necessary.**

22\) **Replace all Telephone Receivers** - All staff should ensure that
telephone handsets are placed back on the cradle so that if
telecommunications are intact they can be quickly used.

b\. *Hazard Monitoring Strategies*. Ongoing monitoring and documentation
of the status of patients, facilities, staff and cost is critical. This
can be accomplished by creating and updating monitoring spreadsheets.

1\) **Monitor patient condition and location** - The Chief of Staff or
designee must maintain a monitoring spreadsheet listing the current
status for each patient, including the following information:

-   Patient name.

-   Identifying number.

-   Condition.

-   Pre-earthquake ward or location.

-   When and how transported (as appropriate).

-   Current location.

2\) **Monitor safety of occupied areas** - The Safety Officer or
designee must establish a team to conduct periodic (e.g., every four
hours) safety rounds of the occupied areas on campus. Information should
be transmitted to the Emergency Operations Center to update the hazard
monitoring spreadsheet.

3\) **Monitor status of facilities** - The Chief, Facilities Management
Service must set up and maintain a continuous damage assessment
monitoring system. This should be documented at the Emergency Operations
Center in a spreadsheet. This information is necessary for transmission
to VISN, VACO or other places where needed. Any printed matter should be
annotated with date and time.

4\) **Monitor staff deployment** - The Human Resources Officer must
maintain a monitoring spreadsheet listing the current status for each
employee, including the information listed below. At the end of each
day, the Human Resources Officer will provide the Fiscal Officer with a
record of actual hours worked that day.

-   Name.

-   T&L unit.

-   Duty status.

-   Current assignment.

-   Current location.

5\) **Monitor resources and costs** - Based on input from Service
Chiefs, the Chief, Fiscal Service or designee must monitor and document
all costs incurred as a result of the earthquake, using a spreadsheet
that includes:

-   Normal and overtime labor costs for all staff.

-   Fee basis costs for displaced Services or transferred patients.

-   Rental costs for major medical equipment systems.

-   Transportation costs.

-   Interim facility construction costs.

-   Loss of referral income.

-   Expenses for supplies, materials, equipment and logistics during
    recovery and response phase.

-   Structural engineering and other disciplines (architectural,
    electrical, mechanical, estimators) consultative costs.

-   Repairing, re-calibrating or replacing damaged equipment.

c\. *Recovery Strategies and Resource Issues*. Between 24 and 72 hours
after the earthquake, the Medical Center should anticipate a transition
from first response to the beginning stages of recovery. During this
period, the Medical Center will begin formulating and implementing
strategic plans for recovery. This is the first opportunity for
leadership to address issues beyond first response. While it is
difficult to project every need, the following have been identified as
key:

1\) **Evaluate damaged equipment** - The first stages of the recovery
phase include the recalibration, repair, or replacement of damaged
equipment and utilities.

a\) [Medical equipment]{.underline} - Certain fixed and portable medical
equipment is extremely sensitive, and should be inspected for damage and
function before use on a patient. Some require calibration or alignment
to exacting standards. (Refer to Medical Equipment Management Program
requirements.) Examples include:

-   Nuclear Medicine (e.g., crystals, scanners).

-   Radiographic and fluoroscopic equipment.

-   Diagnostic ultrasound equipment.

-   Laboratory equipment (e.g., blood gas or blood chemistry analyzers).

-   Research equipment (e.g., electron microscope, gas chromatograph).

-   Radiation oncology equipment.

-   Lithotriptors.

-   Lasers.

-   Microscopes.

-   Dialysis machines and re-use systems.

-   Operating Room and ICU equipment.

b\) [Non-medical equipment]{.underline} - Certain non-medical equipment
also should be inspected for damage and function before use. Examples
include:

-   Fume hoods (biohazard and chemical).

-   Lifts (e.g., fixed patient lift systems, loading dock, auto shop).

c\) [Utility equipment]{.underline} - Certain building service equipment
should be checked for damage and function. Examples include:

-   Valves.

-   Air handlers.

-   Compressors.

-   Pumps.

-   Condensers.

-   Transformers.

-   Automatic transfer switches.

-   High ampacity circuit breakers.

2\) **Seek assistance from experts** - VHA is staffed with a wealth of
talented professionals, and the Medical Center should not hesitate to
call upon these resources. For example, Engineering and Biomedical
Engineering teams from VISN or other Medical Centers can be assembled to
assist in the recovery effort of restarting the physical plant and all
medical equipment. In addition, these teams can be used to help
formulate medium and long-term solutions for displaced or disabled
functions. As Medical Center employees are intimately familiar with the
plant and its housed equipment, they can concentrate on immediate and
short term needs, while specialized teams can focus upon medium and
perhaps longer term problematic issues. The same principle could apply
for other direct patient care disciplines.

3\) **Use and maintain as-built drawings** - The Medical Center should
be aware that inaccurate drawings might pose hazards during short and
long-term construction recovery. Pay attention during any drilling,
digging, or other excavation since undocumented, buried high voltage
electrical feeders, major chilled or potable water supply and return
lines, natural gas or other major utility lines may result in further
damage or injury. All field changes must be continuously documented on
as-built drawings.

4\) **Keep staff informed** - The Chief Executive Officer should
designate a team member to be responsible for keeping staff apprised of
recovery efforts and future disposition of the Medical Center through
daily/weekly updates. Failure to do this will unnecessarily increase the
stress everyone experiences as a result of the earthquake.

5\) **Provide employee counseling** - Psychiatry, Psychology and Social
Work Services should arrange for counseling to all staff who are
suffering from stress or other symptoms related to the earthquake. The
Medical Center acknowledges the importance of maintaining staff health
and well being, particularly during the short and medium term recovery
phases.

6\) **Develop post-quake construction projects** - The Chief, Facilities
Management Service should start preparing a list of potential
Post-Earthquake Recovery Construction Projects. Each designated project
should be accompanied with parametric cost estimates. A parametric cost
estimate is defined as being equivalent to the 35% design stage, with an
approximate [+]{.underline}35% margin of error as compared to fully
developed budget estimates based upon final designs.

7\) **Develop Capital Investment Proposals** - The Medical Center must
submit Capital Investment Proposals in order to obtain funding for
disaster recovery construction projects.

6\. ***External Notification Procedures.***

a\. *Within VA.* VISN and VACO.

b\. *Other Federal Agencies.* Federal Emergency Management
Administration, as necessary; OSHA, within eight (8) hours of one (1)
employee fatality, or three (3) employee hospitalizations resulting from
a single incident.

c\. *Other.* Local fire, policy and rescue as appropriate.

-   Municipal utilities for lifeline systems, such as water,
    electricity, sewage and storm drain.

-   Pre-arranged partners for transport of patients, as necessary.

7\. ***Specialized Staff Training.***

a\. All staff must be trained in earthquake preparedness and individual
hazard reduction strategies.

b\. Technical staff (e.g., Engineering, Safety) should be trained in
post-earthquake evaluation and recovery strategies.

8\. ***References and Further Assistance.***

a.  VHA Directive 2000-012; *Seismic Safety of VA Buildings.*

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a.  VHA Process Action Team Report; *Facilities Management Preparedness
    for Seismic Events*, August 3, 2001.

b.  Bay Area Regional Earthquake Preparedness Project; *Earthquake
    Preparedness for Hospitals (A Project of the California Seismic
    Safety Commission).*

c.  California Office of Emergency Services; *Earthquake.*

d.  California Seismic Safety Commission*; Findings and Recommendations
    on Hospital Seismic Safety*, November, 2001; *The Commercial
    Property Owners Guide to Earthquake Safety; The Homeowners Guide to
    Earthquake Safety, 1998 edition; California Earthquake Loss
    Reduction Plan,* 2002*.*

e.  Applied Technology Council; *Procedures for Post-Earthquake Safety
    Evaluation of Buildings*, 1989; Addendum to the *ATC-20
    Post-Earthquake Building Safety Evaluation Procedures*, 1995.

f.  University of California, San Diego; *Earthquakes, Employee
    Preparedness Guide.*

g.  Los Angeles Fire Department; *Earthquake Tips.*

h.  United States Geological Survey; *Earthquake Hazards Program,
    Earthquake Preparedness.*

i.  Lew, H. S. et. al.; *The January 17, 1994, Northridge Earthquake,
    California.*

j.  Multiple Web Sites. (Most of these sites provide additional
    earthquake-related links so that targeted research can be performed
    to address specific concerns.)

-   [www.oes.ca.gov](http://www.oes.ca.gov/).

-   [www.lafd.org/eqhbtext.htm](http://www.lafd.org/eqhbtext.htm)

-   <http://geology.er.usgs.gov/eastern/earthq.html>.

-   [http://webstore.abag.ca.gov](http://webstore.abag.ca.gov/).

-   [http://www.eqnet.org](http://www.eqnet.org/).

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-   <http://www.fema.gov/library/quakef.htm>.

9\. ***Review Date*.**

(Name)

Chief, (Service)

Attachments:

A. Key Activity Management Tool

B. Key Activity Management Structure

C. Earthquake Emergency Supply Inventory

> *Sample 6.2.1.3*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Fire Response**

1.  ***Description of the Threat/Event.*** Fires in the Medical Center
    have the potential to stress its response readiness and require a
    quicker response than most emergencies. Whether they are the cause
    of a local failure or the result of another event, any major fire in
    a medical center will test its response capabilities to the fullest,
    and may result in significant numbers of casualties and extreme
    property damage.

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1.  ***Impact on Mission Critical Systems.*** If a major fire develops,
    this is a strong indication that possibly the fire protection system
    and alarm/detection system has fully or partially failed. Smoke
    production is the first and greatest hazard to patients, employees
    and visitors, and smoke travel will impact Heating, Ventilating and
    Air Conditioning (HVAC) systems. Fires may also impact all other
    critical engineering systems.

2.  ***Operating Units and Key Personnel with Responsibility to Manage
    this Threat/Event.***

-   Medical Center Director

-   Incident Manager

-   Safety Officer

-   Chief of Police

-   Chief Nursing

-   Chief of Staff

-   Chief Facilities Engineering

-   Chief Environmental Management

-   Service Chief(s) directly affected

4.  ***Mitigation/Preparedness Activities of the Threat/Event.*** State
    several objectives for:

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a.  *Hazard Reduction, Preparedness Strategies and Resource Issues.*

-   Fire safety inspections.

-   Requiring procurement of fire safety materials.

-   Install and properly maintain fire protection, detection, and alarm
    systems.

-   Conduct training and evaluation of drills/exercises.

4.  ***Response/Recovery from the Event/Threat.***

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a.  *Hazard Control Strategies and Resource Issues*. This includes an
    assessment of those areas, which are particularly vulnerable to an
    actual threat/event. For example, the Surgical Intensive Care Unit
    (SICU) would be considered a vulnerable area if it was involved in
    the fire directly or indirectly. Strategies should be identified for
    limiting exposure for vulnerable locations and areas that are
    critical to the mission of the Medical Center.

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a.  *Hazard Monitoring Strategies.* The VA Medical Center will need to
    develop procedures to monitor the impact of the threat/event on
    mission-critical functions. For example, in the case of a fire,
    monitoring fire spread, casualty information, system(s) performance,
    Staff availability, is critical to ensuring proper response.

b.  *Recovery Strategies.* Assess critical systems performance
    continuously and initiate repair as soon as feasible.

c.  *See Attached Charts: Key Activity Management Tool/Structure.*

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5.  ***External Notification Procedure.***

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a.  *Within VA.* VISN Directors

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a.  *Other Federal Agencies.* Notify OSHA within eight (8) hours of
    one (1) employee fatality, or three (3) employee hospitalizations
    resulting from a single incident.

b.  *Other.* JCAHO.

c.  *Community Entities.* Because of the VA Medical Center's
    relationship to the community, it is likely that there are specific
    entities within the community that should be notified that a
    threat/event has occurred. In many cases, this notification will
    trigger a community response to the threat/event, e.g., local Fire
    Department.

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7.  ***Specialized Staff Training.***

    -   Conduct emergency patient transfer techniques.

    -   Conduct vertical evacuation training.

    -   Conduct evacuation training for ORs, ICUs, and ERs.

    -   Conduct training in patient life support systems.

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7.  ***References and Further Assistance.***

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a.  VHA Emergency Management Guidebook.

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a.  All Operating Units in the medical center should review their
    operating unit templates for response/recovery activities.

b.  See sample SOP for Evacuation (Total), Section 6.3.3.7. in the
    Emergency Management Program Guidebook.

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8.  ***Review Date.***

(Name)

Chief, (Service)

Attachments:

A. Key Activity Management Tool

B. Key Activity Management Structure

*Sample 6.2.1.4*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Flood**

1.  ***Description of the Threat/Event.*** Flooding occurs in known
    flood plains when there is prolonged rainfall over several days,
    intense rainfall over a short period of time, or because of ice or
    debris jams in a river. As a result, flooding can disrupt
    transportation systems and damage potable and wastewater systems and
    occupancies within the flood plain.

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1.  ***Impact on Mission Critical Systems.*** N/A.

2.  ***Operating Units and Key Personnel with Responsibility to Manage
    this Threat/Event.***

-   Medical Center Director's Office

-   Facilities Engineering

4.  ***Mitigation/Preparedness Activities of the Threat/Event.***

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a.  *Hazard Control Strategies*. The Medical Center is not situated in
    the 20-, 100- or 500-year flood plain; however, it is dependent upon
    utilities, commodities and availability of trained staff to perform
    its mission(s). Therefore, the following are general control
    strategies:

    -   Remind employees about the dangers of driving in flood-prone
        areas.

    -   Check with suppliers for possible disruptions to utility
        services and deliveries.

    -   Reduce consumption of supplies known to be in limited supply.

    -   Contact home-based patients to check their status.

    -   Maintain regular contact with other VA Medical Centers in the
        VISN.

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a.  *Hazard Monitoring Strategies**.*** Safety Office will monitor the
    flooding and its impact on roads and water systems.

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5.  ***Response and Recovery from Event/Threat.***

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a.  *Actions to Prepare for Threat.* See paragraph 4a above.

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a.  *Responding to an Unanticipated or Anticipated Threat/Event.*

    -   Implement the Medical Center Emergency Operating Plan (EOP).

    -   Request assistance from other VA Medical Centers in the VISN
        for:

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1)  Loss of essential staff.

> 2\) Loss of critical supplies.

-   Place potable water supplier on standby.

-   Establish shelter at Medical Center for employees and their
    dependents.

-   Establish and operate a transportation system for the pickup of
    home-based care patients affected by the flooding.

-   Limit wastewater.

-   Backup staff for essential patient care.

-   Potable water supplier(s).

-   Bus companies.

-   Staff affected by flooding may need time for restoration of
    home/contents.

c.  *See Attached Charts: Key Activity Management Tool/Structure.*

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6.  ***External Notification Procedures.***

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a.  *Within VA.* Notification of VISN will occur if the EOP is
    implemented.

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a.  *Other Federal Agencies.* OSHA - Notify within eight (8) hours of
    one (1) employee fatality, or three (3) employee hospitalizations
    resulting from a single incident.

b.  *Community Entities and Local Governments.* National Weather Service
    Forecast Office.

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7.  ***Specialized Staff Training***. Awareness of hazards created by
    flooding.

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7.  ***Reference and Further Assistance*.**

-   American Red Cross - Talking About Disasters.

-   National Weather Service.

9\. ***Review Date.***

(Name)

Chief, (Service)

Attachments:

A. Key Activity Management Tool

B. Key Activity Management Structure

*Sample 6.2.1.5*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Hurricane**

1.  ***Description of the Threat/Event.*** Hurricanes and tropical
    storms are cyclones with tropical origins. When the sustained winds
    of a tropical storm (winds 39 to 73 MPH) reach a constant speed of
    74 MPH or more, it is called a hurricane. Hurricane winds blow in a
    large spiral around a relatively calm center known as the "eye." The
    "eye" is generally 20-30 miles wide, and the storm may have a
    diameter of 400 miles across. A hurricane can bring torrential
    rains, high winds and storm surge as it nears land. More dangerous
    than the high winds of a hurricane is the storm surge - a dome of
    ocean water that can be 20 feet high and 50 to 100 miles wide.

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1.  ***Impact on Mission Critical Systems.*** N/A.

2.  ***Operating Units and Key Personnel with Responsibility to Manage
    this Threat/Event.***

-   Medical Center Director's Office

-   Facilities Engineering

4.  ***Mitigation/Preparedness Activities for the Threat/Event.***

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a.  *Hazard Reduction Strategies and Resource Issues.*

-   For facilities potentially affected by storm surge, total medical
    center evacuation is the best hazard reduction strategy.

-   For facilities not potentially affected by storm surge, attention
    should be paid to preventing damage due to high winds (e.g.,
    hurricane shutters), reducing the in-patient census, and essential
    staffing, equipment and supplies.

a.  *Preparedness Strategies and Resource Issues.*

-   Storm location, strength and track should be monitored closely.
    Incident action plans should address priorities at 72-, 48- and
    24-hours prior to landfall for protecting patients, employees and
    the VA Medical Center's mission-critical systems.

-   VA Medical Centers potentially affected by storm surge should be
    fully evacuated by the 24-hour timeframe.

4.  ***Response/Recovery from the Threat/Event.***

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a.  *Hazard Control Strategies.* By landfall, the VA Medical Center
    should concentrate on:

-   Maintaining contact with local authorities.

-   Assessing impacts on mission-critical systems.

a.  *Hazard Monitoring Strategies***.** The Safety Office will maintain
    regular contact with the local Emergency Management Agency.

b.  *Recovery Strategies and Resource Issues.* Post-storm priorities
    include checking the welfare of patients, employees and the
    assessment and repair of mission-critical systems.

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d.  *See Attached Charts: Key Activity Management Tool/Structure.*

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6.  ***External Notification Procedures.***

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a.  *Within VA.* VISN will be notified when the VA Medical Center
    implements 72-, 48- and 24-hour pre-plans, trans-event and
    post-event situation reports.

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a.  *Other Federal Agencies.* Evacuation planning should include other
    Federal agencies, as appropriate. Notify OSHA within eight (8) hours
    of one (1) employee fatality, or three (3) employee hospitalizations
    resulting from a single incident.

b.  *Community Entities and Local Governments.*

    -   Local Emergency Management Agency

    -   Local Hospital Association

    -   National Weather Service

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6.  ***Specialized Staff Training*.** Staff and patient education should
    address home preparedness and family evacuation considerations.

7.  ***References and Further Assistance.*** N/A.

8.  ***Review Date.***

(Name)

Chief, (Service)

Attachments:

A. Key Activity Management Tool

B. Key Activity Management Structure

*Sample 6.2.1.6*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Thunderstorm/Lightning**

1.  ***Description of the Threat/Event.*** The National Weather Service
    (NWS) considers a thunderstorm severe if it produces hail at least
    three-quarters of an inch in diameter, has winds of 58 MPH or
    higher, or produces a tornado. Thunderstorms may come singly, in
    clusters or in lines. Some of the most severe weather occurs when a
    single thunderstorm affects one location for an extended period.
    Every thunderstorm produces lightning that kills more people each
    year than tornadoes. Lightning can also do severe damage to
    electrical distribution systems and other systems such as Heating,
    Ventilation and Air Conditioning (HVAC). Heavy rains from
    thunderstorms can lead to flash flooding.

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1.  ***Impact on Mission Critical Systems*.** N/A.

2.  ***Operating Units and Key Personnel with Responsibility to Manage
    this Threat/Event.***

-   Medical Center Director's Office

-   Facilities Engineering

4.  ***Mitigation/Preparedness Activities for the Threat/Event*.**

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a.  *Hazard Reduction Strategies and Resource Issues.*

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1)  Severe weather should be monitored and patients, visitors and staff
    alerted to its existence.

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1)  Lightning protection system for each occupancy should be certified.

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a.  *Preparedness Strategies and Resource Issues.*

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1)  Patients, visitors and staff should be informed on how to obtain
    information about the weather; what the difference is between
    watches and warnings, and the dangers of lightning and flash
    flooding.

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1)  Medical Centers prone to flash flooding should be evacuated if the
    threat is imminent.

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5.  ***Response/Recovery from the Threat/Event.***

    a.  *Hazard Control Strategies*. In the event the Medical Center is
        struck by lightning, an assessment of damage should be performed
        immediately.

    b.  *Hazard Monitoring Strategies**.*** Police and Security (or
        other Service, as appropriate) will maintain a weather-alert
        radio tuned to the local NWS forecast office.

    c.  *Recovery Strategies and Resource Issues*. An assessment of
        mission-critical systems should be conducted after each period
        of severe weather.

    d.  *See Attached Charts: Key Activity Management Tool/Structure.*

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5.  ***External Notification Procedures.***

    a.  *Within VA.* VISN will be notified when the VA Medical Center
        implements its plan.

    b.  *Other Federal Agencies.* Severe weather planning should include
        other Federal agencies, as appropriate. Notify OSHA within
        eight (8) hours of one (1) employee fatality, or three (3)
        employee hospitalizations resulting from a single incident.

    c.  *Community Entities and Local Governments.*

        -   Local Emergency Management Agency

        -   Local Hospital Association

        -   National Weather Service

7\. ***Specialized Staff Training*.** Staff and patient education should
address "watches vs. warnings", and home preparedness considerations.

8\. ***References and Further Assistance***. N/A.

9\. ***Review Date.***

(Name)

Chief, (Service)

Attachments:

A. Key Activity Management Tool

B. Key Activity Management Structure

*Sample 6.2.1.7*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Tornado**

1.  ***Description of the Threat/Event**.* A tornado is a
    violently-rotating column of air extending from a thunderstorm to
    the ground. Tornadoes develop from severe thunderstorms in warm,
    moist, unstable air along and ahead of cold fronts.

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1.  ***Impact on Mission Critical Systems.*** N/A.

2.  ***Operating Units and Key Personnel with Responsibility to Manage
    this Threat/Event.***

-   Medical Center Director's Office

-   Facilities Engineering

4.  ***Mitigation/Preparedness Activities for the Threat/Event***.

a\. Hazard Reduction Strategies and Resource Issues. Severe weather
should be monitored and patients, visitors and staff alerted to its
existence.

b\. Preparedness Strategies and Resource Issues. Patients, visitors and
staff should be informed about how to obtain information about the
weather; what the difference is between watches and warnings; and the
dangers of lightning and flash flooding.

4.  ***Response/Recovery from the Threat/Event.***

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a.  *Hazard Control Strategies.* In the event the Medical Center is
    struck by a tornado, immediate priorities include:

-   Notification of local authorities.

-   Assessment of any on-going negative effects (e.g., Fire).

-   Shut off utilities serving the damaged area.

-   Rescue of injured persons.

-   Relocation of patient care and business functions until restoration
    can occur.

    b.  *Hazard Monitoring Strategies**.*** Police and Security will
        maintain a weather-alert radio tuned to the local NWS forecast
        office.

    c.  *Recovery Strategies and Resource Issues.* An assessment of
        mission-critical systems should be conducted after each period
        of severe weather.

    d.  *See Attached Charts: Key Activity Management Tool/Structure.*

        6.  ***External Notification Procedures.***

            a.  *Within VA*. VISN will be notified when the VA Medical
                Center implements its plan.

            b.  *Other Federal Agencies.* Severe weather planning should
                include other Federal agencies, as appropriate. Notify
                OSHA within eight (8) hours of one (1) employee
                fatality, or three (3) employee hospitalizations
                resulting from a single incident.

            c.  *Community Entities and Local Governments.*

                -   Local Emergency Management Agency

                -   Local Hospital Association

                -   National Weather Service

                    7.  ***Specialized Staff Training*.** Staff and
                        patient education should address "watches vs.
                        warnings", and home preparedness considerations.

                    8.  ***References and Further Assistance.*** N/A

                    9.  ***Review Date.***

(Name)

Chief, (Service)

Attachments:

A. Key Activity Management Tool

B. Key Activity Management Structure

*Sample 6.2.1.8*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Tsunami**

1.  ***Description of the Threat/Event.*** Tsunamis are ocean waves
    created by earthquakes and undersea landslides. A tsunami is
    actually a series of waves that can travel at speeds averaging 450
    (and up to 600) MPH in the open ocean. In the open ocean, ships
    would not feel a tsunami because the wavelength would be hundreds of
    miles long, with amplitude of only a few feet. As the waves approach
    the coast, their speed decreases and their amplitude increases. Wave
    heights have been known to be as large as 100 feet, with the average
    being 10 to 20 feet high. Time between the waves varies between 5
    and 90 minutes, with the first wave usually not being the most
    significant. Areas of greatest risk are less than 25 feet in
    elevation and within one mile from the coastline.

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1.  ***Impact on Mission Critical Systems.*** N/A.

2.  ***Operating Units and Key Personnel with Responsibility to Manage
    this Threat/Event.***

-   Medical Center Director's Office

-   Facilities Engineering

4.  ***Mitigation/Preparedness Activities for the Threat/Event***.

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a.  *Hazard Reduction Strategies and Resource Issues.* For Medical
    Centers located less than 25 feet in elevation and one mile from the
    coastline, vertical evacuation is the only hazard reduction strategy
    due to the speed of onset.

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a.  *Preparedness Strategies and Resource Issues.* Medical Centers
    located less than 25 feet in elevation and one mile from the
    coastline should be connected to the Tsunami Warning System.

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4.  ***Response/Recovery from the Threat/Event.***

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a.  *Hazard Control Strategies.* Upon notification that a tsunami is
    imminent, the VA Medical Center should:

-   Alert and warn all patients, visitors and staff.

-   Evacuate lower floors to upper floors.

b.  *Hazard Monitoring Strategies**.*** Safety Office will maintain
    regular contact with local Emergency Management Agency.

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b.  *Recovery Strategies and Resource Issues.* Post-wave priorities
    include checking the welfare of patients, employees and the
    assessment and repair of mission-critical systems.

c.  *See Attached Charts: Key Activity Management Tool/Structure.*

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5.  ***External Notification Procedures.***

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a.  *Within VA.* VISN will be notified when the VA Medical Center
    implements its plan.

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b.  *Other Federal Agencies.* Evacuation planning should include other
    Federal agencies, as appropriate. Notify OSHA within eight (8) hours
    of one (1) employee fatality, or three (3) employee hospitalizations
    resulting from a single incident.

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c.  *Community Entities and Local Governments.*

-   Local Emergency Management Agency

-   Local Hospital Association

-   National Weather Service

    7.  ***Specialized Staff Training*.** Staff and patient education
        should address home preparedness and family evacuation
        considerations.

    8.  ***References and Further Assistance.*** N/A.

    9.  ***Review Date.***

(Name)

Chief, (Service)

Attachments:

A. Key Activity Management Tool

B. Key Activity Management Structure

*Sample 6.2.1.9*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Volcanic Eruption**

1.  ***Description of the Threat/Event.*** A volcano is a vein through
    which molten rock escapes to the earth's surface. When pressure from
    gases within the molten rock becomes too great, an eruption occurs.
    Volcanic hazards include gases, lava, pyroclastic flows, landslides,
    earthquakes and explosive eruptions. Volcanic ash is actually fine,
    glassy rock fragments and can affect people and equipment hundreds
    of miles away. Volcanic ash can contaminate water supplies, cause
    electrical storms, disrupt the operation of all machinery and
    collapse roofs. The United States is third in the world for the
    number of active volcanoes. Since 1980, as many as five volcanoes
    have erupted each year in the United States.

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1.  ***Impact on Mission Critical Systems.*** N/A*.*

2.  ***Operating Units and Key Personnel with Responsibility to Manage
    this Threat/Event.***

-   Medical Center Director's Office

-   Facilities Engineering

4.  ***Mitigation/Preparedness Activities for the Threat/Event.***

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a.  *Hazard Reduction Strategies and Resource Issues.* If the VA Medical
    Center is located in an area potentially affected by volcanic
    eruptions, hazard reduction strategies include evacuation, shutdown
    of ventilation systems, and garaging of equipment and vehicles.

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a.  *Preparedness Strategies and Resource Issues.* If the VA Medical
    Center is located in an area potentially affected by volcanic
    eruptions, preparedness strategies include:

-   Testing volcano-warning systems.

-   Developing evacuation plans for patients and employees.

-   Protecting mission-critical systems by shutting down ventilation
    systems and garaging essential equipment and vehicles.

-   Purchasing additional supplies and equipment for maintaining
    operations for at least one week.

5.  ***Response/Recovery from the Threat/Event.***

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a.  *Hazard Control Strategies.* In the event that a volcano erupts and
    involves the VA Medical Center, immediate priorities include:

-   Coordination with local authorities to determine projected impacts.

-   Estimation of potential negative effects from lava flows, mudslides,
    flash floods and volcanic ash.

-   Establishing timeframes for decisions/actions.

-   Alerting of home-based patients.

-   Initiation of pre-planning for the relocation of patient care and
    business functions.

    b.  *Hazard Monitoring Strategies**.*** Police and Security will
        maintain a weather-alert radio tuned to the local NWS forecast
        office.

    c.  *Recovery Strategies and Resource Issues.* An assessment of
        mission-critical systems will be conducted every 12 hours during
        the event. When on-going negative effects from the event have
        stopped, restoration of damaged systems will begin, followed by
        resumption of patient care operations and then, business
        functions.

    d.  *See Attached Charts: Key Activity Management Tool/Structure.*

        6.  ***External Notification Procedures.***

            a.  *Within VA.* VISN will be notified when the Medical
                Center implements its plan.

            b.  *Other Federal Agencies*. Severe weather planning should
                include other Federal agencies, as appropriate. Notify
                OSHA within eight (8) hours of one (1) employee
                fatality, or three (3) employee hospitalizations
                resulting from a single incident.

            c.  *Community Entities and Local Governments.*

                -   Local Emergency Management Agency

                -   Local Hospital Association

                -   National Weather Service

                    7.  **Specialized Staff Training.** Staff and
                        patient education should address health
                        precautions and home preparedness
                        considerations.

                    8.  ***References and Further Assistance.*** N/A.

                    9.  ***Review Date.***

(Name)

Chief, (Service)

Attachments:

A. Key Activity Management Tool

B. Key Activity Management Structure

*Sample 6.2.1.10*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Winter Storm**

1.  ***Description of the Threat/Event.*** A major winter storm can last
    for several days and be accompanied by high winds, freezing rain or
    sleet, heavy snowfall, and cold temperatures. Some winter storms can
    be large enough to affect several states, while others may only
    affect a single community.

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1.  ***Impact on Mission Critical Systems.*** N/A.

2.  ***Operating Units and Key Personnel with Responsibility to Manage
    this Threat/Event.***

-   Medical Center Director's Office

-   Facilities Engineering

4.  ***Mitigation/Preparedness Activities for the Threat/Event***.

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a.  *Hazard Reduction Strategies and Resource Issues.*

-   Educating patients and employees about the hazards of winter storms.

-   Protecting mission-critical systems.

-   Testing generators and ensuring adequate fuel supplies (especially
    when ice storms are possible).

a.  *Preparedness Strategies and Resource Issues.*

-   Monitoring the weather and identifying the potential for major
    storms.

-   Projecting supply and equipment needs for a prolonged event and
    scheduling re-supply accordingly.

-   Informing home-based patients on the storm's potential and making
    them aware of various ways the VA Medical Center can help ensure
    their welfare.

-   Creating/expanding the availability of dependent care for essential
    employees.

-   Reducing in-patient census.

***5. Response/Recovery from the Threat/Event.***

a.  *Hazard Control Strategies.*

-   Reduce staffing to meet essential needs.

-   Protect mission-critical systems.

-   Monitor progress and duration of the storm.

a.  *Hazard Monitoring Strategies**.*** Police and Security will
    maintain a weather-alert radio tuned to the local NWS forecast
    office.

b.  *Recovery Strategies and Resource Issues.* An assessment of
    mission-critical systems will be conducted every 12 hours during the
    event.

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d.  *See Attached Charts: Key Activity Management Tool/Structure.*

    6.  ***External Notification Procedures.***

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a.  *Within VA.* VISN will be notified when the VA Medical Center
    implements its plan.

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a.  *Other Federal Agencies.* Severe weather planning should include
    other Federal agencies, as appropriate. Notify OSHA within eight (8)
    hours of one (1) employee fatality or three (3) employee
    hospitalizations resulting from a single incident.

b.  *Community Entities and Local Governments.*

-   Local Emergency Management Agency

-   Local Hospital Association

-   National Weather Service

    7.  ***Specialized Staff Training.*** Staff and patient education
        should address health precautions and home/travel preparedness
        considerations.

    8.  ***References and Further Assistance.*** N/A.

    9.  ***Review Date.***

(Name)

Chief, (Service)

Attachments:

A. Key Activity Management Tool

B. Key Activity Management Structure

*Sample 6.2.2.1*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Bomb Threat**

1.  ***Description of the Threat/Event.*** A bomb threat may be received
    in the form of an actual threat such as those communicated
    telephonically, or observing a suspicious package or material. While
    most threats are false or misleading, there is always the potential
    that a threat is real; and therefore, life threatening. Correct and
    consistent procedures allow for the best decisional options based on
    the information known. There are normally three alternatives when
    faced with a bomb threat:

-   Ignore the threat.

-   Evacuate immediately.

-   Search and evacuate, if warranted.

2.  ***Impact on Mission Critical Systems.*** Typically the threat alone
    will not impact on critical systems, unless there is a decision to
    evacuate a critical area such as an Emergency Room or the Operating
    Suites. The result of an actual explosion will obviously result in
    life endangerment, and create an adverse impact to whatever critical
    systems are affected by the explosion.

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2.  ***Operating Units and Key Personnel with Responsibility to Manage
    this Threat/Event.***

-   Medical Center Director

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-   Incident Manager

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-   Chief of Police

-   Safety Officer

-   Chief of Staff

-   Chief Nursing

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-   Chief of Services affected by threat

3.  ***Mitigation/Preparedness Activities of the Threat/Event.***

-   Develop bomb-threat checklist form.

-   Train all medical center employees on actions to take upon receipt
    of bomb threats and response procedures.

-   Develop and train on search procedures.

-   Test and evaluate response procedures.

5.  ***Response/Recovery from the Event/Threat.***

    a.  *Hazard Control Strategies and Resource Issues*. This includes
        an assessment of those areas, which are particularly vulnerable
        to an actual threat/event. For example, the Emergency Room would
        be considered a vulnerable area if there were a suspect package
        or real enough threat that would cause evacuation. Strategies
        should be identified for limiting exposure for vulnerable
        locations and areas that are critical to the mission of the
        Medical Center, such as patient care.

    b.  *Hazard Monitoring Strategies***.** The VA Medical Center will
        need to develop procedures to monitor the impact of the
        threat/event on mission-critical functions. For example, in the
        case of an explosion, reports on injuries and critical systems
        dictates how the Medical Center will respond and what internal
        and external resources will be required.

    c.  *See Attached Charts: Key Activity Management Tool/Structure.*

        6.  ***External Notification Procedures, in the event of any
            adverse impact.***

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a.  *Within VA.* VISN Director

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a.  *Other Federal Agencies.*

-   Military Explosive Ordinance Disposal (EOD) Teams.

-   FBI

-   OSHA -- Notify within eight (8) hours of one (1) employee fatality,
    or three (3) employee hospitalizations resulting from a single
    incident.

b.  *Community Entities.* Because of the VA Medical Center's
    relationship to the community, it is likely that there are specific
    entities within the community that should be notified that a
    threat/event has occurred. In many cases, this notification will
    trigger a community response to the threat/event; such as,

-   Local community bomb squad or Hazmat team.

-   Office of Emergency Services.

    7.  ***Specialized Staff Training*.** Responders to bomb threats
        must receive training to their level of response. For example:

a\. Police Officers must receive training in:

-   Threat evaluation to both verbal threats and suspect packages,

-   Do's and Don'ts for radio communication,

-   How to set up a safe perimeter; and,

-   How to establish search kits and use them properly.

b\. Supervisors must receive training in:

-   How to properly evacuate a work area,

-   How to search for unusual items; and,

-   Do's and Don'ts when leaving the work areas (i.e., do not shut off
    light switches, computer terminals, etc.).

8\. ***References and Further Assistance.***

a.  VHA Emergency Management Program Guidebook.

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a.  All Operating Units in the medical center should review their
    operating unit templates for response/recovery activities.

9\. ***Review Date.***

(Name)

Chief, (Service)

Attachments:

A. Key Activity Management Tool

B. Key Activity Management Structure

*Sample 6.2.2.2*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Civil Disturbance**

1.  ***Description of the Threat/Event.*** Civil Disturbance may involve
    small to large numbers of individuals, who when gathered together
    may inadvertently or purposely interfere with the Medical Center's
    operational mission.

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1.  ***Impact on Mission Critical Systems.*** Potential impact to the
    Medical Center may include:

-   Blocking access to Veterans who wish to receive medical care.

-   Blocking traffic and interfering with employees, suppliers,
    emergency responders, and others from reaching the Medical Center.

-   Cause injury to persons that will result in medical treatment.

-   Disrupt communication and potentially other critical engineering
    systems.

3.  ***Operating Units and Key Personnel with Responsibility to Manage
    this Threat/Event.*** List the operating units (such as Emergency
    Room, Infectious Disease, Facilities Engineering, etc.) that have a
    significant role in managing this threat/event.

-   Medical Center Director

-   Incident Manager

-   Chief of Police

-   Chief of Staff

-   Chief Nursing

-   Chief Ambulatory Care

-   Safety Officer

-   Chief Engineer

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-   Logistics Coordinator

3.  ***Mitigation/Preparedness Activities of the Threat/Event*.** Hazard
    Reduction/Preparedness Strategies and Resource Issues.

-   Ensure Standard Operating Procedure (SOP) for building(s) security
    is current.

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-   Ensure that supplies and equipment are available for traffic and
    pedestrian control.

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-   Ensure the Medical Center's Emergency Notification and Recall List
    is current.

-   Train and educate Police Officers in civil disturbance response
    procedures, in accordance to VA Police Security and Law Enforcement
    Guidelines.

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-   Educate Medical Center staff as to their role and responsibilities
    during this type of event.

4.  ***Response/Recovery from the Event/Threat.***

a\. *Hazard Control Strategies and Resource Issues*. This includes an
assessment of those areas that are particularly vulnerable to an actual
threat/event. For example, the Emergency Room would be considered a
vulnerable area if access were restricted and/or overrun by persons who
intend to cause disruptions or damage. Strategies should be identified
for limiting exposure for vulnerable locations and areas that are
critical to the mission of the Medical Center, such as patient care.

b\. *Hazard Monitoring Strategies*. The VA Medical Center will need to
develop procedures to monitor the impact of the threat/event on
mission-critical functions. For example, monitoring the numbers involved
in the disturbance, what type of threat is apparent, and what resources
will be needed to maintain medical center operations. Possible response
procedures may include:

-   Notification of Medical Center Director.

-   Activation of the Emergency Operations Center (EOC).

-   Implement coordination procedures with local Police and Fire
    Departments.

-   Contact VISN Director for bed availability or transfer of services.

-   Secure buildings to limit access.

-   Plan work schedules to ensure continued operations.

-   Work with suppliers to ensure availability of critical supplies.

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-   Communicate to all employees the needs of the medical center and
    reassure employees that all will be done to accommodate each of
    their needs or concerns.

c\. *Recovery Strategies.* Conduct any repair work if necessary.

d\. *See Attached Charts: Key Activity Management Tool/Structure.*

5.  ***External Notification Procedures.***

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a.  *Within VA.* If the VHA Medical Center is made aware of a
    threat/event, whom within VA should they notify? If a threat/event
    occurs, whom within VA should they notify?

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a.  *Other Federal Agencies.* Depending on the threat/event, certain
    Federal agencies (FEMA, Department of Health and Human Services,
    Centers for Disease Control, OSHA, EPA) will need to be notified.
    Notify OSHA within 8-hours of one (1) employee fatality, or
    three (3) employees hospitalizations resulting from a single
    incident.

b.  *Community Entities.* Because of the VA Medical Center's
    relationship to the community, it is likely that there are specific
    entities within the community that should be notified that a
    threat/event has occurred. In many cases, this notification will
    trigger a community response to the threat/event.

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6.  ***Specialized Staff Training*.** This section outlines a
    description of necessary strategies to secure the unique resources
    (staff, supplies, etc.) needed to appropriately respond to this type
    of threat/event.

7.  ***References and Further Assistance.***

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a.  VHA Emergency Management Program Guidebook.

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a.  All Operating Units in the medical center should review their
    operating unit templates for response/recovery activities.

9\. ***Review Date.***

(Name)

Chief, (Service)

Attachments:

A. Key Activity Management Tool

B. Key Activity Management Structure

*Sample 6.2.2.3*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Cyber Attack**

1.  ***Description of the Threat/Event*.** As commonly used, the term
    "cyber attack" is one that is directed at automated information
    systems (AIS) and infrastructure that may disrupt, damage or destroy
    AIS programs, equipment and/or data. A cyber attack may be either a
    "physical" attack or an "information" attack. A "physical" attack is
    one that is external and aims to destroy a system or render it
    non-operational or unreliable. This could range from disabling power
    generation and backup to the AIS, physical damage directly inflicted
    on the equipment, software and files, or an attack on the building
    that houses the equipment, files and/or supporting infrastructure.
    An information attack is engineered by hacking, or breaking into the
    system itself and accessing control systems and data. Accordingly,
    users may not be immediately aware that an attack has occurred until
    the AIS begins to experience software or hardware problems, or
    otherwise demonstrates symptoms of system malfunction.

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1.  ***Impact on Mission Critical Systems.*** The use of AIS is
    pervasive in delivering health care today, providing everything from
    patient management information to communications. The focus of an
    impact assessment, therefore, must be on the effects of a cyber
    attack that disrupts AIS functions, compromising the ability of the
    Medical Center to provide continuous health care delivery services.
    These would include loss or damage to vital records and data
    including inability to access test results, as well as the loss of
    the ability to transmit data and patient information. Furthermore,
    the Medical Center will need to review medical, security, HVAC and
    other systems that are controlled or otherwise dependent upon
    computers. In terms of impact, a physical cyber attack can be viewed
    in much the same way as any other event that would cause a
    disruption in AIS. The significant difference when a cyber attack is
    an information attack is that awareness of the attack may not be
    immediately evident; and thus, detection systems and procedures
    become critical in managing and minimizing the consequences. In both
    cases, however, by its very nature a cyber attack is a criminal or
    terrorist activity; and also, becomes a matter for reporting to and
    investigation by the applicable law enforcement agencies.

2.  ***Operating Units and Key Personnel with Responsibility to Manage
    this Threat/Event.***

-   Medical Center Director

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-   Information Resources Management

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-   Chief Information Officer/Office

-   Information Security Officer/Office

-   Police Security and Law Enforcement

4.  ***Mitigation/Preparedness Activities of the Threat/Event.***

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a.  *Hazard Reduction Strategies and Resource Issues.* Hazard reduction
    activities fall within two areas that directly address the two types
    of cyber attacks. *To this end, the Medical Center must have good
    information security and physical security plans and procedures to
    prevent or mitigate against the occurrence of a cyber attack***.**
    Both information and physical security is dependent upon: 1)
    securing the location of the AIS equipment and files, and 2)
    managing and controlling access to the AIS equipment and files. This
    entails the necessity to erect both physical and virtual barriers
    between the system and those that would attack it or use it to
    disrupt other systems within the Medical Center. These procedures
    should be contained in the Information Security and Physical
    Security Plans of the Medical Center. Some of the areas for
    consideration would include:

-   Limiting access - Alarming and electronic surveillance of computer
    rooms and storage areas.

-   Use of firewalls and passwords.

-   Use of PINs to identify system users.

-   Immediate reporting of attempts to gain either physical or
    informational access to AIS.

a.  *Preparedness Strategies and Resource Issues*. As previously noted,
    the effects on an AIS of a cyber attack, at least one of a physical
    nature, are basically no different than those that would come from
    any other natural or man-made occurrence. Accordingly, preparedness
    actions also would similarly describe the capability to duplicate or
    restore system functions and data quickly. In addition, preparedness
    for an information attack requires constant and active vigilance to
    detect an attack early enough to minimize and mitigate against the
    consequences. This includes having a highly-effective surveillance
    activity as part of the Medical Center's Information Security Plan,
    user education, an information program in effect which provides the
    user with the information and awareness to note abnormalities with
    their equipment and software functioning, and procedures and
    protocols for immediate reporting to the responsible operational
    office.

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5.  ***Response/Recovery from the Threat/Event*.** See Attached Charts:
    Key Activity Management Tool/Structure.

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5.  ***External Notification Procedures.*** See Information Security
    Plan. Notify OSHA within eight (8) hours of one (1) employee
    fatality, or three (3) employee hospitalizations resulting from a
    single incident.

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7.  ***Specialized Staff Training*.** See Information Security Plan.

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7.  ***References and Further Assistance.***

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a.  VHA Emergency Management Program Guidebook.

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a.  All Operating Units in the medical center should review their
    operating unit templates for response and recovery activities.

b.  Information Security Plan.

c.  Applicable VA/VHA guidance - (list here).

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9.  ***Review Date.***

(Name)

Chief, (Service)

Attachments:

A. Key Activity Management Tool

B. Key Activity Management Structure

*Sample 6.2.2.5*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Terrorist Threat**

1.  ***Description of the Threat/Event.*** Intelligence has been
    received from competent authorities that a possible terrorist threat
    has been received/identified or an actual terrorist attack has
    occurred. As a result, key Medical Center personnel must be notified
    and heightened security measures need to be considered or
    implemented. Heightened security measures must be implemented in a
    fashion that can be sustained for short or indefinite periods of
    time. Actions taken need to provide for increased safety and
    security of patients, visitors, and staff. Any actions taken should
    be accomplished in a calm, orderly, and professional manner so as
    not to cause unneeded alarm/concern or increased anxiety (fear)
    among the Medical Center population. Tasks listed on Attachment D
    (Security Alert Levels and Taskings) are considered highly sensitive
    and should only be discussed in detail with those persons listed on
    the Release of Information form (Attachment C).

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1.  ***Impact on Mission Critical Systems.*** Implementation of
    heightened security measures will have an adverse impact on
    patients, visitors, and staff. The conducting of 100% identification
    checks, bag checks/inspections, checking incoming mail and supply
    shipments, etc., will result in delays and oftentimes cause
    aggravation to patients, staff, visitors and vendors.

2.  ***Operating Units and Key Personnel with Responsibility to Manage
    this Threat/Event.***

-   Medical Center Director

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-   Chief of Staff

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-   Chief, Police and Security

-   Logistics, Program Manager

-   Facilities Engineering, Program Manager

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-   Director, Medical Services

4.  ***Mitigation/Preparedness Activities of the Threat/Event.***

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a.  *Hazard Reduction Strategies and Resource Issues.* N/A.

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a.  *Preparedness Strategies and Resource Issues.* N/A.

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4.  ***Response/Recovery from the Event/Threat.***

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a.  *Hazard Control Strategies and Resource Issues.*

1\) **Security Alert Level 1:** A general threat of possible terrorist
activity exists, the nature and extent of which are unpredictable, yet
circumstances do not justify full implementation of Alert Level 2.
Actions to be taken must be capable of being maintained for extended
periods of time or possibly indefinitely if required (see Attachment
D**)**.

> Staffing: Normal staffing levels will be maintained; however, a
> heightened state of alertness and readiness will be paramount.

2\) **Security Alert Level 2:** An increased and more predictable threat
of terrorist activity exists. Actions taken must be capable of being
maintained for weeks without significantly affecting day-to-day
operations (see Attachment D).

> Staffing: Staffing may need to be increased. Normally, additional
> staffing will be accomplished through adjustments to the schedule
> using Operations personnel or through voluntary/ mandatory overtime in
> 4 or 8-hour increments (all at the discretion of the Medical Center
> Director.)

3\) **Security Alert Level 3:** An incident occurs or intelligence is
received indicating some form of terrorist action is highly likely.
Actions to be taken may affect day-to-day operations and increase
operating costs. (see Attachment D). (Also, see Attachment E - Door Test
Sheet, and Attachment F - Biological and Chemical Checklist.)

> Staffing: Mandatory 12-hour shifts may be implemented. Police Officers
> working in operational positions may also work 12-hour shifts. Days
> off and scheduled annual leave may be reduced and/or canceled to meet
> staffing needs (all at the discretion of the Medical Center Director).

4\) **Security Alert Level 4:** A terrorist attack has occurred or
intelligence is received that a terrorist action against a specific
location or person is imminent. Normally, this alert level is declared
as a result of a *localized* condition (see Attachment D). (Also, see
Attachment E - Door Test Sheet, and Attachment F - Biological and
Chemical Checklist.)

> Staffing: All VA Police personnel may work 12-hour shifts. All days
> off and annual leave will be canceled. Additional police support will
> be requested from local police authorities (all at the discretion of
> the Medical Center Director).

a.  *Hazard Monitoring Strategies and Resource Issues.*

    -   Continue to monitor intelligence reports as received.

    -   Maintain routine contact with local and Federal Law Enforcement
        agencies to stay abreast of local terrorist activity or civil
        disturbances, etc., if any.

    -   Attend and participate in local law enforcement meetings to
        discuss and exchange ideas on how to handle terrorist threats
        and/or activities. Such groups will consist of local/area Chiefs
        of Police and representatives from Federal Law Enforcement
        agencies and security heads from private industry.

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c.  *Recovery Strategies.*

-   Meet with key medical center staff on a routine basis to discuss
    current intelligence data and information obtained from local law
    enforcement agencies.

-   Provide updates on current status of heightened security and impact
    it is having on medical center operations as well as the human
    impact on patients, visitors, and staff.

d.  See Attachments A and B - Key Activity Management Tool and Key
    Activity Management Structure.

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4.  ***External Notification Procedures.***

-   VISN Director.

-   Local U.S. Marshal Service.

-   OSHA - within eight (8) hours if one (1) employee fatality, or
    three (3) employee hospitalizations from a single incident.

-   FBI.

-   Federal Protective Service.

-   Deputy Assistant Secretary for Security and Law Enforcement,
    Washington, DC.

7.  ***Specialized Staff Training.***

-   Key medical center personnel are adequately trained on procedures
    for implementing Command Post Operations.

-   Medical center staff are adequately trained on all emergency and
    disaster contingency plans and what role they play in each. This
    should include protection and safety of patients, visitors, and
    other staff personnel as well as the security of equipment and
    biological/chemical substances that in the hands of a terrorist
    could cause serious harm or death to large numbers of personnel.

-   Ensure the VA Police and augmentation forces (VA employees other
    than VA Police) are adequately trained and equipped to provide
    heightened security measures that would be perceived as a viable
    obstacle to terrorist components. Heightened security measures
    should ensure that patients, visitors, and staff is comfortable in
    using, visiting, or working in the Medical Center and that
    everything is being done to enhance their security and safety.

7.  ***References.***

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a.  VHA Emergency Management Program Guidebook.

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a.  All Operating Units in the medical center should review their
    operating unit templates for response/recovery activities.

b.  VA Police Handbook 0730.

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9.  ***Review Date.***

(Name)

Chief, (Service)

Attachments:

A. Key Activity Management Tool/Structure

B. Key Activity Management Tool/Structure

C. Release of Information

D. Security Alert Levels and Taskings

E. Exterior Door and Duress Alarm Test Sheet

> F. Biological and Chemical Substances Checklist

*Sample 6.2.2.6*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Violence in the Workplace**

1.  ***Description of the Threat/Event*.** Threats may be real or
    implied. Harassment is considered a form of threat. Threats or
    harassing incidents can take on many forms including, but not
    limited to, telephone calls, letters, face-to-face conversations,
    physical altercations, vandalism, following/stalking and assault on
    employee or family.

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1.  ***Impact on Mission Critical Systems.*** Threat of violence may be
    minimal and slightly or extremely severe and require a variety of
    trained Response Teams in an attempt to defuse situation through
    conflict resolution, or a more specialized Law Enforcement Response
    Team for a situation that has developed into a hostage, barricade
    situation.

2.  ***Operating Units and Key Personnel with Responsibility to Manage
    this Threat/Event.***

-   Medical Center Director

-   Medical Center Associate Director

-   Chief of Staff

-   VA Violence Prevention Response Team (Sometimes referred to as Code
    Orange or Dr. Strong)

-   VA Police

-   Safety Committee

-   Union

-   Outside Law Enforcement Hostage/Barricade Response Team

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-   Other

4.  ***Mitigation/Preparedness Activities of the Threat/Event.***

a\. *Hazard Reduction Strategies and Resource Issues.* This includes an
assessment of those areas that are particularly vulnerable to a violent
threat/event. For example, the Emergency Room, Pharmacy and Psychiatric
areas may be potential high-risk locations. Strategies should be
identified for limiting exposure for vulnerable high-risk areas.

b\. *Preparedness Strategies and Resource Issues*.

-   Staff Training in Workplace Violence Prevention

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-   Medical Center Assigned Violence Prevention Response Team

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-   Policies and Procedures on the Prevention of Workplace Violence

5.  ***Response/Recovery from the Event/Threat.***

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a.  *Hazard Control Strategies and Resource Issues.*

-   Duress Alarms

-   SSTV Monitors

-   Appropriate Staffing

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-   Increase VA Police Patrol Operations

> **Note:** As a last resort, the individual may need to be restrained
> to prevent harm to self or others.

a.  *Hazard Monitoring Strategies***.** The Medical Center must develop
    policy and procedures to monitor, evaluate and abate the impact of
    the threat/event of violence in the workplace. The Safety Committee
    should closely monitor and evaluate violence workplace incidents or
    potential hazards and take appropriate corrective action(s). The
    data of such incidents may be obtained by a number of resources,
    such as VA Police, ASISTS, WICMS or other.

b.  *Recovery Strategies.* The medical center will critique all
    incidents of workplace violence and take appropriate corrective
    action. Corrective action may be through administrative or
    engineering controls.

c.  *See Attached Charts: Key Activity Management Tool/Structure.*

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6.  ***External Notification Procedures.***

-   VISN Director (If incident of high media event or bodily harm or
    injury resulting).

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-   Outside Law Enforcement Hostage/Barricade Response Team.

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-   OSHA - Notify within eight (8) hours of one (1) employee fatality,
    or three (3) employee hospitalizations from single incident.

6.  ***Specialized Staff Training**.*

-   All employee training in the prevention of workplace violence

-   Assigned Violence Prevention Response Team

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-   Training in violence prevention through environmental
    design/physical security

7.  ***References and Further Assistance.***

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a.  Designated Agency Safety and Health Official (DASHO) Letter,
    Violence Prevention (Date).

b.  OSHA Guidelines for the Prevention of Workplace Violence, dated
    1996.

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8.  ***Review Date.***

(Name)

Chief, (Service)

Attachments:

A. Key Activity Management Tool

B. Key Activity Management Structure

*Sample 6.2.3.1.1*

*(Note: This SOP contains some intricate clinical information. For
additional Clinical information or clarification, you may contact Dr.
Margie Scott via the VA Global Address book in Outlook, or your local
infectious disease consultant.)*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Generic Biological Agent Release**

1.  ***Description of the Threat/Event.*** Any number of bacteria,
    viruses and toxins may potentially be used in an intentional fashion
    to injure, kill or incapacitate the public in a terrorist event.
    These may be rare exotic organisms, endemic organisms which usually
    only "accidentally" infect man, or common genetically manipulated
    organisms such as drug resistant strains. These can be spread to the
    public using three main routes of exposure: 1) inhalation exposure
    resulting in predominantly respiratory symptoms; 2) ingestion
    exposure resulting in gastrointestinal or neurological symptoms;
    and 3) contact exposure resulting in cutaneous lesions with or
    without concomitant systemic symptoms. The release of a biological
    agent in the community may occur covertly requiring astute
    diagnostic skills when encountering symptomatic patients, combined
    with pathogen surveillance and reporting mechanisms for recognition
    of the event. The following may be used as clues when evaluating the
    possibility of a potential covert biological agent event:

-   Large or multiple simultaneous outbreaks of an infectious disease.

-   Recognition of infectious diseases that are not endemic to an area.

-   Multiple patients with infectious diseases that may be endemic to an
    area, but rarely infect humans.

-   Increased animal deaths (domestic, livestock or wild) occurring
    simultaneously with human illnesses.

-   Occurrences of multiple drug-resistant infectious diseases.

-   Cluster presentations of:

1\) Acute febrile respiratory illnesses,

2\) Acute febrile illnesses associated with cutaneous lesions,

3\) Gastroenteritis; or,

4)  Bulbar and/or progressive respiratory paralysis.

Alternatively, the release of a biological event within the community
may be perpetrated overtly in the setting of an "announced event"
resulting in immediate mass hysteria of asymptomatic patients. These
occurrences whether related to a real event, hoaxes or a perceived event
could quickly overwhelm and incapacitate an entire health care system if
not managed quickly and appropriately.

Biological agents have specific characteristics that define a clinical
and public health response. The goals are to block the trail of
exposure, to prevent further cases of disease, and to provide safe ways
of treating individual patients. Important characteristics of such
biological organisms include mode of transmission, infectious period,
transmission rate, and incubation period, which define the pattern of
spread; and, together with person density and contact frequency, the
shape of an epidemic curve. The availability of vaccines, their
effectiveness, and whether they may be administered after exposure
define mitigation strategies. The availability of effective
pharmacologic agents for treatment of established cases or prophylaxis
defines the management of individual cases. Knowledge of these
characteristics allows the development of a response plan.

1.  ***Impact on Mission Critical Systems.*** Response to the release of
    a biological agent can quickly overwhelm several mission-critical
    systems including staffing, critical supplies (i.e., antibiotics,
    intravenous fluids, laboratory supplies, anti-toxins) and
    operational space. In addition, a release within a VA Medical Center
    (VAMC) could pose an imminent risk to the Heating, Ventilation and
    Air Conditioning (HVAC) and water supply systems if intentionally or
    accidentally contaminated with organisms. It is important to assess
    the airflow pressure relationships within the Medical Center to
    determine potential impact/risk of secondary spread of aerosolized
    biological agents.

2.  ***Operating Units and Key Personnel with Responsibility to Manage
    this Threat/Event.***

-   *Infection Control Team* - Key role in tracking of potential and
    confirmed cases with reporting responsibilities to the Public Health
    Service. Key role as a local information resource, as needed, for
    health care providers, employees and patients regarding the Centers
    for Disease Control (CDC) guidelines and other public health
    resource updates.

-   *Nursing Service and Chief of Staff* - Key role in tracking patient
    census, staffing utilization and need for additional staff.

-   *Clinical Microbiology Laboratory* - Bio-safety Level 2 (BSL 2) -
    Key role in ruling out potential bacterial bio-warfare agents
    isolated from patient samples with referral of all isolates that
    cannot be ruled out to the Public Health Referral Laboratories for
    specialized confirmatory testing and subsequent reporting to the
    CDC.

> Note: Culturing suspect powders or environmental samples with
> potential of concentrated aerosolizable biological agents should be
> performed in BSL 3 Clinical Microbiology Laboratories, and
> [only]{.underline} with the prior approval from VACO, public health
> service and the local FBI.

-   *Safety Officer/Industrial Hygienist* - Key role as the point of
    contact with HazMat agencies in air, powder, or environmental
    sampling. Key role in monitoring and proper use of specialized PPE
    resources, as needed. Lead role in extending availability of
    respiratory isolation facilities through the use of additional
    system filters and portable units, as available.

-   *Police and Security* - Key role in perimeter control and incident
    site access. Key role in maintaining Chain-of-Custody for all
    potential evidence collected.

-   *Emergency Room Personnel* - Key role in monitoring clinical patient
    workload and recognition of potential clinical syndromes associated
    with bio-warfare agents. Key role in ensuring that all other medical
    emergency capabilities (i.e., cardiac emergencies) are maintained
    and operational.

-   *Medical Service* - Key role in monitoring clinical patient workload
    and recognition of potential clinical syndromes associated with
    bio-warfare agents.

-   *Occupational/Employee Health* - Key role in monitoring occupational
    health conditions/risks, employee concerns, and prophylactic
    therapy, as needed.

-   *Facilities/Engineering* - Key role in ensuring mission-critical
    systems have been protected from contamination and to monitor for
    contamination, as appropriate.

3.  ***Mitigation/Preparedness Activities of the Threat/Event.*** As
    soon as the Medical Center is aware that a potential biological
    event has (or may have) occurred, an initial assessment of potential
    agents based on clinical presentations or the announced agent will
    occur. (See Attachment C for assistance with evaluation of the
    symptomatic patient, and Attachment D for assistance with evaluation
    of the announced biological event. Based on all available
    information at the time of the initial assessment, the following
    will be addressed:

-   Perimeter security level.

-   Activation of Incident Command Station.

-   Activation of Emergency Response Team(s).

-   Determination of most appropriate PPE level for healthcare
    providers.

-   Notification protocol for biologic event.

a.  *Exposure Control Strategies.*

    1.  Potential biohazard within the VAMC.

    2.  Potential biohazard within the community.

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a.  *Exposure Monitoring Strategies.*

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1)  Clinical patient tracking by healthcare providers, Infection Control
    and Clinical Microbiology Laboratory personnel.

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1)  Environmental monitors/sampling, as needed, based upon
    recommendations from the CDC and Public Health Service.

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b.  *Preparedness Strategies and Resource Issues.*

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1)  Clinical education and awareness initiatives.

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1)  Development and updates of the Medical Center's Bio-Terrorism
    Readiness Plan.

2)  Rapid Inventory assessment protocol for critical resources (i.e.,
    staffing, beds, large pre-designated waiting areas) and supplies
    (i.e., antibiotics, X-ray film, laboratory supplies, anti-toxins).

3)  Development and updates of protection and monitoring plan for
    mission-critical systems.

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4.  ***Response/Recovery from the Event/Threat.***

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a.  *Hazard Control and Monitoring Strategies.*

1\) Event within the VAMC:

-   Immediately report any potential biohazard event to VAMC Director,
    Police and Security and the Safety Officer/HazMat team member.

-   Clear all patients and employees from immediate at-risk area.

-   Document details of event and names of all persons within the
    immediate at risk area.

-   VAMC Director, Police and Security and designated HazMat team
    member/Safety Officer will make initial hazard assessment and will
    determine the appropriate next steps.

-   Activate Infection Control Team for initiation of patient/exposed
    employee tracking system, patient/employee educational information
    (fact sheet) and follow-up of cultures.

-   Initiate prophylactic antibiotic therapy for all potentially exposed
    persons, as appropriate.

-   Notify internal personnel, as needed, which may include healthcare
    providers, Pharmacy and Microbiology Laboratory for immediate
    inventory of critical resources.

-   Activate emergency response team(s), HazMat teams, etc., as
    appropriate.

-   Immediately assess potential impact of actual event on
    mission-critical systems to include staffing, critical supplies,
    operational space and HVAC system.

2\) Event in the Community - Notification of a release within the
community may come from any number of outside sources, and the primary
function of the VAMC in this setting may be to treat concerned
asymptomatic or symptomatic patients. Critical guidelines include the
following:

-   Treat all reports of a community biologic event as real, until
    proven otherwise.

-   Notify internal personnel, as needed, which may include VAMC
    Director, Chief of Staff, Nursing, Police and Security, Safety
    Officer/Industrial Hygienist, Emergency Room personnel, healthcare
    providers, Pharmacy, Microbiology Laboratory and Engineering for
    immediate inventory of critical resources.

-   Notify Infection Control Team and the Clinical Microbiology
    Laboratory for active surveillance of potential biologic event
    cases. Initiate patient tracking system, as needed.

-   Immediately assess potential impact of reported community event on
    mission-critical systems to include bed status, staffing levels,
    critical supplies and operational space.

-   Await follow-up information from local authorities and prepare for
    potential presentation of patients.

-   VHA Pharmacies that serve as antibiotic stockpile resources for a
    community will begin immediate recall of staffing, as needed, to
    respond to supply distribution needs within the community.

a.  *Resource Issues.*

1\) Staffing needs will be monitored and addressed by Chief of Staff,
Chief of Nursing, VAMC Director and other involved Service Chiefs.

2\) Critical Supplies - Antibiotic availability will be monitored by
Chief of Pharmacy. If the VHA is the source of an emergency antibiotic
stockpile, the Chief of Pharmacy will be called upon to monitor and
distribute supplies, as needed, for a community release event. This will
be coordinated with the VAMC Director. Additional critical supplies to
assess in a biologic event include alternate antibiotics, anti-toxins,
respiratory isolation equipment/mobile units, X-ray film, laboratory
culture supplies and intravenous fluids.

3\) Isolation supplies and PPE inventories.

4\) Space Management - Assess bed and space availability, respiratory
isolation capacity.

-   Emergency Room capabilities, Acute Care Clinic capabilities,
    current/projected bed capacity and Intensive Care capacity should be
    immediately assessed.

-   If an event of potential mass casualty proportion has occurred, then
    plans for clearing of potential, large designated patient waiting
    areas or cohort treatment sites should be immediately reviewed and
    activated, as needed.

-   If event has occurred within the VAMC, patients and employees may be
    relocated to alternate sites, or alternate health care facilities
    based upon previously established agreements/memoranda of
    understanding.

5\) Notify VISN and request standby or more active assistance from other
VISN facilities, other VISNs, Emergency Response Teams, Pharmaceutical
Caches, etc.

b.  *Clinical Response.*

1\) Triage and initial patient assessment for those involved in a
biologic event may require removal of potentially contaminated clothing
and a self-shower where appropriate. Decontamination protocols used for
a chemical event are rarely needed in the setting of a biologic event.
However, if the type of event is unknown and not clearly established as
either a biologic or delayed chemical event, default protocols should
revert to chemical decontamination (see Attachment D for assistance with
evaluation of the announced biologic event). All collected potential
evidence should be double-bagged, labeled and held using
Chain-of-Custody procedures.

2\) Treatment Protocols for the most likely or known biologic agent will
be based upon current CDC guidelines or other public health resources to
include choice of antibiotic(s), length of therapy, use of vaccine, use
of anti-toxins or agent-targeted human anti-globulins.

3\) Isolation and Quarantine Protocols will be based on the most current
available CDC guidelines.

4\) All VAMC quarantine decisions will be made by the VAMC Director
and/or Incident Commander based upon recommendations from Infection
Control and the CDC/Public Health Service.

5\) Admission decisions will be made by the healthcare providers.

6\) Patients who are treated and released will be provided an
information fact sheet about the biologic agent reported, with
instructions to call the hospital immediately if any warning signs or
concerns arise.

7\) All patients treated and evaluated for exposure to a biologic agent
must be reported to the Infection Control Team.

8\) The Infection Control Team will monitor all potential and proven
cases, making appropriate reports to both the VAMC Director and the
Public Health Service. The Public Health Service will notify the CDC of
all suspected and confirmed biologic event cases, as deemed appropriate.

> *Note: 1) Physicians dealing with patients who have been involved in
> an intentional terrorist biologic event, will most likely be dealing
> with a clinical entity they have never treated or even seen before. It
> is essential in these circumstances to rely upon the clinical
> expertise and recommendations provided by the Centers for Disease
> Control and other public health resources. Treatment protocols are
> likely to evolve over time with updates as more is learned about the
> specific biologic strain used in the release, an "exposure" is
> redefined, and as additional resources such as vaccines and/or
> anti-toxins become available.*
>
> *2) The Infection Control Team working with the Chief of Staff and
> VAMC Director will notify Health Care Providers when CDC treatment
> guidelines are updated, or as new resources are made available. The
> Infection Control Team can monitor the APIC web site
> ([www.apic.org](http://www.apic.org/)) and CDC web site
> ([www.bt.cdc.gov](http://www.bt.cdc.gov/)) for the most current CDC
> updates, protocols and recommendations.*
>
> *3) Even ONE case of confirmed smallpox represents an immediate
> international emergency and requires immediate notification of the
> local Public Health Service, CDC, WHO and FBI.*
>
> *4) All criminal investigations related to a bio-terrorist event are
> in the jurisdiction of the FBI.*

d.  *Recovery strategies.*

1\) Periodic critical supply inventories with re-supply or
supplementation from outside facilities, as needed.

2\) Periodic staffing census with workload redistribution, as needed.

3\) Close monitoring of patient census and bed status.

5.  ***External Notification Procedures.***

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a.  *Within VA*. VISN, VACO.

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a.  *Other State and Federal Agencies.* Local Public Health Service,
    CDC, Federal Bureau of Investigation (FBI), Federal Emergency
    Management Agency (FEMA), Department of Defense (DoD), Environmental
    Protection Agency (EPA), Occupational Safety and Health
    Administration (OSHA) reporting for employee injuries. Notify OSHA
    within 8-hours of one (1) employee fatality, or three (3) employees
    hospitalized from a single incident.

b.  *Community Entities.* Neighboring hospitals, emergency response
    systems (police, firefighters, EMS, 911 operators).

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6.  ***Specialized Staff Training.***

a\. *Health Care Provider Training* - Recognition of clinical syndromes
associated with biologic agents, treatment protocols, CDC and other
public health guidelines.

b\. *Infection Control Team Training* - Passive and active surveillance
systems for monitoring reportable infectious disease pathogens.
Coordination with the designated Public Health Laboratory.

c\. *Safety Specialist/Industrial Hygienist* - Recommended agent
sampling and environmental monitor protocols for biologic agents.

d\. *Clinical Microbiology Laboratories* -

1\) Recommended specimen collection protocols, culture methods, rule-out
protocols and local referral resources for various biologic agents and
various BSL Laboratory requirements. A few examples are noted in the
table below. Always contact the Public Health Laboratory and CDC prior
to collection and transport of samples to their facility for BSL 3 and 4
organisms.

+--------------+------------+---------+------------------------+-----+
| **Agent**    | *          | **Agent | **Clinical Samples**   | *   |
|              | *Disease** | Type**  |                        | *BS |
|              |            |         |                        | L** |
+--------------+------------+---------+------------------------+-----+
| Bacillus     | Anthrax    | B       | Blood, Pleural fluid,  | 2   |
| anthracis    |            | acteria | CSF, Stool, Skin       |     |
|              |            |         | lesions; acute &       |     |
|              |            |         | convalescent serum     |     |
+--------------+------------+---------+------------------------+-----+
| Yersinia     | Plague -   | B       | Blood, Lymph node      | 2-3 |
| pestis       | "Black     | acteria | aspirate, sputum;      |     |
|              | Death"     |         | acute & convalescent   |     |
|              |            |         | serum                  |     |
+--------------+------------+---------+------------------------+-----+
| Francisella  | Tularemia  | # B     | Blood, Lymph node      | 2-3 |
| tularensis   |            | acteria | aspirate, sputum;      |     |
|              |            |         | acute & convalescent   |     |
|              |            |         | serum [(Very dangerous |     |
|              |            |         | for laboratory         |     |
|              |            |         | workers!)]{.underline} |     |
+--------------+------------+---------+------------------------+-----+
| Variola      | Smallpox   | Virus   | Blood, skin, tissue;   | 4   |
|              |            |         | acute & convalescent   |     |
|              |            |         | serum                  |     |
+--------------+------------+---------+------------------------+-----+
| Viral        | Ebola;     | Viruses | Blood, skin, tissue;   | 4   |
| Hemorrhagic  |            |         | acute & convalescent   |     |
| Fevers       | Marburg,   |         | serum                  |     |
|              | etc.       |         |                        |     |
+--------------+------------+---------+------------------------+-----+
| Clostridium  | Botulism   | B       | Nasal swabs; stool     | 2   |
| botulinum    |            | acteria | cultures; acute &      |     |
|              |            | Toxin   | convalescent serum     |     |
+--------------+------------+---------+------------------------+-----+
| Ricin        | Ricin      | Castor  | Tissue or blood for    | 2   |
|              | poisoning  | bean    | toxicological testing  |     |
|              |            | Toxin   |                        |     |
+--------------+------------+---------+------------------------+-----+

2)  Education regarding detection limits for definitive diagnosis of
    various biologic agents based on culture methods, molecular methods
    and rapid antigen detection methods.

  --------------- ----------- --------------- ------------- -------------------
  **Approximate                                             
  Detection                                                 
  Limits of                                                 
  Various                                                   
  Diagnostic                                                
  Methods (in                                               
  CFUs)**                                                   

  Culture         PCR         Direct          Direct        Antigen
                              Hybridization   Microscopy    Immunoassays

  1               10-100      100-1000        10,000        100,000+
  --------------- ----------- --------------- ------------- -------------------

3\) Recommended samples for serologic studies and future antigen and/or
molecular studies as requested by the Public Health Service.

e\. *Police and Security* - Introductory training on potential biologic
risks, BSL designation for various types of organisms and PPE
recommendations.

f\. *Environmental Management Service Personnel* -- Introductory
training on potential biologic risks, BSL designation for various types
of organisms and PPE recommendations.

g\. *Social Work Service* -- Introductory training on potential biologic
risks, BSL designation for various types of organisms and PPE
recommendations.

7.  ***References and Further Assistance*.**

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a.  Local Public Health Service/State Health Department.

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a.  Centers for Disease Control.

b.  Local FBI Representatives.

c.  Textbook of Military Medicine.

d.  Web Sites:

-   CDC Bio-terrorism web site: [www.bt.cdc.gov](http://www.bt.cdc.gov/)

-   US Army Medical Research Institute of Infectious Diseases. Physician
    Handbook

-   For Management of Biologic Casualties:
    [www.usamriid.army.mil/education/](http://www.usamriid.army.mil/education/)

f\. Phone Numbers

-   USAMRIID 1-301-619-2833

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-   US Public Health Service 1-800-872-6367

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-   Domestic Preparedness Information Line 1-800-368-6498

-   National Response Center 1-800-424-8802

8.  ***Review Date.***

(Name)

Chief, (Service)

Attachments:

A. Key Activity Management Tool

B. Key Activity Management Structure

C. Sample Biologic Surveillance Plan (Symptomatic Patient)

D. Sample Biologic Event Plan

E. Infection Control BioTerrorism Checklist

*Sample 6.2.3.1.2*

*(Note: This SOP contains some intricate clinical information. For
additional Clinical information or clarification, you may contact Dr.
Margie Scott via the VA Global Address book in Outlook, or your local
infectious disease consultant.)*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Anthrax Release in the Community or VA Medical Center**

1.  ***Description of the Threat/Event.*** Anthrax is a biological
    hazard caused by the organism *Bacillus anthracis*. In most parts of
    the world, it can be found naturally in the soil and in cattle or
    other livestock. This bacteria forms spores that can infect humans
    if the spores are ingested (contaminated meat), inhaled or directly
    touched. There are three clinical types of anthrax, depending on the
    route of entry:

-   *Cutaneous anthrax* - is the least serious of the three, producing
    ulcerated dark black skin lesions that are usually not painful. If
    left untreated, the infection can spread to the blood. This form may
    be fatal in 1 in 20 cases.

-   *Intestinal anthrax* - is caused by the ingestion of spores (i.e.,
    contaminated meat) producing severe food poisoning symptoms with
    bloody diarrhea and cramping abdominal pain. It is frequently fatal.

-   *Inhalational anthrax* - is caused when airborne spores are breathed
    into the lungs and transported to the mediastinum where they grow
    very rapidly. Initial symptoms usually develop in 2--10 days
    beginning as a flu-like illness with fever, respiratory symptoms and
    chest pain. The infection may then rapidly spread to the blood
    resulting in shock 2-6 days after initial presentation. This form is
    usually fatal if not treated very early. Recent data suggests a much
    lower clinical fatality rate if treated very early and aggressively.

2.  ***Impact on Mission Critical Systems.*** Response to the release of
    a biological agent such as anthrax can quickly overwhelm several
    mission-critical systems including staffing, critical supplies
    (i.e., antibiotics) and operational space. In addition, a release of
    anthrax spores within a VA Medical Center (VAMC) poses an imminent
    risk of Heating, Ventilation and Air Conditioning (HVAC)
    cross-contamination to other medical center locations and response
    to this contamination potential may require temporary shutdown and
    loss of HVAC function. It is important to identify medical center
    airflow pressure relationships to determine impact/risk of secondary
    spread.

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2.  ***Operating Units and Key Personnel with Responsibility to Manage
    this Threat/Event.***

-   *Infection Control Team* -- Key role in tracking of potential and
    confirmed cases with reporting responsibilities to the Public Health
    Service. Key role as a local information resource, as needed, for
    healthcare providers, employees and patients regarding the Centers
    for Disease Control (CDC) guidelines and other public health
    resource updates.

-   *Nursing Service and Chief of Staff* -- Key role in tracking patient
    census, staffing utilization and need for additional staff.

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-   *Clinical Microbiology Laboratory* - Bio-safety Level (BSL) 2 - Key
    role in ruling out potential *Bacillus* isolates from patient
    samples with referral of all isolates that cannot be ruled out to
    the Public Health Referral Laboratories for specialized confirmatory
    testing and subsequent reporting to the CDC.

Note: Laboratory plating and culturing of suspect powders or
environmental samples with potential of concentrated aerosolizable
spores should be performed in BSL 3 Clinical Microbiology Laboratories,
and [only]{.underline} with agreement from VACO, public health service
and the local FBI. Laboratories should identify the most appropriate
referral laboratory for specialized testing.

-   *Safety Officer/Industrial Hygienist* - Key role as the point of
    contact with HazMat agencies in air, powder, or environmental
    sampling. Key role in monitoring and proper use of specialized PPE
    resources as needed.

-   *Police and Security* - Key role in perimeter control and incident
    site access. Key role in maintaining Chain-of-Custody for all
    potential evidence during investigation of potential anthrax release
    within the VAMC.

-   *Emergency Room Personnel* - Key role in monitoring clinical patient
    workload and recognition of potential clinical syndromes associated
    with anthrax. Key role in ensuring that all other medical emergency
    capabilities (i.e., Cardiac emergencies) are maintained and
    operational.

-   *Medical Service* - Key role in monitoring clinical patient workload
    and recognition of potential clinical syndromes associated with
    anthrax.

-   *Occupational/Employee Health* - Key role in monitoring occupational
    health conditions/risks, employee concerns, and prophylactic therapy
    as needed.

3.  ***Mitigation/Preparedness Activities of the Threat/Event.***
    Although inhalational anthrax is not contagious from
    person-to-person, anthrax spores are highly infectious creating a
    serious airborne risk immediately after a release or due to
    secondary aerosolization. For this reason, strict measures should be
    taken to limit further contamination of VAMC staff, patients and
    visitors.

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a.  *Hazard Reduction.*

-   Notification protocol to follow when a potential biohazard is
    encountered.

-   Exposure control strategies:

    1.  Potential biohazard within the VAMC.

    2.  Potential biohazard within the community.

        -   Exposure monitoring strategies.

            1.  Clinical patient tracking by healthcare providers,
                infection control and clinical microbiology laboratory
                personnel.

            2.  Environmental monitors/sampling, as needed, upon request
                of CDC or Public Health Service.

a.  *Preparedness Strategies and Resource Issues.*

    -   Clinical education and awareness initiatives.

    -   Development and updates of the Medical Center's Bio-terrorism
        Readiness Plan.

    -   Rapid Inventory assessment protocol for critical resources
        (i.e., staffing, beds, large pre-designated waiting areas) and
        supplies (i.e., antibiotics, X-ray film, laboratory supplies).

    -   Development and updates of protection and monitoring plan for
        mission-critical systems.

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4.  ***Response/Recovery from the Event/Threat.***

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a.  *Hazard Control and Monitoring Strategies.*

> 1\) Release within the VAMC -

-   Immediately report any potential biohazard release to VAMC Director,
    Police and Security and Safety Officer/HazMat team member.

-   Clear all patients and employees from immediate at-risk area.

-   Document details of incident and names of all persons within the
    immediate at-risk area.

-   VAMC Director, Police and Security, and designated HazMat team
    member/Safety Officer will make initial hazard assessment.

-   Categorize as *Low* or *High Risk* and contact proper local
    authorities.

-   Proceed with investigation ([only]{.underline} if previously
    approved), [or]{.underline} turn investigation over to the local
    authorities for sample collection and cultures.

-   Initiate prophylactic antibiotic therapy for all potential exposed
    persons as appropriate.

-   Activate Infection Control Team for initiation of patient/exposed
    employee tracking system, patient/employee educational information
    (fact sheet) and follow-up of cultures.

-   Notify internal personnel, as appropriate (i.e., Healthcare
    Providers, Pharmacy, and Microbiology Laboratory) for immediate
    inventory of critical resources).

-   Immediately assess potential impact of actual event on
    mission-critical systems to include staffing, critical supplies,
    operational space and HVAC system.

> 2\) Release in the Community - Notification of a release within the
> community may come from any number of outside sources, and the primary
> function of the VHA facility in this setting will be to treat
> concerned asymptomatic or symptomatic patients. Critical guidelines
> include the following:

-   Treat all reports of a community release as real, until proven
    otherwise.

-   Notify internal personnel, as needed, which may include the VAMC
    Director, Chief of Staff, Police and Security, Safety
    Officer/Industrial Hygienist, Nursing, Emergency Room Personnel,
    Healthcare Providers, Pharmacy, and Microbiology Laboratory to allow
    for immediate inventory of critical resources.

-   Notify Infection Control Team and the Clinical Microbiology
    Laboratory for active surveillance of potential anthrax cases.
    Initiate patient tracking system as needed.

-   Immediately assess potential impact of reported community event on
    mission-critical systems to include staffing, bed/staffing levels,
    critical supplies and operational space.

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-   Await follow-up information from local authorities and prepare for
    potential presentation of patients.

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-   VAMC Pharmacies that serve as antibiotic stockpile resources for a
    community will begin immediate recall of staffing, as needed, to
    respond to supply distribution needs within the community.

b\. *Resource Issues.*

1)  Staffing Needs - will be monitored and addressed by Chief of Staff,
    Chief of Nursing, VAMC Director and other involved Service Chiefs.

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1)  Critical Supplies - Antibiotic availability will be monitored by
    Chief of Pharmacy. If the VAMC is the source of an emergency
    antibiotic stockpile, the Chief of Pharmacy will be called upon to
    monitor and distribute supplies, as needed, for a community release
    event. This will be coordinated with the VAMC Director. Additional
    critical supplies to assess in the event of an anthrax release
    include X-ray film, Laboratory culture supplies, and intravenous
    fluids.

2)  Space Management - Assess bed and space availability.

    -   Emergency Room capabilities, Acute Care Clinic capabilities and
        current/projected bed availability should be immediately
        assessed.

    -   If an event of potential mass casualty proportion has occurred,
        then plans for clearing of potential large designated patient
        waiting areas or cohort treatment sites should be immediately
        reviewed and activated as needed.

    -   If release has occurred within the VAMC, patients and employees
        must be relocated to alternate sites or alternate healthcare
        facilities, as appropriate.

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c.  *Clinical Response.*

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1)  Triage and initial patient assessment for those immediately exposed
    to an anthrax spore release should include removal of clothes with
    collection of clothes as potential evidence (double-bagged and
    labeled); self-shower where appropriate with thorough washing of
    hair for removal of potential spores and provision of clean clothes.
    Privacy and containment are important. (Chemical decontamination
    procedures are not appropriate for treatment of persons exposed to
    anthrax spores!)

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1)  Treatment Protocols will be guided by CDC and other Public Health
    updates (i.e., choice of antibiotic(s), length of therapy and use of
    vaccine if available).

2)  Admission decisions will be made by the Healthcare Providers.

3)  All quarantine decisions will be made by the VAMC Director based
    upon recommendations from the Infection Control Team and the Public
    Health Service.

4)  Patients who are treated and released will be provided an
    information fact sheet about anthrax with instructions to call the
    hospital immediately if any warning signs arise.

5)  All patients treated and evaluated for potential anthrax exposure;
    [or]{.underline}, potential anthrax-related symptoms must be
    reported to the Infection Control Team.

6)  The Infection Control Team will monitor all potential cases and make
    appropriate reports to the VAMC Director and the Public Health
    Service. The Public Health Service will notify the CDC of all
    suspected and confirmed cases.

> Note: Physicians dealing with patients who have been involved in an
> anthrax spore release will most likely be dealing with a clinical
> entity they have never treated or even seen before. It is essential in
> these circumstances to rely upon the clinical expertise and
> recommendations provided by the Centers for Disease Control and other
> Public Health Officials. Treatment protocols are likely to evolve over
> time with updates as more is learned about the specific biologic
> strain used in the release, an exposure is redefined, and as
> additional resources such as vaccines become available. A currently
> acceptable protocol for treatment of patients exposed to anthrax is
> noted below:

  ------------------- ------------- ------------------ -------------------
  Antibiotic          Dosage        **Duration (with   **Duration (without
                                    Vaccine)**         Vaccine)**

  Ciprofloxacin       500mg bid     30 days            60 days

  Doxycyline          100mg bid     30 days            60 days

  *Note: Patients may                                  
  be switched to                                       
  Amoxicillin for                                      
  completion of                                        
  antibiotic therapy                                   
  after sensitivity                                    
  studies confirm the                                  
  isolate is                                           
  penicillin                                           
  sensitive.*                                          
  ------------------- ------------- ------------------ -------------------

7)  The Infection Control Team working with the Chief of Staff and VAMC
    Director will notify healthcare providers when treatment guidelines
    are updated or as new resources are made available. The Infection
    Control Team can monitor the Association for Professionals in
    Infection Control and Epidemiology (APIC) and/or CDC web sites for
    these updates.

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c.  *Recovery Strategies.*

    -   Periodic critical supply inventories with re-supply or
        supplementation from outside facilities, as needed.

    -   Periodic staffing census with workload redistribution, as
        needed.

    -   Close monitoring of patient census and bed status.

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5.  ***External Notification Procedures.***

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a.  *Within VA.* VISN, VACO.

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a.  *Other State and Federal Agencies*. Local Public Health Service,
    CDC, Federal Bureau of Investigation (FBI), Federal Emergency
    Management Association (FEMA), Department of Defense (DoD),
    Environmental Protection Agency (EPA), Occupational Safety and
    Health Administration (OSHA) reporting for employee injuries. Notify
    OSHA within eight (8) hours of one (1) employee fatality, or
    three (3) employee hospitalizations resulting from a single
    incident.

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c.  *Community Entities*. Neighboring hospitals, emergency response
    systems (police, firefighters, EMS, 911 operators).

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6.  ***Specialized Staff Training.***

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a.  *Healthcare Provider Training* - Recognition of clinical syndromes
    associated with anthrax, treatment protocols, CDC guidelines, APIC
    guidelines.

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a.  *Infection Control Team Training* - Passive and active surveillance
    systems for monitoring reportable infectious disease pathogens.

b.  *Safety Specialist/Industrial Hygienist* - Recommended agent
    sampling and environmental monitor protocols for anthrax spores.

c.  *Clinical Microbiology Laboratories* - Recommended culture methods,
    rule-out protocols, and local referral resources.

d.  *Social Work Service* - Introductory training on anthrax disease
    presentations, risks, treatments and follow-up.

e.  *Police and Security* - Introductory training on potential anthrax
    spore risks, PPE recommendations.

f.  *Environmental Management Service Personnel* - Introductory training
    on potential anthrax spore risks, PPE recommendations.

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7.  ***References and Further Assistance.***

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a.  Local Public Health Service/State Health Department.

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a.  Centers for Disease Control.

b.  Local FBI representatives.

c.  Textbook of Military Medicine.

e\. Multiple Web Sites.

-   CDC Bio-terrorism web site:
    [www.bt.cdc.gov](http://www.bt.cdc.gov/).

-   US Army Medical Research Institute of Infectious Diseases. Physician
    Handbook.

-   For Management of Biologic Casualties:
    [www.usamriid.army.mil/education](http://www.usamriid.army.mil/education).

f\. Phone Numbers.

-   USAMRIID 301-619-2833

-   US Public Health Service 1-800-872-6367

-   Domestic Preparedness Information Line 1-800-368-6498

-   National Response Center 1-800-424-8802

8.  ***Review Date.***

(Name)

Chief, (Service)

Attachments:

A. Key Activity Management Tool

B. Key Activity Management Structure

*Sample 6.2.3.1.3*

*(Note: This SOP contains some intricate clinical information. For
additional Clinical information or clarification, you may contact Dr.
Margie Scott via the VA Global Address book in Outlook, or your local
infectious disease consultant.)*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Smallpox Release in the Community or VA Medical Center**

1.  ***Description of the Threat/Event.***

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a.  *Agent.* Variola virus is the etiological agent of smallpox. The
    only known reservoir for the virus outside of laboratory settings is
    humans; no known animal or insect reservoirs or vectors exist. The
    most frequent mode of transmission was person-to-person, spread
    through direct deposit of infective droplets onto the nasal, oral,
    or pharyngeal mucosal membranes, or the alveoli of the lungs from
    close, face-to-face contact with an infectious person. Indirect
    spread (i.e., not requiring face-to-face contact with an infectious
    person) through fine-particle aerosols or a fomite containing the
    virus was less common. Transmission through contaminated bedclothes
    and blankets has been well documented over the centuries.

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a.  *Clinical Disease***.** Symptoms of smallpox begin 12-14 days
    (range: 7-17) after exposure, starting with a 2-3 day prodrome of
    high fever, malaise, and prostration with severe headache and
    backache. This pre-eruptive stage is followed by the appearance of a
    maculopapular rash (i.e., eruptive stage) that progresses to papules
    1-2 days after the rash appears; vesicles appear on the fourth or
    fifth day; pustules appear by the seventh day; and scab lesions
    appear on the fourteenth day. The rash appears first on the oral
    mucosa, face, and forearms; then spreads to the trunk and legs.
    Smallpox patients are most infectious during the first week of the
    rash when the oral mucosa lesions ulcerate and release substantial
    amounts of virus into the saliva. A patient is no longer infectious
    after all scabs have separated (i.e., 3-4 weeks after the onset of
    the rash).

b.  During the smallpox era, overall mortality rates were approximately
    30%.

c.  *Public Health Response.* The primary public health response is
    based on ring-immunization of exposed individuals and preventing
    potentially infected individuals from spreading disease further by
    isolation. The steps include identification of potential contacts,
    establishing vaccination sites, vaccinating, and confining
    individuals until the end of the 17-day incubation period, i.e.,
    quarantine. Although isolation may occur at home, public health may
    require quarantining large groups of individuals in hospitals or
    geographic areas.

d.  Vaccinia vaccine is a highly-effective immunizing agent that enabled
    the global eradication of smallpox. Neutralizing antibodies induced
    by vaccinia vaccine are genus-specific and cross protective for
    other Orthopoxviruses (e.g., monkeypox, cowpox, and variola
    viruses). Although the level of antibody that protects against
    smallpox infection is unknown, after percutaneous administration of
    a standard dose of vaccinia vaccine, \>95% of primary vaccinees
    (i.e., persons receiving their first dose of vaccine) will
    experience neutralizing or hemagglutination inhibition antibody at a
    titer of [\>]{.underline}1:10 (21). Neutralizing antibody titers of
    [\>]{.underline}1:10 persist among 75% of persons for 10 years after
    receiving second doses and [\<]{.underline}30 years after receiving
    three doses of vaccine.

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1.  ***Impact on Mission Critical Systems.***

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a.  Response to release of a biological agent such as smallpox in the
    community can quickly overwhelm individual mission critical systems
    in a VA Medical Center (VAMC). Examples include staffing and
    operational space required for patient care or quarantine, staff
    shortages from community quarantine, or family concerns leading to
    family-driven work absence.

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a.  Breaks in procedure or unanticipated exposures may overwhelm a whole
    Medical Center, for example, by exposing personnel and requiring
    quarantine of the Medical Center.

b.  Targeted releases of agent or Heating, Ventilation and Air
    Conditioning (HVAC) cross-contamination may define areas of the
    Medical Center, patients and staff as contacts.

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2.  ***Operating Units and Key Personnel with Responsibility to Manage
    this Threat.***

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a.  *Infection Control Team/Epidemiology* - Key role in tracking
    potential and confirmed cases; infection control management of
    patients using airborne precautions (private room, negative
    pressure, N95 respirator) or, when the Medical Center is
    overwhelmed, cohorting (isolation of infectious patients in areas
    with HVAC isolation and control of exhausted air; N95 use by staff);
    reporting responsibilities to local (Health Department) and national
    \[Centers for Disease Control (CDC)\] public health; local
    information resource on changing public health recommendations;
    resource on community/outbreak information; vaccination decisions
    for staff, patients, and visitors; identification of
    sources/outbreak investigation

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a.  *Engineering Service* - Assessment of isolation rooms and negative
    pressure systems; identification of areas suitable for cohorting
    patients both in waiting areas and after hospitalization.

b.  *Clinical Laboratory* - Electron microscopy for pox identification,
    Polymerase Chain Reaction (PCR) testing of clinical samples
    \[Bio-Safety Level (BSL) 4 requirements in labs\]; accrual and
    tracking of acute and convalescent sera.

c.  *Safety/Industrial Hygiene* - Support of N95 respirator usage
    (fit-testing).

d.  *Police and Security* - Key role in perimeter control, site access,
    and Chain-of-Custody issues. Perimeter access and site control may
    pertain to staff, staff relatives/family, and patients and require
    ingress and egress control. Chain of Custody issues must be
    coordinated with the Federal Bureau of Investigation (FBI) and local
    law enforcement.

e.  *Medical Service* - Clinical diagnosis of cases; treatment.

f.  *Nursing Service* - Staffing and bed support; maximum restriction of
    non-essential personnel from patient rooms (i.e., Environmental
    Management, Nutrition and Food services personnel).

g.  *Emergency Department* - Monitoring incoming patients suspected of
    exposure or disease; decisions on maintaining separate clinical
    activity.

h.  *Employee/Occupational Health* - Employee vaccination/clinical care
    (identification of vaccine contraindications), information flow/risk
    communication.

i.  *EMS/Safety* - Isolation of all disposables, bed linens, etc. from
    patients with on-site autoclaving if possible.

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3.  ***Mitigation/Preparedness Activities of the Threat/Event.***
    Smallpox is a disease with person-to-person, HVAC, and fomite
    transmission. A single case constitutes an international emergency
    and mandates immediate reporting to the local public health
    authority, which will in turn notify CDC, FBI, and World Health
    Organization (WHO) according to the National Response Plan.

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a.  *Hazard Reduction.*

    -   Notification plan.

    -   Activation of hospital emergency plan.

    -   Perimeter control potential: staffing requirements, heightened
        security requirements for access control.

    -   Building systems assessment for cohorting potential.

    -   Exposure control/Infection control: Airborne and contact
        precautions are necessary for smallpox. Patients are to be
        placed in an isolation room with negative pressure and HEPA
        exhaust; wear surgical masks when transported through the
        Medical Center, which should only occur if absolutely necessary;
        or cohorted in common, exposed areas with HVAC isolation and
        exhaust.

    -   Separation of new, unexposed patients from potential smallpox
        cases.

    -   Strict airborne and contact precautions.

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a.  *Preparedness Strategies and Resources.*

    -   Vaccination.

    -   Education (clinical recognition tools, infection control
        guidelines).

    -   Standard precautions plus N95 respirators for all personnel with
        patient contact.

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4.  ***Response/Recovery from the Event/Threat.***

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a.  *Hazard Control and Monitoring Strategies.*

1\) Release/case within the VAMC.

-   Immediately report any potential smallpox case or smallpox biohazard
    release to VAMC Director and/or Police and Security, Infection
    Control, Safety Officer, and Employee/Occupational Health.

-   Clear all patients and employees from immediate at-risk area.

-   Document details of incident and names of all persons within the
    immediate at risk area (i.e., who have become contacts and require
    vaccination).

-   Turn criminal investigation process over to the FBI.

-   Contact CDC/Public Health Service (PHS) for sample collection and
    shipping instructions.

-   Contact CDC for availability of smallpox immune globulin and
    vaccine.

-   Activate Infection Control Team for initiation of patient/exposed
    employee tracking system, patient/employee educational information
    (fact sheet).

-   Initiate vaccination for all potential exposed persons as
    appropriate through public health (CDC).

-   Notify internal personnel, as appropriate, including Chief of Staff,
    Healthcare Providers, Nursing Service, Pharmacy, Microbiology
    Laboratory, and Engineering for immediate inventory of critical
    resources.

-   Immediately assess potential impact of actual event on
    mission-critical systems to include staffing, critical supplies,
    operational space, potential for patient and staff exposures and
    HVAC system.

2\) Release in the community - Notification of a release within the
community may come from any number of outside sources, and the primary
function of the VAMC in this setting will be to treat concerned
asymptomatic or symptomatic patients. Critical guidelines include the
following:

-   Treat all reports of a community release as real until proven
    otherwise.

-   Notify internal personnel, as appropriate, including VAMC Director,
    Chief of Staff, Police and Security, Nursing, Safety
    Officer/Industrial Hygienist, Employee/Occupational Health,
    Emergency Room Personnel, Healthcare Providers, Pharmacy, and
    Microbiology Laboratory for immediate inventory of critical
    resources.

    -   Notify Infection Control Team and clinical staff for active
        surveillance of skin rash cases. Initiate patient tracking
        system, as needed.

    -   Notify the Clinical Microbiology Laboratory of potential for
        electron microscopy needs and paired sera collections.

    -   Immediately assess potential impact of reported community event
        on mission critical systems to include staffing, critical
        supplies and operational space.

    -   Await follow-up information from local authorities and prepare
        for potential presentation of patients.

        b.  *Resource Issues.*

            1.  Staffing needs will be monitored and addressed by Chief
                of Staff, Chief of Nursing, VAMC Director, and other
                involved service chiefs.

            2.  Critical Supplies - Vaccine availability at present only
                through local and national (CDC) public health. This
                will be coordinated with the VAMC Director. Additional
                critical supplies to assess in the event of potential
                smallpox case include X-ray film, laboratory culture
                supplies and intravenous fluids. Experimental treatment
                with antiviral agents (Gelfinavir) may be possible if
                the drug is on hand.

            3.  Space Management - Assess isolation room and cohorting
                bed and space availability.

            4.  Emergency Room capabilities, acute care clinic
                capabilities and current/projected bed availability
                should be immediately assessed.

            5.  If release has occurred within the VAMC, patients and
                employees may be quarantined on site or relocated to
                alternate care sites or alternate healthcare facilities.

                c.  *Clinical Response.*

                    1.  Triage and initial patient assessment for those
                        immediately exposed to a physical (non-clinical)
                        exposure should include removal of clothes with
                        collection of clothes as potential evidence
                        (double-bagged and labeled), self-shower and
                        provision of clean clothes. Exposure to clinical
                        cases requires no decontamination activities.
                        Privacy and containment are important. (Chemical
                        decontamination procedures are not appropriate
                        for treatment of persons exposed to smallpox!)

                    2.  Treatment Protocols will be based upon CDC
                        guidelines to include vaccination, (if
                        available) use of antivirals, immune globulin,
                        and supportive clinical care.

                    3.  Clinical admission/treatment decisions will be
                        made by the Healthcare Providers.

                    4.  All quarantine decisions will be made by the
                        VAMC Director based upon recommendations of the
                        Infection Control Team and the Public Health
                        Service (CDC).

                    5.  All patients treated and evaluated for potential
                        smallpox exposure; OR, potential smallpox
                        related symptoms must be reported to the
                        Infection Control Team.

                    6.  The Infection Control Team will monitor all
                        potential cases and make appropriate reports to
                        the VAMC Director and the Public Health Service.
                        The Public Health Service will notify the CDC of
                        all suspected and confirmed cases.

> Notes: 1) Vaccination of Healthcare Providers: Vaccine is currently
> available only through CDC. Vaccination decisions.
>
> 2\) Exposure definition: Contacts are currently defined as having been
> within 2 yards of a known smallpox case.
>
> 3\) The Infection Control Team working with the Chief of Staff and
> VAMC Director will notify Healthcare Providers when CDC
> treatment/exposure guidelines are updated or as new resources are made
> available. The Infection Control Team can monitor the Association for
> Professionals in Infection Control and Epidemiology (APIC) and/or CDC
> web sites for these updates.

d.  *Recovery Strategies.*

    1.  Periodic critical supply inventories with re-supply or
        supplementation from outside facilities, as needed.

    2.  Periodic staffing census with workload redistribution, as
        needed.

    3.  Close monitoring of patient census and bed status.

    4.  Decontamination.

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5.  ***External Notification Procedures.***

    a.  *Within VA*. VISN, VACO.

    b.  *Other State and Federal Agencies.* Public Health Service, CDC,
        FBI, Federal Emergency Management Agency (FEMA), Department of
        Defense (DoD), Environmental Protection Agency (EPA),
        Occupational Safety and Health Administration (OSHA). Notify
        OSHA within eight (8) hours of one (1) employee fatality, or
        three (3) employee hospitalizations resulting from a single
        incident.

    c.  *Community Entities.* Neighboring hospitals, emergency response
        systems (police, firefighters, EMS, 911 operators).

6.  ***Specialized Staff Training.***

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a.  Healthcare Provider Training - Recognition of clinical syndromes
    associated with smallpox, treatment protocols, CDC guidelines.

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a.  Infection Control Team Training - Passive and active surveillance
    systems for monitoring reportable infectious disease pathogens as
    outlined by the CDC.

b.  Safety Specialist/Industrial Hygienist - N95 respirator usage.

c.  Clinical Laboratories - Electron microscopy procedures for smallpox.

d.  Social Work Service - Introductory training on smallpox
    presentations, risks, treatments, family implications, and
    follow-up.

e.  Police and Security - Introductory training on smallpox risks,
    Personal Protective Equipment (PPE) recommendations.

f.  Environmental Management Service Personnel - Introductory training
    on smallpox risks, decontamination of environments, bed-clothing
    management, PPE recommendations.

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7.  ***References and Further Assistance.***

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a.  Public Health Service/Local, County, State Health Departments

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a.  Centers for Disease Control

b.  Local FBI representatives

d\. Multiple Web Sites.

-   CDC Bio-terrorism web site: [www.bt.cdc.gov](http://www.bt.cdc.gov/)

-   US Army Medical Research Institute of Infectious Diseases. Physician
    Handbook.

-   For Management of Biologic Casualties:
    [www.usamriid.army.mil/education/](http://www.usamriid.army.mil/education/)

-   Smallpox Recommendations from CDC (Advisory Committee on
    Immunization Practices)
    <http://www.cdc.gov/mmwr/preview/mmwrhtml/00050577.htm>

-   CDC Interim Smallpox Response Plan and Guidelines, Executive Summary
    [www.bt.cdc.gov/DocumentsApp/Smallpox/RPG/index.asp](http://www.bt.cdc.gov/DocumentsApp/Smallpox/RPG/index.asp)

-   Textbook of Military Medicine

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-   CDC Bio-terrorism Response Plan
    <http://www.bt.cdc.gov/Documents/Planning/PlanningGuidance.PDF>

    -   Phone Numbers.

USAMRIID 1-301-619-2833

US Public Health Service 1-800-872-6367

Domestic Preparedness Information Line 1-800-368-6498

National Response Center 1-800-424-8802

8.  ***Review Date***

(Name)

Chief, (Service)

Attachment:

A. Key Activity Management Tool

B. Key Activity Management Structure

*Sample 6.2.3.1.4*

*(Note: This SOP contains some intricate clinical information. For
additional clinical information or clarification, you may contact Dr.
Margie Scott via the VA Global Address book in Outlook, or your local
infectious disease consultant.)*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Respiratory Viral Outbreak Event (e.g., SARS or Pandemic
Influenza*)***

1\. ***Description of the Threat/Event***. Although respiratory viruses
are common and cyclic with each year's seasonal progression, few cause
significant life threatening illness in the immunocompetent host.
Historically, epidemics and pandems devastate populations of elderly,
young adults and children on a worldwide scale, such as influenza in
1918. Recently, the Severe Acute Respiratory Syndrome (SARS) caused by a
uniquely modified Corona virus (CoV) caused substantial morbidity and
mortality in affected countries. Although the United States was not the
focus of a major SARS outbreak, ease of travel makes this an
ever-present risk with each returning SARS outbreak season and with
other viral infections. The Centers for Disease Control and Prevention
(CDC) has established guidelines for infection control and isolation
within healthcare facilities
(<http://www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm>) to minimize the
potential for a devastating outbreak within the medical center setting.
Specific recommendations for SARS have been issued from CDC and
summarized on a specific Veterans Health Administration (VHA) web site
(<http://vaww.vhaco.va.gov/phshcg/SARS/Default.htm>). The
recommendations for serious highly virulent pandemic influenza virus
outbreak will likely be very similar, with the exception of the
availability of vaccine under development for several likely emerging
infections. Please consider recommendations below for SARS as a model
plan that could also be used for influenza pandemic.

a\. **Severe Acute Respiratory Syndrome (SARS).** During the 2003 global
epidemic, SARS-Corona virus (CoV) caused unprecedented levels of
morbidity and mortality among healthcare personnel and disrupted
healthcare delivery systems, leading in some instances to closure of
hospitals in China and Canada. This rapid spread from affected patients
to healthcare personnel was caused from the very efficient respiratory
droplet transmission of the viral particles from patient to caregivers.
Rapid implementation and strict adherence to infection control measures
are essential for controlling transmission in the healthcare setting.

b\. Several lessons learned have resulted from the global experience
with SARS-CoV. Some of these are:

-   Transmission of SARS-CoV appears to occur predominantly through
    close interactions with infected persons.

-   Persons with unrecognized SARS-CoV disease can contribute to the
    initiation or expansion of an outbreak, especially in healthcare
    settings.

-   Transmission of SARS-CoV in a single healthcare facility can have
    far-reaching public health effects.

-   Transmission to healthcare workers has occurred primarily after
    close, unprotected contact with symptomatic persons [before
    implementation]{.underline} of infection control precautions.

-   Certain high-risk procedures and events can increase the risk of
    SARS-CoV transmission.

-   Infection control is a primary public health intervention for
    containing the spread of SARS-CoV.

-   Patients with SARS-CoV disease [need to be isolated]{.underline} to
    minimize the risk of transmission to others.

-   Patients with mild SARS-CoV disease can be safely isolated in
    locations other than acute-care facilities, such as at home or in
    community facilities designated for isolation of SARS patients.

2\. ***Impact on Mission Critical Systems.*** Response to an outbreak of
a serious respiratory viral pathogen can quickly overwhelm several
mission-critical systems including staffing, critical supplies (i.e.,
antiviral agents, intravenous fluids, laboratory supplies,
immunizations) and operational space. In addition, patients who
unknowingly have been placed in non-isolation rooms may cause further
spread of viral particles through the Heating, Ventilation and Air
Conditioning (HVAC) system. It is important to assess the air pressure
differential and air exchange rate relationships within the medical
center to determine potential impact/risk of secondary spread of
aerosolized viral particles.

Airborne Infection Isolation Room (AIIR) Definition: An AIIR is a
single-patient room in which environmental conditions are controlled to
minimize the possibility of airborne transmission of infectious agents.
These rooms have specific requirements for controlled ventilation,
including: 1) a specified number of required air exchanges per hour
(ACH) (i.e., 6 for old buildings; 12 for new construction or
renovation); 2) monitored negative pressure relative to hallways; and,
3) air exhausted directly to the outside preferably or passed through a
high-efficiency purifying air (HEPA) filter if recirculated. These
requirements are detailed in the *Guideline for Environmental Infection
Control in Healthcare Facilities, 2003*
([www.cdc.gov/ncidod/hip/enviro/guide.htm](http://www.cdc.gov/ncidod/hip/enviro/guide.htm)).

3\. ***Operating Units and Key Personnel with Responsibility to Manage
this Threat/Event.***

-   *Infection Control Team* - Key role in tracking of potential and
    confirmed cases, with reporting responsibilities to the Public
    Health Service. Acts as a local information resource, as needed, for
    healthcare providers, employees and patients regarding public health
    resource updates and recommendations. Works with Engineering and
    Safety to rapidly implement appropriate signage within facility
    (e.g., AIIRs).

-   *Bed Control and Administrator On Duty (AOD*) - Key role includes
    working with the infection control team regarding designation of
    isolation rooms, room assignments and patient placement. Coordinates
    physical transfer of patients, and ensures receiving location is
    prepared to accept patient without delay. Ensures dissemination of
    timely staff education regarding threat and appropriate personal
    protective equipment (PPE) measures (e.g., training of staff from
    Nursing, Environmental Management, Engineering, Police, Laboratory,
    Radiology, Pharmacy, etc.).

-   *Nursing Service and Chief of Staff* - Key role in tracking patient
    census, staffing utilization and need for additional staff.

-   *Clinical Microbiology Laboratory* *BSL 2* - Key role in ruling out
    potential common bacterial agents isolated from patient samples.
    Handling of send-out specimens with attention to Department of
    Transportation (DOT) regulations. Performs rapid antigen testing, as
    available for serious viral respiratory pathogens.

-   *Safety Officer/Industrial Hygienist* - Key role in monitoring the
    proper use of specialized PPE resources, as needed (e.g., fit
    testing). Lead role in extending availability of respiratory
    isolation facilities through the use of additional system filters
    and portable units, as available.

-   *Police* - Key role in maintaining order and safety of overall
    facility.

-   *Emergency Room Personnel* - Key role in monitoring clinical patient
    workload and recognition of potential clinical syndromes associated
    with severe respiratory viral pathogens. Key role in ensuring that
    all other medical emergency capabilities (i.e., cardiac emergencies)
    are maintained and operational.

-   *Medical Service* - Key role in monitoring clinical patient workload
    and recognition of potential clinical syndromes associated with
    severe respiratory viral agents.

-   *Occupational/Employee Health* - Key role in monitoring occupational
    health conditions/risks, employee concerns and prophylactic therapy,
    as needed.

-   *Facilities/Engineering* - Key role in ensuring mission-critical
    systems have been protected from contamination; and to implement
    critical systems ongoing, monitors both during and after the threat
    (e.g., verification that AIIRs meet air exchange differential rate
    requirements).

-   *Environmental Management* - Ensuring that durable medical equipment
    has undergone cleaning after contamination.

4\. ***Mitigation/Preparedness Activities of the Threat/Event.*** As
soon as the Medical Center is aware that a probable or confirmed case of
SARS or Pandemic Influenza virus case has occurred in the United States
or contiguous countries, the medical system should prepare to rapidly
detect and treat potential patients in such a manner to allow proper
management of cases while protecting all healthcare personnel and the
medical center. Several steps should be addressed to assure that the
medical center is prepared for such an event. These are outlined below.

a\. Preparedness Planning.

-   Pre-event designation of physical locations within the medical
    center currently available for admission of respiratory isolation
    patients, and designation of potential expansion locations for AIIR
    surge capacity through patient treatment groups (cohort management)
    and/or use of portable negative air units.

-   Educate staff regarding strict adherence to and proper use of
    standard infection control measures, especially hand hygiene (i.e.,
    hand washing or use of an alcohol-based hand rub). For complete
    recommendations on hand hygiene, refer to:
    [www.cdc.gov/handhygiene/](http://www.cdc.gov/handhygiene/).

-   Reinforce education on the recommended procedures for Standard,
    Contact and Airborne Infection Isolation (AII) Precautions (see
    [www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm](http://www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm)).

-   Implement the *Infection: Don't Pass It On* campaign, based on CDC's
    hand and respiratory hygiene, with materials developed within VHA
    <http://vaww.vhaco.va.gov/phshcg/InfectionDontPassItOn/Default.htm>.

-   Ensure that personnel have access to appropriate PPE, instructions
    and training in PPE use, and respirator fit testing.

-   Consider planning alternatives for management of large numbers of
    patients requiring respiratory isolation when AII facilities are
    inadequate.

-   Develop a system to track hospital personnel exposure and illness
    potentially related to SARS exposure
    (<http://www.cdc.gov/ncidod/sars/guidance/I/occupational.htm>).

b\. Early Recognition and Prevention of Transmission in Outpatient
Clinic Settings

-   Post visual alerts (in appropriate languages) at the entrance to
    outpatient facilities (e.g., emergency departments, physicians'
    offices, outpatient clinics) instructing patient and the persons who
    accompany them to: 1) inform healthcare personnel of symptoms of a
    respiratory infection when they first register for care, and 2)
    practice respiratory hygiene/cough etiquette.

-   Use respiratory hygiene/cough etiquette:

> 1\) Cover the nose/mouth when coughing or sneezing.
>
> 2\) Use tissues to contain secretions.
>
> 3\) Dispose of tissues in the nearest waste receptacle after use.
>
> 4\) Perform hand hygiene after coughing and potentially contacting
> secretions.

-   Mask and separate persons with respiratory infection symptoms.

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-   During periods of increased respiratory infection in the community,
    offer masks to persons who are coughing. Either procedure masks
    (i.e., with ear loops) or surgical masks (i.e., with ties) may be
    used to contain respiratory secretions; respirators are not
    necessary. Encourage coughing persons to sit at least 3 feet away
    from others in common waiting areas. Some facilities may wish to
    institute this recommendation year-round. Consider instituting a
    separate waiting area for individuals with respiratory symptoms.

-   Follow current CDC/Hospital Infection Control Professional Advisory
    Committee (HICPAC) recommendations on use of respiratory protection
    level (droplet vs. airborne). Droplet precautions should be
    practiced by healthcare workers by wearing surgical or procedure
    mask for close contact in addition to standard contact and barrier
    precautions/PPE.

c\. Early Detection and Isolation of Patients Potentially at Risk for
SARS-CoV Disease or Pandemic Influenza, per CDC Case definitions and
guidance
(<http://vaww.vhaco.va.gov/phshcg/SARS/facility_preparation.htm>). When
considering options to enhance early detection and isolation of patients
potentially infected with SARS, the worldwide status of current cases is
essential. One of the following two schemes should be used, depending on
the current activity status of SARS.

1\) Screening and Triage When No Known Cases of SARS Are Being Reported
Worldwide. Only patients requiring hospitalization for radiographically
confirmed pneumonia (or acute respiratory distress syndrome) of unknown
etiology should be screened for SARS or other similar epidemiologic risk
factors. The suspicion for SARS-CoV disease should be raised if, within
10 days of symptom onset, the patient:

-   Has a history of travel to mainland China, Hong Kong or Taiwan, or
    close contact with an ill person with a history of recent travel to
    one of these areas; [or]{.underline},

> Note: Close contact - A person who has cared for or lived with a
> person with SARS-CoV disease or had a high likelihood of direct
> contact with respiratory secretions and/or body fluids of a person
> with SARS-CoV disease. Examples of close contact include kissing or
> hugging, sharing eating or drinking utensils, talking within 3 feet,
> and direct touching. Close contact does not include activities such as
> walking by a person or briefly sitting across a waiting room or
> office.

-   Is employed in an occupation associated with a risk for SARS-CoV
    exposure (e.g., healthcare worker with direct patient contact;
    worker in a laboratory that contains live SARS-CoV);
    [or]{.underline},

-   Is part of a cluster of cases of atypical pneumonia without an
    alternative diagnosis.

> Note: The 2003 SARS-CoV outbreak likely originated in mainland China,
> and neighboring areas such as Taiwan and Hong Kong are thought to be
> at higher risk due to the large volume of travelers from mainland
> China. Although less likely, SARS-CoV may also reappear from other
> previously affected areas. Therefore, clinicians should obtain a
> complete travel history. If clinicians have concerns about the
> possibility of SARS-CoV disease in a patient with a history of travel
> to other previously affected areas (e.g., while traveling abroad, had
> close contact with another person with pneumonia of unknown etiology
> or spent time in a hospital in which patients with acute respiratory
> disease were treated), they should contact the local or state health
> department.

2\) Screening and Triage When Known Confirmed Cases of SARS Have Been
Reported Worldwide.

a\) Screen all patients with fever or lower respiratory symptoms, with
or without pneumonia, to determine if, within 10 days of the onset of
symptoms, they had:

-   Close contact with a person suspected of having SARS-CoV disease;
    [or]{.underline},

-   A history of foreign travel (or close contact with an ill person
    with a history of travel) to a location with documented or suspected
    SARS-CoV transmission; [or]{.underline},

-   Exposure to a domestic or occupational location with documented or
    suspected SARS-CoV (including a laboratory that contains live
    SARS-CoV), or close contact with an ill person with such an exposure
    history.

b\) For persons with a high risk of exposure to SARS-CoV (e.g., persons
previously identified through contact tracing or self-identified as
close contacts of a laboratory-confirmed case of SARS-CoV disease;
persons who are epidemiologically linked to a laboratory-confirmed case
of SARS-CoV disease), the clinical criteria should be expanded to
include, in addition to fever or respiratory symptoms, the presence of
any other early symptoms of SARS-CoV disease (subjective fever, chills,
rigors, myalgia, headache, diarrhea, sore throat, rhinorrhea). The more
common early symptoms include chills, rigors, myalgia, and headache. In
some patients, myalgia and headache may precede the onset of fever by
12-24 hours. However, diarrhea, sore throat and rhinorrhea may also be
early symptoms of SARS-CoV disease.

c\) Patients who require hospitalization for pneumonia and who do not
have a known epidemiologic link to a setting in which SARS-CoV has been
documented should be screened for additional risk factors using the
questions that apply when no SARS-CoV is documented in the world (i.e.,
employment in an occupation at particular risk for SARS-CoV exposure;
part of a cluster of atypical pneumonias without an alternative
diagnosis).

d\) Healthcare workers who are the first points of contact (e.g., triage
and reception) should be trained to perform SARS-CoV screening. If
screening personnel are not available, healthcare providers should
screen symptomatic patients for SARS-CoV disease risk factors before
initiating history taking and physical examination. If SARS symptoms and
risk factors are present, follow the clinical algorithm for patient
management
([www.cdc.gov/ncidod/sars/clinicalguidanceframe2.htm](http://www.cdc.gov/ncidod/sars/clinicalguidanceframe2.htm)).

e\) Outpatient infection control

-   Patients with fever or lower respiratory symptoms, with or without
    pneumonia, who have been exposed to SARS-CoV or who have SARS risk
    factors should be suspected of having SARS-CoV disease and isolated
    as soon as possible. Such patients should be given a mask (surgical
    or procedure) to wear and immediately placed in a private
    examination room or cubicle. If available, an AIIR should be used.

-   Where limited space and examination room capacity preclude these
    measures, the patient should sit as far away as possible from other
    patients in the waiting area.

-   Family members or friends who accompany the patient should be
    considered at risk for SARS-CoV disease and screened for fever and
    lower respiratory symptoms. If either is present, infection control
    measures to prevent SARS-CoV transmission should be applied.

-   Healthcare workers should wear gown, gloves, appropriate level of
    respiratory protection and splash protection (if needed).

f\) Disposition.

-   Hospital admission or discharge of a possible SARS patient should
    generally be based on the patient's clinical condition and
    healthcare needs. If diagnostic, therapeutic or supportive regimens
    do not necessitate hospitalization, patients with possible SARS-CoV
    disease should not be hospitalized.

-   Exceptions include persons for whom no other alternative for
    providing safe infection control is available. Such persons include
    travelers, homeless persons and persons who would be returned to an
    environment where infection control measures are not feasible or
    practical (e.g., crowded dormitories, prisons and jails, detention
    centers, homeless shelters, other multi-person single-room
    dwellings). These persons should be hospitalized and isolated as
    recommended in paragraph d below. As soon as appropriate
    arrangements can be made for out-of-hospital care, the patient can
    be discharged. Alternatively, the patient may be admitted to a
    designated residential facility for isolation of convalescing
    SARS-CoV disease cases, if one exists.

-   During transport between locations, patients should wear a mask.
    Public transportation (e.g., bus, train) should be avoided.

-   Disposition of patient samples, tissues and remains is covered below
    in paragraph e.

d\. Infection Control Precautions for Hospitalized SARS or Pandemic
Influenza Patients.

1\) Patient Placement:

-   Admit patients with SARS-CoV disease to an Airborne Infection
    Isolation Room (AIIR).

-   If there is a lack of AIIRs and/or a need to concentrate infection
    control efforts and resources, patients may be cohorted on a floor
    or nursing unit designated for the care of SARS patients only,
    rather than placed in AIIRs throughout the hospital. This strategy
    physically isolates SARS patients and also makes it possible to
    dedicate resources and appropriately trained staff to their care.
    Experience in some settings in Taiwan and Toronto demonstrated that
    cohorting SARS patients, without use of AIIRs, effectively
    interrupted transmission. Thus, although single AIIRs are
    recommended for SARS isolation, other strategies may provide
    effective overall infection control, particularly if air-handling
    systems in existing rooms/units/floors can be modified to allow
    these areas to operate under negative pressure relative to
    surrounding areas.

-   Even if a facility has chosen to cohort SARS patients, properly
    designed and operated AIIRs are preferred for 1) patients who are
    known to have transmitted SARS-CoV to other persons and 2) patients
    in whom the risk of SARS is being assessed.

-   Designate "clean" and "dirty" areas for isolation materials.
    Maintain a stock of clean patient care and PPE supplies outside the
    patient's room. Decide where contaminated linen and waste will be
    placed. Locate receptacles close to the point of use, and separate
    from the clean supplies. Also designate the location where reusable
    PPE (e.g., goggles, face shields) will be placed for cleaning and
    dis-infection before reuse.

-   Limit equipment and staff to minimum needed to care for patient in
    isolation rooms.

2\) Patient Transport:

-   Limit patient movement and transport outside the AIIR to medically
    necessary purposes. Whenever possible, use portable equipment to
    perform x-rays and other procedures in the patient's room.

-   If transport or movement is necessary, ensure that the patient wears
    a surgical mask, puts on a clean patient gown, and performs hand
    hygiene before leaving the room. If a mask cannot be tolerated
    (e.g., due to the patient's age or deteriorating respiratory
    status), apply the most practical measures to contain respiratory
    secretions.

-   Limit contact between SARS patients and others by using less
    traveled hallways and elevators when possible.

3\) Visitors:

-   Limit visits to patients with known or possible SARS-CoV disease to
    persons who are necessary for the patient's emotional well being and
    care.

-   Visitors who have been in contact with the patient before and during
    hospitalization are a possible source of SARS-CoV. Therefore,
    schedule and control visits to allow for appropriate screening for
    SARS-CoV disease before entering the hospital and appropriate
    instruction on use of PPE and other precautions (e.g., hand hygiene,
    limiting surfaces touched) while in the patient's room.

4\) Hand Hygiene: Strict hand hygiene should be implemented.

5\) Personal Protective Equipment (PPE): Gloves, gown, respiratory
protection, and eye/face protection (as needed) should be donned before
entering a SARS patient's room or designated SARS patient-care area.
This level of protection is required for the majority of patient
contacts. Instructions on how to safely don, use and remove PPE are
being developed and will be provided at
[www.cdc.gov/ncidod/sars/](http://www.cdc.gov/ncidod/sars/) when
available. Removal of PPE in a manner that prevents contamination of
clothing and skin is a priority.

-   [Respiratory protection]{.underline} - If CDC recommends use of N-95
    level protection, wear a NIOSH-certified N-95 filtering face piece
    respirator for entering an AIIR or designated SARS patient-care
    area. If N-95 or higher level of respiratory protection is not
    available, then wear a snug-fitting surgical mask to prevent nose
    and mouth contact with large respiratory droplets. Discard
    respirators upon leaving the patient room or area.

> Note: Complete respiratory programs as outlined by OSHA must be in
> place to include training, fit testing, and fit training to ensure
> proper fit and appropriate selection of respiratory protection
> equipment. For further details see:
> [www.osha.gov/SLTC/etools/respiratory/](http://www.osha.gov/SLTC/etools/respiratory/).
> The program should be administered by someone with training.

-   [Eye and face protection]{.underline} - It is not yet known whether
    routine eye protection is needed to prevent SARS-CoV transmission.
    Routinely wear eye protection when within 3 feet of a patient with
    SARS-CoV. If splash or spray of respiratory secretions or other body
    fluids is likely, protect the eyes with goggles or a face shield, as
    recommended for Standard Precautions. The face shield should fully
    cover the front and wrap around the side of the face. Corrective
    eyeglasses or contact lenses alone are not considered eye
    protection.

6\) Medical Waste: Medical waste has not been implicated in the
transmission of SARS-CoV. Therefore, no special handling procedures are
recommended for SARS-CoV-contaminated medical waste.

7\) Textiles (linen and laundry): Contact with textiles has not been
implicated in the transmission of SARS-CoV. Therefore, no special
handling procedures are recommended for linen and laundry that may be
contaminated with SARS-CoV. Wash and dry linen according to routine
standards and procedures
([www.cdc.gov/ncidod/hip/enviro/guide.htm](http://www.cdc.gov/ncidod/hip/enviro/guide.htm)).

8\) Dishes and Eating Utensils: Dishes and eating utensils have not been
implicated in SARS-CoV transmission. Therefore, no special precautions,
beyond those for Standard Precautions, are recommended for dishes and
eating utensils used by a patient with known or possible SARS-CoV
disease.

-   Wash reusable dishes and utensils in a dishwasher with recommended
    water temperature
    ([www.cdc.gov/ncidod/hip/enviro/guide.htm](http://www.cdc.gov/ncidod/hip/enviro/guide.htm)).

-   Wear gloves when handling patient trays, dishes, and utensils.

9\) Patient-Care Equipment:

-   Follow standard practices for handling and reprocessing used
    patient-care equipment, including medical devices. Wear gloves when
    handling and transporting used patient-care equipment. Wipe heavily
    soiled equipment with an EPA-approved hospital disinfectant before
    removing it from the patient's room. Follow current recommendations
    for cleaning and disinfection or sterilization of reusable
    patient-care equipment.

-   Wipe external surfaces of portable equipment for performing x-rays
    and other procedures in the patient's room with an EPA-approved
    hospital disinfectant upon removal from the patient's room.

10\) Environmental Cleaning and Disinfection: Cleaning and disinfection
of environmental surfaces are important components of routine infection
control in healthcare facilities. Although little is known about the
extent of environmental contamination in SARS patients' rooms,
epidemiologic and laboratory evidence suggests that the environment
could play a role in transmission. Therefore, cleaning and disinfection
are critical to the control of SARS-CoV transmission. Environmental
cleaning and disinfection for SARS-CoV follows the same principles
generally used in healthcare settings.

-   Clean and disinfect SARS patients' rooms at least daily and more
    often when visible soiling/contamination occurs. Give special
    attention to frequently touched surfaces (e.g., bedrails, bedside
    and over-bed tables, TV control, call button, telephone, lavatory
    surfaces including safety/pull-up bars, doorknobs, commodes,
    ventilator surfaces) in addition to floors and other horizontal
    surfaces.

-   Because so little is known about environmental transmission of
    SARS-CoV, placement of patients in rooms that do not have carpeting
    is preferred because non-carpeted floors are easier to clean and
    disinfect. If use of carpeted rooms cannot be avoided, vacuuming
    should be done daily, and personnel should wear the recommended PPE.
    Follow current CDC environmental guidelines for vacuuming and
    shampooing carpeted floors in patient rooms
    ([www.cdc.gov/ncidod/hip/enviro/guide.htm](http://www.cdc.gov/ncidod/hip/enviro/guide.htm)).

-   After an aerosol-generating procedure (e.g., intubation), clean and
    disinfect horizontal surfaces around the patient. Clean and
    disinfect as soon as possible after the procedure.

-   Clean and disinfect spills of blood and body fluids in accordance
    with current recommendations for Standard Precautions
    ([www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm](http://www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm)).

11\) Aerosol-Generating Procedures: Because aerosol-generating
procedures may pose a greater risk of SARS-CoV transmission, additional
precautions are recommended for healthcare workers who perform or assist
with these procedures. Procedures that stimulate coughing and promote
the generation of aerosols include aerosolized or nebulized medication
administration, diagnostic sputum induction, bronchoscopy, airway
suctioning, endotracheal intubation, positive pressure ventilation via
face mask (e.g., BiPAP, CPAP), and high-frequency oscillatory
ventilation.

12\) Infection Control Measures:

-   Limit performance of aerosol-generating procedures on SARS patients
    to those that are considered medically necessary. Clinically
    appropriate sedation during intubation and bronchoscopy may minimize
    resistance and coughing during the procedure.

-   Limit the number of healthcare workers in the room.

-   Perform aerosol-generating procedures in an AIIR.

-   Air-cleaning devices, such as portable HEPA filtration units, may be
    used to further reduce the concentration of contaminants in the air.
    Keep doors closed except when entering or leaving the room, and
    minimize entry and exit during the procedure.

-   Submicron filters on exhalation valves of mechanical ventilators may
    prevent contaminated aerosols from entering the environment.
    Although the effectiveness of this measure in reducing the risk of
    SARS-CoV transmission is unknown, the use of such filters is prudent
    during high-frequency oscillatory ventilation of patients with
    SARS-CoV disease.

13\) PPE for Aerosol-Generating Procedures: The optimal combination of
PPE for preventing SARS-CoV transmission during aerosol-generating
procedures has not been determined. Wearing PPE during these procedures
protects the respiratory tract from inhalation of droplet nuclei and the
mucous membranes, skin, and clothing from contact with infectious
respiratory secretions. PPE should cover the torso, arms, and hands as
well as the eyes, nose, and mouth. PPE must be compatible with the needs
of healthcare worker protection and patient care. The following PPE is
recommended:

-   Disposable isolation gown, preferably with fluid-resistant
    properties, to protect the body and exposed areas of the arms. A
    disposable full-body isolation suit is an option, and may provide
    greater protection of the skin, especially around the neck. Surgical
    hoods, which fully cover the head, neck, and face, (with the
    addition of an N-95 or higher-level disposable particulate
    respirator), have been used in some settings. It is unknown whether
    covering exposed areas of skin or hair on the head will further
    reduce the risk of transmission.

-   Pair of disposable gloves that fit snuggly over the gown cuff.

-   Eye protection (i.e., goggles) to protect the eyes from respiratory
    splash or spray. Goggles should fit snuggly (but comfortably) around
    the eyes. A face shield may be worn over goggles to protect exposed
    areas of the face but should not be worn as a primary form of eye
    protection for these procedures.

-   Respiratory protection \-- During aerosol-generating procedures,
    there must be minimal respirator face-seal leakage to fully protect
    the worker from exposure to aerosolized infectious droplets. The
    following respiratory protection options should be considered:

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-   Disposable particulate respirators (e.g., N-95, N-99, or N-100) are
    sufficient for routine respiratory protection for Airborne Infection
    Isolation and are the minimum level of respiratory protection
    required for healthcare workers who are performing
    aerosol-generating procedures. To ensure adequate protection,
    healthcare workers must be fit- tested to the respirator model that
    they will wear
    ([www.cdc.gov/niosh/99-143.html](http://www.cdc.gov/niosh/99-143.html))
    and also know how to check the face-piece seal. A fit-check should
    be performed each time a respirator is put on, before entering the
    patient room. Workers who cannot wear a disposable particulate
    respirator because of facial hair or other fit limitations should
    wear a loose-fitting (i.e., helmeted or hooded) PAPR.

-   Healthcare facilities in some SARS-affected areas routinely used
    higher levels of respiratory protection for performing
    aerosol-generating procedures on patients with SARS-CoV disease. It
    is unknown whether these higher levels of protection will further
    reduce transmission. Factors that should be considered in choosing
    respirators in this setting include availability, impact on
    mobility, impact on patient care, potential for exposure to higher
    levels of aerosolized respiratory secretions, and potential for
    reusable respirators to serve as fomites for transmission. Higher
    levels of respiratory protection include:

> PAPR with loose-fitting face piece that forms a partial seal with the
> face.
>
> PAPR with hood that completely covers the head and neck and may also
> cover portions of the shoulder and torso.
>
> PAPR with tight-fitting face piece (half and full face-piece).
>
> Full face-piece negative-pressure (non-powered) respirators with N, R,
> or P-100 filters.

e\. Infection Control for Laboratory and Pathology Procedures.

1\) Specimen Collection and Handling.

-   Healthcare workers who collect specimens from SARS patients should
    wear PPE as appropriate for Standard, Contact, and AII Precautions.

-   Standard facility procedures for specimen collection and transport
    to the clinical laboratory should be followed.

-   All specimens should be appropriately contained (bagged if
    necessary) and have a completed laboratory requisition slip
    attached. Information on the requisition slip should indicate that
    the patient is or could be infected with SARS-CoV. Laboratory
    personnel should be alerted to the possibility of SARS-CoV to ensure
    safe handling procedures.

2\) Laboratory Procedures. Biosafety Levels 2 and 3 are recommended for
the appropriate sample types of SARS-CoV infected or potentially
infected specimens.

3\) Post-Mortem Handling of Human Remains. In general, safety procedures
for human remains infected with SARS-CoV should be consistent with those
used for any autopsy procedure. However, additional respiratory
protection is needed during an autopsy procedure that generates aerosols
(e.g., use of oscillating saws). Personal protective equipment (PPE):

-   Wear standard autopsy PPE, including a scrub suit worn under an
    impervious gown or apron, eye protection (i.e., goggle, face
    shield), double surgical gloves with an interposed layer of
    cut-proof synthetic mesh gloves, surgical mask or respirator, and
    shoe covers.

-   Add respiratory protection if aerosols might be generated. This
    includes N-95 or N-100 disposable particulate respirators or PAPR.
    Autopsy personnel who cannot wear a disposable particulate
    respirator because of facial hair or other fit limitations should
    wear a loose-fitting (i.e., helmeted or hooded) PAPR.

-   Remove PPE before leaving the autopsy suite and disposed in
    accordance with facility policies and procedures.

f\. Occupational Health Issues.

1\) Surveillance and Monitoring of Healthcare Workers.

-   Establish a process to identify personnel who enter the rooms or
    units where SARS patients are provided care. Possible mechanisms
    include self-reports, sign-in sheets or logs.

-   Instruct personnel who have unprotected contact with patients with
    SARS-CoV disease or who have early symptoms of SARS-CoV disease to
    immediately notify occupational health, infection control or a
    designee.

-   Develop a system to identify healthcare personnel who provided care
    to a patient who was later identified as having SARS-CoV disease.

2\) Management of Exposures and Other Contacts with SARS Patients. An
[unprotected high-risk exposure]{.underline} occurs when a healthcare
worker is in a room with a SARS patient during an aerosol-generating
procedure or event *and* the recommended infection control precautions
are either absent or breached. If a healthcare worker has an unprotected
high-risk exposure but has no symptoms of SARS-CoV disease, the worker:

-   May be excluded from duty (e.g., administrative leave) for 10 days
    after the date of the last high-risk exposure.

-   Should be vigilant for the development of fever and/or respiratory
    symptoms.

-   Should be actively monitored for the development of fever and/or
    respiratory symptoms for 10 days after the date of the last
    high-risk exposure.

If a healthcare worker has [an unprotected, non-high-risk
exposure]{.underline} and has no symptoms of SARS-CoV disease, the
healthcare worker:

-   Need not be excluded from duty.

-   Should be vigilant for the development of fever and/or respiratory
    symptoms (i.e., measure and record body temperature twice daily for
    10 days following the date of last unprotected exposure, and
    immediately notify the healthcare facility if symptoms develop).

-   Should be actively monitored for the development of fever and lower
    respiratory symptoms before reporting to duty.

g\. Exposure Control Strategies.

h\. Exposure Monitoring Strategies.

-   Clinical patient tracking by Healthcare Providers, Infection Control
    and Clinical Microbiology Laboratory Personnel.

-   Environmental monitors/sampling, as needed, based upon
    recommendations from the CDC and Public Health Service.

i\. Preparedness Strategies and Resource Issues.

-   Clinical education and awareness initiatives.

-   Development and updates of the Medical Center's Biologic and
    Terrorist Event Readiness Plan.

-   Rapid Inventory assessment protocol for critical resources (i.e.,
    staffing, beds, large pre-designated waiting areas) and supplies
    (i.e., antibiotics, X-ray film, laboratory supplies, anti-toxins).

-   Development and updates of protection and monitoring plan for
    mission-critical systems.

5\. ***Response/Recovery from the Event/Threat***.

a\. *Hazard Control and Monitoring Strategies*.

-   Immediately assess potential impact of event on mission-critical
    systems to include bed status, staffing levels, critical supplies
    and operational space.

-   Await follow-up information from local authorities and prepare for
    potential presentation of patients.

b\. *Resource Issues*.

-   Staffing needs will be monitored and addressed by Chief of Staff,
    Chief of Nursing, VAMC Director and other involved Service Chiefs.

-   Critical Supplies - Antibiotic availability will be monitored by
    Chief of Pharmacy. Additional critical supplies to assess in a
    biologic event include alternate antiviral agents, vaccines,
    respiratory isolation equipment/mobile units, radiology supplies and
    laboratory supplies.

-   Isolation supplies and PPE inventories.

-   Space Management - Assess bed and space availability, respiratory
    isolation capacity.

-   Emergency Room capabilities, Acute Care Clinic capabilities,
    current/projected bed capacity and Intensive Care capacity should be
    immediately assessed.

c\. *Clinical Response*.

-   Triage and initial patient assessment for those potentially involved
    patients.

-   Treatment Protocols for the most likely or known pathogen as
    determined by infection control guidelines.

-   Isolation and Quarantine Protocols if needed.

-   All VAMC quarantine decisions will be made by the VAMC Director
    and/or Incident Commander based upon recommendations from Infection
    Control and the CDC/Public Health Service.

-   Admission decisions will be made by the Healthcare Providers.

-   Patients who are treated and released will be provided an
    information fact sheet about the biologic agent reported, with
    instructions to call the hospital immediately if any warning signs
    or concerns arise.

-   The Infection Control Team will monitor all potential and proven
    cases, making appropriate reports to both the VAMC Director and the
    Public Health Service. The Public Health Service will notify the CDC
    of all suspected and confirmed biologic event cases, as deemed
    appropriate.

> Notes: 1. Physicians dealing with patients who may potentially have
> SARS or the Pandemic Flu will most likely be dealing with a clinical
> entity they have never treated or seen. It is essential to rely upon
> resources from the medical field, particularly lessons learned from
> other countries who have dealt with these challenges such as China,
> Canada, etc. Treatment and diagnostic protocols are likely to evolve
> over time as more is learned about the specific outbreak and the
> unique characteristics of the viral pathogen involved.
>
> 2\. The Infection Control Team working with the Chief of Staff and
> VAMC Director will notify Health Care Providers when treatment
> guidelines are updated, or as new resources are made available. The
> Infection Control Team can monitor the APIC web site
> ([www.apic.org](http://www.apic.org/)) and/or CDC web site
> ([www.bt.cdc.gov](http://www.bt.cdc.gov/)) for the most current
> updates, protocols and recommendations.

d\. *Recovery strategies*.

-   Periodic critical supply inventories with re-supply or
    supplementation from outside facilities, as needed.

-   Periodic staffing census with workload redistribution, as needed.

-   Close monitoring of patient census and bed status.

6\. ***External Notification Procedures.***

a\. *Within VA*. VISN, VACO.

b\. *Other Agencies.* Local Public Health Service, CDC, OSHA reporting
for employee injuries.

OSHA - Notify within 8-hours of one (1) employee fatality, or three (3)
employees hospitalized from a single incident.

c\. *Community Entities.* Neighboring hospitals, emergency response
systems (police, firefighters, EMS, 911 operators).

7\. ***Specialized Staff Training.***

a\. *Health Care Provider Training* - Recognition of clinical syndromes
associated with SARS and/or Pandemic Influenza, diagnostic protocols,
treatment protocols, CDC and/or other public health infection control
guidelines.

b\. *Infection Control Team Training* - Aggressive active surveillance
systems for monitoring potential, high-risk patients for infection with
SARS or Pandemic influenza virus. Coordination efforts with the
designated Public Health Laboratory.

c\. *Safety Specialist/Industrial Hygienist* - Recommended agent
sampling and environmental monitor protocols for viral agents.

d\. *Clinical Microbiology Laboratories and send-out referral
laboratories* -

1\) Recommended specimen collection protocols per CDC and/or APIC
guidelines.

2\) Availability, whenever possible for use of rapid antigen detection
systems for presumptive diagnosis prior to viral cultures or molecular
confirmation.

3\) Culture recommendations to rule out other common pathogens causing
significant respiratory disease (e.g., Streptococcus pneumoniae,
Legionella).

4\) Transport guidelines for shipping of hazardous biologic samples.

5\) Recommended samples for acute and convalescent serum testing and/or
molecular epidemiologic studies by the Public Health Service.

6\) Recommended electron microscopy Negative Image methods training for
viral pathogens in respiratory secretions or other pertinent body
fluids.

e\. *Police and Security* - Introductory training on potential risks and
PPE recommendations.

f\. *Environmental Management Service Personnel* - Introductory training
for potential viral transmission risks, various types of viral organisms
to consider, PPE recommendations and waste management concerns.

g\. *Social Work Service* - Introductory training on potential viral
transmission risks and PPE recommendations. Special training for dealing
with family members and unique complexities of placement concerns
(nursing home, extended care and other transfer needs).

8\. ***References and Further Assistance*.**

a\. Local Public Health Service/ Health Department.

b\. Association for Infection Control Practitioners web site:
[www.apic.org](http://www.apic.org/).

c\. Centers for Disease Control: [www.cdc.gov](http://www.cdc.gov/).

d\. Hand hygiene reference:
[www.cdc.gov/handhygiene/](http://www.cdc.gov/handhygiene/).

e\. Standard, Contact, and Airborne Infection Isolation Precautions:
[www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm](http://www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm).

f\. For more detailed information about infection control precautions,
please see
[www.cdc.gov/ncidod/hip/isolat/isolat.htm](http://www.cdc.gov/ncidod/hip/isolat/isolat.htm).

g\. For more information about SARS, visit
[www.cdc.gov/ncidod/sars](http://www.cdc.gov/ncidod/sars/) or call the
CDC public response hotline at (888) 246-2675 (English), (888) 246-2857
(Español), or (866) 874-2646 (TTY).

9\. ***Review Date***.

(Name)

Chief, (Service)

*Sample 6.2.3.2.1*

*(Note: This SOP contains some intricate clinical information. For
additional Clinical information or clarification, you may contact Dr.
Margie Scott via the VA Global Address book in Outlook, or your ER
specialist or toxicologist.)*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Chemical Event (External)**

1.  ***Description of the Threat/Event.*** Chemical spills or releases
    may occur in any community where a VA Medical Center (VAMC) is
    located. Hazardous chemicals are transported, used, and stored in
    vast quantities in every community. Chemical spills and releases may
    be caused from industrial or transportation accidents, and from
    terroristic events. The results may involve a large number of
    injured and contaminated casualties. The Medical Center must know
    and understand its role in the community. Issues involving
    decontamination are complex and require resources not typically
    found at VAMCs. In addition, there are regulatory requirements that
    must be met; such as, all persons conducting decontamination must
    meet First Responder Operations Level, in accordance with
    Occupational Safety and Health Administration (OSHA) standard
    1910.120(q). Protection of the Medical Center and its occupants is
    critical to the mission of continuous patient care.

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1.  ***Impact on Mission Critical Systems.*** Chemical spills external
    to the Medical Center are a real threat to the Medical Center's
    mission. If patients arrive and contaminate the Emergency Room (ER)
    or other treatment areas, this will cause these areas to be shut
    down, impacting patient care. In addition, employees will be exposed
    to potential toxic or other harmful materials, if entry is not
    controlled.

2.  ***Operating Units and Key Personnel with Responsibility to Manage
    this Threat/Event.***

-   Medical Center Director

-   Incident Manager

-   Safety Officer

-   Chief of Police

-   Chief Nursing

-   Chief of Staff

-   Chief, Facilities Engineering

-   Chief, Environmental Management

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-   Service Chief(s) directly affected.

4.  ***Mitigation/Preparedness Activities of the Threat/Event.***

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a.  *Hazard Reduction Strategy Issues.*

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1)  **Risk and Planning Issues** - Events that involve external chemical
    releases require risk assessment of known chemicals within the
    community, response role, resources and training needs, and
    understanding regulatory requirements.

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1)  **Types of Hazardous Materials Spills/Release Events** - In order
    for any VAMC to respond appropriately to an external or Weapons of
    Mass Destruction (WMD) event, which may involve mass casualties, it
    must first prepare itself for handling smaller events that may occur
    within the VAMC itself \[*Note to Writer: See sample SOP
    6.2.3.2.2. - Chemical Event (Internal)*\] or within the local
    community. See Attachment C - External HazMat Response Plan.

2)  **Risk Assessments** - Provide a starting point as to what hazards
    can be expected, and what type of PPE is required. This process can
    be easily done for internal emergencies. However, it becomes more
    complex once the risk assessment moves beyond the VAMC. Brief
    examples include:

    -   **Internal Locations** - \[*Note to Writer: See SOP Sample
        6.2.3.2.2. - Chemical Event (Internal)\]*.

    -   **Industrial Locations within the Community** - Is as diverse as
        the type of community where the VAMC resides. Such areas may
        include agricultural, manufacturing, refineries, construction,
        papermills, chemical processing, etc. The 29 CFR 1910.120,
        Hazardous Waste Operations and Emergency Response (HazWoper and
        its Appendices A-E), Resource Conservation and Recovery Act
        (RCRA), and Superfund Amendments and Reauthorization Act (SARA)
        Title III direct facilities and communities to plan for
        hazardous materials spill/release events, based on amounts of
        hazardous materials and/or threshold levels for designated
        extremely hazardous materials located at facilities. Access to
        hazardous chemical information can be obtained via the
        communities Local Emergency Planning Committee (LEPC). This
        allows VAMCs to plan for specific chemicals and address Personal
        Protective Equipment (PPE) needs. However, this will not address
        all chemicals used or transported in the community or all
        chemicals in the community since many industries use significant
        amounts of chemicals that are below SARA Title III requirements.

    -   **Transportation -** Doing Risk Assessment involving chemicals
        in transport is very difficult, unless one is planning for
        chemicals already known to be used within the VAMC and the
        community. Hazardous materials are transported via motor
        vehicles, railroad, shipping, and aircraft. In most but not all
        cases during events involving transportation incidents,
        emergency responders will identify the materials involved.
        Terrorist activities may include industrial chemical(s) that are
        being transported.

    -   **Terrorist/WMD Events** - At present, Risk Assessments must be
        centered on known industrial chemical compounds, and
        military-grade chemical agents. There is scientific research and
        military testing available for review. For example, the Chemical
        Stockpile Emergency Preparedness Program (CSEPP) has conducted
        extensive research on PPE when exposed to chemical nerve agents.
        The leading authority in the United States for providing
        information on PPE involving WMD materials is the Department of
        Defense (DoD). CSEPP is an example where DoD has consulted with
        other Federal agencies such as the Centers for Disease Control
        (CDC), National Institute for Occupational Safety and Health
        (NIOSH), OSHA, and Federal Emergency Management Agency (FEMA),
        to develop PPE standards for both responders and those providing
        medical treatment away from the incident that involves military
        type chemical agents.

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4)  Coordinate with the community so that all are aware of what role the
    VAMC can act in the event of a community chemical emergency.

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4)  If the role is to decontaminate patients, then proper type,
    location, and associated equipment and supplies must be procured.

5)  Proper PPE must also be provided. OSHA standards must be met,
    including medical surveillance requirements.

6)  Initiate an inspection and test program for all PPE that will be
    used by decontamination personnel.

7)  Conduct training and evaluation of drills/exercises.

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b.  *Hazard Prevention Strategy Issues.* Decision Matrix for Selection
    of Personal Protection Equipment (PPE) and Decontamination.

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1)  **Issues and Assumptions.**

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a)  Type and hazard of the chemical spill/release: Until ruled out, all
    chemical spills/releases will be classified as hazardous to human
    health, and exposure routes will occur via skin absorption or
    respiratory inhalation.

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a)  Location of Spill/Release - Zones will be classified as the
    following:

-   Hot Zone - Perimeter designated around the chemical spill/release
    area, where levels of exposure and protection will be the highest
    and therefore, more hazardous. Only trained emergency responders
    will be allowed in this area.

-   Warm Zone - Perimeter outside the Hot Zone where hazardous exposures
    will be at a lessor level, or may not be present at all. Only
    trained emergency responders will be allowed in this area.

-   Cold Zone - No hazardous exposure levels are present and area is
    classified as a safe area.

2)  **Decontamination** - The act of removing/washing hazardous
    substances from the body normally using soap and water. For the
    purposes of this SOP, decontamination occurs away from the Hot Zone
    and is classified as a Warm Zone. It is located outside the treating
    Medical Center so as not to allow contamination inside the building.
    It is critical that the following items are addressed in order to
    achieve effective decontamination and protect patient, employees,
    and the Medical Center.

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a)  Type and physical location of decontamination facility.

[1]{.underline}. Models range from small portable to fixed (constructed)
facilities. Determination will be based in part on role within
community, resources availability 24/7, engineering utilities (hot/cold
water, HVAC, electric and containment methods).

[2]{.underline}. Location should be near and outside the ER entrance.
Issues that need to be addressed include:

-   Access and size area outside ER entrance.

-   Adequate number of showers, and the use of tepid water.

-   Privacy of individuals.

-   Ability to triage, secure and direct patient flow, crowd control,
    including the "worried well".

-   Ensure location is not near HVAC air intakes or other hospital
    openings.

-   Ensure wastewater permits (if applicable) can be obtained.

-   If portable system is selected, storage location, numbers or persons
    needed to erect 24/7, etc., must be considered.

b\) Provide adequate equipment and supplies to support decontamination,
to include:

-   Buckets, sponges, soap, brushes, trash containers, etc.

-   Methods of handling patient movement including non-ambulatory that
    may include use of stretchers, and roller system.

-   Collection methods for patient clothing, valuables, etc.

-   May use pagers or other communication means to notify
    decontamination personnel.

c\) Coordinate roles and responsibilities with local emergency planners
in the community. The local emergency medical system must have a full
understanding of the VAMC's capabilities, as well as who to coordinate
and approve receipt of potentially contaminated patients.

d\) Provide response to decontamination alerts or emergencies,
decontamination technique training, staff response training, and proper
use of PPE (See paragraph 3) below).

[1]{.underline}. Develop response and security lockdown and perimeter
control procedures for alerts in potential chemical emergencies. Issues
that need address include:

-   What agency(s) will notify the VAMC, and who is the caller directed
    to 24/7.

-   Identify who is notified internally and what are they to do.

-   Based on alert information, what security actions need to be
    implemented?

-   Develop PPE protocol for Police Officers located at security
    perimeter.

-   Identify outside agencies that must be notified.

[2]{.underline}. Develop procedures for receiving unannounced chemical
contaminated casualties, to include:

-   When first observing that person(s) are contaminated, initiate
    actions to be taken by staff to protect themselves, i.e.
    decontaminating themselves and patient, obtaining and wearing PPE,
    reporting the incident, etc.

-   Initiate security lockdown procedures.

-   If treatment area is contaminated, identify alternate care areas to
    be used, and methods to transport patients.

-   List of those who will be contacted to decontaminate the facility;
    i.e. internal or external.

-   Identify what external agencies are to be notified of event. *Note:
    This may be a crime or a pre-cursor to a larger event.*

[3]{.underline}. Develop procedures for handling chemical contaminated
mass casualties. The VAMC may know that mass casualties will be coming,
or they may start arriving unannounced. Knowing who to coordinate with
on a local, state and higher level will facilitate handling of
contaminated patients. The following actions must be initiated:

-   Staff must initiate use of PPE.

-   Initiate security lockdown procedures.

-   Activate notification of decontamination team and other responders
    who are tasked to provide necessary (medical and operational),
    equipment and supplies.

-   Ensure decontamination facility is ready for use.

-   Establish medical (medical coordinator, triage, patient
    monitoring/evaluation, and treatment), and operational (EOC,
    incident commander, safety and health, logistics, transportation,
    and security) assignments, with emphasis on chemical protection and
    treatment.

-   Establish internal and external communications with emergency
    responders.

-   Initiate the Mass Casualty SOP.

-   Use standard "universal protection" protocols for medical personnel
    working in the ER or other treatment areas (Cold Zone).

3\) **Selection of PPE and minimum levels of protection** - Selection of
PPE is based on manufacturer recommendation using scientific research
and testing. In the case of respirators, NIOSH approval must also be
given. The 29 CFR 1910.132-139 and its Appendices under Subpart I,
Personal Protective Equipment, and 1910.120 HazWoper, provides OSHA's
requirements. Defining levels of protection must have a firm scientific
basis. Peripheral factors such as type event, expected exposure levels,
use of direct reading instruments, response roles and responsibilities,
training and experience, engineering controls, preplanning, risk
assessments, etc., affect PPE use and required levels of protection.
Listed below are guidelines for defining levels of protection for the
various events that a VAMC may be involved in with regards to
decontaminating and treatment.

> Note: The PPE levels for decontamination are based on the assumption
> that decontamination activities at the VAMC are located remotely from
> the spill/release area. The only exposure expected for VAMC staff
> would be from those persons who have been contaminated and require
> medical treatment. Decontamination techniques must involve removal of
> contaminated clothing and use of liquid solutions (normally mild soap
> and water). Using proper decontamination techniques will reduce the
> chance of chemical exposure to medical personnel.

4\) **PPE Levels.**

a)  Level A - Fully encapsulating chemical resistive suit that allows no
    vapor to enter the suit. Respiratory protection is the use of a Self
    Contained Breathing Apparatus (SCBA) and/or supply air (SA). Other
    features include inner/outer chemical resistive gloves and boots,
    and Personal Alert System (PAS) device. Typically worn by responders
    into the Hot Zone where Immediately Dangerous to Life and Health
    (IDLH) atmospheres may be present.

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a)  Level B - Full-body chemical resistive suit. It does not offer the
    same level of protection due to open seams within the suit.
    Respiratory protection is SCBA and/or SA. Typically worn by
    responders in the Hot Zone, where the route of exposure (skin
    absorption) level is less than Level A.

b)  Level C - For the purposes of this SOP, protection requires a
    full-body chemical resistive suit, respiratory protection is
    positive air-purifying respirator (PAPR) using combination (P-100,
    Organic Vapor, Acid Gases) cartridges or its equivalent, inner/outer
    gloves and chemical resistive boots. Typically worn by responders in
    the Warm Zone (decontamination area at the Medical Center that is
    located away from the Hot Zone).

c)  Level D - For the purposes of this SOP, full-body chemical resistive
    suit. No respiratory protection required. Normally inner/outer
    gloves, eye protection, faceshield, and chemical resistive boots.
    Typically worn by responders in a Warm Zone area (decontamination
    area at the Medical Center that is located away from the Hot Zone)
    where the route of exposure is skin contact only.

5\) **Response Levels.**

a\) HazMat Teams - Emergency responders expected to respond to the
chemical spill/release event and enter the Hot Zone area.

-   First Responder Technician Level - Are those responders that meet
    OSHA 1910.120 requirements and initiate offensive action to stop or
    clean up the hazardous material(s). Normally wears level A or B
    protection.

-   First Responder Operations Level - Are those responders that meet
    OSHA 1910.120 requirements and respond in a defensive mode, e.g.
    assess, and control or contain the spill/release remotely. They may
    be in close proximity to the spill/release (Hot Zone), but do not
    offensively attempt to stop the spill/release. Level of protection
    is normally A or B.

> b\) Medical Center Decontamination (Decon) Teams - For the purpose of
> this SOP, are those responders that meet 1910.120 requirements for
> First Responder Operations Level, with emphasis on decontamination.
> Decon responders are expected to decontaminate patients who arrive at
> the Medical Center (Warm Zone) which is located away from the
> spill/release event (Hot Zone). Level of protection is normally C or
> D.
>
> Note: Exposure levels, unknown materials, and regulatory standards may
> require a higher level of protection.
>
> d\) Specialized Responders - Those responders not normally part of the
> HazMat or Decon Teams, but may be required to be involved in the
> emergency and wear PPE. At the Medical Center, it may be a police
> officer for traffic control or someone from Engineering Service that
> is required to do repair work.

####### Decision Matrix

  ------------- ----------------- --------------------- ------------------
  **PPE         **Type Exposure** **Response Location** **Type Response**
  Levels**                                              

  A             Vapor / Skin      Hot Zone              HazMat Team

  B             Vapor / Skin      Hot Zone              HazMat Team

  C             Vapor / Skin      Warm Zone             Decon Team

  D             Skin              Warm Zone             Decon Team
  ------------- ----------------- --------------------- ------------------

5.  ***Response/Recovery from the Event/Threat.***

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a.  *Hazard Control Strategies and Resource Issues*. This includes an
    assessment of those areas, which are particularly vulnerable to an
    actual threat/event. For example, if the ER was contaminated, what
    planning and resources would be needed to relocate the ER and
    medically check potentially exposed patients or employees? If there
    was a spill/release in the community and the community requested
    assistance, the following is offered.

    1.  **Community Emergencies, Including Transportation Incident** -
        Present unique problems to the VAMC. The VAMC must have a clear
        understanding as to its role within the community during
        hazardous material events. If it is expected to assist with
        decontamination, it must plan, procure the necessary supplies
        and equipment, establish decontamination procedures, receive any
        regulatory approvals, and communicate its capabilities to the
        community. Receiving casualties from the community can be
        expected under two scenarios, via EMS or on their own volition.
        If arriving via EMS, the odds are greater that the hazardous
        material will be known, and possible that the person(s) needing
        attention have underwent some decontamination. Persons arriving
        on their own may have not received medical or decontamination
        attention. In addition, the identity of the hazardous material
        may not be known. In each of the above scenarios, the exposure
        levels to health care workers would be much lower than at the
        site of spill or release. The unknown question is: "What type
        and protection level is adequate?" All efforts must be taken to
        identify the material via emergency responders, persons arriving
        at the VAMC, or other sources such as community Risk
        Assessments, industry officials, etc.

    2.  **Terrorist/WMD Events** - Events involving military warfare
        agents, i.e. chemical, biological, and radiological, offers the
        greatest challenge to VAMCs for assisting with decontamination
        and medical treatment. In addition to the health concerns
        presented to medical care staff, there is the issue to handling
        mass casualties at the same time. The DoD and other Federal
        agencies have provided valuable information to assist with
        understanding the health hazards as well as providing specific
        criteria for PPE. Most noted are CSEPP and the Domestic
        Preparedness Program. CSEPP has also provided research and
        technical data as well as documents that address coordination
        with other regulatory authorities (NIOSH, CDC, FEMA, OSHA, etc.)
        as to the type and level of PPE.

    3.  **Response Actions.**

        -   Upon notification, the Medical Center Director will decide
            if casualties can be decontaminated and treated. If so,
            initiate external chemical decontamination procedures.

        -   Attempt to identify what type hazardous material(s) are
            involved.

        -   Implement Incident Command System (ICS), activate the
            Emergency Operations Center (EOC) and staff accordingly.

        -   Ensure trained responders are notified and responding to set
            up decontamination unit.

        -   Secure entrances to the Medical Center so as to prevent
            contamination.

        -   Communicate with all affected operational units to ensure
            readiness.

        -   Maintain lines of communication with local community.

        -   Assess operational impact to Medical Center and patient
            care.

        -   Monitor exposures and safe work procedures during
            decontamination operations.

        -   Monitor patient symptoms and treatment outcomes.

        -   Continue evaluation of overall incident response and respond
            appropriately.

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a.  *Hazard Monitoring Strategies***.** The VAMC will develop procedures
    to communicate with local response agencies to ensure accurate data
    is available on what hazards are present, or type event is in
    progress.

b.  *See Attached Charts: Key Activity Management Tool/Structure.*

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5.  ***External Notification Procedures.***

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a.  *Within VA.* VISN Directors

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a.  *Other Federal Facilities.*

    -   OSHA - Notify within eight (8) hours of one (1) employee
        fatality, or three (3) employee hospitalizations resulting from
        a single incident.

    -   EPA.

    -   FBI for terrorist event.

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a.  *Other.* Joint Commission on Accreditation of Healthcare
    Organizations (JCAHO).

b.  *Community Entities.* Because of the VHA facility's relationship to
    the community, it is likely that there are specific entities within
    the community that should be notified that a threat/event has
    occurred. In many cases, this notification will trigger a community
    response to the threat/event, e.g. local Fire Department/HAZMAT
    Team.

-   Offices of Emergency Service's (both state and local level).

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-   State Health Departments.

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-   City or local water and sanitary sewer systems.

-   State Environmental Agency.

6.  ***Specialized Staff Training.***

-   OSHA 1910.120 Hazard Awareness Training for Police Officers.

-   OSHA 1910.120 Hazardous Materials First Responder Operations Level
    for personnel conducting decontamination.

8.  ***References and Further Assistance.***

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a.  VHA Emergency Management Program Guidebook.

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a.  All Operating Units in the medical center should review their
    operating unit templates for response/recovery activities.

b.  VHA Document, *Rapid Contingency Plans for Responding to Victims of
    a Chemical Attack*, October 2001.

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9.  ***Review Date.***

(Name)

Chief, (Service)

Attachments:

A. Key Activity Management Tool

B. Key Activity Management Structure

C. External HAZMAT Response Plan

*Sample 6.2.3.2.2*

*(Note: This SOP contains some intricate clinical information. For
additional Clinical information or clarification, you may contact Dr.
Margie Scott via the VA Global Address book in Outlook, or your ER
specialist or toxicologist.)*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Chemical Event (Internal)**

1.  ***Description of the Threat/Event.*** Chemical spills or releases
    may occur at any VA Medical Center (VAMC). Hazardous chemicals are
    used daily and stored throughout the Medical Center. Typical hazards
    associated with chemicals include, corrosives, flammables, toxins,
    and explosives. Typical areas where chemicals are found include
    engineering shops, laboratories, boiler plants, swimming pool areas,
    dental services, supply warehouses, patient therapy, and pharmacies.
    Storage of low hazard chemicals, when stored with incompatibles, may
    result in fires or explosions if mixed or spilled together. The
    result of chemical spills may cause hazardous vapors to enter
    Heating, Ventilation and Air Conditioning (HVAC) systems, create
    fires or explosions, or chemically burn a person's body. Response to
    chemical spills is a least three (3) tiers, depending upon the
    hazard of the spill or release. They include:

-   User can safely clean up the spill.

-   The Medical Center has established an internal HAZMAT team to assess
    the spill/release and may clean it up.

-   The Medical Center is not able to clean up the spill or stop the
    release and must rely on outside assistance; i.e., Fire Department
    HAZMAT teams, or contractors.

1.  ***Impact on Mission Critical Systems.*** Chemical spills at VAMCs
    are probably not a rare event. It is rare that a spill or release
    will cause an adverse impact to Medical Center operations or its
    occupants. However, if an event occurs that results in injuries or
    adverse impact to the Medical Center, response will be most
    difficult for the Medical Center to handle unless it has skilled
    resources on hand or available locally. In addition, chemical events
    that cause injury or contamination to the environment will require
    notification and coordination with other state and federal agencies.

2.  ***Operating Units and Key Personnel with Responsibility to Manage
    this Threat/Event.***

-   Medical Center Director

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-   Chief of Staff

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-   Incident Manager

-   Safety Officer

-   Chief of Police

-   Chief Nursing

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-   Chief of Staff

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-   Chief. Facilities Engineering

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-   Chief, Environmental Management

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-   Service Chief(s) directly affected

4.  ***Mitigation/Preparedness Activities of the Threat/Event.*** State
    several objectives for.

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a.  *Hazard Reduction Strategy Issues.*

    1.  Risk Assessment - Identify internal locations that hazardous
        materials are present and may include boiler and chiller plant
        operations, laboratories, engineering shops, environmental
        management services, research, sterilization operations, etc.
        While not perfect, the Risk Assessment (RA) can provide a fairly
        accurate picture of the type of chemicals used at the VAMC and
        hazards expected. Fortunately, the Occupational Safety and
        Health Administration (OSHA) requirements have already provided
        a framework to accomplish this task. The Code of Federal
        Regulations (CFR) (29 CFR 1910.1200, Hazard Communication; 29
        CFR 1910.1450, Occupational Exposure to Hazardous Chemicals in
        Laboratories; and the 29 CFR 1910. 132, General Requirements
        under Subpart I-Personal Protective Equipment) are but a few of
        OSHA standards that VAMCs must comply with. In addition the
        Environmental Protection Agency (EPA) provides guidance and
        requirements. The Resource Conservation and Recovery Act (RCRA)
        40 CFR Parts 260-165, and Superfund Amendments and
        Reauthorization Act (SARA Title III) address emergency planning
        and response to chemical releases. Information such as chemical
        and biological inventories, type hazards, and Personal
        Protective Equipment (PPE) requirements should have been
        identified. However, in most cases PPE selection is based on
        normal workday exposure and use, and may not always apply
        towards unexpected spills or releases.

    2.  Inspect chemical storage areas that may indirectly cause
        explosions; such as, flammable liquids storage, chemical storage
        (incompatibles), and storage of materials around heating
        devices.

    3.  Update chemical inventories annually.

    4.  Install and properly maintain fire protection, detection, and
        alarm systems.

    5.  Ensure full body and eye wash stations are located appropriately
        for on-site decontamination, and inspected and tested in
        accordance with industry standards.

    6.  Ensure that personnel responding to medical emergencies have
        appropriate training and proper PPE.

    7.  Conduct training and evaluation of drills/exercises.

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a.  *Response Plan.* Every Medical Center must have a plan to respond to
    internal chemical spills/releases (see Attachment C - Internal
    HAZMAT Response Plan). It is not required that Medical Centers have
    an internal HAZMAT team, but it is most important that plans address
    how to handle injuries, contain the material(s), and identify the
    hazardous materials. In addition, the following guidelines are
    offered:

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1)  Type and hazard of the chemical spill/release - Until ruled out, all
    chemical spills/releases will be classified as hazardous to human
    health, and exposure routes will occur via skin absorption or
    respiratory inhalation.

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1)  Contain chemical spill/release, including using the HVAC system to
    control vapor travel.

2)  Train on how to handle employee or other occupant injuries due to
    chemical exposure.

3)  Secure the area so as to prevent injuries and contamination.

4)  Initiate notification of top management and services that are
    affected.

5)  Ensure that if medical response occurs, that training has been
    accomplished in hazard awareness and that proper PPE is provided.

6)  Location of Spill/Release - Zones will be classified as the
    following:

    -   Hot Zone - Perimeter designated around the chemical
        spill/release area, where levels of exposure and protection will
        be the highest, and therefore more hazardous.

    -   Warm Zone - Perimeter outside the hot zone where hazardous
        exposures will be at a lesser level, or may not be present at
        all. Only emergency responders will be allowed in this area.

    -   Cold Zone - No hazardous exposure levels are present and are
        classified as a safe area.

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8)  Decontamination - Is the act of removing/washing hazardous
    substances from the body normally using soap and water. Gross
    decontamination can occur internal to the building by using nearby
    water sources such as eye and body wash stations. Those persons
    assisting must be protected appropriately. For the purposes of this
    standard operating procedure (SOP), a decontamination facility is
    located away from the Hot Zone and is classified as a Warm Zone. It
    is located outside the treating Medical Center so as not to allow
    contamination inside the building. It is critical that the following
    items are addressed in order to achieve effective decontamination
    and protect patients, employees, and the Medical Center.

a\) Select and properly locate the decontamination facility.

b\) Develop procedures for decontamination and treatment of employees
due to internal emergencies. Issues to be concerned with include:

-   Develop decontamination and treatment procedures that are to take
    place when an employee is contaminated by a chemical on site.

-   Identify who are the responders to the incident, and those clinical
    and support services that are expected to respond for reasons of
    medical triage, security and perimeter control, safety and health,
    engineering system control, logistics and transportation.

-   If response is within the VAMC, determine that PPE is made available
    to responders.

-   Provide adequate equipment and supplies to support decontamination.

-   Coordinate roles and responsibilities with local emergency planners
    in the community

-   Provide adequate decontamination technique training, and proper use
    of PPE.

> (*Note to Writer: For additional information on PPE and
> decontamination, also see sample Healthcare First Receiver
> Decontamination SOP, Section 6.3.3.2. in the Emergency Management
> Program Guidebook*.)

9)  Selection of PPE and Minimum Levels of Protection - Selection of PPE
    is based on manufacturer's recommendation using scientific research
    and testing. In the case of respirators, National Institute on
    Occupational Safety and Health (NIOSH) approval must also be given.
    29 CFR 1910.132-139 and its Appendices under Subpart I, Personal
    Protective Equipment, and 1910.120 HAZWOPER provide OSHA's
    requirements. Defining levels of protection must have a firm
    scientific basis. Peripheral factors such as type event, expected
    exposure levels, use of direct reading instruments, response roles
    and responsibilities, training and experience, engineering controls,
    preplanning, RA's, etc., affect PPE use and required levels of
    protection. Listed below are guidelines for defining levels of
    protection for the various events that a VAMC may be involved in
    with regards to decontaminating and treatment.

> **Note:** The PPE levels are based on the assumption that
> decontamination activities at the VAMC are remote from the
> spill/release area. The only exposure expected would be from the
> persons who have been contaminated and require medical treatment.
> Decontamination techniques must involve removal of contaminated
> clothing and use of liquid solutions (normally mild soap and water).
> Using proper decontamination techniques will reduce the chance of
> chemical exposure to medical personnel.

10) PPE Levels.

    a.  Level A - Fully encapsulating chemical resistive suit that
        allows no vapor to enter the suit. Respiratory protection is use
        of a Self-Contained Breathing Apparatus (SCBA) and/or supply air
        (SA). Other features include inner/outer chemical-resistive
        gloves and boots, and Personal Alert System (PAS) device.
        Typically worn by responders into the Hot Zone where Immediately
        Dangerous to Life and Health (IDLH) atmospheres may be present.

    b.  Level B - Full-body chemical resistive suit. It does not offer
        the same level of protection due to open seams within the suit.
        Respiratory protection is SCBA and/or SA. Typically worn by
        responders in the Hot Zone, where route and level of exposure is
        less than that expected and found for Level A.

    c.  Level C - For the purposes of this SOP, full-body chemical
        resistive suit. Respiratory protection is air purifying.
        Normally inner/outer gloves and chemical resistive boots.
        Typically worn by responders in the Warm Zone (decontamination
        area at the Medical Center that is located away from the Hot
        Zone).

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d)  Level D - For the purposes of this SOP, full-body chemical resistive
    suit. No respiratory protection required. Normally inner/outer
    gloves, eye protection, face shield, and chemical resistive boots.
    Typically worn by responders in a Warm Zone area (decontamination
    area at the Medical Center that is located away from the Hot Zone),
    where the route of exposure is skin contact only. *Note: Exposure
    levels, unknown materials, and regulatory standards may require a
    higher level of protection.*

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d)  Standard Universal Precautions - Healthcare providers' protection
    level appropriate for treating decontaminated patients in the VAMC's
    Cold Zone.

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11) Response Levels.

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a)  HazMat Teams - Emergency responders expected to respond to the
    chemical spill/release event and enter the Hot Zone area. It is rare
    that a Medical Center will elect to create and maintain a HAZMAT
    team. Usually the local community HAZMAT responders are used.
    However, if it is decided that a HazMat team is to be used, OSHA has
    specific training, PPE, medical surveillance, and other
    requirements. It is a program that requires high maintenance to
    ensure proper readiness and compliance with regulations. Guidelines
    are as follows:

    -   First Responder Technician Level - Are those responders that
        meet OSHA 1910.120 requirements and initiate offensive action to
        stop or clean up the hazardous material(s). Normally wears level
        A or B protection.

    -   First Responder Operations Level - Are those responders that
        meet OSHA 1910.120 requirements and respond in a defensive mode,
        e.g., assess, and control or contain the spill/release remotely.
        They may be in close proximity to the spill/release (Hot Zone),
        but do not offensively attempt to stop the spill/release. Levels
        of protection is normally A or B.

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b)  Medical Center Decontamination (Decon) Teams - For the purpose of
    this SOP, are those responders that meet 1910.120 requirements for
    First Responder Operations Level, with emphasis on decontamination.
    Decon responders are expected to decontaminate patients who arrive
    at the Medical Center (Warm Zone) which is located away from the
    spill/release event (Hot Zone). Level of protection is normally C or
    D.

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b)  Specialized Responders - Those responders not normally part of the
    HAZMAT or Decon teams, but may be required to be involved in the
    emergency and wear PPE. At the Medical Center, it may be a police
    officer for traffic control or someone from Engineering Service that
    is required to do repair work.

***[Decision Matrix]{.underline}***

  --------------- ------------------ -------------------- ----------------
  **PPE Levels**  **Type Exposure**  **Response           **Type
                                     Location**           Response**

  A               Vapor / Skin       Hot Zone             HAZMAT Team

  B               Vapor / Skin       Hot Zone             HAZMAT Team

  C               Vapor / Skin       Warm Zone            Decon Team

  D               Skin               Warm Zone            Decon Team
  --------------- ------------------ -------------------- ----------------

4.  ***Response/Recovery from the Event/Threat.***

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a.  *Hazard Control Strategies and Resource Issues*. This includes an
    assessment of those areas that are particularly vulnerable to an
    actual threat/event. For example, if a chemical spill occurred
    within the facility, issues such as who responds, what level of
    response, what type of protection is available for the hazard
    present, what actions must be taken to protect occupants, are a few
    problems that need to be addressed.

    -   VAMCs have the advantage of access to chemical inventories, PPE
        assessment for workplace activities, and hazards expected. Most
        chemicals used are stored in small amounts. Where there is bulk
        storage, the typical hazards normally involve corrosives (skin
        contact), and are located in engineering areas such as boiler
        and chiller plants. However, VAMCs with clinical and research
        laboratories may have all types of hazardous materials stored;
        such as toxins, flammables, corrosives, etc., and VAMCs must
        have plans that detail how the facility will respond to
        hazardous materials spill events. The responders to these areas
        for the purpose of rescue, assessment, containment or handling
        the spill will require at least a protection level of A or B,
        unless it can be determined that a lower level of protection is
        safe. The responders may or may not be facility staff. VAMC
        responders must be properly protected prior to any handling or
        treatment of injured persons. The Medical Center must also have
        plans for transport, decontamination procedures, and treatment
        of patient.

    -   Upon notification, the Medical Center Director will decide if
        casualties can be decontaminated and treated. If so, initiate
        internal chemical decontamination procedures.

    -   Attempt to identify what type hazardous material(s) are
        involved.

    -   Activate the Emergency Operations Center (EOC) and staff
        accordingly.

    -   Ensure any medical responders to the scene are appropriately
        protected.

    -   Ensure trained responders are notified and responding to set up
        decontamination unit.

    -   Establish perimeter and monitor engineering systems.

    -   Communicate with all affected operational units to ensure
        readiness.

    -   Maintain lines of communication with local community.

    -   Assess operational impact to Medical Center and patient care.

    -   Continue evaluation of incident response, and respond
        appropriately.

        a.  *Hazard Monitoring Strategies***.** The medical center
            facility will need to develop procedures to communicate with
            local response agencies to ensure accurate data is available
            on what hazards are present, or type event is in progress.

        b.  See Attachments A and B - Key Activity Management Tool and
            Key Activity Management Structure.

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5.  ***External Notification Procedures.***

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a.  *Within VA.* VISN Directors

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a.  *Other Federal Facilities.*

    -   OSHA - Notify within eight (8) hours of one (1) employee
        fatality, or three (3) employee hospitalizations resulting from
        a single incident.

    -   EPA.

    -   Federal Bureau of Investigation (FBI) for terrorist event.

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a.  *Other.* Joint Commission on Accreditation of Healthcare
    Organizations (JCAHO).

b.  *Community Entities.* Because of the facility's relationship to the
    community, it is likely that there are specific entities within the
    community that should be notified that a threat/event has occurred.
    In many cases, this notification will trigger a community response
    to the threat/event; e.g., local Fire Department/HAZMAT team.

    -   Offices of Emergency Service's (both state and local level).

    -   State Health Departments.

    -   City or local water and sanitary sewer systems.

    -   State Environmental Agency.

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6.  ***Specialized Staff Training.***

-   OSHA 1910.120 Hazard Awareness Training for Police Officers.

-   OSHA 1910.120 Hazardous Materials First Responder Operations Level
    for personnel conducting decontamination, and/or responding in a
    defensive mode to assess or contain the spill release remotely.

-   OSHA 1910.120 Hazardous Materials First Responder Technician Level
    for personnel taking offensive action to contain or clean up spill.

7.  ***References and Further Assistance.***

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a.  VHA Emergency Management Program Guidebook.

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a.  All operational units in hospital should review their operating unit
    templates for response/recovery activities.

b.  VHA Document, *Rapid Contingency Plans for Responding to Victims of
    a Chemical Attack*, October 2001.

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8.  ***Review Date.***

(Name)

Chief, (Service)

Attachments:

A. Key Activity Management Tool

B. Key Activity Management Structure

C. Internal HAZMAT Response Plan

*Sample 6.2.3.3*

*(Note: This SOP contains some intricate clinical information. For
additional clinical information or clarification, you may contact Dr.
Margie Scott, Dr. Linda H. Williams or Mr. Joseph Stanley Bravenec via
the VA Global Address book in Outlook, or your local radiologic
consultant.)*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Patients with Radiation Exposure or Radioactive
Contamination**

1\. ***Description of the Threat/Event***. Exposure to ionizing
radiation may occur from medical therapy or research, hospital or
industrial accident or terrorist event. Because radiation is invisible
and most people are unaware of the extent of ongoing daily exposure from
natural sources, the personal response to an event involving radiation
exposure is likely to be one of panic. Both panic and the effects of
radiation must be included in all phases of event management. Similarly,
because radiation is an invisible danger, the identification that
radiation has been released in an event may be delayed, unless screening
procedures are consistently practiced. Identification of radiation
involvement in an event will be facilitated by appropriate inquiry upon
initial facility contact regarding a potential event, and by appropriate
inquiry and radiation screening at the point of perimeter entry.

In radiation events involving a radiological dispersal devise (RDD or
*dirty bomb*) or a nuclear weapon, radiation may be accompanied by
trauma from the explosive force of the delivery device. For some
victims, radiation exposure and external damage may be minimal, while
internal injury from the shock wave may be severe. Secondary fires may
also produce additional injury. This sample Standard Operating Procedure
(SOP) is intended to cover the radiation aspects of such an event.
(*Note to Writer: Please refer to the sample Trauma Readiness for
All-Hazards Disaster Response Plan in the Emergency Management Program
Guidebook, Section 6, for more information on management of these
additional problems.)*

Factors that must be considered in implementation of the response plan
include:

-   How many victims are involved?

-   Are the involved victims also injured?

-   Are victims exposed to or contaminated with radiation?

-   If victims are contaminated, is the contamination external, internal
    or both?

-   If internal contamination is involved, was the route inhalation,
    ingestion or penetration?

-   What is the radiation source?

-   What is the degree of radiation exposure or contamination?

-   What victim-specific factors must be considered? Is a special
    population involved, such as infant, pregnant, elderly or frail
    victims, etc?

The number of victims and method of delivery (degree of explosive force
if blast involved) will be the prime determinant of the extent of
response required. A Mass Casualty Incident (MCI) (such as an accident
involving radioactive materials transportation, detonation of a dirty
bomb or of a conventional or improvised nuclear weapon) may require
activation of the facility and community disaster plan. An accident of
limited scope within the facility may be handled primarily by facility
resources in coordination with mandated regulatory agencies. National
Council on Radiation Protection and Measurement Report (NCRP) No. 111,
Section 4.5, discusses classification of radiation emergencies.

2\. ***Impact on Mission Critical Systems.*** Contamination by
radioactive particles may present a significant risk to the critical
mission of the healthcare facility. Remediation will occur after the
emergency, and may be extensive and costly. Thus, detection of radiation
contamination of victims and equipment entering the facility following
an event is important. More important is the understanding that
treatment of life-threatening trauma [always]{.underline} precedes
decontamination and consideration of exposure when radiation is the only
contaminant. The *Medical Management of Radiological Casualties Handbook
(*Military Medical Operations Office, Armed Forces Radiobiology Research
Institute, December 1999, 1st edition, International Medical Publishing,
Inc. McLean, Virginia, page 90) describes the accepted principle in
managing radiation victims as: *No living victim may be so
radiologically contaminated so as to constitute an immediate hazard to
personnel.* Techniques exist to minimize hospital contamination if
victims must enter the hospital for procedures prior to final
decontamination. The handling of radiation victims' arrival based upon
the probability classification into 3 groups is helpful: Combined
(Radiation Contamination + Trauma), External Contamination and Internal
Contamination. Victims with external contamination are at risk for
internal contamination leading to incorporation. Incorporation, or
uptake of the radioactive material into internal organs, occurs as a
result of internal contamination and is a serious hazard to the patient.
Because victims with external contamination are at risk for internal
contamination leading to incorporation, decontamination is urgently
needed after patient stabilization. Thus screening for radiation should
occur as soon as life-threatening conditions have been stabilized.

Management of contaminated materials and wastes is necessary to avoid
facility and environmental contamination. Wastewater should be contained
and/or properly disposed of only after clearance by the Radiation Safety
Officer (RSO). However, concern over release of contaminated water
should [not]{.underline} delay decontamination of the victim. All
contaminated items should be bagged, preferably in sealed plastic bags;
labeled; and placed in clearly marked containers. The RSO should oversee
management of all radioactive materials and items. The importance of
maintaining the legal chain of custody in these procedures must be
recognized. (*Note to Writer: For additional information, please refer
to sample Chain of Custody Readiness Plan in Section 5, Part 6A, of the
Emergency Management Program Guidebook.*)

For additional information on the types of contamination and control,
see Attachment A.

3\. ***Operating Units and Key Personnel with Responsibility to Manage
this Threat/Event***. The facility Emergency Medical Response Team
(EMRT) should address the radiation response component as emphasized
below. Use of the all-hazards approach to disaster management, with
screening for radiation in any potentially deliberate incident, should
be considered. The RSO is a critical member of the team responding to an
incident involving radiation, and involvement with the existing facility
disaster response team rather than establishing a separate team should
be considered. Facilities without an EMRT may designate selected
individuals for the roles and functions described below. Designation of
this function in writing to the involved individual is recommended. The
team positions delineated below are identified to facilitate handling of
a radiological event with multiple victims. In smaller events, certain
positions may be combined for management with fewer team members.

**Figure 1: Designated Radiological Response Personnel**

**Key Positions and Functions**

+------------------+---------------------------------------------------+
| **Role\*\***     | #### **Function**                                 |
+==================+===================================================+
| Security         | Secures the radiation emergency area and controls |
| Personnel        | crowds. In a Mass Casualty Incident assures       |
|                  | facility lockdown with controlled access. Handles |
|                  | chain of custody.                                 |
+------------------+---------------------------------------------------+
| Team Coordinator | Leads, advises and coordinates with attention to  |
|                  | specifics of an event involving radiation.        |
|                  | Specifically, assures laboratory activation for   |
|                  | initial and follow-up sampling.                   |
+------------------+---------------------------------------------------+
| Triage Officer   | Performs triage with attention to Radiation       |
|                  | Triage protocol.                                  |
+------------------+---------------------------------------------------+
| Patient Tracker  | Tracks and records movement of patients with      |
|                  | suspected or known Radiation Contamination.       |
+------------------+---------------------------------------------------+
| Designated       | May function as Team Coordinator or Triage        |
| Physician or     | Officer. Provides emergency medical care with     |
| Senior Medical   | diagnosis and treatment of immediate problems,    |
| Clinician        | with attention to acute radiation effects and     |
|                  | interaction of radiation with trauma. Assures     |
|                  | referral mechanisms for follow-up of intermediate |
|                  | and long-term radiation effects.                  |
+------------------+---------------------------------------------------+
| Nurse            | Assists physician with medical procedures,        |
|                  | collection of specimens and decontamination;      |
|                  | assesses patient\'s needs and intervenes          |
|                  | appropriately.                                    |
+------------------+---------------------------------------------------+
| Technical        | Records and documents medical and radiological    |
| Recorder         | data.                                             |
+------------------+---------------------------------------------------+
| Radiation Safety | Supervises all aspects of monitoring and          |
| Officer          | contamination control. Facilitates proper         |
|                  | mandatory notification of regulatory agencies in  |
|                  | an event. Assures that personnel in the triage,   |
|                  | decontamination and medical areas have sufficient |
|                  | monitors and training in their use and that       |
|                  | monitoring for radiation occurs at all            |
|                  | significant events and drills.                    |
+------------------+---------------------------------------------------+
| Radiation Safety | Monitors patient and area. Advises on             |
| Staff            | contamination, with attention to preventing       |
|                  | contamination of diagnostic equipment in areas    |
|                  | patient must visit for testing or treatment.      |
|                  | Advises on exposure control, tracks time and dose |
|                  | for personnel entering area. Maintains survey     |
|                  | equipment and assures proper use.                 |
+------------------+---------------------------------------------------+
| Laboratory       | Assists with collection and analysis of           |
| Technician       | biological samples, with specific attention to    |
|                  | collection of initial and follow-up CBC and       |
|                  | differential counts, and initial nasal, oral, and |
|                  | wound swabs.                                      |
+------------------+---------------------------------------------------+
| Public           | Releases accident information to public media.    |
| Information      | Specific training on Risk Communication in        |
| Officer (PIO)    | radiation events is advised for any Public        |
|                  | Information personnel who may be placed in this   |
|                  | role.                                             |
+------------------+---------------------------------------------------+
| Medical Center   | Coordinates Medical Center response, and assures  |
| Director         | normal Medical Center operations. Works with PIO  |
|                  | in reassuring public with truthful and forthright |
|                  | communication.                                    |
+------------------+---------------------------------------------------+
| Maintenance      | Aid in preparation of the Radiation Contamination |
| Personnel        | Control Treatment Area (RaCCTA). Following event, |
|                  | coordinates cleanup with Radiation Safety Staff.  |
+------------------+---------------------------------------------------+
| Laboratory       | Provides routine clinical analysis of biological  |
| Technician       | samples.                                          |
+------------------+---------------------------------------------------+
| Social Worker    | Coordinates information between victims, their    |
|                  | significant others and family.                    |
+------------------+---------------------------------------------------+
| Chaplain         | Provides spiritual counsel and comfort to the     |
|                  | victims, their significant others and family,     |
|                  | with special emphasis on those victims who are    |
|                  | terminal.                                         |
+------------------+---------------------------------------------------+
| Human Resource   | In a Mass Casualty Incident involving the         |
| Management       | community, provides information to significant    |
|                  | others or family of workers on site and acts as   |
|                  | liaison during an extended event.                 |
+------------------+---------------------------------------------------+
| Patient Liaison  | Provides education to the victim on the event,    |
|                  | obtains information to answer specific questions  |
|                  | for the patient concerning radiation and hazards, |
|                  | facilitates stress reduction through identifying  |
|                  | patient needs and mobilizing the appropriate team |
|                  | member.                                           |
+------------------+---------------------------------------------------+

\*\* As soon as possible upon assignment to these positions, specific
education on the unique features of responding to radiation events
should be completed.

4\. ***Mitigation/Preparedness Activities of the Threat/Event.***

a\. Pre-Event Education and Planning. Damage mitigation for a
radiation/nuclear event starts prior to the event. Because panic
associated with the concept of a dirty bomb or other
nuclear/radiological event may result in as much or more harm to the
public than the actual radiation itself, on-going staff and public
education is a significant mitigating action. Specific education is a
highly feasible mitigation strategy for this threat because of the
limited number of radiological agents, the lack of rapid development of
new isotopes, and the very specific technical mitigation strategies.
Such education can reduce much of the advantage of nuclear/radiological
agents to terrorists and prepare hospital personnel to respond in a
rational and safe manner to any event with a radiation release. Thus,
basic education on radiation should be incorporated into the annual
facility-wide education program. This education should include, at a
minimum, the following components:

-   The nature of radiation, background versus significant exposure with
    the associated risks and benefits.

-   Recognition of the radiation hazard symbol.

-   Risk reduction measures.

-   Some information on the hospital/community protocols for handling a
    radiation event.

-   Decontamination techniques in radiation events.

The facility education program should be identified by Administration as
a facility contribution to the public health needs of the community and
nation. Adequate pre-event planning requires a consistent ongoing effort
that begins with Administrative commitment for facility preparation
through team support and development. The identification of enthusiastic
interested team members with ready access to supportive administration
is essential. Following identification of these elements, a systematic
program combining didactic education with mini drills, culminating in
major drills, should be developed. After expertise is developed and
demonstrated in these exercises, ongoing practice to maintain the team
skills will be required.

b\. Identification of a Radiation Event. Early identification of the
presence of radiation is needed to minimize the risk to the mission of
the healthcare facility by radioactive contamination. Identification may
occur through notification of the facility by community authorities,
through appropriate screening of victims during their initial facility
contact, or by radiation monitoring during the event. Screening should
occur whenever a victim of a possible hazardous material (HAZMAT)
incident or deliberate event contacts the facility, and whenever a
victim arrives at the perimeter entry point. The screen should include
an inquiry concerning whether signs or symbols indicating radiation
hazards were noted and whether symptoms or physical signs of radiation
injury are present. In addition, a radiation detection instrument should
be used at the decontamination site for all HAZMAT events.

1\) Initial Facility Contact and Event Verification. When the hospital
receives a call reporting an event possibly involving radiation, certain
information is needed to facilitate adequate actions in preparation for
arrivals. This information includes the number of victims, type and
severity of both injuries and symptoms, whether contamination is known
to be present and, if known, whether the contamination is external or
internal. This information should be collected and documented in a
systematic manner, and is best achieved by a preformatted protocol. (See
Attachment B, Potential or Known Radiation Event - Initial Facility
Contact Report; and Attachment C, Initial Multiple Radiation Victim
Report.) The Initial Facility Contact Report form should be completed
first. The Initial Multiple Radiation Victim Report would be used only
if multiple victims are involved and if the situation allows sufficient
time. To reduce anxiety on the part of the call recipient and increase
the ease and accuracy of data collection, routine "initial contact"
mini-drills should be conducted using the forms. After each contact
drill, participants should be allowed to discuss their participation
experience and ask for further information. This educational practice
will serve to enhance performance and calmness, should a real world
event occur.

2\) Radiation Monitor Screening. Any event involving multiple casualties
that may be intentional should utilize screening with a radiation
monitor to exclude the possibility of covert radiological dispersal. The
threat of a dual-release event must be considered, and only active
screening at an event can exclude the possibility of radiation. A number
of radiation survey instruments are available for this purpose. Proper
utilization of these devices requires device calibration, battery
maintenance and training, with emphasis on proper screening technique
and avoidance of survey meter contamination. (See Attachment D,
Radiation Instrumentation and Screening.)

c\. Plan for Reception of Possibly Contaminated Victims - Facility
Lockdown and Restricted Access. In a major event involving radiological
or nuclear materials, such as a radiological dispersal device or nuclear
weapon, immediate facility lockdown with limitation of access may be
necessary to avoid contamination of the facility and to assure
continuity of operations. Immediate facility lockdown with restricted
access should be considered as part of a standing facility protocol upon
notification of a radiological/nuclear event until the risk of
contamination is known. If the initial facility contact raises the
question of contamination and this cannot be ruled out prior to arrival,
the facility decontamination plan should be activated. Assume victims
are contaminated until this possibility is excluded by screening.
However, in a radiological or nuclear event, the purpose of this
lockdown is [not]{.underline} to exclude the entry of patients with
life-threatening injuries. The goal of lockdown in radiation emergencies
is to channel patients with life-threatening conditions into the
facility along designated routes to allow contamination control until
the patient can be stabilized sufficiently to safely undergo
decontamination. If special traffic patterns and entrance routes are
specified in this plan, be certain ambulance and other transport
personnel are notified. Some facilities may elect to use stationary
pre-deployed signage or to deploy temporary directional marques to
delineate these routes.

The ratio of doors to security personnel for many facilities renders
lockdown solely by security personnel impractical due to the time
involved. This difficulty can be overcome by pre-assignment of lockdown
of specific doors to designated personnel by area throughout the
facility. The use of mini-drills documenting time to simulated lockdown
will verify the effectiveness of the assignments and knowledge of
procedures by personnel. (*Note to Writer: Please refer to the sample
Lockdown-Heightened Security Procedures SOP, Section 6.3.4.3. of the
Emergency Management Program Guidebook, for additional information.*)

Adequate planning for radiation events includes establishment of a
Radiation Event Supply Inventory (See Attachment E for a suggested
list), and pre-identification of appropriate areas for decontamination
of patients without serious injury and for an internal radiation
contamination control treatment area.

5\. ***Response/Recovery from the Event/Threat***.

a\. Preparation for Patient Arrival and Reception.

1\) Activation Procedures. Verify that hospital decontamination
procedures are activated and that external perimeters have been secured
and appropriate directional signage posted. (*Note to Writer: Please
refer to the sample Healthcare First Receiver Decontamination Readiness
Plan, Section 5, Part 1, of the Emergency Management Program
Guidebook.*)

2\) RSO Notification. Notify the RSO to issue dosimeters, prepare
instruments and mobilize nuclear medicine and other
appropriately-trained staff to assist with radiation surveys.

3\) Establish Perimeter. Prepare the Perimeter Entry Point Team with
appropriate personal protective equipment (PPE). Level C PPE with a PAPR
is appropriate for decontamination procedures involving radioactive
material. However, this level of protection is not needed in many
situations, and the following protective clothing is usually sufficient
as described in the REAC/TS discussion under Response Team Preparation:

"Protective Clothing **-** The purpose of protective clothing is to keep
bare skin and personal clothing free of contaminants. Members of the
radiological emergency response teams should dress in surgical clothing
(scrub suit, gown, mask, cap, eye protection, and gloves). Waterproof
shoe covers also should be used. All open seams and cuffs should be
taped using masking or adhesive tape. Fold-over tabs at the end of each
taped area will aid removal. Two pairs of surgical gloves should be
worn. The first pair of gloves should be under the arm cuff and secured
by tape. The second pair of gloves should be easily removable and
replaced if they become contaminated. A radiation dosimeter should be
assigned to each team member and attached to the outside of the surgical
gown at the neck where it can be easily removed and read. If available,
a film badge or other type of dosimeter can be worn under the surgical
gown. A waterproof apron can also be worn by any member of the team
using liquids for decontamination purposes.

This protective clothing is effective in stopping alpha and some beta
particles but not gamma rays. Lead aprons, such as those used in the
X-ray Department, are not recommended since they give a false sense of
security - they will not stop most gamma rays."
<http://www.orau.gov/reacts/care.htm#Techniques>.

4\) Self-Decontamination Area. Establish or verify that supplies are
available in the appropriate area for self-decontamination. If possible,
this should be a pre-selected external site. (*Note to Writer: For
further information on self-decontamination, please refer to the sample
Healthcare First Receiver Decontamination Readiness Plan, Section 5,
Part 1, of the Emergency Management Program Guidebook.*)

5\) Staff Selection. If staff numbers allow selection of those who will
work with the contaminated victims, exclude those who are pregnant or
potentially-pregnant staff. If time allows, consider obtaining a
baseline CBC and differential for staff selected to work in the
contaminated area and a pregnancy test, where applicable.

6\) Staff Briefing. Brief the nurses and other involved personnel on
radiation safety precautions. Emphasize that staff risk is considered
low if these standard precautions are followed, and that panic and
anxiety are significant risk factors in radiation events and are
frequently much greater than the actual radiation threat.

7\) Selection and Preparation of a Radiation Contamination Control
Treatment Area (RaCCTA).

a)  If possible, this should be a pre-selected internal site.

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a)  The controlled area should be large enough to accommodate the
    anticipated number of victims.

b)  If possible, select a treatment area:

-   Close to the entrance used from the outside decontamination area
    into the hospital.

-   That is not critical to facility functions.

-   That does not contain major stationary equipment.

-   That is not in a frequently used traffic pathway, and that is as far
    away from the nursing station and areas used by other personnel as
    feasible with provision of good medical care.

-   With private sanitary facilities.

-   Without carpet.

-   Where ventilation can be controlled. Although control of ventilation
    may be desirable, this is not mandatory. If available, choose a room
    with a dedicated or isolated ventilation system. However, it is
    considered unlikely that significant quantities of radioactive
    contaminants will become airborne through the ventilation system.
    (Reference American Medical Association, *A Guide to the Hospital
    Management of Injuries Arising from Exposure to or Involving
    Ionizing Radiation,* 1984.)

d\) Remove equipment that will not be needed in treatment of the
victims, and cover equipment that will remain in the room. Large items
such as tables or chairs may be covered with leak proof absorbent paper.
Saran wrap or plastic bags may be used to cover smaller items such as
telephones, doorknobs, call system controls, and equipment handles.

e\) Demarcate the controlled area with tape or floor markings. This
control line distinguishes the contaminated from the uncontaminated
area. Place a wide strip of tape on the floor around the entrance to the
internal radiation treatment area. Clearly label the contaminated and
the uncontaminated areas. The contaminated area is the controlled area.
Use a buffer zone or secondary control line for added security.

f\) Cover the treatment table or bed with several layers of waterproof
disposable sheeting.

g\) Cover the floor area with brown wrapping paper or butcher paper. If
paper is unavailable, bed sheets or square absorbent pads may be used.
Tape the floor covering securely to the floor to reduce the fall hazard.

h\) Line several large containers, such as waste containers or boxes,
with plastic garbage bags. Apply the Radiation Hazard label to some of
these and clearly label one for contaminated disposable items, one for
contaminated non-disposable items, and one for linens. Management and
labeling of biohazard waste must be in accordance with facility
infection control policies. All radiation contaminated items, including
linens, clothing, etc, must be appropriately labeled and handled in
accordance with standard infection control policies.

i\) Prepare for laboratory sampling of contaminated patients. Assure
that adequate CBC tubes and supplies needed for blood drawing are in the
treatment area. Nasal swabs, 24-hour urine collection jugs appropriately
labeled for radiation, zip lock plastic bags with patient identification
and radiation labels will be needed. A deep tray or box lined with
absorbent paper and a plastic bag to contain any spills sufficiently
large to contain the urine jugs will be needed.

8\) Access Route Preparation. Selection and Preparation of the route and
access to the Radiation Contamination Control Treatment Area (RaCCTA).

a\) If possible, the route and alternates should be pre-selected.

b\) Prevent tracking of contaminants by covering floor areas. Cover the
floor area from the entrance to be used by the contaminated victims to
the Radiation Contamination Control Treatment Area (RaCCTA). This is
most easily accomplished by unrolling rolls of brown wrapping paper or
butcher paper. Again, tape securely to floor to prevent falls.

c\) Restrict access to the controlled area. Rope off the route to
prevent unauthorized entry. Tape the floor along this route to indicate
the clean area outside the route. This will aid in post-event surveying
and cleanup.

9\) Preparation to Survey.

a\) Check survey instruments: test battery.

b\) Prepare survey instrument by covering probe or window with thin
plastic wrap (such as Saran wrap) or a plastic baggie to avoid
contamination of the instrument.

c\) Check and record the background radiation levels for the treatment
area, the corridor and the facility entrance. If your facility has an
outside decontamination area, record background for it also.

d\) Review survey procedures. (See Attachment E: Radiation
Instrumentation and Screening.)

b\. Patient Arrival, Radiation Screening, and Triage. (*Note to Writer:
See the Emergency Management Program Guidebook sample SOP on Triage
During a Mass Casualty Incident, Section 6.3.3.4; and sample Healthcare
First Receiver Decontamination Readiness Plan, Section 5, Part 1.*)

Note: When chemical contamination is involved, the Standard Operating
Procedure for chemical contamination should be used.
[Chemical]{.underline} decontamination takes precedence over radiation
decontamination.

1\) Perimeter Entry Point Screening and Direction.

a)  At the perimeter entry point if the patient is sufficiently stable,
    screen the ambulance or transportation vehicle and patient for
    radiation with an appropriate radiation survey meter. Contamination
    is possible whenever a radiation survey meter reading above
    background is obtained. Question all patients about recent nuclear
    medicine tests. Depending upon the situation, consider whether
    Attachments B, C or F may be helpful at this point.

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a)  If it is known that the patient has not been contaminated, then
    direct the patient through the designated clean route into the
    facility.

b)  If contamination is identified **and** the patient is sufficiently
    **stable**, direct the patient to the decontamination area for
    decontamination prior to entry into the facility. However, when
    contamination involves only radioactive material, the patient with
    **serious trauma** or **life threatening** medical problems **should
    always** receive medical stabilization before decontamination. This
    difference from chemical decontamination exists because of the
    accepted principle that radioactive contamination from a living
    patient will not endanger the life of a healthcare worker (reference
    *Medical Management of Radiological Casualties Handbook:* Military
    Medical Operations Office, Armed Forces Radiobiology Research
    Institute, December 1999, 1st edition, International Medical
    Publishing, Inc. McLean, Virginia, page 90). Incorporation of a
    pre-decontamination trauma stabilization area into the triage plan
    for radiation events should be considered to address this
    contingency. However, direct entry into the prepared radiation
    containment area should **not** be delayed if required for
    lifesaving intervention.

d\) If contamination is identified and the patient is not medically
stable, if possible without significant delay or harm, remove clothing,
linens, etc. prior to hospital entry. All clothing or items removed
should be bagged, labeled and handled as legal evidence. Appropriate
procedures must be followed to maintain the legal integrity of the
chain-of-custody for these items. (*Note to Writer: Refer to sample
Chain-of-Custody Readiness Plan, Section 5, Part 6A of the Emergency
Management Program Guidebook.*) Do [not]{.underline} delay the patient
for clothing removal if the delay will compromise the patient. Wrap the
patient and stretcher in clean sheeting, and secure it to contain any
contamination. Direct the patient to the Radiation Contamination Control
Treatment Area. Transportation personnel and the vehicle should be
regarded as contaminated, and should not leave until surveyed and
released by the RSO.

2\) Triage and Radiation-Specific Prioritization for Victims in a
Radiological Event:

a\) *General Triage* - Triage of victims from a radiological event
should follow the same principles used in sorting victims of any
incident. Since the degree of radiation injury will not be initially
apparent for many of the victims, triage criteria will be based
primarily on associated injuries and complaints. The triage method and
tagging system used will vary according to local facility practices.
(*Note to Writer: Refer to sample SOP on Triage During a Mass Casualty
Incident, Section 6.3.3.4. of the Emergency Management Program
Guidebook.*) See Attachment F for a suggested Radiation Patient Intake
Screening Tool that provides a quick method for screening and
documentation of symptoms, signs and injuries for victims presenting
from a potential radiation event.

b\) *Prioritization of Irradiated Patients* - General principles to
assist in appropriately prioritizing patients who have been exposed to
radiation include:

-   Combined injury patients, those with both radiation and injury,
    constitute the most serious patient population. The mortality from
    injury may be significantly increased if the patient has received
    radiation.

-   Contamination is medically urgent, since internal contamination and
    subsequent incorporation may follow. Incorporation can result in
    future adverse health effects if the amount of incorporated
    radioactive material is high. See Internal Contamination below.

-   Irradiation of the whole body or some specific body part does
    [not]{.underline} constitute a medical emergency, even if the amount
    of radiation received is high. Medical treatment, although needed,
    is not needed emergently because the effects of irradiation usually
    are not evident for days to weeks. Patients with severe symptoms
    occurring shortly after exposure and that are related to radiation
    alone will most likely have received a lethal radiation dose.

c\) *Severe Radiation Exposure* - Victims who have received very high
doses of radiation from a gamma or neutron source may exhibit signs and
symptoms indicating the level of exposure. Early neurological signs,
such as confusion and delirium, when due only to radiation, indicate a
lethal dosage of radiation. Other signs of lethal radiation injury
include a high fever, profuse vomiting and bloody diarrhea within 2
hours of exposure (nearly 100% mortality). In a mass casualty incident
such patients should be triaged as *Expectant* and managed as
*Palliative Care* patients until the patients who are expected to
survive have been triaged and received appropriate medical care. (Refer
to Attachment C, Initial Multiple Radiation Victim Report.)

c\. Treatment of Non-Contaminated Patients/Clean Area Patient
Management.

1\) *Patient Management.* On arrival in the clean area, the patient
should again be questioned concerning potential exposure and, if
exposure was possible, a baseline CBC and differential drawn and a
baseline urinalysis obtained. Whenever possible, it may be helpful to
obtain a historic, pre-event CBC baseline from the patient's medical
record for comparison. (See Laboratory Involvement, paragraph f.4
below.) A radiation survey meter should be available in the clean area;
and if a question arises regarding contamination, the person should be
re-screened carefully.

2\) *If Radioactive Contamination Is Discovered After Patient Has Been
Admitted.* Continue attending to the patient's medical needs. Secure
entire area where victim and attending staff have been. Do not allow
*anyone* or *anything* to leave the area until cleared by the RSO.
Establish control lines, and prevent the spread of contamination.
Completely assess the patient's radiological status. Personnel should
remove contaminated clothing before exiting area; they should be
surveyed, shower, dress in clean clothing and be re-surveyed before
leaving area.

d\. Decontamination of Radioactively Contaminated Patients Without
Life-Threatening Conditions. All patients with possible or proven
contamination with radioactive materials **whose medical condition is
sufficiently stable** should undergo decontamination prior to entry into
the facility. The purpose of decontamination is to prevent or reduce
incorporation of the material (internal contamination), to reduce the
radiation dose from the contaminated site to the rest of the body, to
contain the contamination, and to prevent it's spread (REAC/TS). Removal
of clothes is estimated to remove over 80% of external contamination,
with some sources stating this removes over 95%. Decontamination with
water or soap and water should then follow, including the hair and all
portions of the body. Shampoo with conditioner or soap with lotion
conditioners should [not]{.underline} be used, as conditioners may
increase radiation particle adherence. The teeth should be brushed, and
mouth and nose rinsed. Swabbing the nostrils and mouth prior to rinsing
for documentation of radioactivity is preferred. Even if radioactivity
is totally removed from the mouth and nose by rinsing, radioactivity on
swabs from these areas indicates the probability of internal
contamination through inhalation or ingestion. After decontamination,
the victim should be re-screened with a radiation detector (usually a GM
meter), and any areas still positive for radiation so indicated with
indelible pen. Thus, decontamination follows the same procedure as for
chemical decontamination with the following exceptions:

1\) *Medical Priority:* Patients with radioactive material contamination
should [always]{.underline} have life-threatening conditions stabilized
[before]{.underline} decontamination.

2\) *Radiation Decontamination Cycle:* The pattern of decontamination
for radioactive material contamination is a repetitive cycle of survey,
scrub, rinse and resurvey. For each cycle, the survey count should be
dropping. The goal is less than 100 counts per minute over an area of 10
square cm, or until further reduction is not achieved. Continue the
survey, scrub, rinse and resurvey procedure until this goal is reached.
If this goal cannot be reached, then contain the area with a sealed
plastic dressing and obtain professional assistance. The continued
presence of radioactivity may indicate an imbedded radioactive fragment
or other internal contamination. Marking around the site with an
indelible pen will allow for ready localization of the site for
repetitive decontamination efforts.

3\) *Radiation Safety Principles:* Safety criteria for workers in the
contamination area are based upon the three protective factors which
limit radiation exposure: Time, distance and shielding. Accurate
tracking of personnel and time served in the contaminated zone is
essential for safety. Personnel should be rotated frequently to minimize
time of exposure, and a record of time spent maintained for permanent
records. Distance is a major factor in reducing exposure, so personnel
working in the decontamination area should remain as far from the victim
as is possible without limiting the decontamination efforts. Special
shielding other than usual decontamination gear is not usually warranted
in the decontamination area. Any radioactively contaminated objects that
must be handled should be handled with forceps or tongs with as long a
handle as is available and feasible. Even centimeters can significantly
reduce radiation exposure from many sources.

e\. Management of Contaminated Materials.

1\) Contaminated water or fluids should be contained and/or released
only after clearance by the RSO. However, concern over release of
contaminated water should not delay decontamination efforts.

2\) Clothing, jewelry, and other contaminated items should be bagged
preferably in sealed plastic bags, labeled, and placed in clearly marked
containers. Uncontaminated items should be labeled for identity and
stored separately. (*Note to Writer: Please refer to the sample
Chain-of-Custody Readiness Plan, Section 5, Part 6A, in the Emergency
Management Program Guidebook.*)

3\) If a contaminated patient uses a toilet, it should be flushed three
times and the RSO notified for screening/cleansing.

f\. Management of the Contaminated Injured Patient in the Radiation
Contamination Control Treatment Area.

1\) Procedures in the Radiation Contamination Control Treatment Area
(RaCCTA). \[See above sections also on Protective Clothing discussion
and Selection and Preparation of a Radiation Contamination Control
Treatment Area (RaCCTA).\] The following control measures should be used
to minimize the spread of contamination and control exposure:

a\) Use of strict isolation precautions, including protective clothing
and double bagging.

b\) At a minimum, protective clothing for staff should include gowns,
double gloves surgical masks with eye shield, caps, boots. If available,
gowns should be water resistant.

c\) Staff should wear radiation dosimeters, if available.

d\) Change outer gloves whenever the potential for contamination has
occurred. Many gloves will be needed for multiple changes.

e\) Change instruments, drapes, etc., when they become contaminated.

f\) Double bag all contaminated items, including shrapnel and other
embedded items, and clearly label with victim identification, date and
time. Chain-of-custody procedures should be followed. Plastic bags in
all sizes will be needed for bagging contaminated items. Place metallic
shrapnel in a lead-lined container, if available. If a lead-lined
container is unavailable, move radiation-contaminated shrapnel to a
location at least six feet away from personnel.

[1]{.underline}. Use waterproof materials to limit spread of
contaminated liquids

[2]{.underline}. Use plastic-lined containers for clothing, linens,
dressings, etc, to control waste.

[3]{.underline}. Control ventilation as possible.

[4]{.underline}. Designate storage area for wastes (outside hospital).

[5]{.underline}. It may be helpful to establish a "safe line" in the
room containing a contaminated patient who will be there for some hours
and may need staff in the room but not in actual contact. Seek the RSO's
assistance in establishing this line, which can be marked on the floor
with tape.

2\) Patient arrival and order of treatment priority. (See preceding
paragraphs also.) Patients who have been identified with
life-threatening injuries requiring stabilization prior to
decontamination may arrive with their clothing intact or partially or
totally removed depending on the situation prior to arrival to the
RaCCTA. Upon arrival, stabilization with attention to the ABCs of life
support assumes priority over any decontamination efforts. (See
Attachment I, General Order of Medical Care for the Contaminated Injured
Patient.) The approximate order of priority for patient medical
management is:

a\) First aid and resuscitation - attend to the ABC's and emergency
treatment protocols to obtain medical stabilization.

b\) Medical stabilization with attention to defining all injuries.

c\) Definitive treatment of serious injuries.

d\) Prevention/minimization of serious injuries.

e\) Assessment of external contamination and decontamination.

f\) Treatment of other minor injuries.

g\) Containment of contamination to treatment area.

h\) Minimization of external radiation to treatment personnel.

i\) Assessment of internal contamination.

j\) Treatment of internal contamination. (Note: Contaminated patients
admitted with an airway or endotracheal tube must be considered to be
internally contaminated.)

k\) Assessment of local radiation injuries/radiation burns: Note: Burns
from radiation usually develop days to weeks later. Initial signs of
erythema (redness) should be recorded as possible indication of exposure
sites, but this initial redness is usually from dilation of blood
vessels rather than a true burn and usually disappears after several
hours. Burns present initially are usually thermal or chemical.

l\) Long-term follow-up of patients.

m\) Counseling of patients and family members about long-term effects
and risks (Reference NCRP 138).

Although resuscitation and medical stabilization take priority,
attention to the method of clothing removal, when necessary during
medical care, may minimize the spread of contamination. Cut clothing
with minimal disturbance of the cloth, rather than ripping or
unsnapping. Roll the cut clothing so the outer surface is wrapped
inward, thus containing the contamination.

3\) Baseline essential diagnostic testing. Collect and process patient
specimens using spill precautions for:

a)  Blood for CBC and DIFF.

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a)  Baseline urinalysis.

b)  Urine, 24-hour collection.

c)  Swab each nostril and collect the swabs in separate, labeled
    containers.

d)  Swab each wound separately and label swabs.

e)  Emesis.

f)  Sputum, if significant quantity is being produced.

g)  Feces, 24-hour collection.

h)  Send the urine, feces, emesis, sputum and individual swabs for
    radiation counting.

i)  All urine from contaminated patients should be collected in
    appropriately labeled 24-hour urine collection containers. Keep
    these containers in a deep tray or box lined with absorbent paper
    and a plastic bag to contain any spills. Contact the RSO for
    appropriate shielding for the collection box. If shielding is not
    available, store this at least 6 feet from any working area with
    personnel.

4\) Laboratory Involvement: In an event with possible radiation victims,
prediction of both severity of illness and future survival depends upon
the total dose of radiation exposure. The most critical information for
estimation of this radiation exposure dosage is the rate of decline of
the total lymphocyte count (TLC), which is obtained from a CBC with
differential count. Thus, deployment of a laboratory technician for
immediate drawing of a stat CBC with differential count with notation of
date and time for each victim is helpful. The TLC from the time closest
to the actual exposure will serve as the post-event baseline. Each
radiation exposure victim that remains on site for 3 to 6 hours should
have a second CBC with differential drawn, with repeat testing every 3
to 6 hours for the first 48 hours. This TLC count is plotted against
time and compared with the Andrew's nomogram for estimation of the
severity of exposure. If after 48 hours the TLC has not fallen
significantly, the possibility of a significant radiation exposure can
be excluded for that patient. The CBC and TLC data should accompany the
victim wherever he/she is transferred.

a\) Most current hematology analyzers automatically calculate the
absolute lymphocyte count. When the instrumentation does not have this
automated function, the TLC is obtained by multiplying the total White
Blood Cell (WBC) count by the percentage of lymphocytes from the
differential cell count.

b\) Whenever possible, a historic pre-exposure baseline should be
obtained from the patient's medical record for comparison purposes to
exclude a preexisting low baseline TLC. Most adults have a normal white
blood cell count (WBC) in the 5000 to 10,000 cells/ccm range, but some
ethnic groups tend to have significantly lower levels (2,500 to 5,000
cells/ccm) without adverse effects.

c\) The most accurate assessment possible for prediction of survival
probability can be achieved through combining this quantitative
information with the symptomatic and historical information. Chromosomal
analysis can be added at a later time, preferably drawn at 24 hours (or
thereafter) post-exposure, as confirmatory data. (See Attachment J,
Cytogenetic Assessment of Radiation Dose.)

d\) Urine and fecal samples should be obtained in the emergency area,
and the RSO contacted for instructions on storage and sampling for legal
and medical data. After the initial baseline urinalysis is obtained, all
subsequent urine from contaminated patients should be collected in
appropriately labeled 24-hour urine collection containers. Keep these
containers in a deep tray or box lined with absorbent paper and a
plastic bag to contain any spills. Contact the RSO for appropriate
shielding for the collection box. If shielding is not available, store
this at least 6 feet from any working area with personnel.

5\) Decontamination of injured patients. Injured patients contaminated
with radiation require decontamination [after]{.underline}
stabilization. Wounds should be decontaminated first to reduce
absorption of radioactive material, and because the open tissue is more
easily damaged by radiation or chemicals. Care must be taken not to
recontaminate the wound during further decontamination.

a\) The order of decontamination for the body is:

[1]{.underline}. Wounds.

[2]{.underline}. Orifices.

[3]{.underline}. Areas of high contamination.

[4]{.underline}. Areas of low contamination.

b\) Wound Care - Irrigate open wounds and cover with sterile dressing.
For a procedural demonstration of wound care go to
<http://www.orau.gov/reacts/procedures.htm>.

c\) Intact Skin - It is important [note]{.underline} to damage intact
skin with overly aggressive decontamination, as broken or irritated skin
will allow increased damage to tissue by radiation and increased
absorption of any chemicals that are present.

d\) Decontamination should include the following:

[1]{.underline}. Survey and mark radioactive areas with waterproof
marker.

[2]{.underline}. Brush teeth and rinse mouth frequently if oral
contamination.

> [3]{.underline}. Soap and water showering (including hair). Note: Do
> [not]{.underline} use a shampoo or soap that includes conditioner or
> moisturizer, as these can increase the binding of radioactive
> materials.
>
> [4]{.underline}. Repeat the survey for counts per minute. The goal is
> less than 100 counts per minute over an area of 10 square cm, or until
> further reduction is not achieved. The cycle used is to survey, scrub,
> rinse, and resurvey until this goal is reached.
>
> [5]{.underline}. If this goal cannot be reached, then contain the area
> with a sealed plastic dressing and obtain professional assistance.
>
> [6]{.underline}. This decontamination procedure is effective for mixed
> radiation/chemical contamination. However, the chemical
> decontamination protocol should be followed when it is known that
> chemicals are involved.

g\. Special treatment considerations for the irradiated patient.

1\) The principle of wound closure in the irradiated patient. Debride
and close wounds primarily rather than allowing to heal by secondary
intention, if at all possible. The usual principle for contaminated
wound management in the trauma patient is to leave the wound open and
allow it to heal by secondary intention. However, wound healing is
compromised following radiation, and an open wound serves as a potential
site of fatal infection. Even if extensive debridement is required to
allow early closure, this may significantly reduce the risk of fatal
infection from the site.

2\) Window for invasive repair procedures in the irradiated patient.
Wound and burn care, surgery and orthopedic repair should be done in the
first 48 hours or delayed for 2 to 3 months. Many patients who have
suffered trauma (from an explosion or burn) combined with an acute
exposure to penetrating radiation will have an increased chance of dying
as compared to patients who have suffered from the same dose of
radiation without trauma. If a patient has received an acute dose
greater than 200 rads, efforts should be made to close wounds, cover
burns, reduce fractures and perform surgical stabilization and
definitive treatments within the first 48 to 72 hours after injury.
After 48 to 72 hours, surgical interventions should be delayed until
recovery of the hematopoietic system and tissue repair processes,
usually a period of 2 to 3 months.

3\) Referral for specialized consultations. Consultation with
specialists in hematology/oncology, radiation, and infectious disease
should be obtained as indicated.

4\) Extent of radiation injury from exposure.

a\) Exposure to high levels of penetrating radiation can involve the
whole body (uniformly or non-uniformly), a significant portion of the
body, or a small, localized part. The exposure can be acute, protracted,
or fractionated over time.

b\) Local Injury - Most radiation injuries are local injuries,
frequently involving the hands. These local injuries seldom cause the
classical signs and symptoms of the acute radiation syndrome.

-   Consider local radiation injury in the differential diagnosis if the
    patient presents with a skin lesion without a history of chemical or
    thermal burn, insect bite, or history of skin disease or allergy. If
    the patient gives a history of possible radiation exposure (such as
    from a radiography source, X-ray device, or accelerator) or a
    history of finding and handling an unknown metallic object, note the
    presence of any of the following: erythema, blistering, dry or wet
    desquamation, epilation, ulceration. Local injuries to the skin
    evolve very slowly over time and symptoms may not manifest for days
    to weeks after exposure.

-   Conventional wound management is usually ineffective in these cases.
    Consultation with experts regarding definitive diagnosis, tissue
    dose, treatment, and prognosis is recommended.

c\) Generalized radiation exposure. When an extensive area of the body
is involved, systemic effects are more likely and depend both on the
body area and site and the radiation dose. \[See Acute Radiation
Syndrome (ARS), paragraph 6 below.\]

5\) Prevention and Treatment of Internal Contamination and
Incorporation. Treatment of internal contamination should be addressed
quickly, since incorporation, the actual entry of radioactive materials
into the cell, may follow and can result in future adverse health
effects. Radioactive materials are processed by the body in the same
manner as materials that are not radioactive. The amount of radiation
that is incorporated depends on the physiological status of the patient
as well as the physical and chemical nature of the contaminant. The rate
of incorporation is variable, and can occur rapidly within minutes, or
slowly over days to months. Thus, time can be critical and treatment
(preventing incorporation and enhancing decorporation) urgent. Several
methods of preventing incorporation (e.g., catharsis, emesis, gastric
lavage, diluting and alkalinizing medications) might be applicable
depending upon which radioactive material was involved, and can be
prescribed by a physician. Some of the medications or preparations used
in decorporation should be stocked locally.

If the event involved a nuclear release, then Potassium Iodide (KI) may
be used as a blocking agent to reduce incorporation of radioactive
iodine. Most people have heard about KI pills for use in nuclear
accidents. However, many people do not know when this is indicated, when
it will not work and when it should not be used or used with much
caution. KI is usually indicated when given within 3-4 hours of
radioactive Iodine plume exposure. It is effective only in preventing
the uptake of radioactive iodine by the thyroid gland. Only one dose is
necessary, unless exposure continues due to the short half-life of
radioactive iodine, which results in its quick decay. If exposure to
radioactive iodine is prolonged, the dose may be repeated once each 24
hours except in infants, nursing mothers and pregnancy. KI may produce
severe hypothyroidism with resultant mental retardation in the unborn
and in infants. When it is used in these conditions, a physician should
guide the treatment and follow the TSH; and if this is abnormal, the
Free T4. Because KI should be avoided in certain conditions, it is
advisable when time permits for the victim to consult their physician
prior to taking this medication.

If internal contamination is suspected or has occurred, obtaining
biological specimens is crucial. (See baseline essential diagnostic
testing, paragraph f.3 above.) The contaminated patient admitted with an
airway or endotracheal tube must be considered to be internally
contaminated.

Decorporation is the process of releasing radioactivity from the body;
and certain medications are known to increase this, thus reducing the
harmful effects of the radiation. Some of the medications or
preparations used in decorporation might not be available locally, and
should be stocked when a decontamination station is being planned and
equipped. Examples of specific agents used for selected radionuclides
are given in Attachment G. Expert guidance is available from NCRP 65,
Poison Control Centers, or call REAC/TS (865-576-3131) or the 24-hour
emergency number (865-576-1005). Please refer to the REAC/TS website for
more information on decorporation agents, such as Prussian blue and DTPA
compounds.

6\) Acute Radiation Syndrome. Acute radiation syndrome (ARS) is an acute
illness caused by irradiation of the whole body (or a significant
portion of it). It follows a somewhat predictable course and is
characterized by signs and symptoms that are manifestations of cellular
deficiencies and the reactions of various cells, tissues, and organ
systems to ionizing radiation. The acute radiation syndrome is produced
if enough radiation reaches enough sensitive tissue. Important factors
in development of ARS are a high dose, a high dose rate, penetrating
irradiation, and the degree of body exposure. The source of radiation
does not matter if the dose is high enough; it will produce the same
effect (i.e. reactor, nuclear weapon, industrial source, medical therapy
source).

Immediate, overt manifestations of the acute radiation syndrome require
a large (i.e., hundreds of rem, usually whole-body) dose of penetrating
radiation delivered over a short period of time. Penetrating radiation
comes from a radioactive source or machine that emits gamma rays,
X-rays, or neutrons. The signs and symptoms of this syndrome are
non-specific and may be indistinguishable from those of other injuries
or illness.

The ARS is characterized by four distinct phases: a prodromal period, a
latent period, a period of illness, and one of recovery or death. During
the prodromal period patients might experience loss of appetite, nausea,
vomiting, fatigue, and diarrhea; after extremely high doses, additional
symptoms such as fever, prostration, respiratory distress, and
hyperexcitability can occur. However, all of these symptoms usually
disappear in a day or two, and a symptom-free, latent period follows,
varying in length depending upon the size of the radiation dose. A
period of overt illness follows, and can be characterized by infection,
electrolyte imbalance, diarrhea, bleeding, cardiovascular collapse, and
sometimes short periods of unconsciousness. Death or a period of
recovery follows the period of overt illness.

In general, the higher the dose the greater the severity of early
effects and the greater the possibility of late effects. Depending on
dose, the following syndromes can be manifest:

-   Hematopoietic Syndrome - characterized by deficiencies of WBC,
    lymphocytes and platelets, with immunodeficiency, increased
    infectious complications, bleeding, anemia, and impaired wound
    healing.

-   Gastrointestinal Syndrome - characterized by loss of cells lining
    intestinal crypts and loss of mucosal barrier, with alterations in
    intestinal motility, fluid and electrolyte loss with vomiting and
    diarrhea, loss of normal intestinal bacteria, sepsis, and damage to
    the intestinal microcirculation, along with the hematopoietic
    syndrome.

-   Cerebrovascular/Central Nervous System Syndrome - primarily
    associated with effects on the vasculature and resultant fluid
    shifts. Signs and symptoms include vomiting and diarrhea within
    minutes of exposure, confusion, disorientation, cerebral edema,
    hypotension, and hyperpyrexia. Fatal in short time.

-   Skin Syndrome - can occur with other syndromes; characterized by
    loss of epidermis (and possibly dermis) with "radiation burns."

(For further details on management of ARS, see Attachment H*.*)

The most important clinical laboratory test to obtain is a STAT CBC with
differential. Repeat in 4-6 hours, then every 6 to 8 hours for 24 to 48
hours. Look for a drop in the absolute lymphocyte count if the exposure
was recent (see Attachment H). If the initial WBC and platelet counts
are abnormally low, consider the possibility of exposure a few days to
weeks earlier.

h\. Management of the Dead:

1\) Cadaver storage will depend upon the number of victims and amount
and type of contamination. Consult with the RSO for determination of the
safety of storage in the usual morgue area and whether decontamination
of the body/bodies is needed.

2\) Autopsies, Embalming, Burial and Cremation: Consult with the RSO for
determination of relative risk for the specific victim. Most victims
with low-level radiation contamination can be safely autopsied with
appropriate contamination control techniques and protective clothing.
The time of exposure may be limited by rotating the individual
performing the post-mortem examination.

i\. Event Follow-up should be coordinated with or directed by the RSO
and include:

1\) Personnel follow-up: Measurement of the incorporated radiation
burden of all personnel who were involved in the event should be
considered if internal radioactive contamination was involved. For
example, if radioactive iodine was the isotope involved, the thyroid
burden should be measured. Which procedures, if any, are applicable
should be determined in consultation with the RSO.

2\) Collection of waste for decay-in-storage or decontamination.

3\) Decontamination and survey of the involved areas. Before returning
any of the radioactive contamination control area to usual function, it
must be decontaminated and released by the RSO.

4\) Removal of Radioactive signage should occur [only]{.underline} after
clearance by the RSO.

j\. Psychological Stress in Radiation Events: Panic and psychological
stress should be anticipated in both patients and staff. Anticipate that
the majority of patients who present from an event involving radiation
will be experiencing acute anxiety and are at risk for both acute
psychological stress and post-traumatic stress disorder. Adequate
information provided early in the course of the event may alleviate some
of this emotional/ psychological reaction and reduce the risk of
subsequent post-traumatic stress disorder. Brief the patient on the
anticipated screening procedures, and provide the opportunity to ask
questions. If you do not know the answers, take his name and contact
information and assure him that you will have someone provide the
information to him. Do this only if you will follow-up and verify that
this is done. A patient liaison is helpful for this purpose. Staff and
patients should both receive after-action debriefing and counseling to
reduce the risk of Post-Traumatic Stress Disorder (PTSD). Although the
risks and benefits of debriefing and counseling have not been definitely
documented, at this time it is thought these are most likely beneficial.

6\. ***External Notification Procedures***.

a\. Notification requirements and pathways are determined by the amount
and type of radioactive material involved, the quantity of exposure, and
the circumstances in which the incidents occurred. The RSO for the
facility will identify the appropriate regulatory agencies requiring
notification and coordinate this with the Medical Center Director.

b\. Radiation emergencies requiring activation of the Emergency Plan may
need to be reported to: the VISN, the VA National Health Physics Program
(NHPP), the State Radiation Control Program, the Nuclear Regulatory
Commission (NRC) and OSHA, depending upon the specific circumstances.
Consult the RSO for reporting requirements.

c\. Community Entities. If the nature of the event could affect the
community, contact:

-   State/Local OES.

-   State/local Health Department (or entity assigned responsibility for
    radiation control).

7\. ***Specialized Staff Training*.** Each member of this team should be
familiar with the hospital's written plan and be required to participate
in scheduled drills. More frequent drills (quarterly or semiannually)
should be considered by subgroups such as decontamination, triage, or
radiological monitoring. Special training must be instituted to
accommodate staff turnover.

The training should include demonstrations and actual hands-on use of
equipment, as well as classroom instruction. Technical staff should be
aware of the additional resources and current information referenced in
this SOP. The emergency plan training program should also include
training, as needed, for those outside agencies which may be required to
respond to an emergency, such as police, fire, ambulance and emergency
medical personnel. This training should include specific instruction in
the institution\'s procedures for notification, basic radiation
protection, site access and the expected roles of the trainees.

8\. ***References and Resources***.

a\. Armed Forces Radiobiology Research Institute (AFRRI) Publications,
*Medical Management of Radiological Casualties Handbook*, 2^nd^ edition,
April 2003, and Terrorism with Ionizing Radiation Pocket Guide.

b\. Centers for Disease Control and Prevention Radiation Emergencies
Page.
([www.bt.cdc.gov/radiation/index.asp](http://www.bt.cdc.gov/radiation/index.asp)
and <http://www.bt.cdc.gov/radiation/index.asp#clinicians>).

c\. CDC Radiation Emergencies Interim Guidelines for Hospital Response
to Mass Casualties from a Radiological Incident; Smith, JM, and Spano,
MA, December 2003.
(<http://www.bt.cdc.gov/radiation/pdf/MassCasualtiesGuidelines.pdf>).

d\. Center for Risk Communication.
(<http://www.centerforriskcommunication.com/home.htm>) and
(<http://www.centerforriskcommunication.com/links.htm>).

e\. *Medical Treatment of Radiological Casualties*, Department of
Homeland Security Working Group on Radiological Dispersal Device
Preparedness.
(<http://www1.va.gov/emshg/docs/Radiologic_Medical_Countermeasures_051403.pdf>).

f\. *Disaster Medicine*; Hogan and Burnstein, 2002.

g\. *Disaster Preparedness for Radiology Professionals, Response to
Radiological Terrorism, A Primer for Radiologists, Radiation
Oncologists, and Medical Physicists.* American College of Radiology
Disaster Preparedness Task Force, Version 2.1, 2002.
(<http://www.acr.org/s_acr/bin.asp?TrackID=&SID=1&DID=13945&CID=968&VID=2&DOC=File.PDF>).

h\. The Food and Drug Administration, US Food and Drug Administration
Radiological Emergency Response Plan, April 26, 2004.
(<http://www.fda.gov/oc/ocm/radplan.html>).

i\. The Health Physics Society. ([www.hps.org/](http://www.hps.org/)).

j\. *Medical Management of Radiation Accidents*; Gusev, Guskova,
Mettler; 2001.

k\. The Medical Basis for Radiation-Accident Preparedness; REAC/TS
Conference, 2002.

l\. Mettler and Voelz, *Major Radiation Exposure - What to Expect and
How to Respond*, New England Journal of Medicine, 2002; 346: 1554-61.

m\. National Council on Radiation Protection and Measurement Report No.
111, *Developing Radiation Emergency Plans for Academic, Medical or
Industrial Facilities. (*<http://www.ncrponline.org/ncrprpts.html>)

n\. National Council on Radiation Protection and Measurement Report No.
65, *Management of Persons Accidentally Contaminated With
Radionuclides*, 1980. (<http://www.ncrponline.org/ncrprpts.html>).

o\. National Council on Radiation Protection and Measurement Report No.
138, *Management of Terrorist Events Involving Radioactive Material*,
2001. (<http://www.ncrponline.org/ncrprpts.html>).

p\. Oak Ridge Associated Universities Radiation Emergency Assistance
Center/Training Site. (<http://www.orau.gov/reacts/guidance.htm>).

q\. VHA Emergency Management Program Guidebook.
([http://vaww.ceosh.med.va.gov](http://vaww.ceosh.med.va.gov/)).

r\. VHA Office of Quality and Performance, Pocket Card, Radiological
Terrorism. (<http://www.oqp.med.va.gov/>).

s\. Waselenko, JK, et al. *Medical Management of the Acute Radiation
Syndrome: Recommendations of the Strategic National Stockpile Radiation
Working Group*, Annals of Internal Medicine, Jun 2004; 140: 1037 - 1051.
(<http://www.annals.org/cgi/content/full/140/12/1037?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=Waselenko&searchid=1104356267873_4683&stored_search=&FIRSTINDEX=0&journalcode=annintmed>)

t\. Many other federal agencies and entities have resources for current
advice and assistance. Three prominent groups for peacetime response
are:

> 1\) Oak Ridge Institute for Science and Education
>
> REAC/TS (Radiation Emergency Assistance Center/Training Site)
>
> Attn: Pat Cooley
>
> P.O. Box 117, MS 39
>
> Oak Ridge, TN 37831-0117
>
> Phone: 865-576-3131

FAX: 865-576-9522

> 2\) Medical Radiobiology Advisory Team (MRAT)
>
> Armed Forces Radiobiology Research Institute
>
> National Naval Medical Center
>
> 8901 Wisconsin Avenue, Building 42
>
> Bethesda, MD 20889-5603

301-295-0316

3\) VHA Medical Emergency Radiological Response Team (MERRT)

Team Leader: Lawrence Flesh, MD

Emergency Management Strategic Healthcare Group (EMSHG)

VA Medical Center

Albany, NY 12208

Phone: 518-626-5515 (Administrative)

518-626-7315 (Clinical)

**Acknowledgement**: Much of the material in this SOP is taken from
<http://www.orau.gov/reacts/guidance.htm>.

9\. ***Review Date.***

(Name)

Chief, (Service)

Attachments:

A. Types of Radioactive Contamination.

B. Potential or Known Radiation Event: Initial Facility Contact Report,
Treatment for Selected Internal Contaminants.

C. Initial Multiple Radiation Victim Report.

D. Radiation Event Supplies.

E. Radiation Instrumentation and Screening.

F. Radiation Patient Intake Screening Tool.

G. Treatment for Selected Internal Contaminants.

H. Acute Radiation Syndrome and the Andrew's Nomogram.

I. General Order of Medical Care for the Contaminated Injured Patient.

J. Cytogenetic Assessment of Radiation Dose.

K. Radiation in Combination with Other Agents.

L. Management of the Moderately to Severely Irradiated Patient.

M. Key Activity Management Structure.

*Sample 6.2.3.4*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Explosion -- Internal VAMC Event (Engineering and Evacuation
Considerations)**

1.  ***Description of the Threat/Event*.** Internal explosion events
    occurring within a VA Medical Center (VAMC) will tax emergency
    response to its fullest capability. Whether the event is a local
    failure, such as a boiler, or the result of another emergency, such
    as a terrorist event, any explosion in the Medical Center may result
    in large numbers of casualties, inability to maintain medical
    treatment capabilities and property damage. As with fires, proper
    and quick response to this event will lessen the impact and may
    possibly save lives.

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1.  ***Impact on Mission Critical Systems.*** Although an explosion at
    the Medical Center is a rare event, the impact to patients, visitors
    and employees, as well as the infrastructure, can be high. It is
    most important that VAMCs keep peripheral Standard Operating
    Procedures (SOPs) current. For example, SOPs governing critical
    engineering systems, evacuation, transportation and alternative care
    sites must be kept current in order to properly respond to this
    event.

2.  ***Operating Units and Key Personnel with Responsibility to Manage
    this Threat/Event.***

-   Medical Center Director

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-   Safety and Security

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-   Health and Medical

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-   Equipment, Plant and Utilities

4\. ***Mitigation/Preparedness Activities of the Threat/Event***.

a\. Conducting proper preventive maintenance and inspections on critical
systems that may directly or indirectly cause explosions. Examples
include boilers, oxygen systems, compressed gas systems.

b\. Inspect storage areas that may indirectly cause explosions, such as
flammable liquids storage, chemical storage (incompatibles), and storage
of materials around heating devices.

c\. Install and properly maintain fire protection, detection and alarm
systems.

d\. Oversee and document all vendor-performed work.

e\. Conduct training and evaluation of drills/exercises.

5.  ***Response/Recovery from the Event/Threat.***

    a.  *Hazard Control Strategies and Resource Issues.* This includes
        an assessment of those areas that are particularly vulnerable to
        an actual threat/event. For example, if the oxygen system were
        lost due to its involvement at or near the explosion, this would
        affect all critical patient care areas.

    b.  *Hazard Monitoring Strategies***.** The VAMC will need to
        develop procedures to monitor the impact of the threat/event on
        mission-critical functions. For example, in the case of an
        explosion, monitoring damage/fire spread, casualty information,
        system(s) performance and staff availability, is critical to
        ensuring proper response.

    c.  *Recovery Strategies.* Assess critical systems performance
        continuously and initiate repair or replacement, as soon as
        feasible.

    d.  See Attachments A and B - Key Activity Management Tool and Key
        Activity Management Structure.

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6.  ***External Notification Procedures.***

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a.  *Within VA.* VISN Directors.

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a.  *Other Federal Facilities.*

-   Occupational Safety and Health Administration (OSHA) - Notify within
    eight (8) hours of one (1) employee fatality, or three (3) employee
    hospitalizations resulting from a single incident.

-   Environmental Protection Agency (EPA).

c.  *Other.* Joint Commission on Accreditation of Healthcare
    Organizations (JCAHO).

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c.  *Community Entities.* Because of the VAMC's relationship to the
    community, it is likely that there are specific entities within the
    community that should be notified that a threat/event has occurred.
    In many cases, this notification will trigger a community response
    to the threat/event, e.g. local Fire Department.

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7.  ***Specialized Staff Training.***

a\. Training on emergency patient transfer techniques.

b\. Training on vertical evacuation training.

c\. Training on evacuation training for operating units, Intensive Care
Units (ICUs) and Emergency Rooms (ERs).

d\. Conduct training on patient life support systems.

8.  ***References and Further Assistance.***

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a.  VHA Emergency Management Program Guidebook, Section 6, Sample
    Standard Operating Procedures (SOPs) related to this topic.

-   Alternate Care Sites, Section 6.3.3.1.

-   Decontamination, Section 6.3.3.2.

-   Triage During a Mass Casualty Incident, Section 6.3.3.4.

-   Trauma Management in a Mass Casualty Incident (MCI)/Blasts and
    Explosions, Section 6.3.3.5.

-   VHA Pharmacy Cache, Section 6.3.3.6.

-   Evacuation (Total), Section 6.3.3.7.

-   Fatality Management, Section 6.3.3.8.

-   Mass Casualty Incident, Section 6.3.3.9.

-   Alerting and Warning Systems, Section 6.3.4.1.

-   Facility Access Control, Section 6.3.4.2.

-   Lockdown/Security - Heightened Security Procedures, Section 6.3.4.3.

-   Fire Suppression System Failure, Section 6.3.4.4.

a.  All Operating Units in the medical center should review their
    operating unit templates for response/recovery activities.

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8.  ***Review Date.***

(Name)

Chief, (Service)

Attachments:

A. Key Activity Management Tool

B. Key Activity Management Structure

*Sample 6.3.1.1*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Business Relocation**

1.  ***Description of the Threat/Event*.** Business relocation becomes
    necessary when all, or a portion of the VA Medical Center and/or its
    supporting critical system infrastructure becomes damaged or
    rendered non-operational. Business relocation refers to the planning
    for and execution of plans and procedures to continue critical
    patient and non-patient functions at alterative sites, or by using
    alternative methods and procedures (such as contracting). A plan for
    business relocation is critical to providing continuity of care to
    the eligible patient population.

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1.  ***Impact on Mission Critical Systems.*** N/A.

2.  ***Operating Units and Key Personnel with Responsibility to Manage
    this Threat/Event**.* All operating units that have critical
    functions to perform must be included within this SOP.

3.  ***Mitigation/Preparedness Activities of the Threat/Event*.**

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a.  *Hazard Reduction Strategies and Resource Issues*. N/A.

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a.  *Preparedness Strategies and Resource Issues.* Preparedness for
    business relocation can be approached in several ways depending upon
    availability of local internal and external resources to rapidly
    replicate the critical functions that have been damaged or otherwise
    rendered non-operational (*Note to Writer: See sample SOP on Patient
    Access to Services, Section 6.3.1.4 in the Emergency Management
    Program Guidebook*). The approaches used most likely will include
    one or a combination of the following:

-   Relocation of the damaged or non-operational function to another
    available building (or structure such as a tent or trailer), on or
    off-site.

-   Contracting for necessary health care delivery services.

-   Sharing of functions or services with other community health care
    delivery facilities.

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-   Transfer of functions to another VA Medical Center or community
    health care delivery resource.

All of the above are only to be considered as "temporary" approaches
that would be in effect for no more than 60 days. Within that timeframe,
either the Medical Center or systems would have to be restored to full
operation; a decision rendered by higher VA authority to extend
temporary operations until the primary Medical Center and systems can be
restored; or a decision made by VA not to repair or replace the damaged
Medical Center or support system. In the latter case, arrangements would
have to be made for permanent relocation of all or a portion of business
functions. (For example, as a result of the damage to the inpatient
building of a VA Medical Center resulting from the 1994 Northridge
earthquake, a decision was made by VA not to replace the building and
continue to provide inpatient services at the Medical Center. The
Medical Center's mission was then changed to the provision of only
outpatient services.)

5\. ***Response/Recovery from the Threat/Event.***

a.  Hazard Control Strategies. N/A.

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a.  Hazard Monitoring Strategies. N/A.

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a.  Recovery Strategies. N/A.

6\. ***External Notification Procedures.***

a.  *Within VA*. Implementation of plans and procedures to relocate
    functions and activities must be reported to the VISN. In addition,
    if relocation affects other VA medical facilities within or outside
    of the VISN, these facilities will require notification.

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a.  *Other Federal Agencies.* As applicable. If there are other federal
    agencies and departments within the area that will be affected by
    the relocation of the local VA Medical Center's functions, they will
    require notification. This is especially true if the Medical Center
    must suspend or otherwise make arrangements for the provision of
    services that are provided to these agencies or departments under
    local agreements. These must be carefully reviewed in terms of legal
    obligations and consequences if the local VA either cannot meet the
    agreement's provisions, or cancels the agreement.

-   OSHA -- Notify within eight (8) hours of one (1) employee fatality,
    or three (3) employee hospitalizations resulting from a single
    incident.

c\. *Community Entities*. As above. If there are community entities that
are affected by the relocation, they must be included. It is critical
that Veterans Service Organizations (VSOs) and local Public Information
outlets (radio, TV, newspaper) are informed to provide information to
the eligible VA population of both the availability and location of
displaced services and functions.

7\. ***Specialized Staff Training.*** Staff of all functional activities
needs to be aware of relocated functional locations and when these will
be implemented.

8\. ***References and Further Assistance.***

a.  VHA Emergency Management Program Guidebook.

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a.  All Operating Units in the medical center should review their
    operating unit templates for response/recovery activities.

9\. ***Review Date.***

(Name)

Chief, (Service)

*Sample 6.3.1.2*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Communications Disruption**

1\. ***Description of the Threat/Event*.** The disruption of telephones,
mail, faxes, radios, and pagers are addressed.

2\. ***Impact on Mission Critical Systems***. Some systems affected
would be:

-   Access to Services - Appointment scheduling, telephone triage
    service to outpatients, patient ordering of prescription refills.

-   Ordering Supplies.

-   Patient treatments/procedures delayed due to slowed communications
    among staff (Laboratory, X-ray, Pharmacy, Codes Red, and Blue).

-   Safety and Security functions may be less efficient/effective due to
    reduced communications (Codes Red, Blue).

3\. ***Operating Units and Key Personnel with Responsibility to Manage
this Threat/Event.***

-   Medical

-   Safety and Security

-   Information Management

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-   Logistics

4\. ***Mitigation/Preparedness Activities of the Threat/Event.***

a\. *Hazard Reduction Strategies and Resource Issues.*

-   Invest in most reliable communications systems, ensure good
    maintenance and repair and have several back-ups.

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-   Establish redundant systems.

b\. *Preparedness Strategies and Resource Issues.*

-   Develop and test operating unit templates for communication systems
    failure.

5\. ***Response/Recovery from the Threat/Event.***

a.  *Hazard Control Strategies*. N/A

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a.  *Hazard Monitoring Strategies.*

-   Develop plan for monitoring and reporting of outages, consequences
    and interim communication methods

c.  *Recovery Strategies.*

-   Consider use of cell phones, e-mail, couriers, satellite phones, and
    radios.

d\. *See Attached Charts: Key Activity Management Tool/Structure.*

6\. ***External Notification Procedures.***

a.  *Within VA.* If the VHA facility is made aware of a threat/event,
    whom within VA should they notify? If a threat/event occurs, whom
    within VA should they notify?

-   Check Network policy for need to notify.

b.  *Other Federal Agencies.* Depending on the threat/event, certain
    federal agencies (FEMA, Department of Health and Human Services,
    OSHA, Centers for Disease Control, EPA) may need to be notified. For
    example:

-   OSHA - Notify within eight (8) hours of one (1) employee fatality,
    or three (3) employee hospitalizations resulting from a single
    incident.

b.  *Community Entities.* Because of the VA Medical Center's
    relationship to the community, it is likely that there are specific
    entities within the community that should be notified that a
    threat/event has occurred. In many cases, this notification will
    trigger a community response to the threat/event.

-   Community entities may need to be notified, depending upon the VA
    Medical Center's role in the community.

7\. ***Specialized Staff Training*.** This section outlines a
description of necessary strategies to secure the unique resources
(staff, supplies, etc.) needed to appropriately respond to this type of
threat/event.

8\. ***References and Further Assistance.***

a\. VHA Emergency Management Program Guidebook.

b\. All Operating Units in the medical center should review their
operational unit templates for response/recovery activities.

9\. ***Review Date.***

(Name)

(Title)

Attachments:

A.  Key Activity Management Tool

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A.  Key Activity Management Structure

*Sample 6.3.1.3*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Critical Supplies Shortage**

1.  ***Description of the Threat/Event*.** The shortage of critical
    supplies such as treatment drugs or vaccines during an epidemic.

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1.  ***Impact on Mission Critical Systems.*** Shortages of critical
    supplies may be caused by or exacerbated by an epidemic triggering
    increased demands for out-patient appointments and admissions, which
    tax other resources.

2.  ***Operating Units and Key Personnel with Responsibility to Manage
    this Threat/Event.***

-   Medical - Patient Care, Pharmacy.

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-   Logistics - Procurement.

4.  ***Mitigation/Preparedness Activities of the Threat/Event.***

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a.  *Hazard Reduction Strategies and Resource Issues.*

    -   Consider stockpiling critical supplies.

    -   Quick-ship contracts.

-   Agreements within the community to \"borrow\" supplies.

b\. *Preparedness Strategies and Resource Issues.* N/A.

4.  ***Response/Recovery from the Threat/Event.***

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a.  *Hazard Control Strategies*. This includes an assessment of those
    areas, which are particularly vulnerable to an actual threat/event.
    For example, the emergency room would be considered a vulnerable
    area if there were a release of a chemical agent in the community,
    since it is likely that exposed victims could walk into the
    emergency room seeking treatment from the VA Medical Center.
    Strategies should be identified for limiting exposure for vulnerable
    locations and areas that are critical to the mission of the Medical
    Center, such as patient care.

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a.  *Hazard Monitoring Strategies.*

-   Operating Units can monitor needs and stock of critical supplies.
    This activity will be made more difficult in the case of unexpected
    epidemics. The focus might be aimed at prioritizing likely events
    and needs in a quickly changing environment.

c.  *Recovery Strategies*.

    -   Quick-ship contracts.

-   Agreements with other community hospitals to share short supplies.

6\. ***External Notification Procedures.***

a.  *Within VA.* If the VA Medical Center is made aware of a
    threat/event, whom within VA should they notify? If a threat/event
    occurs, whom within VA should they notify?

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a.  *Other Federal Agencies.* Depending on the threat/event, certain
    federal agencies (FEMA, Department of Health and Human Services,
    OSHA, Centers for Disease Control, EPA) will need to be notified.

b.  OSHA -- Notify within eight (8) hours of one (1) employee fatality,
    or three (3) employee hospitalizations resulting from a single
    incident.

c.  *Community Entities.* Because of the VA Medical Center's
    relationship to the community, it is likely that there are specific
    entities within the community that should be notified that a
    threat/event has occurred. In many cases, this notification will
    trigger a community response to the threat/event.

7\. ***Specialized Staff Training.***

8\. ***References and Further Assistance.***

a.  VHA Emergency Management Program Guidebook.

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a.  All Operating Units in the medical center should review their
    operating unit templates for response/recovery activities.

9\. ***Review Date.***

(Name)

(Title)

*Sample 6.3.1.4*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Patient Access to Services**

1.  ***Description of the Threat/Event*.** The ability of the VA Medical
    Center to ensure continuity of care to Veterans is directly linked
    to its ability to maintain unimpeded access to those services.
    Denial or restriction of access can be created by physical and other
    barriers, an acute increase in demand for services (e.g., response
    to an epidemic or mass casualty event), and/or loss or reduction of
    capability − all of which can result from the Medical Center being
    affected by a natural, technological or man-made disaster.

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1.  ***Impact on Mission Critical Systems.*** N/A.

2.  ***Operating Units and Key Personnel with Responsibility to Manage
    this Threat/Event.*** All.

3.  ***Mitigation/Preparedness Activities for the Threat/Event*.**

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a.  *Hazard Reduction Strategies and Resource Issues.* (See applicable
    SOPs on Hazards.)

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a.  *Preparedness Strategies and Resource Issues*. Preparedness
    strategies focus on having alternatives and "work arounds" for each
    of the areas that may create access problems for the served Veteran
    population. Each situation or barrier should have in place a planned
    response or set of responses. The following are some examples:

  ---------------------------------- ------------------------------------
  Situation                          Response

  Flooded roadways leading to the    Outreach using mobile vans,
  Medical Center.                    establishment of temporary clinics,
                                     use of alternative facilities,
                                     increase in use of mailed
                                     prescription program.

  Epidemic (Increase in demand)      Outreach for provision of
                                     prophylaxis, use of staff from other
                                     VA Medical Centers, resource sharing
                                     with other VA Medical Centers.
                                     Extension of clinics' hours. Refer
                                     to sister hospitals.

  Public Transportation Strike       Use of Volunteer Service vans and
                                     personnel; Outreach.

  Medical Center non-operational.    Transfer agreements; MOUs for use of
  (Closed − short-term)              alternative sites for primary care
                                     and screening; referrals/transport
                                     of patients to other VA Medical
                                     Centers or local medical facilities.
  ---------------------------------- ------------------------------------

5.  ***Response/Recovery from the Threat/Event.*** Refer to applicable
    critical system(s) failure SOP(s). **(**"Work arounds" and
    alternatives are short term fixes to minimize and mitigate the
    consequences from an event. To restore full access to services will
    necessitate removal of the access barrier. For example, flooded
    roadways will have to again be made passable, or Medical Center
    damage or systems failure that closed a Medical Center will have to
    be repaired or otherwise addressed. Accordingly, reference will have
    to be made to the applicable SOP addressing the critical system or
    systems failure.)

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5.  ***External Notification Procedures.*** Any event that causes a
    deviation from normal operations resulting in the actual or
    potential restriction of access to services for the Veteran
    population is reportable.

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a.  *Within VA.* VISN.

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a.  *Other Federal Agencies.* As determined by VISN /VA Headquarters.

-   OSHA -- Notify within eight (8) hours of one (1) employee fatality,
    or three (3) employee hospitalizations resulting from a single
    incident.

c.  *Community Entities*.

-   Local hospitals

-   EMS

-   VSOs

-   Public Information Sources (for informing the Veteran population).

6.  ***Specialized Staff Training.*** See applicable SOP*.* (Medical
    Center staff will have to be aware of the procedures that will be
    instituted in each of the situations that may affect access to
    services.)

8\. ***References and Further Assistance.***

a.  VHA Emergency Management Program Guidebook.

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a.  All Operating Units in the medical center should review their
    operating unit templates for response/recovery activities.

9\. ***Review Date.***

(Name)

(Title)

*Sample 6.3.1.5*

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Records Preservation**

1.  ***Description of the Threat/Event*.** Unless protected, records can
    be destroyed or rendered inaccessible as a consequence of a variety
    of events including fire, water leakage, and cyber attacks. While
    the loss of some records may not pose a significant problem, certain
    records are critical to ensure continuity of care for the Veteran
    population, as well as continuation of the VA Medical Center
    operations.

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1.  ***Impact on Mission Critical Systems.*** N/A***.***

2.  ***Operating Units and Key Personnel with Responsibility to Manage
    this Threat/*Event.**

-   Patient Care Services

-   Ancillary Services

-   Inpatient Units

-   Clinics

-   Administration

-   Business Office

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-   Information Resources Management

3.  ***Mitigation/Preparedness Activities for the Threat/Event*.**

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a.  *Hazard Reduction Strategies and Resource Issues.* (See applicable
    SOPs.on Hazards.)

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a.  *Preparedness Strategies and Resource Issues.* Preparedness
    strategies with regard to protection of critical records lend
    themselves to a procedural approach so that: 1) vital records can be
    protected; and, 2) resources necessary to protect those records are
    the result of careful evaluation and planning. The suggested steps
    are as follows:

-   Step 1. Identify critical records and where they are located.

-   Step 2. Assess storage sites for vulnerabilities to theft and damage
    from water, fire and other hazards.

-   Step 3. Assess procedures for handling, tracking and return of
    records.

-   Step 4. Based upon the assessment, implement physical and procedural
    mitigation actions that will serve to protect the records from the
    hazards identified. (Examples include fire-rated cabinets, improved
    locks and limited access, waterproof containers, and record
    relocation.)

-   Step 5. Determine which records, in priority order, that would need
    to be removed or retrieved from a facility in an evacuation -- given
    time and staff resources to do so. (For example, inpatient treatment
    records should have the highest priority for relocation if inpatient
    units are being evacuated.)

-   Step 6. Determine, based upon vulnerabilities and criticality, which
    records should be duplicated and stored in other locations including
    off-site.

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-   Step 7. Initiate procedures for duplication of records (For example,
    daily backups for AIS and tape storage).

4.  ***Response/Recovery from the Threat/Event.***

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a.  *Hazard Control Strategies*. N/A.

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a.  *Hazard Monitoring Strategies***.** N/A.

c\. *Recovery Strategies.*

-   Recovery strategies will vary depending upon the extent and
    thoroughness of the preparedness actions taken. This could range
    from simple retrieval of records from their storage location during
    the recovery process, to acquiring the backup tapes and records from
    off-site storage facilities. Even if damaged, there are specialized
    document and information system restoration and retrieval services
    available that may be able to salvage and restore some records.

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-   Locations and contact numbers of these services should be included
    in the standard operating procedure.

5.  ***External Notification Procedures.*** To the extent that loss of
    records will affect continuity of operations, especially patient
    care, and/or have legal implications, the loss of these records must
    be reported.

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a.  *Within VA*. VISN.

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a.  *Other Federal Agencies*. OSHA -- Notify within eight (8) hours of
    one (1) employee fatality, or three (3) employee hospitalizations
    resulting from a single incident.

c\. *Community Entities.* To be determined.

6.  ***Specialized Staff Training*.** Staff training should focus on the
    procedures implemented for the handling, tracking and securing of
    records. Applicable staff should also be aware of the location and
    procedures to be used regarding the removal of critical records in
    advance of a potential hazard occurring, or as applicable, in the
    response or recovery process.

8\. ***References and Further Assistance.***

a.  VHA Emergency Management Program Guidebook.

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a.  All Operating Units in the medical center should review their
    operating unit templates for response/recovery activities.

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9.  ***Review Date.***

(Name)

(Title)

*Sample 6.3.1.6*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Staffing Shortage**

1.  ***Description of the Threat/Event*.** An acute staffing shortage
    may arise from an epidemic, a mass casualty event, and a community
    wide situation (such as a blizzard) causing difficulty in
    transportation or fears of lack of safety.

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1.  ***Impact on Mission Critical Systems.*** Potential impact on all
    systems.

2.  ***Operating Units and Key Personnel with Responsibility to Manage
    this Threat/Event***. There is potential impact on all Operating
    Units.

3.  ***Mitigation/Preparedness Activities of the Threat/Event.*** State
    several objectives for:

a\. *Hazard Reduction Strategies and Resource Issues.*

-   Eliminate or reduce labor intensive activities through automation.

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-   Vaccinate staff against infectious diseases.

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-   Organize 4-wheel drive teams for weather-related problems.

b\. *Preparedness Strategies and Resource Issues.* Develop
service-specific short staffing plans.

5\. ***Response/Recovery from the Threat/Event.***

a\. *Hazard Control Strategies.*

-   Outsourcing staffing contracts.

-   Quick ship contracts (Example -- disposable sterile supplies and
    instruments).

-   Admissions -- Diverting incoming patients, discharging or
    transferring inpatients.

-   Postponing non-emergent clinic appointments and procedures.

-   Cross-training of staff for essential functions.

-   Organize 4-wheel drive transportation.

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-   Extended tours of duty.

b\. *Hazard Monitoring Strategies**.***

-   Staffing levels monitored in each functional unit.

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-   Monitor business continuity factors.

c\. *Recovery Strategies.* N/A.

d\. *See Attached Charts: Key Activity Management Tool/Structure.*

6\. ***External Notification Procedures.***

a\. *Within VA.* Notify VISN Director, as required.

b\. *Other Federal Agencies.* OSHA -- Notify within eight (8) hours of
one (1) employee fatality or three (3) employee hospitalizations
resulting from a single incident.

c\. *Community Entities.* Notify community entities if patients diverted
or transferred, as indicated in community emergency plans.

7\. ***Specialized Staff Training.*** Cross-training of staff for
critical functions.

8\. ***References and Further Assistance.***

a\. VHA Emergency Management Program Guidebook.

b\. All Operating Units in the medical center should review their
operating unit templates for response/recovery activities.

9\. ***Review Date.***

(Name)

(Title)

Attachments:

A.  Key Activity Management Tool

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A.  Key Activity Management Structure

*Sample 6.3.1.7*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **VISTA and Other Computer Systems Disruption**

1.  ***Description of the Threat/Event*.** Disruption of VISTA and other
    widely used software programs, such as CPRS, may be due to
    accidental or intentional causes. *(See SOPs for Cyber Attack and
    Electrical Power Failure.)* Regardless of the cause, this SOP
    addresses the consequences. Mitigation and recovery strategies may
    be affected by the cause.

2\. ***Impact on Mission Critical Systems.***

-   Management Planning and Intelligence Functions may be slowed by loss
    of VISTA and Outlook email communication.

-   Automated Logistics, Finance, Administration functions will be
    non-operational until the software functions are restored.

-   Business Continuity Functions (such as appointment scheduling and
    medical records preservation) will be non-operational until software
    functions are restored.

-   Safety and Security Functions may be compromised if warning,
    security, and fire suppression systems are computerized.

-   Health and Medical Functions that are computerized (CPRS, Pharmacy)
    will be non-operational.

*3. **Operating Units and Key Personnel with Responsibility to Manage
this Threat/Event.***

-   Information Management Service

-   Logistics

-   Business Continuity

-   Safety and Security

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-   Health and Medical

4\. ***Mitigation/Preparedness Activities of the Threat/Event***. State
several objectives for:

a\. *Hazard Reduction Strategies and Resource Issues.* Information
Security measures including software backup/recovery procedures.

b\. *Preparedness Strategies and Resource Issues.* Generate Operating
Unit Templates for specific strategies.

5\. ***Response/Recovery from the Threat/Event.***

a\. *Hazard Control Strategies.*

-   Repair or restore system.

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-   Designate alternate processing sites.

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-   Rebuild VISTA.

-   Contact software/service providers for assistance.

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-   Implement manual information systems.

b\. *Hazard Monitoring Strategies**.***

-   Status reports by IRM.

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-   Status reports by Operating Units.

c\. *Recovery Strategies.* Maintain independent PCs not affected by
disruption.

d\. *See Attached Charts: Key Activity Management Tool/Structure.*

6\. ***External Notification Procedures.***

a.  *Within VA*. Determine need to notify VISN.

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a.  *Other Federal Agencies.* Depending on the threat/event, certain
    federal agencies (FEMA, Department of Health and Human Services,
    Centers for Disease Control, OSHA, EPA) will need to be notified.
    For example, OSHA -- Notify within eight (8) hours of one (1)
    employee fatality or three (3) employee hospitalizations resulting
    from a single incident.

b.  *Community Entities.* Because of the VA Medical Center's
    relationship to the community, it is likely that there are specific
    entities within the community that should be notified that a
    threat/event has occurred. In many cases, this notification will
    trigger a community response to the threat/event.

7\. ***Specialized Staff Training.***

-   Information security training.

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-   IRM staff technical training.

8\. ***References and Further Assistance.***

a.  VHA Emergency Management Program Guidebook.

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a.  All Operating Units in the medical center should review their
    operating unit templates for response/recovery activities.

9\. ***Review Date*.**

(Name)

(Title)

Attachments:

A. Key Activity Management Tool

B. Key Activity Management Structure

*Sample 6.3.2.1*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Alarm Systems Failure**

1\. ***Description of the Threat/Event*.** Failure of security, medical
and safety alarms due to power failure or alarm system failure. Alarms
include fire, code blue, intrusion, nurse call, elevators, refrigeration
of drugs, blood, food, and lab samples.

2\. ***Impact on Mission Critical Systems.*** Failure of alarms will
impact:

-   **Health and Medical** - Pharmacy and Lab security and drug safety,
    code blue response, medical gas delivery, locked ward security
    alarms, wander guards, refrigeration alarms

-   **Safety and Security** - Intrusion alarms, fire alarms, ethylene
    oxide alarms, exhaust hood function alarms

-   **Plant and Utilities** - Alarms for operations of systems for
    boiler plant, HVAC, medical gas, refrigeration alarms, fire alarms.

-   **Logistics and Finance** - Security alarms.

-   **Telecom/Information Management** - Security alarms.

3\. ***Operating Units and Key Personnel with Responsibility to Manage
this Threat/Event.***

-   Infection Control

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-   Safety and Security

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-   Plant and Utilities

-   Health and Medical

-   Logistics and Finance

-   Telecom/Information Management

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-   Management Planning and Intelligence

4\. ***Mitigation/Preparedness Activities of the Threat/Event.***

a\. *Hazard Reduction Strategies and Resource Issues.*

-   Eliminate/reduce need for alarms.

-   Ensure critical systems are on emergency power outlets.

-   Conduct preventive maintenance.

-   Ensure adequate supplies of critical materials that are alarmed
    (medical gas).

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-   Develop and implement comprehensive monitoring of alarm operation
    and the events they are designed to alert − a manual back-up system.

b\. *Preparedness Strategies and Resource Issues.*

-   Develop back up systems such as portable medical gas.

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-   Train for back-up procedures.

5\. ***Response/Recovery from the Threat/Event.***

a\. *Hazard Control Strategies*.

-   Identify back-up supplies and procedures (portable medical gas, fire
    watch, airflow testing, security checks).

-   Quick-ship contracts for critical supplies and equipment that are
    alarmed for shortages.

-   Consider redundant alarm or monitoring systems.

-   Increase safety and security surveillance (air monitoring, video
    surveillance, physical inspection).

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-   Develop and post emergency response contact information and
    procedures for each operating unit.

b\. *Hazard Monitoring Strategies***.**

-   Refrigerator/freezer temperature recorders.

-   Alarm testing and reporting.

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-   Activate back-up plans.

c\. *Recovery Strategies.* N/A*.*

d\. *See Attached Charts: Key Activity Management Tool/Structure.*

6\. ***External Notification Procedures.***

a.  *Within VA.* If the VA Medical Center is made aware of a
    threat/event, whom within VA should they notify? If a threat/event
    occurs, whom within VA should they notify?

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a.  *Other Federal Agencies.* Depending on the threat/event, certain
    federal agencies (FEMA, Department of Health and Human Services,
    OSHA, Centers for Disease Control, EPA) will need to be notified.
    OSHA -- Notify within eight (8) hours of one (1) employee fatality,
    or three (3) employee hospitalizations resulting from a single
    incident.

b.  *Community Entities.* Because of the VA Medical Center's
    relationship to the community, it is likely that there are specific
    entities within the community that should be notified that a
    threat/event has occurred. In many cases, this notification will
    trigger a community response to the threat/event.

7\. ***Specialized Staff Training*.** This section outlines a
description of necessary strategies to secure the unique resources
(staff, supplies, etc.) needed to appropriately respond to this type of
threat/event.

-   Staff training and drills on alarm failure procedures.

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-   Alarm testing and maintenance procedures.

8\. ***References and Further Assistance.***

a.  VHA Emergency Management Program Guidebook.

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a.  All Operating Units in the medical center should review their
    operating unit templates for response/recovery activities.

9\. ***Review Date.***

(Name)

(Title)

Attachments:

A.  Key Activity Management Tool

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A.  Key Activity Management Structure

*Sample 6.3.2.2*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Electrical Power Failure**

1.  ***Description of the Threat/Event*.** A utility electrical power
    failure, which is followed by activation of the emergency
    generator(s), which provides power to, selected electrical outlets
    and lighting.

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1.  ***Impact on Mission Critical Systems.*** With the loss of power
    from the utility power source, the emergency generator(s) will
    activate, but electrically powered equipment and systems not
    connected to designated emergency power outlets will not be
    operational. Examples may include:

-   Lighting − (Emergency lighting should be provided by battery power
    in areas such as stairwells.)

-   HVAC and ancillary support equipment.

-   Communications -- Public address systems; telephone/signal closets;
    computer servers and peripherals.

-   Special Ventilation -- Special exhaust systems (negative or positive
    pressure rooms, clean benches, biological safety cabinets and fume
    hoods in Research, Pharmacy, Pathology, Nuclear Medicine and
    Clinical Laboratory.)

-   Fire and Security alarms.

-   Refrigerators for food and medicines may not be on emergency power.

-   Sterilizers.

-   Trash compacting.

-   Various office equipment.

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-   Various medical equipment.

3\. ***Operating Units and Key Personnel with Responsibility to Manage
this Threat/Event.***

-   Facilities Engineering

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-   Health and Medical

-   Information Management

-   Logistics

-   Biomedical

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-   Safety and Security

4\. ***Mitigation/Preparedness Activities of the Threat/Event.*** State
several objectives for:

a\. *Hazard Reduction Strategies and Resource Issues.*

-   Emergency generator and power distribution testing, and preventive
    maintenance, fuel supply, adequacy of number of emergency power
    outlets (and placement), backup fuel supplies, routes of egress from
    dark areas must be lighted by emergency lighting. Stock flashlights,
    batteries, disposable sterile supplies and equipment. Install and
    test emergency lighting.

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-   Adequate uninterrupted power supply to critical equipment and
    systems must be provided.

b\. *Preparedness Strategies and Resource Issues.* Documented training
of all clinical staff on the proper identification and use of emergency
power must be accomplished. Each operating unit must have a plan of
action to address power outages. Clinical staff must prepare contingency
plans for rapid deployment of battery powered equipment (e.g., portable
suction units).

5\. ***Response/Recovery from the Threat/Event.***

a\. *Hazard Control Strategies.* When a power outage occurs, critical
equipment should be checked immediately to ensure they are plugged into
emergency power outlets. Quick-ship contracts should be developed for
essential supplies and equipment.

b\. *Hazard Monitoring Strategies.* When a power outage occurs critical
equipment should be checked immediately to ensure they are plugged into
emergency power outlets. Fire alarms and security alarms should be
checked to ensure they are operating. Engineering staff should monitor
electrical loads for possible load shedding. For extended outages, fuel
supplies must be closely monitored.

c\. *Recovery Strategies.* Replace spoiled food and medicines with
quick-ship contracts.

d\. *See Attached Charts: Key Activity Management Tool/Structure.*

6\. ***External Notification Procedures.***

a.  *Within VA.* Notify VISN Director or designee.

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a.  *Other Federal Agencies.* OSHA -- Notify within eight (8) hours of
    one (1) employee fatality, or three (3) employee hospitalizations
    resulting from a single incident.

b.  *Community Entities.* Local hospitals may need to be notified if the
    decision is made to divert or transfer patients, or if there is a
    community-wide power outage.

7\. ***Specialized Staff Training.***

-   All staff training on routes of egress and proper use of emergency
    power outlets.

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-   Engineering staff training on emergency generator testing and
    preventive maintenance.

8\. ***References and Further Assistance.***

a.  VHA Emergency Management Program Guidebook.

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a.  All Operating Units in the medical center should review their
    operating unit templates for response/recovery activities.

9\. ***Review Date.***

(Name)

(Title)

Attachments:

A.  Key Activity Management Tool

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A.  Key Activity Management Structure

*Sample 6.3.2.3*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Elevators/Vertical Transport Failure**

1.  ***Description of the Threat/Event*.** Vertical transport systems
    can be disabled because of electrical power or electronic control
    faults, localized failure modes in individual systems or possibly
    from automatic recall malfunctions related to safety overrides
    during an alarm status. In some cases, the downtime can be
    protracted; so commensurate planning and response protocols are
    necessary.

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1.  ***Impact on Mission Critical Systems.*** Depending on the length of
    downtime, the absence of vertical transport systems can mal-affect
    patient care, as well as present the need for immediate rescue
    operations to remove trapped occupants from elevator cabs. Both
    possibilities may require immediate attention and interim alternate
    transport deployment in order to preserve continuity of care and
    safety. In a most extreme case, a post-surgical or emergency room
    patient could be en route to the Intensive Care Unit during
    transport failure. In addition, service-oriented vertical transport
    systems such as dumbwaiters used in Nutrition and Food Service,
    Pharmacy or Laboratory can hinder the timely delivery of food to
    patients, therapeutic drugs to in-patient areas or laboratory
    specimens for processing, respectively.

2.  ***Operating Units and Key Personnel with Responsibility to Manage
    this Threat/Event.***

-   Safety and Security

-   Logistics

-   Facilities Engineering

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-   Communications

4\. ***Mitigation/Preparedness Activities of the Threat/Event***. State
several objectives for:

a\. *Hazard Reduction Strategies and Resource Issues.*

-   Documented preventive maintenance procedures on all vertical
    transport systems, or on-call means via local Fire Department to
    initiate rescue efforts.

-   Perform and document drills and exercises to test the rescue
    team(s).

-   Test all internal (elevator) cab communications devices.

-   Post clear, multi-lingual instructions in emergent communications
    for trapped occupants.

-   Limit distribution/document possession of all elevator
    "return/control" keys.

-   Test elevator control function in conjunction with fire or other
    alarm exercises.

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-   If not already configured, consider selected vertical transport for
    inclusion in Life Safety Branch of emergency power distribution
    system.

b\. *Preparedness Strategies and Resource Issues.*

-   Publish (or reference) policy for 24/7 designated elevator occupant
    rescue team.

-   Documented training for all involved staff assigned to elevator
    rescue team

-   On-call availability of local Fire Department for rescue efforts.

-   Maintain readily deployable two-way radio communications.

-   Define alternate vertical transport methods; and,

-   Maintain stock of appropriate stretchers for patient transport via
    stairwells.

-   Prepare alternate delivery means for food, pharmaceuticals or
    patient specimens.

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-   Designate appropriate manpower to execute the manual transport and
    delivery activities necessitated by the loss of elevators or other
    vertical transport systems.

5\. ***Response/Recovery from the Threat/Event.***

a.  *Hazard Control Strategies*. Vertical transport systems should be
    used as designated. For example, elevators designated for
    freight-only should not be used to transport patients, staff or
    visitors. Return-control keys for elevators should not be abused for
    personal or convenience needs, and aggregate carriage weight limits
    should not be exceeded. Similarly, inappropriate cargo should not be
    placed in dumbwaiters.

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a.  *Hazard Monitoring Strategies***.** The most important matter is to
    monitor the condition of trapped occupants in elevator cabs.
    Secondly, repair and restoration efforts should be tracked so that
    affected Operating Units can be timely informed. In this manner,
    their respective contingency plans can be appropriately deployed
    with minimized delay. It may be necessary for medical consultation
    depending upon the condition of trapped occupants. In the spectrum
    of possible situations, the most dramatic may involve introduction
    of medical staff or equipment into the immobilized cab in order to
    administer care to the trapped occupant.

b.  *Recovery Strategies.* Assemble and utilize labor pool until
    transport systems are operational.

c.  *See Attached Charts: Key Activity Management Tool/Structure.*

6\. ***External Notification Procedures.***

a.  *Within VA.* N/A.

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a.  *Other Federal Agencies.* OSHA -- Notify within eight (8) hours of
    one (1) employee fatality, or three (3) employee hospitalizations
    resulting from a single incident.

b.  *Community Entities.* N/A.

7\. ***Specialized Staff Training.*** Police, Safety and appropriate
Facilities Engineering/Environmental Management staff should be trained
on means and methods of proper and safe rescue of trapped elevator cab
occupants.

8\. ***References and Further Assistance.***

a.  Medical Center Memorandum XXX, subject: Elevator Cab Rescue
    Procedures.

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a.  Facilities/Engineering Service Policy XXX, subject: Training
    Requirements for Elevator Cab Rescue Procedures.

b.  All Operating Units in the medical center should review their
    operating unit templates for response/recovery activities.

9\. ***Review Date.***

(Name)

(Title)

Attachments:

A.  Key Activity Management Tool

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A.  Key Activity Management Structure

*Sample 6.3.2.4*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Heating, Ventilation and Air Conditioning (HVAC) Failure**

1.  ***Description of the Threat/Event*.** A failure of the heating,
    ventilation and air conditioning systems will result in unsuitable
    room temperatures and air circulation.

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1.  ***Impact on Mission Critical Systems.*** A failure of the heating,
    ventilation and air conditioning systems may affect a wide range of
    mission-critical systems to varying degrees depending on the climate
    and mission.

2.  ***Operating Units and Key Personnel with Responsibility to Manage
    this Threat/Event.***

    -   Facilities Engineering

    -   Logistics

    -   Operations

    -   Safety

    -   Health & Medical

    -   Security

-   Plant and Utilities

4\. ***Mitigation/Preparedness Activities of the Threat/Event***.

a.  *Hazard Reduction Strategies and Resource Issues.* Reduce potential
    for freezing of fire sprinklers by maintaining temperature in cold
    climates.

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a.  *Preparedness Strategies and Resource Issues.*

-   Stockpile blankets, room heaters, portable AC units (minimum 5-ton
    water-cooled units). Reduce inpatients by discharge, transfer, and
    defer admissions.

-   Prepare prioritized list by area for evacuation.

-   Prepare written protocol inpatient minimum/maximum, time-weighted
    exposure to temperature/relative humidity extremes.

-   Prepare load-shedding priorities with interdisciplinary concurrence.

-   Prepare list of 24/7 sources for portable HVAC supplementary
    equipment.

-   Prepare list of 24/7 deployable large scale HVAC equipment

-   Prepare internal patient area consolidation protocol.

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-   Prepare sister hospital transfer protocol.

5\. ***Response/Recovery from the Threat/Event.***

a\. *Hazard Control Strategies.*

-   Evaluate needs and distribute blankets, room heaters.

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-   Install air conditioning units.

b\. *Hazard Monitoring Strategies**.***

-   Nursing monitors patient comfort/stress due to loss of heat/cool;
    document room temperature and room humidity with recorders.

-   Track backlog of procedures, admissions. Estimate needs.

-   Facilities Engineering estimates heating/cooling needs (BTUs) for
    expected temperature.

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-   Industrial Hygienist/Safety evaluates occupational health relative
    to heat/cold stress.

c\. *Recovery Strategies.* Use temperature and ventilation mitigation
strategies: Blankets, room heaters, room air conditioners.

d\. *See Attached Charts: Key Activity Management Tool/Structure.*

6\. ***External Notification Procedures.***

a.  *Within VA.* If the VA Medical Center is made aware of a
    threat/event, whom within VA should they notify? If a threat/event
    occurs, whom within VA should they notify?

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a.  *Other Federal Agencies.* Depending on the threat/event, certain
    federal agencies (FEMA, Department of Health and Human Services,
    OSHA, Centers for Disease Control, EPA) will need to be notified.
    OSHA -- Notify within eight (8) hours of one (1) employee fatality,
    or three (3) employee hospitalizations resulting from a single
    incident.

b.  *Community Entities.* Because of the VA Medical Center's
    relationship to the community, it is likely that there are specific
    entities within the community that should be notified that a
    threat/event has occurred. In many cases, this notification will
    trigger a community response to the threat/event.

7\. ***Specialized Staff Training.*** Awareness training for heat/cold
stress.

8\. ***References and Further Assistance.***

a.  VHA Emergency Management Program Guidebook.

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a.  All Operating Units in the medical center should review their
    operating unit templates for response/recovery activities.

9\. ***Review Date.***

(Name)

(Title)

Attachments:

A.  Key Activity Management Tool

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A.  Key Activity Management Structure

*Sample 6.3.2.5*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Room/Hood Exhaust Failure**

1\. ***Description of the Threat/Event*.** The failure of:

-   Special room ventilation (positive/negative pressure, TB rooms).

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-   Hood exhaust (biological safety cabinets, clean benches, fume
    hoods).

2\. **Impact on Mission Critical Systems.** Failure of These Will
Affect:

-   Treatment of patients with special infection control needs.

-   Preparation and administration of chemotherapy drugs and nuclear
    medicines.

-   The scavenging of waste anesthetic gas and vapors in the Operating
    Room and Dental Clinic. Without good scavenging systems, employees
    will be overexposed to waste anesthetic gas/vapors.

-   Compliance with OSHA regulations on TB Control, Hazardous Drugs,
    Bloodborne Pathogen Standard, Formaldehyde Standard, Ethylene Oxide
    Standard, Hazard Communication Standard, Laboratory Standard, and
    others.

-   CDC recommendations for TB, infection controls, and universal
    precautions.

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-   Employee Health.

3\. ***Operating Units and Key Personnel with Responsibility to Manage
this Threat/Event.***

-   Facilities Engineering

-   Safety

-   Pharmacy

-   Infection Control

-   Nuclear Medicine

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-   Surgery

4\. ***Mitigation/Preparedness Activities of the Threat/Event.***

a\. *Hazard Reduction Strategies and Resource Issues.*

-   Eliminate or reduce the need for hazardous and infectious materials
    that require use of local exhaust ventilation (biological safety
    cabinets, fume hoods, clean benches, anesthetic-scavenging systems).

-   Eliminate or reduce the need for positive/negative pressure rooms
    and air changes.

-   Contract out services, or consolidate activities.

-   Develop contracts/agreements for emergency outsourcing.

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-   Ensure exhaust hoods, surgery room ventilation, and
    positive/negative pressure rooms are on emergency power.

b\. *Preparedness Strategies and Resource Issues.* Develop respirator
program for short-term emergencies in critical activities.

5\. ***Response/Recovery from the Threat/Event.***

a.  *Hazard Control Strategies*. (See paragraph 4a.)

b\. *Hazard Monitoring Strategies***.** The VA Medical Center will need
to develop procedures to monitor the reciprocal impact of the
threat/event on mission critical functions. For example, in the case of
a flood, how will the Medical Center monitor the impact of rising water
levels on its mission critical areas (patient care, energy plant, etc.)?

c\. *Recovery Strategies*. N/A.

d\. *See Attached Charts: Key Activity Management Tool/Structure.*

6\. ***External Notification Procedures*.**

a.  *Within VA*. N/A.

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a.  *Other Federal Agencies.* Depending on the threat/event, certain
    federal agencies (FEMA, Department of Health and Human Services,
    OSHA, Centers for Disease Control, EPA) will need to be notified.
    OSHA -- Notify within eight (8) hours of one (1) employee fatality,
    or three (3) employee hospitalizations resulting from a single
    incident.

b.  *Community Entities.* Because of the VA Medical Center's
    relationship to the community, it is likely that there are specific
    entities within the community that should be notified that a
    threat/event has occurred. In many cases, this notification will
    trigger a community response to the threat/event.

*7. **Specialized Staff Training. ***Respiratory protection training for
completion of critical procedures where room or hood exhaust fails.

8\. ***References and Further Assistance.***

a.  VHA Emergency Management Program Guidebook.

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a.  All Operating Units in the medical center should review their
    operating unit templates for response/recovery activities.

9\. ***Review Date.***

(Name)

(Title)

Attachments:

A.  Key Activity Management Tool

B. Key Activity Management Structure

> *Sample 6.3.2.6*
>
> S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Steam Distribution Failure**

1\. ***Description of the Threat/Event***. The failure of the steam
distribution system may be due to failure in the distribution system,
such as a valve.

2\. ***Impact on Mission Critical Systems***. Possible loss of:

-   Hot water supply for bathing

-   HVAC system

-   Infection Control - Steam sterilization

-   Food - Steam kettle cooking, reheating of patient meals

3\. ***Operating Units and Key Personnel with Responsibility to Manage
this Threat/Event***.

-   Infection Control

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-   Facilities Engineering

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-   Safety

-   Food and Nutrition

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-   Health and Medical

4\. ***Mitigation/Preparedness Activities of the Threat/Event***.

a\. Hazard Reduction Strategies and Resource Issues.

-   Switch to use of more disposable supplies and equipment to mitigate
    loss of sterilizers.

-   Back-up heating and cooling systems.

-   Define and maintain minimum stocking levels of sterile supplies.

-   Possible quick response and short term planning for patient bathing
    alternatives.

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-   Alternative warm meal for patients.

b\. Preparedness Strategies and Resource Issues. Develop quick-ship
contracts for disposables to replace sterilization.

5\. ***Response/Recovery from the Threat/Event***.

a\. Hazard Control Strategies.

-   Quick-ship contracts for emergency supplies of disposables to
    mitigate the loss of steam sterilization.

-   Emergency stocks of waterless hand sanitizer to mitigate the loss of
    warm water for handwashing.

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-   Deploy all other preparedness strategies.

b\. Hazard Monitoring Strategies. Facilities Engineering may monitor the
impact on systems.

c\. Recovery Strategies. N/A.

d\. See Attached Charts: Key Activity Management Tool/Structure.

6\. ***External Notification Procedures.***

a\. *Within VA*. Notify as needed.

b\. *Other Federal Agencies*. OSHA -- Notify within eight (8) hours of
one (1) employee fatality or three (3) employee hospitalizations
resulting from a single incident.

c\. *Community Entities*. Notify community entities if patients are
diverted/transferred.

7\. ***Specialized Staff Training***. Employees performing sterilization
must be trained to recognize equipment failure.

8\. ***References and Further Assistance***.

a\. VHA Emergency Management Program Guidebook.

b\. All Operating Units in the medical center should review their
operating unit templates for response/recovery activities.

9\. ***Review Date***.

(Name)

(Title)

Attachments:

A.  Key Activity Management Tool

B.  Key Activity Management Structure

*Sample 6.3.2.7*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Internal Transport Systems Failure**

1\. ***Description of the Threat/Event.*** Transport conduits such as
those for pneumatic tube, laundry or refuse systems can become disabled
due to internal faults, or electrical or pneumatic utility failures.
These systems are extremely high-maintenance, and frequent disruption is
not uncommon. Moreover, their constant use and high-duty cycles
underscore the dependence the VA Medical Center has on such systems.
Accordingly, even short-term failures can be quite disruptive, and
appropriate measures must be taken to prepare for such eventualities.

2\. ***Impact on Mission Critical Systems.*** The mal-effects of system
disruption may include:

-   **Pneumatic Tube** - Disruption is directly proportional to the
    number of access ports connected to the system. Typically, these may
    include Laboratory, Surgery, Ambulatory Care, Intensive Care Units,
    Emergency Room and other direct patient care areas. The loss of
    ability to obtain STAT deliveries and, for example, blood-gas
    analyses is a direct impediment to administration patient care. If
    the system is connected to various Administrative areas such as
    Fiscal, A&MM or other support services, disruption will cause delays
    in the transfer of information and requested action.

-   **Laundry Chutes or Tubes** - Since soiled linens, towels and other
    items are constantly generated even a short-term blockage or
    disruption in service can produce significant problems. Clean
    patient linens are a necessity, and supplies can be disrupted if
    in-house Laundry flow is impeded.

-   **Refuse Chutes or Tubes** - More so than the constant production of
    soiled linens, the generation of both biohazardous and common waste
    is unrelenting. Even the shortest of disruptions or blockages can
    quickly grow from nuisance to impediment.

3\. ***Operating Units and Key Personnel with Responsibility to Manage
this Threat/Event.***

-   Health and Medical

-   Logistics

-   Supply

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-   Facilities Engineering

4\. ***Mitigation/Preparedness Activities of the Threat/Event***.

a\. *Hazard Reduction Strategies and Resource Issues.*

-   Documented preventive maintenance programs for all systems.

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-   Appropriate repair/replacement parts inventory maintained, or

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-   Service contract with specified availability and response times in
    force.

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-   System operators should be trained on safe and appropriate use of
    each system.

b\. *Preparedness Strategies and Resource Issues.* Operating Unit
work-arounds established and periodically reviewed. Examples: Alternate
delivery, transport and storage means identified in the event of
disruption of transport system.

5\. ***Response/Recovery from the Threat/Event.***

a\. *Hazard Control Strategies.*

-   Respond to notification of the event as quickly as possible. This
    will allow for containment of the fault area and most rapid
    deployment of work-arounds.

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-   Consider elimination of total systems or number of access ports.

b\. *Hazard Monitoring Strategies.* The status of the event fallout and
recovery efforts should be rapidly shared with affected Operating Units.
In this manner, decisions can be made quickly and work-arounds
implemented so that any disruption is minimized.

c\. *Recovery strategies.* Train response/recovery team*.*

d\. *See Attached Charts: Key Activity Management Tool/Structure*.

6\. ***External Notification Procedures.***

a\. *Within VA*. N/A.

b\. *Other Federal Agencies.* OSHA -- Notify within eight (8) hours of
one (1) employee fatality or three (3) employee hospitalizations
resulting from a single incident.

c\. *Community Entities.* Because of the VA Medical Center's
relationship to the community, it may be necessary to notify selected
institutions. For example, nearby medical centers (or sister VA medical
centers) may be able to assist in laundry or refuse storage and
handling. Similarly, contracted laundry or refuse firms may have to be
contacted for quick delivery, removal or other assistance.

7\. ***Specialized Staff Training.*** Users, maintainers and repairs of
each system should be appropriately trained in accordance with
manufacturers' recommendations and consistent with safety and other
on-point local policies and procedures.

8\. ***References and Further Assistance.***

a.  Facilities Engineering, Environmental Management Service Policy or
    Procedures on use and maintenance of Pneumatic Tube, Laundry
    Chute/Tube or Refuse Chute/Tube Systems.

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a.  All Operating Units in the medical center should review their
    operating unit templates for response/recovery activities.

9\. ***Review Date.***

(Name)

(Title)

Attachments:

> A. Key Activity Management Tool
>
> B. Key Activity Management Structure

*Sample 6.3.2.8*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Medical Gases System Failure**

1\. ***Description of the Threat/Event*.** Medical Gases are essential
for the entire spectrum of direct patient care delivery and for
controlling or powering certain utility systems or equipment.
Accordingly, these systems are absolutely critical, and merit particular
attention. Such systems typically include: oxygen, medical (i.e., clean,
compressed) air, medical vacuum, and in a more localized delivery venue,
anesthetic gases.

The oxygen, medical air and vacuum delivery systems are considerable
engineering systems. For the former, exacting standards are required for
manifold connections and refilling procedures. Medical air and vacuum
sources are provided through in-plant, electromechanical devices which
function on rotational continuous operation. These are workhorse systems
that require expert and intensive maintenance. All these systems have
multi-valved, long distribution lines which must be maintained in clean,
fully functioning condition from source to delivery point.

Surgery is the primary anesthetizing location, but other areas may also
be provided with anesthetic gases. The criticality of maintaining these
systems is self evident and thus also warrants salient attention.
Finally, medical (compressed) air can be used to power biomedical
equipment (e.g., ventilators, surgical tools), tools, or may constitute
a control function for HVAC systems.

2\. ***Impact on Mission Critical Systems.*** The loss of any of these
systems would present an immediate, widespread negative impact to direct
patient care and several ancillary or support functions. A few examples
illustrate this concern: Any patient undergoing surgery at the time of
an unexpected failure would require immediate attention. Immediate
provision of temporary oxygen or compressed air would have to be
accomplished by portable cylinders. Similarly, portable suction units
would have to be connected to provide vacuum in the absence of centrally
provided suction capability. Without this intervention, the patients
would be placed at risk. The operating room suite would be unable to
continue operations until a stable temporary provision of all gases is
in place. The Intensive Care, Emergency Room, Spinal Cord Injury
(especially ventilator-dependent patients), step-down units and all
other in-patient areas would be similarly disaffected.

There would be additional fallout related to utilities and equipment
functionality. For example, certain HVAC controls may rely upon the
provision of medical (compressed) air. The absence could render the HVAC
system to less-than-optimal status, or worse. Some medical and shop
equipment, which requires medical air would also be unusable, absent the
provision of a portable medical air source.

The total impact is far reaching, widespread and demands immediate and
sustained vigilance to prevent imminent danger and remedy the causal
malfunction.

3\. ***Operating Units and Key Personnel with Responsibility to Manage
this Threat/Event.***

-   Medical Center Director

-   Incident Manager

-   Logistics

-   Supply

-   Facilities Engineering

-   Business Continuity

-   Plant and Utilities

-   Medical Devices

-   Medial Gases

-   HVAC

-   Health and Medical

4\. ***Mitigation/Preparedness Activities of the Threat/Event*.**

a\. *Hazard Reduction Strategies and Resource Issues.*

-   A well documented, effective maintenance program for all systems.

-   Complement any in-house maintenance with documented service from
    competent, certifiable firms.

-   Stock appropriate level and quantity of replacement parts.

-   Closely monitor all vendor activities, including main and back-up
    liquid oxygen supply tanks.

-   Periodically test and document all systems for proper function and
    purity (i.e., absence of contamination).

-   Maintain excellent record drawings, which clearly delineate
    locations of all key (isolation) valves and line runs (whether pipe
    or hose). (This helps minimize the accidental cutting of lines or
    damaging of valves during unrelated construction work.)

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-   Record drawings should be timely and accurately updated to reflect
    any changes, additions, deletions (abandoned lines or sources) to
    any of the medical gas systems.

b\. *Preparedness Strategies and Resource Issues.*

-   Maintain appropriate back-up quantities of cylinder (portable) gas
    sources.

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-   Train all respective staff on the use, maintenance and recognition
    of failure modes and especially clinical staff on rapid response to
    the sudden, unexpected loss or other compromised delivery of medical
    gases.

5\. ***Response/Recovery from the Threat/Event.***

a.  *Hazard Control Strategies*.

    -   Operating Units should swiftly take action in accordance with
        their respective procedures.

    -   Communication is key. With so many direct patient care and
        supporting Operating Units involved in the response/recovery
        effort, a timely, concise and clear communication is essential.

-   If possible, the location of the fault, or malfunction, should be
    contained (e.g., if it occurred in the line, rather than at the
    source).

b\. *Hazard Monitoring Strategies**.***

-   Most critically, patient status should be monitored and documented.

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-   Repair efforts should be monitored and timely communicated so that
    Logistics will know when, and if, further temporary provision (and
    needed quantities) of gases can be identified.

c\. *Recovery Strategies*. Resume use of central medical gas after
repair of equipment and certification of gas quality is complete.

d\. *See Attached Charts: Key Activity Management Tool/Structure.*

6\. ***External Notification Procedures.***

a.  *Within VA.* VISN.

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a.  *Other Federal Agencies.* OSHA -- Notify within eight (8) hours of
    one (1) employee fatality, or three (3) employee hospitalizations
    resulting from a single incident.

b.  *Community Entities.* Because of the VA Medical Center's
    relationship to the community, it is likely that there are specific
    entities within the community that should be notified that a
    threat/event has occurred. In this case, other health care
    facilities may be contacted for alternate care sites.

7\. ***Specialized Staff Training.*** In addition to the training listed
above, maintenance staffs require specific technical training on all
electromechanical systems that are to be maintained in-house. This
training should be documented and refreshed, as required.

8\. ***References and Further Assistance.***

a.  List all other relevant SOPs here.

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a.  All Operating Units in the medical center should review their
    operating unit templates for response/recovery activities.

*9. **Review Date.***

(Name)

(Title)

Attachments:

> A. Key Activity Management Tool
>
> B. Key Activity Management Structure

*Sample 6.3.2.9*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Roads and Grounds Blocked**

1\. ***Description of the Threat/Event*.** Natural and unnatural events
may impair access to the VA Medical Center by blocking roads and grounds
or entrances to buildings: Weather-related events such as floods, snow
or ice, earthquake, trees or power lines falling across the roads, auto
accident, or civil disturbance.

2\. ***Impact on Mission Critical Systems.***

-   **Safety and Security** - If the Medical Center's roads are blocked,
    staff and patients may have to park vehicles off campus or at
    alternate parking lots, which may create security and safety
    hazards. Fire Department may not be able to gain access.

-   **Health and Medical** - Appointments may be canceled due to
    "no-shows" by staff or patients. Critical supplies (medicines,
    blood, laboratory samples) may not be deliverable.

-   **Plant and Utilities** - Critical supplies may be delayed (liquid
    oxygen). Waste disposal may be delayed. Construction contractor
    staff and equipment may not be able to gain access.

-   **Logistics** - Supplies may be delayed. Contractor staff and
    equipment may not be able to gain access.

3\. ***Operating Units and Key Personnel with Responsibility to Manage
this Threat/Event.***

-   Plant and Utilities

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-   Safety and Security

4\. ***Mitigation/Preparedness Activities of the Threat/Event***.

a\. *Hazard Reduction Strategies and Resource Issues.*

-   Consider construction of alternate roads and entrances to/within
    property.

-   Remove diseased trees near roads and buildings.

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-   Establish snow/ice removal policy that includes early response to
    avoid road closings.

b\. *Preparedness Strategies and Resource Issues.*

-   Increase stocks of critical supplies during potential inclement
    weather and floods.

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-   Establish clear policy and procedures between local and VA Police
    for control of civil disturbance.

5\. ***Response/Recovery from the Threat/Event.***

a\. *Hazard Control Strategies.*

-   Establish internal capacity and procedures for road clearing,
    de-icing, fallen tree moving.

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-   Establish contract for emergency road clearing, de-icing, fallen
    tree removal.

b\. *Hazard Monitoring Strategies**.*** VA Police, Safety and Facilities
Engineering Management may monitor situation.

c\. *Recovery Strategies.*

-   Implement procedures for clearing roads, de-icing, moving
    obstructions, and clearing crowds.

-   Implement quick-ship for critical supplies.

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-   Consider moving the Supply Receiving function to receive critical
    supplies.

d\. *See Attached Charts: Key Activity Management Tool/Structure.*

6\. ***External Notification Procedures.***

a\. *Within VA.* Check with VISN policy and procedure.

b\. *Other Federal Agencies.* Depending on the threat/event, certain
federal agencies (FEMA, Department of Health and Human Services, Centers
for Disease Control, OSHA, EPA) will need to be notified. OSHA -- Notify
within eight (8) hours of one (1) employee fatality, or three (3)
employee hospitalizations resulting from a single incident.

c\. *Community Entities.* Because of the VA Medical Center's
relationship to the community, it is likely that there are specific
entities within the community that should be notified that a
threat/event has occurred. In many cases, this notification will trigger
a community response to the threat/event.

7\. ***Specialized Staff Training.*** N/A.

8\. ***References and Further Assistance.***

a.  VHA Emergency Management Program Guidebook.

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a.  All Operating Units in the medical center should review their
    operating unit templates for response/recovery activities.

9\. ***Review Date.***

(Name)

(Title)

Attachments:

> A. Key Activity Management Tool
>
> B. Key Activity Management Structure

*Sample 6.3.2.10*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Waste and Debris Removal**

1.  ***Description of the Threat/Event*.** General strategies for the
    management of event-generated debris and wastes, including hazardous
    wastes.

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1.  ***Impact on Mission Critical Systems.*** N/A

2.  ***Operating Units with Responsibility in Managing this
    Threat/Event.***

-   Facilities Engineering Service

-   Environmental Management Service

-   Safety Service

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-   Industrial Hygiene

4\. ***Mitigation/Preparedness Activities for the Threat/Event.***

a.  *Hazard Reduction Strategies and Resource Issues.* N/A.

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a.  *Preparedness Strategies and Resource Issues.*

-   Scenarios for training and drills should include damage caused to
    the VA Medical Center. Key Operations Managers should develop an
    understanding of the internal capabilities for handling various
    types of event-generated debris and wastes.

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-   Vendors of and contact information for heavy equipment and waste
    management services should be listed in the VA Medical Center's
    Resource Matrix.

5\. ***Response/Recovery from the Threat/Event.***

a\. *Event Control Strategies.*

-   Access should be controlled near debris and waste generated by the
    event.

-   Debris and waste should be evaluated for potential health hazards by
    appropriate staff.

-   A determination of the urgency for proper disposal should be
    conducted.

-   Recommendations for disposal should be developed.

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-   Debris and waste removal operations should be thoroughly documented.

b\. *Event Monitoring Strategies**.*** N/A

c\. *Recovery Strategies and Resource Issues.* N/A

d\. *See Attached Charts: Key Activity Management Tool/Structure.*

6\. ***External Notification Procedures.***

a.  *Within VA.* VISN will be notified when VA Medical Center implements
    its plan.

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a.  *Other Federal Agencies.* Support from other Federal agencies, such
    as GSA, should be considered.

b.  *Community Entities and Local Governments.*

-   Local Emergency Management Agency

-   Local Hospital Association

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-   Local Airport Authority

7\. ***Specialized Staff Training.*** Consider cross-training for waste
collection, storage and disposal activities during acute staff
shortages.

8\. ***References and Further Assistance.*** N/A

9\. ***Review Date.***

(Name)

(Title)

Attachments:

> A. Key Activity Management Tool
>
> B. Key Activity Management Structure

*Sample 6.3.2.11*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Water Delivery/Potability**

1.  ***Description of the Threat/Event*.** The delivery of potable water
    to VA Medical Centers can be disrupted by a number of natural and
    unnatural events.

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1.  ***Impact on Mission Critical Systems.***

-   Plant and Utilities systems requiring water -- Heating and cooling
    system, spray paint booths, steam sterilization, wastewater
    treatment plants, and potable water treatment plants.

-   Biomedical Equipment.

-   Kitchen and Canteen -- Dishwashing, food preparation.

-   Infection Control -- Drinking water, toilets, handwashing, and steam
    sterilization.

-   Housekeeping -- Water-based cleaning.

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-   Patient Care -- Bathing.

3\. ***Operating Units and Key Personnel with Responsibility to Manage
this Threat/Event.***

-   Facilities Engineering

-   Surgery

-   Infection Control

-   SPD (sterile supply)

-   All medical units (hand washing, patient bathing)

-   Kitchen

-   Canteen

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-   Safety and Security

4\. ***Mitigation/Preparedness Activities of the Threat/Event***.

a\. *Hazard Reduction Strategies and Resource Issues.*

-   Consider building a water supply tower.

-   Explore possibility of potable well water supply that can be
    quick-connection as an interim source.

-   Adequate preventative maintenance and key valves, pumps and other
    key components of the potable with distribution system.

-   Consider strategic placement of accessible isolation valves.

-   Security of VA-operated water treatment plant and/or water tower
    should be evaluated.

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-   VA Police should establish adequate security of VA-operated potable
    water treatment plants, wastewater treatment plants, and medical
    waste storage.

b\. *Preparedness Strategies and Resource Issues.*

-   Either deploy or have available a quantity of portable toilets.

-   Explore military or other availability of water tank trucks.

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-   Stock at least short-term supply of potable drinking water.

5\. ***Response/Recovery from the Threat/Event.***

a\. *Hazard Control Strategies.* Stock bottled water for drinking,
waterless handwashing product. Agreement (MOU/contract) with National
Guard or private contractor to supply portable potable water and
toilets.

b\. *Hazard Monitoring Strategies.*

-   Monitor water supplies and needs, water quality (natural and
    unnatural contamination).

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-   Monitor infection control activities, OSHA compliance. Monitor EPA
    compliance at potable water plant and wastewater treatment plant.

c\. *Recovery Strategies.* Before normal water system is used for
drinking water, it needs to be tested to ensure safety.

d\. *See Attached Charts*: *Key Activity Management Tool/Structure.*

6\. ***External Notification Procedures.***

a.  *Within VA.* N/A.

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a.  *Other Federal Agencies.* Depending on the threat/event, certain
    federal agencies (FEMA, Department of Health and Human Services,
    Centers for Disease Control, OSHA, EPA) will need to be notified.

-   **OSHA** -- Notify within eight (8) hours of one (1) employee
    fatality, or three (3) employee hospitalizations resulting from a
    single incident.

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-   **EPA** -- relative to VA-operated potable water plant, wastewater
    treatment plant.

c\. *Community Entities.* Because of the VA Medical Center's
relationship to the community, it is likely that there are specific
entities within the community that should be notified that a
threat/event has occurred. In many cases, this notification will trigger
a community response to the threat/event.

7\. ***Specialized Staff Training.*** N/A.

8\. ***References and Further Assistance.***

a.  VHA Emergency Management Program Guidebook.

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a.  All Operating Units in the medical center should review their
    operating unit templates for response/recovery activities.

b.  OSHA and EPA regulations.

9\. ***Review Date.***

(Name)

(Title)

Attachments:

> A. Key Activity Management Tool
>
> B. Key Activity Management Structure

*Sample 6.3.3.1*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Alternate Care Site**

1.  ***Description of the Threat/Event*.** An alternate care site is a
    temporary location where patient triage, treatment/supportive care
    and holding occur. One may be established as a result of a VA-DoD
    Contingency Hospital System activation (e.g., patient reception area
    at the airport) as a result of a partial or total evacuation of
    patients from the VA Medical Center (e.g., in another health care
    institution or previously unoccupied space), or in order to provide
    care at special events (e.g., aid station). A Memorandum of
    Understanding (MOU) is used to set forth guidelines under which each
    hospital will transfer or accept patients in the event of a partial
    or total hospital evacuation in an emergency situation. (See
    Attachment A, sample MOU.)

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1.  ***Impact on Mission Critical Systems.*** See Evacuation (Total)
    SOP.

2.  ***Operating Units and Key Personnel with Responsibility to Manage
    this Threat/Event.***

-   Medical Center Director

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-   Medical Service, etc.

3.  ***Mitigation/Preparedness Activities for the Threat/Event.***

a\. *Hazard Reduction Strategies and Resource Issues.* N/A.

b\. *Preparedness Strategies and Resource Issues.* Develop a basic
capability to organize an alternate care site. Actions include:

-   Site Selection (e.g., Expand existing space or use of remote space.)

-   Logistics - Service − (e.g., supply, facilities, food, etc.)

> Support − (e.g., communications, transportation, etc.)

-   Patient Management − (e.g., medicines, records, tracking, etc.)

5\. ***Response/Recovery from the Threat/Event.***

a\. *Hazard Control Strategies.*

1\) Determine need for alternate care site:

-   Actual vs. perceived need (consider availability of resources within
    timeframe).

-   Consider alternatives (e.g., discharge stable patients, relocate to
    other VA facilities, etc.)

2\) Determine requirements for patient care and administrative support.

-   Site selection criteria (e.g., location, available space, utilities,
    security, loading dock, elevators, etc.)

b\. *Hazard Monitoring Strategies***.** The Chief of Staff will monitor
the establishment of alternate care sites.

c\. *Recovery Strategies and Resource Issues*. Demobilization planning
should begin once occupancy is established.

d\. *See Key Activity Management Structure/Tool attached to Evacuation
(Total) SOP.*

6\. ***External Notification Procedures.***

a.  *Within VA.* VISN will be notified when the Medical Center
    implements its plan.

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a.  *Other Federal Agencies.* Support from other Federal agencies, such
    as GSA, should be considered*.* OSHA - Notify within eight (8) hours
    of one (1) employee fatality, or three (3) employee hospitalizations
    resulting from a single incident.

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a.  *Community Entities and Local Governments.*

-   Local Emergency Management Agency

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-   Local Hospital Association

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-   Local Airport Authority

*7. **Specialized Staff Training.*** Staff and education should address
organization of alternate care sites and the management of patients.

8\. ***References and Further Assistance.*** N/A.

9\. ***Review Date.***

(Name)

(Title)

Attachments:

> A. Memorandum of Understanding

*Sample 6.3.3.2*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Healthcare First Receiver Decontamination**

1\. ***Description of Threat/Event*.** Events involving Chemical,
Biological, Radiological, Nuclear and Explosives (CBRNE) may put VA
healthcare workers, patients and visitors at risk if contaminated
patients arrive seeking treatment. The term First Receivers is used to
describe those employees who are expected to provide security, triage,
decontamination, treatment and other activities that may require donning
Personal Protective Equipment (PPE). This Standard Operating Procedure
(SOP) is designed to establish procedures for preparedness, mitigation,
response and recovery activities.

2\. ***Impact on Mission Critical Systems*.** Decontamination set-up and
operations are guided by the Mission Critical Considerations Template
(see Attachment A). Critical Systems that scored high and required
review and action are discussed below:

> a\. *Electrical Power* - Describe how electrical power is provided
> and, if using facility power, whether it is on emergency power.

b.  *Heating, Ventilation and Air Conditioning (HVAC)* - Discuss setting
    up decontamination away from air intakes.

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b.  *Room or Hood Exhaust **- ***Discuss issues as appropriate.

c.  *Water Delivery* - Address how decontamination system receives
    water, and how it is heated.

d.  *Waste Stream* **-** Explain how wastewater from decontamination
    operations is contained, and the procedures for disposing of it.

e.  *Critical Supplies* - Discuss where supplies are located, and how
    they accessed 24/7 for decontamination operations.

f.  *Communications* **-** Address how First Receivers are expected to
    communicate within the decontamination area. Also, this should refer
    to the Medical Center's communication Standard Operating Procedure
    (SOP).

3\. ***Operating Units and Key Personnel with Responsibility to Manage
Threat/Event*.** (See Attachment B, Job Action Sheets; and Attachment C,
Decontamination Organizational Chart.) Implementation of decontamination
procedures usually requires activation of the Medical Center's Incident
Command System (ICS). Operating Units involved may include:

a\. Medical Center Director's Office

b\. Incident Manager

c\. Health and Medical

d\. Safety

e\. Security

f\. Operations

g\. Logistics

h\. Strategic Planning

i\. Business Continuity

j\. Finance and Administration

k\. Plant and Utility Systems

4\. ***Mitigation/Preparedness Activities for the Threat/Event*.** A
principle reason for conducting effective mitigation and preparedness
activities is to verify the Medical Center's community role and
expectations. Coordination with community emergency response planners is
critical to ensure the success of events that require hospitals to
receive, decontaminate and treat casualties. Activities that will assist
the Medical Center in preparing for such emergencies include:

a\. **Risk Assessment:** All Medical Centers must conduct a Hazard
Vulnerability Analysis (HVA) based on Joint Commission on Accreditation
of Healthcare Organization (JCAHO) requirements. All activities
involving healthcare receiver decontamination will be based on the HVA.
The HVA is reviewed at least annually, and must be approved by the
Medical Center Director or designee. The scope of an HVA must include
those emergencies that the facility may reasonably expect to be involved
in that require decontamination and/or isolation. Areas to be considered
include, but may not be limited to:

1\) Internal Locations:

-   Boiler and Chiller Plants

-   Clinical and Research Laboratories

-   Sterilization Areas

-   Engineering Shops and Storage Areas

-   Environmental Management Services

-   Supply Receiving

> Note: OSHA requires facilities to have a chemical inventory of
> hazardous materials.

2\) External Industrial Location within the Community: Information
needed to conduct risk assessments for external locations may be
obtained using the following resources:

-   The Superfund Amendment and Reauthorization Act (SARA Title III)
    requires that certain industries report chemical inventories to the
    community's Local Emergency Planning Committee (LEPC). This
    information is available from the LEPC upon request. Although not
    all chemicals within the community are required to be on this list,
    it is a good first step in identifying what is being used and stored
    within the community.

-   Information provided by local industries and emergency responders
    (e.g., fire departments, as part of a healthcare and/or Emergency
    Medical System) help identify the type of hazardous materials that
    may be present during emergencies.

3\) External Industrial Locations Adjacent or Near the Community:
Industrial locations (such as nuclear power plants, agriculture and
industrial chemical manufacturing and large storage and distribution
centers) should be included in the HVA plan. Information on these
industries may be obtained a variety of ways:

-   SARA Title III chemical inventory lists may or may not be available.

-   Sharing information obtained by larger healthcare associations.

-   Working with county and state emergency response agencies.

-   Obtaining information directly from the industries themselves or a
    combination of the above.

4\) External Events Involving Transportation of Hazardous Materials
Within and Near the Community: Risk assessments must be performed for
hazardous materials transported on railroads, highways, waterways,
aircraft and other modes of transportation. It is difficult to obtain
information on hazardous materials that are transported in or near the
community. Information for conducting risk assessments on transportation
operations is often inadequate. Attempts may be made to obtain
information through:

-   Direct communication with commercial transport industries.

-   Requesting information from community hazardous material responders.

5\) Terrorist/WMD Events: Much information is available for planning on
hazardous materials that may involve chemical, biological, radiological,
nuclear and explosives. Coordinating information with federal, state and
local governments is critical in identifying the risks involved to
people and to the healthcare system. Local and federal agencies will
provide low-classified information on groups that may pose a threat.
Information is available from:

-   Department of Homeland Security

-   Department of Transportation

-   Department of Defense

-   Federal Bureau of Investigation

-   Health and Human Services

b\. **Resource Assessment:** The extent of the Medical Center's
involvement in the community response plan is directly related to the
resources available at the Medical Center. Resources can be separated
into two categories:

1\) [Personnel Resources]{.underline}: Development of team starts with
the identification of team members. (See Attachment D, Power Point
Presentation on Team Building.) Some people volunteer to be members;
others become members due to the nature of their positions and duties.
All team members must be physically able to work in potentially
hazardous environments, be medically able to wear personal protective
equipment (PPE), complete minimum training requirements, and agree to
maintain the competencies required of team members. In addition, the
team will include personnel that support the decontamination operation.

Examples of decontamination functions and associated roles may include
the following: (Note: See also Attachment B, Job Action Sheets.)

-   *Safety and Health*. This position may be called the Decontamination
    Safety Officer. Duties of this position include ensuring that safety
    and health regulations are met, and that training and
    decontamination operations are being conducted in the safest
    possible manner.

-   *Incident Commander*. This position is in charge of the hospital's
    response to the emergency. This position is normally located in the
    Emergency Operations Center (EOC); however, depending on the size of
    the facility and the type of emergency, this position may be located
    near the decontamination site.

-   *Medical Coordinator*. This position is normally located in the
    Emergency Department. The person in this position is in charge of
    the overall decontamination and treatment processes.

-   *Decontamination Triage Leader*. This position is located at the
    perimeter or entry control site. This person makes decisions on
    whether decontamination is required, or if people should be directed
    to another entrance for medical treatment.

-   *Clinicians*. Clinicians are not required to be part of the team
    assigned to conduct decontamination of contaminated victims.
    However, it is recommended that clinicians be involved in triage at
    the perimeter or control access points.

-   *Police and Security*. Police must be located at key perimeter
    control areas. Personal protective equipment (PPE) will be required
    for all Officers that may come in contact with contaminated persons.

-   *Decontaminating Personnel*. Personnel conducting decontamination
    activities may include both clinical and non-clinical staff.
    Although clinicians are not required to conduct actual
    decontamination activities, it is recommended that a clinician be
    present in the decontamination area. The number of decontaminating
    personnel needed will be dependent on the size, capacity and
    duration of the decontamination operation. All decontaminating
    personnel wearing PPE must work in teams of at least two members.

-   *Logistics Support Personnel*. In most cases personnel in support
    functions are not required to wear PPE. Logistic support functions
    are critical to the success of the decontamination operation.
    Examples of logistics support for decontamination operations
    include:

◊ Equipment/Materials Support (Logistics Officer). Setting up
decontamination equipment; ensuring that appropriate equipment is
provided for washing and rinsing, and, ensuring adequate supplies of
clothing, blankets, etc., are provided are only a few of the support
functions involved in decontamination.

◊ Personnel Support Officer. Primarily provides support to
decontamination team members and patients. Support functions include
performing vital sign monitoring, assisting team members in donning PPE,
tracking teams conducting decontaminating operations, tracking patients
and assisting in escorting victims.

◊ Communications Officer. Effective communication during events
involving decontamination is critical to the success of the operation
and the safety and well-being of all concerned. Radio communication for
those wearing PPE is highly recommended.

◊ Transportation Officer. Transportation to and from the decontamination
site may be required. Personnel transporting staff and patients may be
required to wear PPE.

2\) [Equipment Resources]{.underline}. The Medical Center's role in the
community and the personnel available to assist in the emergency
determines the type of decontamination facility needed. VHA Directive
2003-045 provides minimum specifications for portable decontamination
systems. PPE and associated equipment must meet OSHA and VHA standards.

c\. **Training.** Training must be provided to all personnel
participating in all response levels involved in decontamination.
Training must meet OSHA Emergency Response and VHA Decontamination
Training requirements.

1\) Awareness Level training will be provided for all persons assigned
to the Emergency Operation Center (EOC) and those who work in the
contaminant-free part of the Medical Center, such as the Emergency
Department. Examples of EOC members and support personnel that should
receive Awareness Level training include:

+--------------------------------------+-------------------------------+
| -   Medical Center Director          | -   Safety Officer            |
+--------------------------------------+-------------------------------+
| -   Chief of Staff                   | -   Chief A&MMS               |
+--------------------------------------+-------------------------------+
| -   Associate Medical Center         | -   Chief Fiscal Officer      |
|     Director                         |                               |
+--------------------------------------+-------------------------------+
| -   Decontamination Coordinator      | -   Medical Coordinator       |
+--------------------------------------+-------------------------------+
| -   Chief Nursing                    | -   Police/Security not       |
|                                      |     assigned to wear PPE      |
+--------------------------------------+-------------------------------+
| -   Chief Pharmacy                   | -   All Support Personnel not |
|                                      |     assigned to wear PPE      |
+--------------------------------------+-------------------------------+
| -   Public Affairs Officer           | -   Emergency Department      |
|                                      |     staff not assigned to     |
|                                      |     wear PPE                  |
+--------------------------------------+-------------------------------+
| -   Chief Engineering                | -   All other persons         |
|                                      |     assigned to support       |
|                                      |     decontamination           |
|                                      |     emergencies, but not      |
|                                      |     assigned to wear PPE      |
+--------------------------------------+-------------------------------+
| -   Chief Police                     |                               |
+--------------------------------------+-------------------------------+

2\) Operations Level training will be provided to all personnel assigned
to wear PPE, whether or not they are expected to conduct actual
decontamination activities. VAMCs must identify and track the number of
persons trained at the Awareness and Operations Levels, and certify
their competencies.

3\) Operations Level training and exercises shall include the following:

-   Personnel roles, lines of authority and communication.

-   Initiating, performing and concluding an emergency decontamination
    operation. (See Attachment E, External HAZMAT Response Plan Flow
    Chart.)

-   Emergency alerting and response procedures.

-   Hazard recognition of contaminated patients, including signs and
    symptoms.

-   Proper selection of PPE*.*

-   PPE donning/doffing procedures. (See Attachment F, PPE Donning and
    Doffing Sequence.)

-   Perimeter and site control.

-   Patient triage and tracking. (*Note to Writer: See the Emergency
    Management Program Guidebook, Section 6.3.3.4, sample SOP on Triage
    During a Mass Casualty Incident.)*

-   Procedures to provide individual privacy during the decontamination
    process.

-   Rapid removal, handling, tracking and/or disposition of contaminated
    clothing and personal items.

-   Rapid removal, handling, tracking and disposition of patients'
    medical devices (e.g., contact lenses, glasses, braces, prosthetics
    and wheelchairs).

-   Emergency medical treatment of contaminated individuals. (*Note to
    Writer:* *See also appropriate sample SOPs for Chemical, Biological
    and Radiological events in the Emergency Management Program
    Guidebook, Section 6.*)

-   \*Procedures for decontaminating non-ambulatory patients.

-   Instructions for ambulatory patients to conduct
    self-decontamination. (See Attachments G, Patient-Directed Self
    Decontamination; and, Attachment G1, Decontamination Posters -
    Step-by-Step Process.)

-   Procedures for decontaminating skin and hair.

-   Procedures for decontaminating eyes.

-   Procedures for decontaminating open wounds.

-   Procedures for removing contaminated fragments.

-   Procedure for bodily fluid sample collection as a marker of
    exposure.

-   Procedures for evidentiary chain-of-custody. (*Note to Writer: See
    sample Chain-of-Custody Readiness Plan in Emergency Management
    Program Guidebook, Section 5, Part 6A.*)

-   Safe disposal of contaminated waste.

-   Procedures for proper handling of contaminated human remains.

-   Collection and disposal of contamination runoff.

-   Procedures for decontaminating equipment (including reusable patient
    equipment).

-   Procedures for decontaminating the facility.

5\. ***Response.*** Upon notification from the community or identifying
an announced external event due to sudden presentation of potentially
contaminated victims, the Medical Center must initiate response
procedures (see Attachment E, External HAZMAT Response Plan Flow Chart).

a\. Response actions include:

-   Initiate emergency response, security lockdown and perimeter control
    procedures. (*Note to Writer: See sample SOP for Lockdown -
    Heightened Security Procedures in the Emergency Management Program
    Guidebook, Section 6.3.4.3*.)

-   Activate the Medical Center EOP, which will include activation of
    appropriate external hazardous material or terrorism SOPs.

-   Implement the decontamination ICS.

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-   Verify that security/lockdown procedures have been implemented.

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-   Attempt to identify the contaminants and the type of emergency.

-   Verify that decontamination and support staff are on-site and that
    all tasks are assigned.

-   Activate the deployment and/or use of decontamination facilities and
    all associated equipment and supplies.

-   Activate the medical cache or other pharmaceuticals appropriate for
    the emergency. (*Note to Writer: See sample VHA Pharmaceutical Cache
    SOP in the Emergency Management Program Guidebook, Section
    6.3.3.6.)*

-   Verify that communication systems and procedures are in place for
    decontamination and EOC operations.

-   Implement and monitor safety protocols, such as verifying the proper
    level and type of PPE to be used; and checking critical vital signs,
    such as blood pressure, temperature, etc., of all personnel wearing
    PPE. (See Attachment F, PPE Donning and Doffing Sequence.)

-   Brief decontamination, security and triage team members, and ensure
    that they understand their mission.

-   Check and verify proper donning of PPE. (See sample checklist, PPE
    Donning and Doffing Sequence, Attachment F.)

-   Verify that all emergency medical supplies or devices, such as Mark
    I's, are available.

-   Monitor exposures and safe work practices during decontamination
    operations, if possible.

-   Verify that procedures are in place to monitor decontamination
    activities, teams progress and team member well-being.

-   Verify that triage protocols have been communicated and activated.
    (*Note to Writer: See sample Triage During Mass Casualty Incidents
    SOP in the Emergency Management Program Guidebook, Section
    6.3.3.4.*)

-   Verify communication and appropriate coordination with local
    responders. (In many communities the EOC will be tasked with
    coordinating with outside agencies. However, the Emergency
    Department is also in communication with local responders and
    hospitals. This coordination must be synchronized so that both the
    Medical Coordinator in the Emergency Department and the EOC have the
    same information.)

-   Verify that appropriate security concerns, such as crime scene
    evidence and chain-of-custody procedures, are in place. (*Note to
    Writer: See sample Chain-of-Custody Readiness Plan in Section 5,
    Part 6A, of the Emergency Management Program Guidebook.*)

-   Monitor decontamination operations for both ambulatory and
    non-ambulatory to verify proper procedures and techniques. (See
    Attachment H, Patient Decon Procedures.)

-   Ensure that additional teams are being readied to rotate, as needed.

b\. External Notification may include:

-   Within VHA - VISN Directors

VHA Central Office, if appropriate

-   Other Federal Agencies - OSHA. Notify within eight hours of one
    employee fatality, or three employee hospitalizations resulting from
    a single incident.

Environmental Protection Agency (EPA)

Federal Bureau of Investigation (FBI) for terrorist event

Centers for Disease Control (CDC)

-   Community Entities. Because of the VHA facility's relationship to
    the community, it is likely that there are specific entities within
    the community that should be notified that a threat/event has
    occurred. In many cases, this notification will trigger a community
    response to the threat/event, e.g. local Fire Department/HAZMAT
    Team.

Offices of Emergency Services (both state and local level)

State and Local Health Departments

City or local water and sanitary sewer systems

State Environmental Agency

-   Other - JCAHO

6\. ***Recovery*.** Recovery actions are initiated when the Incident
Commander declares the emergency secured. Recommended actions include:

-   Initiate proper PPE doffing procedures.

-   Identify equipment/materials that will not or cannot be properly
    decontaminated.

-   Ensure that any contaminated equipment/materials are safe guarded
    for proper disposal.

-   Ensure that contaminated wastewater is secured and initiate
    procedures for proper handling and disposal.

-   Monitor patient symptoms and treatment outcomes.

-   Monitor all team members for signs, symptoms, and mental well-being.

-   Coordinate with appropriate authorities on disposition of evidence
    and contaminated materials.

-   Initiate actions to replenish equipment/supplies to ensure emergency
    operational readiness.

-   Complete an After-Action Report.

7\. ***References and Further Assistance.***

a\. VHA Emergency Management Program Guidebook.

b\. Occupational Safety and Health Administration website:
([www.osha.gov/dts/osta/bestpractices/firstreceivers_hospital.pdf](http://www.osha.gov/dts/osta/bestpractices/firstreceivers_hospital.pdf))

c\. Medical Surge Capacity and Capability. A Management System for
Integrating Medical and Health Recourses During Large-Scale Emergencies,
2004; The CAN Corporation.

d\. Jane's Chem-Bio Handbook, 2^nd^ Edition.

8\. ***Review Date.***

(Name)

Chief, (Service)

Attachments:

A. Mission Critical Considerations for Decontamination of a Mass
Casualty Event

B. Decontamination Job Action Sheets

C. HAZMAT Decon Resource Team Organizational Chart

D. Building a Hospital Decontamination Team Slide Presentation

E. External HAZMAT Response Plan Flow Chart

F. PPE Donning and Doffing Sequence

G. Patient-Directed Self-Decontamination

G1. Decontamination Posters - Step-by-Step Process

H. Patient Decon Procedures

*Sample 6.3.3.3*

*(Note: This SOP contains some intricate clinical information. For
additional clinical information or clarification, you may contact Dr.
Ralph DePalma or Dr. Michael Hodgson, via VA Global Address Book in
Outlook, or your local trauma/ER specialist.)*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Trauma Management in a Mass Casualty Incident - Blasts and
Explosions**

1\. ***Description of the Threat/Event***.

a\. **Trauma and Mass Casualty Incidents (MCI) in the US.** A mass
casualty incident (MCI) is any event in which the number of patients and
the severity of injuries exceed the resources of the healthcare
facility. The imbalance of needs to resources may be due to the large
number of patients; to the number or severity of the injuries; to
limited equipment, supplies or staff; or, to the presence of conditions
beyond the available medical capabilities. Careful pre-hospital triage
and direct transport of trauma victims to hospitals of the appropriate
trauma level facilitates smooth coordinated trauma response in daily
practice. During a large mass casualty incident, all appropriate
designated trauma level institutions may become overwhelmed because of
patient self-referral, delivery by privately owned vehicles and blockage
of usual transportation routes to designated trauma facilities. In an
event of this nature, hospitals not designated as trauma facilities may
be faced with the need to deliver emergency triage, stabilization and
treatment prior to transfer to a trauma facility. These events may be
the result of a natural disaster or an intentional non-natural event
(see Attachments A - C).

b\. **Goal of Triage and Trauma Care**. In an MCI, the primary goal is
to prevent deaths during the so-called "golden hour" of care delivery,
separate out minor injuries to spare needed resources, and minimize
long-term mental health consequences. The "golden day" rule refers to
the dramatic increase in mortality after 24 hours of burial in
structural collapse. The overall goals are to minimize the likelihood of
death, stabilize the patient with minimization of morbidity and
mortality until definitive care is available, and to maximize the
efficiency of patient transfer and transport to appropriate definitive
trauma facilities.

c\. **Legal Aspects of an MCI with Trauma**. In terrorist incidents, the
documentation and the legal chain of custody in these procedures must be
recognized. (*Note to Writer: For additional chain-of-custody
considerations, please refer to Section 5, Part 6A, in the Emergency
Management Program Guidebook.)*

d\. **Event Characteristics**. The characteristics of an event leading
to mass casualties have some predictive value for the distribution of
injuries. Blasts and explosions in closed spaces (i.e., buses or
buildings) result in a relatively higher proportion of primary blast
injuries, with the need for at least short-term observation. Explosions
with structural collapse are associated with relatively fewer severe
injuries as many of the most severely injured individuals have died.
Concerns for combined exposures, i.e., including radiation and chemical
exposures, generate the need for radiation measurement, searches for
unusual accompanying presentations and decontamination. Factors that
should be considered in the event of an MCI include:

-   How many victims are involved?

-   What is the type of event and the anticipated types of injuries?

-   Is it likely from the estimated number of victims that the VA
    Medical Center (VAMC) will need to receive trauma victims and
    provide emergency care and stabilization until another facility can
    accept them for definitive care or until the definitive care can be
    made available at the VAMC?

-   Are involved victims also contaminated; and, if so, what is known?

-   What victim-specific factors must be considered? Is a special
    population involved, such as infant, pregnant, elderly or frail
    victims?

2\. ***Impact on Mission Critical Systems***. The number of victims and
mechanism of injuries (i.e., degree of explosive force if blast
involved) are the prime determinants of the extent of response required.
An MCI with trauma may quickly overwhelm several mission-critical
systems including staffing, critical supplies (i.e., ventilators, blood
supply, antibiotics) and operational space. If the incident is due to
terrorism and contamination is involved, all the risks related to the
type of contamination must be mitigated. \[*Note to Writer: When
contamination is involved, please refer to the Emergency Management
Program Guidebook, Section 5, unique event sample readiness plans, and
Section 6 for sample Standard Operating Procedures (SOPs).*\]

3\. ***Operating Units and Key Personnel/Responsibility to Manage
Events***.

-   *Medical Center Director or Designee i*s responsible to act as the
    Incident Commander/Manager (IC), and is responsible for all VAMC
    response planning and actions.

-   *Emergency Program Coordinator (EPC)* is responsible to ensure that
    the Emergency Operations Plan (EOP) is current, assists the IC with
    internal (Key Operations Managers) and external (community or
    agency) coordination.

-   *Chief of Staff* is responsible for providing proper medical health
    and treatment care services and assuring appropriate clinical skills
    and training.

-   *Associate Director or designee* is responsible for monitoring and
    ensuring VAMC operations and services as they relate to patient
    services are implemented.

-   *Emergency Department Director or Designated Medical Coordinator* is
    responsible for ensuring clinical personnel are familiar with the
    trauma readiness plan and SOPs; and participate in trauma-related
    educational endeavors and drills to assure ability to respond to an
    MCI with trauma. Key role in developing and maintaining functional
    trauma procedures/protocols in conjunction with Chief of Surgery for
    trauma MCI.

-   *Emergency Room and Urgent Care Personnel* - Key role in patient
    reception, triage, stabilization, treatment and disposition. Key
    role in ensuring that all other medical emergency capabilities
    (i.e., cardiac emergencies) are maintained and operational.

-   *Chief of Surgery* - Responsible for developing and maintaining
    trauma procedures and protocols.

-   *Chief of Anesthesiology/Anesthesiology Staff* are responsible for
    providing supportive services to assist with intubation and airway
    access, intravenous access and anesthesiology services, as
    indicated.

-   *Chief of Medicine* is responsible for assuring ongoing patient
    care, providing appropriate medical services as needed in support of
    patients from the event, and collaborating with the Emergency
    Department Director and Chief of Surgery as needed to assure optimum
    patient support.

-   *Medical Service* - Key role in clinical care of patients in
    conjunction with Surgery Service to assure timely and appropriate
    stabilization and treatment of patients. Key role in maintaining
    continuity of patient care operations and monitoring clinical
    patient workload. Key role in identifying clusters of clinical signs
    or symptoms that could indicate exposure to a chemical, biological
    or radioactive contaminant.

-   *Chief of Nursing/Nursing Service -* Key role in tracking patient
    census, staffing utilization and need for additional staff.
    Encourages Nursing staff in educational endeavors on trauma
    management.

-   *Chief of Radiology/Radiology Staff* are responsible for providing
    radiological support services. In MCIs with trauma, the number of
    functional x-ray machines and the rate of processing may be the
    limiting factor in the processing of victims. Interventional
    Radiology services will probably be needed to assist with line
    placement and diagnostic testing. CT and Ultrasound will have key
    roles in patient assessment.

-   *Infection Control Team* - Provides information as needed for
    healthcare providers, employees and patients regarding concerns
    related to infection control, with emphasis on any staff exposed to
    blood and body fluids.

-   *Clinical Laboratory* - Provides collection and analysis of
    biological specimens as needed to support clinical care. Blood Bank
    key in providing blood components.

-   *Safety Officer* is responsible for monitoring and initiating
    actions to ensure safe actions are taken during the emergency event.

-   *Safety Officer/Industrial Hygienist* - When potential or actual
    contamination is involved, key role as the point of contact with
    HAZMAT agencies in substance sampling or environmental sampling. Key
    role in monitoring and proper use of specialized personal protective
    equipment (PPE) resources as needed.

-   *Public Affairs* will act as the point-of-contact for the media and
    other governmental agencies that may request information concerning
    the incident and its impact upon patients, staff and facility.

-   *Police Chief* ensures that lockdown and police procedures, traffic
    and crowd control, crime scene and investigation, and perimeter
    control are implemented.

-   *Police Service* is responsible for perimeter control and incident
    site access. Key role in implementing chain-of-custody processes for
    all potential evidence during investigation of event within the
    VAMC.

-   *Occupational/Employee Health* - Key role in monitoring occupational
    health conditions/risks, employee concerns and prophylactic therapy
    as needed. Tracks and provides care and documentation for any
    employee exposed to blood or body fluids.

-   *Chief Engineer* is responsible for protecting, repairing and
    maintaining plant utility systems, communications and medical
    equipment necessary for patient care and VAMC operation.

-   *Chief A&MMS* is responsible for logistical function as it relates
    to providing facilities, transportation, supplies, equipment,
    services, etc.

-   *Chief Fiscal* is responsible for providing funding and tracking
    expenses that relate to VAMC response to the emergency event.

-   *Social Work -* Coordinate information between victims, family and
    significant others.

-   *Chaplain* - Provides spiritual counsel and comfort to the victims
    and their significant others and family, with special emphasis on
    those victims who are terminal.

-   *Human Resource Management* - In an MCI involving the community,
    provides information to significant others or family of workers on
    site and acts as liaison during an extended event in coordination
    with Public Affairs.

4\. ***Mitigation/Preparedness Activities for the Threat/Event***.

a\. *Hazard Reduction Strategies and Resource Issues*. Ensure that
appropriate equipment and supplies are available, including portable,
battery-powered otoscopes for pre-hospital triage.

b\. *Preparedness Strategies and Resource Issues*. Develop a basic
capability to organize a response to an MCI with trauma. Pre-event
education and planning may include:

1\) Staff Training.

2\) Protocol Development. Determination of screening and assessment
tools for use for rapid patient intake, assessment and tracking before
an event**.** (See Attachment D, Trauma Patient Initial Intake Screening
Form.)

3\) Equipment Readiness. Basic equipment that may be necessary (e.g.,
command vests, signage, forms/tags, backboards, crash cart, oxygen,
ventilators, IV fluids, thoracotomy trays, chest tubes,
cricothyroidotomy kits, dopplers, battery-powered untethered otoscopes,
ultrasound units, etc.). Pre-stocked disaster/trauma carts.

4\) Space. Space management plans should include identification of three
specific locations:

a\) A triage area before the entrance to the main Emergency Department
should be identified; this is also potentially useful for
decontamination.

b\) A separate area where mental health/anxiety patients may be triaged
should be identified.

c\) An area for treatment of minor injuries apart from the main
Emergency Department should be organized.

5\) Staffing assignments. Mid-level experienced clinicians should staff
the triage and the minor injury areas; mental health professionals
should staff the mental health areas. Specialty surgeons should be
assigned to operative interventions. Experienced emergency physicians
should staff the Emergency Department treatment and triage rooms used
after patients have entered the facility. Additional personnel should be
anticipated for assistance with litter bearing, patient and supplies
tracking, ancillary support services and patient admission and transport
coordination.

5\. ***Response/Recovery from the Threat/Event***.

a\. *Hazard Control Strategies*. Preparation for Patient Arrival and
Reception.

1\) Receive/Verify Notification: Receive and confirm the information on
the MCI by callback to the source or verification during the original
call.

2\) Provide Internal Notification: Alert staff; maintain ongoing
communications.

3\) Facility Lockdown and Restricted Access: Establish traffic and
access control procedures, including facility lockdown when appropriate.

4\) Staff Briefing. Brief staff on the anticipated arrival of trauma
victims. Consider mobilizing all available staff to the Emergency
Department.

5\) Designate Triage and Treatment Areas.

6\) Prepare the Areas (e.g., deliver pre-stocked disaster or treatment
carts).

7\) Patient Reception - General Triage: Triage, including repeat triage
for those arriving by medical transport, occurs immediately upon arrival
and should not take over one minute per patient. Triage and tagging
method vary between facilities. Examples include Battlefield Triage to
categories of immediate, urgent, delayed, minimal or expectant
\[reference Emergency War Surgery NATO Handbook:
<http://www.vnh.org/EWSurg/ch05/05TreatmentofBI.html>; or START (Simple
Triage and Rapid Treatment):
<http://www.citmt.org/start/background.htm>\].

8\) "Upside Down" Presentation: Less severely injured disaster victims
often arrive at medical facilities before transport-dependent, more
severely injured patients. Plans must anticipate these later arrivals
with greater injuries and provide appropriate access to the needed level
of care.

b\. *Patient Stabilization and Treatment*.

1\) Listen for breathing; look for chest movement; feel for pulse.

2\) Establish an airway:

-   Chin lift, jaw thrust, stabilize head, avoid neck movement.

-   Intubation\--Avoid head tilt if neck injury possible.

-   With mass casualties, a clamp, pin, or towel may be used as an
    expedient with unconscious victims to keep the tongue out of the
    back of the throat and maintain the airway.

3\) Perform rescue breathing and chest compression, if indicated.

4\) Cover open chest wound, treat tension pneumothorax (i.e., needle
decompression in the short term).

5\) Manage Bleeding:

-   Control bleeding with pressure.

-   Internal bleeding should be controlled surgically.

-   Judicious fluid use to maintain organ perfusion while minimizing
    bleeding prior to surgical control.

-   Goal - Maintain mentation.

-   Maintain Mean Arterial Pressure 80-85 (Systolic 100, Palpable Radial
    Pulse of less than 120). Increase infusion rate **only** when goals
    not met.

c\. *Other Issues in Management of the Trauma Patient*.

1\) *If Radioactive Contamination Is Discovered After Patient Has Been
Admitted.* Continue attending to the patient's medical needs. Secure
entire area where victim and attending staff have been. Do not allow
*anyone* or *anything* to leave the area until cleared by the Radiation
Safety Officer through establishment of control lines to prevent the
spread of contamination. (*Note to Writer: Refer to the sample SOP on
Patients With Radiation Exposure or Radioactive Contamination in the
Emergency Management Program Guidebook, Section 6.2.3.3, for further
details.)*

2\) *If Chemical Contamination Is Discovered After Patient Has Been
Admitted.* Immediately notify the Safety Officer and HAZMAT Team, and
follow appropriate notification procedures and facility protocol for
dealing with a HAZMAT incident. (*Note to Writer: See appropriate sample
Readiness Plans in the Emergency Management Program Guidebook, Section
5, for further information on Decontamination, Chemical, Biological and
Radiological Emergency Response.)*

d\. *Special Considerations for Blast Injury*.

1\) Injuries resulting from blasts and explosions are classified to four
groups:

a\) [Primary]{.underline} - Direct Blast Effects (over and under
pressurization).

-   Tympanic membrane rupture.

-   Pulmonary.

-   Hollow viscus injury (colon, bladder).

-   Fragmentation injuries (shrapnel from device).

b\) [Secondary]{.underline} - structural collapse and projectiles.

-   Crush injuries: blunt trauma.

-   Fragmentation injuries: penetrating trauma.

c\) [Tertiary]{.underline} injuries.

-   Patients thrown: penetrating and blunt trauma.

d\) [Quaternary]{.underline} injuries.

-   Burns.

-   Exposure to toxic inhalants.

-   Asphyxiation.

2\) Triage Algorithm based on otoscopic exam for tympanic membrane
rupture (See chart below):

> ![](media/image1.wmf)

(For further information, refer to DePalma, R, et al., Blast Injury:
Clinical Consequences and Immediate Management Strategies, New England
Journal of Medicine; In Press 2005.)

Tympanic membrane (T.m.) injury represents the organ most sensitive to
blast pressure. Patients with intact T.m. and no other injuries or
symptoms may be released.

> 3\) Pulmonary Injury. Pulmonary barotrauma is the most common critical
> injury to individuals close to a blast center whether in civilian or
> military populations. Systemic acute gas embolism (AGE) from pulmonary
> disruption is believed to occlude brain or spinal cord blood vessels.
> Central nervous system injury due to AGE must be differentiated from
> the direct effects of head trauma and concussion. Body armor does not
> protect against the barotrauma of primary blast injury.
>
> 4\) Colonic Rupture. The colon is the visceral structure most
> frequently affected by *primary* blast injury. Rupture of the colon
> and, less frequently, the small intestine also occur as an immediate
> result of blast but may also present as *delayed* rupture.
>
> 5\) Eye. Rupture of the globe, serous retinopathy and hyphema may
> occur and requires immediate treatment. Facial fractures are more
> commonly due to flying objects or direct trauma.
>
> 6\) Traumatic Brain Injury. Primary blast injury leads to brain injury
> by concussion, as well as by barotrauma caused by AGE. Losses of
> consciousness and coup/contra-coup injury had been attributed to
> secondary or tertiary mechanisms; though, with the increased use of
> body armor in the military, evidence of central nervous system damage
> associated with survival after explosions and direct blast effect has
> been increasingly recognized.
>
> 6\) Crush Injury. Crush syndrome is a metabolic derangement resulting
> from damage to muscle tissues with the release of myoglobin, urates,
> potassium and phosphates, leading to oliguric renal failure.
> Appropriate treatment includes hydration and alkalization.
>
> 7\) Compartment Syndrome. Compression damages a muscle within its
> inelastic sheath. The resulting swelling promotes local ischemia and a
> vicious cycle of swelling, increased compartment pressures, decreased
> tissue perfusion and further ischemia. The landmark sign of
> compartment syndrome is pain out of proportion to the injury, with
> even passive movement of an affected extremity exacerbating pain.

e\. *Special Considerations in Pregnant Trauma Patients*.

1\) Pregnancy should be considered in girls and women between the ages
of 10 and 50 years of age, and pregnancy testing should be considered in
females in this age range. Inquiry into the menstrual history will
assist in excluding this possibility in younger and older patients.

2\) Two patients are being assessed and treated - both the mother and
the unborn. The life of the unborn depends upon the mother's health,
thus direct initial management toward maternal resuscitation.

3\) The best initial care for the unborn is the provision of optimum
resuscitation and care for the mother, and early assessment of the
unborn.

4\) Order of care should be: Initial Survey and Resuscitation for the
Mother, Fetal Assessment, and Secondary Survey of the Mother to include
Pelvic Examination preferably by an Obstetrician. Fetal heart rate
monitoring is indicated at greater than 20-24 weeks gestation.

5\) Pregnancy produces changes in both anatomy and physiology, which
alter both injury patterns and the response to trauma.

6\) Significant change includes increased oxygen consumption, thus early
provision of supplemental oxygen is indicated and hypervolemia of
pregnancy indicating the need for early fluid resuscitation.

7\) [Early consultation]{.underline} with both an obstetrician and a
surgeon should be obtained in all pregnant trauma patients. Full
discussion of this topic is beyond the scope of this document, and
qualified medical practitioners must attend to these patients as soon as
possible. Some conditions of concern include uterine rupture, abruption
placenta or placental separation, amniotic fluid embolization,
Disseminated Intravascular Coagulation (DIC), and fetal loss.

8\) Peri-mortem Cesarean Section within 4-5 minutes of maternal cardiac
arrest may be successful, unless the mother has been hypovolemic. In
cases of hypovolemia, this is unlikely to be successful due to prolonged
fetal compromise.

9\) Disseminated Intravascular Coagulation (DIC) may occur rapidly in
the pregnant trauma patient. Findings include decreasing fibrinogen
levels (note that fibrinogen levels normally increase 1.5-2.0 times
during pregnancy; decreasing levels from baseline should be considered
significant), low platelet count, and reduction in other coagulation
factors. Management includes urgent uterine evacuation and management of
the depleted factors.

10\) Consider Rh immunoglobulin therapy within 72 hours in all
Rh-negative pregnant trauma patients with possible fetomaternal
hemorrhage (any degree of trauma of the abdomen or thorax) to avoid Rh
sensitization.

f\. *The Pediatric Trauma Patient*. Treatment of the pediatric patient
requires specialized knowledge of normal developmental stages,
pharmacology with calculation of drug dosages on a weight basis and
avoidance of specific drugs, and specialized knowledge of Pediatric
Advanced Life Support. Consideration should be given to developing a
contingency plan, which includes pre-event identification and credential
verification of qualified Pediatricians and Surgeons skilled in
management of pediatric trauma patients who would plan to report to the
facility Emergency Department for activation of temporary privileges in
an event of activation of the EOP and when local pediatric facilities
are overwhelmed or inaccessible. Sources must be identified for rapid
availability of pediatric supplies and equipment, and these should be
rapidly obtained as soon as such a situation is recognized.

g\. *The Elderly Trauma Patient*. Fatality rates with trauma are
increased in the elderly patient, but no good criteria exist to
determine which factors are determinants of mortality. Aggressive early
treatment has been shown to improve survival in the elderly trauma
patient. Many of these patients return to their pre-injury level of
function after recovery. Ethical considerations warrant that the
patient's right to self-determination as expressed in pre-existing
Advance Directives should be considered in the massively injured elderly
patient. It is inappropriate to withhold care based upon consideration
of age. Consideration of age-related changes in physiology and reserve
capacity are necessary to provide optimal care.

h\. *Recovery Strategies and Resource Issues.* An assessment of
mission-critical systems, medical resources and personnel needs should
be conducted every 12 to 24 hours during the event and forwarded to the
Emergency Operations Center (EOC) so that a Situation Report (SITREP)
can be compiled.

6\. ***Notification Procedures***.

a\. Provide notification and Situation Reports (SITREPs) to the Network
Director.

b\. Contact secondary VA Medical Centers, if necessary.

c\. Coordinate with local, county and state emergency response agencies,
as appropriate.

d\. Coordinate with state/local Offices of Emergency Services.

7\. ***References and Resources***.

a\. *Advanced Trauma Life Support for Doctors*^^ Student Course manual
7^th^ Edition;  2004 American College of Surgeons; ISBN 1-880696-14-2.

b\. The American Association for the Surgery of Trauma Webnet:
<http://www.aast.org/> and <http://www.aast.org/injury/injury.html>.

c\. Advanced Burn Life Support Pre-Hospital Course
(<http://www.ameriburn.org/ABLSCourseDescriptions.htm>).

d\. Centers for Disease Control and Prevention (CDC): *Mass Trauma Data
Instrument,*
<http://www.bt.cdc.gov/masstrauma/pdf/rapidassessmentform.pdf>.

e\. Centers for Disease Control and Prevention (CDC): *Coping With a
Traumatic Event,* <http://www.bt.cdc.gov/masstrauma/copingpub.asp>.

f\. Centers for Disease Control and Prevention (CDC): *Explosions and
Blast Injuries: A Primer for Clinicians,*
<http://www.bt.cdc.gov/masstrauma/explosions.asp>.

g\. Centers for Disease Control and Prevention (CDC): *Traumatic
Incident Stress: Information For Emergency Response Workers*,
<http://www.cdc.gov/niosh/unp-trinstrs.html>.

h\. Center for Mental Health Services/ Division of Prevention, Traumatic
Stress and Special Programs/Emergency Mental Health and Traumatic Stress
Services Branch: *Emergency Mental Health and Traumatic Stress,*
<http://www.mentalhealth.org/cmhs/EmergencyServices/links.asp>.

i\. Community Emergency Response Team (CERT) Training, March 2004,
Module 4: Disaster Medical Operations, Lesson 15: *Patient Assessment
and Treatment,*
<http://training.fema.gov/EMIWeb/downloads/is31715PatientAssess.pdf>.

j\. *Current Emergency Diagnosis and Treatment*; Stone, K.C., Humphries,
R.L; 2004 5^th^ edition; Lange Medical Books/McGraw-Hill.

k\. DePalma R, et al.; *Blast Injury: Clinical Consequences and
Immediate Management Strategies*, New England Journal of Medicine; In
Press 2005.

l\. *Disaster Mental Health: Dealing with the Aftereffects of
Terrorism*, National Center for PTSD, Veterans Affairs,
<http://www.ncptsd.org/disaster.html>.

m\. *Emergency War Surgery,* Second United States Revision of The
Emergency War Surgery NATO Handbook; Bowen, T.E, and Bellamy, R. (eds);
US Department of Defense, Government Printing Office**,** Washington,
D.C., 1988, <http://www.vnh.org/EWSurg/EWSTOC.html>.

n\. Komar, A.R, and Prem, P; *Abdominal Trauma, Penetrating*; Website
eMedicine, last updated 11/17/2004,
<http://www.emedicine.com/MED/topic2805.htm>.

o\. McMorran, J, et. al; Trauma Medicine Section, General Practice
Notebook,
<http://www.gpnotebook.co.uk/simplepage.cfm?ID=342556749&linkID=49095>.

p\. National Center for Post Traumatic Stress Disorder (PTSD),
Department of Veterans Affairs, <http://www.ncptsd.org/>.

q\. Online Training Module in *Life-Saving Invasive Procedures*,
Emergency Medicine Education Online,
<http://www.biodigital.org/voz2/open.htm>.

r\. START System, Critical Illness and Trauma Foundation, Inc., Bozeman,
MT, (<http://www.citmt.org/start/background.htm>).

s\. *Trauma Protocol Manual*, Division of Trauma, Vanderbilt University,
<http://www.mc.vanderbilt.edu/surgery/trauma/mdprotocolstyle.htm>.

8\. ***Review Date***.

(Name)

Chief, (Service)

Attachments:

A. Common Trauma in Natural Disasters

B. Common Trauma in Non-Natural Disasters

C. Secondary Effects of Disasters

D. Trauma Patient Initial Intake Screening Form

E. Glasgow Coma Scale

*Sample 6.3.3.4*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Triage During a Mass Casualty Incident (MCI)**

1\. ***Description of the Threat/Event***. Triage is the sorting of
patients based on their medical needs. It is a fluid process beginning
at the field site and continuing in an ongoing manner until treatment
and disposition occurs. VA Medical Centers (VAMCs) practice an
all-hazards approach to casualty triage and treatment. A Mass Casualty
Incident (MCI) is any type of emergency that overwhelms the available
resources, regardless of the number of casualties. An MCI may result
from any natural or accidental disaster or terrorist incident that
overwhelms personnel, supplies and/or equipment. Nuclear/radiological,
biological, chemical, incendiary, explosive materials or any combination
of these may be involved. An example of an MCI could include a terrorist
setting off an explosion in a shopping mall with a lethal chemical
dispersion, an earthquake eruption along the New Madrid fault line, or a
multi-vehicle traffic accident involving a tanker truck carrying
chlorine. In each incident, the local resources would be overwhelmed,
and a mass casualty event would unfold.

> Even though VAMCs practice an all-hazards approach to emergency
> response, there are significant differences that must be identified
> between a Hazardous Material (HAZMAT) non-terrorist event and a
> Nuclear, Biological or Chemical (NBC) terrorist event.

a\. HAZMAT Non-Terrorist Event Compared to a NBC Terrorist Incident. A
terrorist attack is a deliberate hazardous material incident that has
the potential to produce extremely large numbers of casualties. These
deliberate attacks can range from a simple pipe bomb placed under a
tanker truck to the release of a lethal nerve agent in an enclosed
space. Current technology and labeling requirements allow first
responders on the scene to quickly identify or classify many of the
toxic chemicals released during an industrial HAZMAT incident. However,
only advanced detection systems allow identification of the lowest
toxicological threshold concentrations for chemical agents, such as
nerve agents. Such systems are very costly and, thus, may not be locally
available. Hospital personnel must be prepared to classify the potential
agent based on symptoms and presentation, and must appropriately protect
their hospitals and employees through use of properly selected personal
protective equipment (PPE).

In the United States, about 70% of hazardous material accidents involve
only one or two victims. In contrast, a terrorist HAZMAT incident may
include dozens to thousands of victims. The Tokyo subway attack produced
5,500 casualties, which stormed the local emergency rooms of surrounding
hospitals. Following this incident, about 10% of the first responders
and many physicians, nurses and hospital support staff became
symptomatic from sarin off-gassing from the victims' clothing. Even
minute quantities of NBC agents remaining on the victim pose a serious
threat to hospital personnel.

The majority of HAZMAT incidents are not considered environmental crime
scenes; however, an act of terrorism involving NBC agents is a federal
crime. The incident site will be designated a crime scene, and all
evidence collected (i.e. clothing and foreign particles) will be key
components of the response to allow identification of the
perpetrator(s). Interagency coordination at the local, state and federal
levels is an absolute necessity for appropriate handling of the NBC
terrorist incident. The hospital incident management system will need to
be implemented, and hospitals will need to quickly deploy administrative
and public relations personnel to a designated location in order to
provide accurate and timely information. (*Note to Writer: See sample
Chain-of-Custody Readiness Plan in the Emergency Management Program
Guidebook, Section 5, Part 6A.*)

Hospitals must be aware that after a NBC terrorist incident/attack,
there may be a secondary device present at or near the original incident
site, as well as potentially at their hospital. As an important resource
for medicating the effects of an NBC attack, hospitals inherently
represent secondary targets. Secondary devices may be of the
conventional high-explosive type or may be constructed to deliver
additional nuclear, biologic or chemical materials.

(See Attachment A - HAZMAT Non-Terrorist Event Compared to a NBC
Terrorist Incident.)

b\. Things to considerations prior to setting up for triaging an MCI
include:

-   Anticipated number of people involved.

-   Is trauma associated with the incident?

-   Is there a possibility of contaminants, which will require
    decontamination?

-   If contamination is suspected, is the source isolated?

-   What is the patient population involvement (i.e., adult vs.
    pediatric)?

The VAMC uses the Simple Triage And Rapid Treatment (START) Triage and
JumpSTART Pediatric MCI Triage systems in an MCI to provide a
reproducible, standardize and simplified triage process of sorting
casualties, providing a rapid response and eliminating the subjective
nature of triage.

> (*\*Note to Writer: If decontamination is required, review the sample
> Healthcare First Receiver Decontamination SOP in the Emergency
> Management Program Guidebook, Section 6.3.3.2.*)

2\. ***Impact on Mission Critical Systems***. Many situations in the
community can cause an MCI that has the potential of adverse impact on
mission-critical systems. By definition, an MCI is any event that
overwhelms facility/community resources including staff, equipment
(i.e., ventilators, cardiac monitors, etc) or supplies (i.e.,
antibiotics, IV fluids, laboratory supplies, anti-toxins, etc.). It is
imperative to identify procedures for facility lockdown to ensure
protection of the current patients, staff and facility. Other systems
that may be impacted include Heating, Ventilation and Air Conditioning
(HVAC) intake vents in relation to the staged triage/decontamination
area; water delivery for associated decontamination following triage;
water contaminated waste control; and transportation of "walking
wounded" casualties to a location for continued observation after triage
and treatment has occurred. In a chemical event, vapor exposure requires
a minimum of one-hour observation time, and a liquid exposure requires
up to an eighteen-hour observation time to ensure delayed symptoms do
not occur. (*Note to Writer: See Section 5, Part 4, of the Emergency
Management Program Guidebook, sample Chemical Event And Terrorist
Readiness Plan.*)

3\. ***Operating Units and Key Personnel with Responsibility to Manage
this Threat/Event***. Response to an MCI will quickly overwhelm several
mission-critical systems including staffing, critical supplies (i.e.,
antibiotics, intravenous fluids, laboratory supplies, anti-toxins) and
operational space. In addition, the release of a biological or chemical
agent within or close to the facility could pose an imminent risk to the
HVAC and water supply systems, if intentionally or accidentally
contaminated with organisms, and add much difficulty to the triage and
decontamination process. It is important to assess the airflow pressure
relationships within a facility and to determine the appropriate area
for the triage and decontamination units to be set. In an MCI, the
Triage Officer is in charge of the triage process and reports to the
Medical Coordinator of the event.

4\. ***Key Personnel and Management Responsibilities***.

-   *Infection Control Team* - Tracking of potential and confirmed cases
    with reporting responsibilities to the Public Health Service. Local
    information resource.

-   *Nursing Service and Chief of Staff* - Tracking patient census,
    staffing utilization, triage and treat of casualties.

-   *Safety Officer/Industrial Hygienist* - Monitoring and proper use of
    specialized PPE resources, as needed. Lead role in extending
    availability of respiratory isolation rooms.

-   *Police and Security* - Key role in perimeter control, incident site
    access and chain-of-custody issues.

-   *Emergency Room Personnel* - Monitoring clinical patient workload.
    Ensuring that other medical emergency capabilities (i.e., Cardiac
    emergencies) are maintained.

-   *Medical Service* - Monitoring patient workload and recognition of
    potential cases.

-   *Occupational/Employee Health* - Monitoring occupational health
    conditions/risks.

-   *Facilities/Engineering* - Ensuring mission-critical systems are
    protected.

-   *Environmental Management* - Supports triage by providing patient
    litter bearers and runners, as needed.

-   *Emergency Medical Response Team (EMRT)* - Includes members from the
    Emergency Department, Environmental Management and Police and
    Security, Nursing, Mental Health, Environmental Services, Infection
    Control, Chaplin Services to name only a few. Anyone interested and
    willing to work as a team member is welcome to join the EMRT.

-   *Mental Health Service and Chaplin Service* - Supports the "worried
    well," and initiates debriefing of casualties and staff as needed.

5\. ***Mitigation/Preparedness Activities of the Threat/Event***.

a\. Hazard Reduction Strategies and Resource Issues. Education/drills
are needed to enhance triage and decontamination procedures. The
education and training for the EMRT and Emergency Department staff must
include START and JumpSTART, followed by practice drills to ensure a
safe, efficient triage process. JumpSTART was developed and is used if
the victim appears to be a child. Conversely, if the victim appears to
be an adult or young adult, START is used. During an MCI, triage
provides the organizational framework that promotes the greatest good
for the greatest number of casualties.

VAMCs will use START and JumpSTART Pediatric MCI triage programs as an
appropriate method of triage during a hospital-based, first-receiver
MCI. START triage is an adult level, four tiered, color-coded system
that utilizes a Red tag as critical; Yellow tag as delayed; Green tag as
minimal or walking wounded; and Black tag as expectant or deceased.
Another way to recognize the meaning of the four levels: Red is compared
to a critical care unit; it has more resources available to provide care
to the patient (i.e., staff, ventilators). Yellow is comparable to a
Medical Surgical Ward; resources are available to include staff to
assess and provide care to the patient, but not as many resources as in
the Red area. Green is compared to the clinic setting; less resources
are available, minimal care is still provided and patients are still
observed and assessed as needed. If the patient's condition changes,
they are moved to a different level of care as appropriate.

**Decision Matrix - START Triage System**

**Adult Level, 4-Tiered Triage System**

  -- ----------- ---------------- ------------------------- -----------------
     **Color**   **Definition**   **Hospital Equivalent     **Level of
                                  Area**                    Resources**

     Red         Critical or      Critical Care Area        Most staff,
                 Immediate                                  equipment,
                                                            supplies
                                                            available

     Yellow      Delayed          Medical/Surgical Ward     Less than
                                                            Critical, but
                                                            resources still
                                                            available

     Green       Walking Wounded  Clinic setting            Fewer resources;
                 or Minimal                                 staff to provide
                                                            observation and
                                                            first aid

     Black       Expectant or     Morgue                    Staff available
                 Deceased                                   only for tracking
                                                            and coordination
  -- ----------- ---------------- ------------------------- -----------------

EMRT or ED staff with basic first-aid knowledge can effectively use
START or JumpSTART triage. In START, the triage officer asks all
casualties to follow a designated person to the Green area. This reduces
the number of casualties to be triaged. The casualties in the Green area
still require supervision and, depending on the situation, may require
decontamination and continued observation.

In the event of a chemical exposure, patients must be observed for one
to eighteen hours. (*Note to Writer: See sample Chemical Event And
Terrorist Readiness Plan, Section 5, Part 4, of the Emergency Management
Program Guidebook.*) All of the victims who did not relocate will
require assessment, using START or JumpSTART. This process should take
no longer than one minute per victim and will focus on three major
areas: respiratory status, pulse and neurological (or mental) status. As
the triage officer moves through each level of assessment, any condition
deemed as critical (Red tag) stops the process. The victim is tagged,
and the triage officer goes to the next casualty. (See Attachment B -
START Flowchart.)

In 1995, the JumpSTART Pediatric MCI Triage program was developed to
coincide with the START system. With START, a child could not be
adequately triaged, since START did not address the unique anatomy and
physiology of children, including their normal physiological function,
age and/or developmental status. An example of this would be that a
two-year old who normally breathes 30 times per minute would be tagged
as critical using START criteria, even though this respiratory function
and rate is normal for a 2 year old. The other major difference in
JumpSTART is that if the child does not have spontaneous respirations
but does have a pulse, they are given five rescue breaths. If they then
regain spontaneous respirations, they are tagged Red or critical. The
rationale is that in children, respiratory arrest is more likely to
occur than cardiac arrest, and by giving the rescue breaths there is a
strong possibility spontaneous respirations will begin. Also, most
people will have difficulty not doing anything more for a child who is
not breathing. The steps following the respiratory assessment give
specific direction to be very time-efficient and provide the best level
of care. However, if after the rescue breaths, the child does not regain
spontaneous respirations, they are tagged Black. (See Attachment C -
JumpSTART Pediatric Triage.)

b\. Preparedness Strategies and Resource Issues.

1\) During drills, triage teams work together to protect each other, the
facility and the victims involved in the MCI.

2\) Identify the appropriate number of staff to don PPE in a
decontamination event and additional staff needed to be ready to relieve
the working teams.

3\) Identify the equipment necessary for a triage/decontamination
procedure.

4\) The hospital receiver, triage/contamination zone must have several
triage teams placed and ready to triage. VAMC provides triage teams in
groups of two to support this function.

5\) Two members are located at the perimeter entry point (PPE required),
to identify the casualties who are involved in the MCI vs. patients
coming in from another source.

6\) A two-member triage team is stationed inside the
triage/decontamination zone (PPE is required).

7\) If the MCI involves casualties with trauma, there will be a
two-member triage/treatment team in the triage/decontamination zone (PPE
required).

8\) There will be two-member teams in each area of the decontamination
tent. (*Note to Writer: See sample Healthcare First Receiver
Decontamination SOP, Emergency Management Program Guidebook, Section
6.3.3.2.*)

9\) A two-member triage team is located in the post-decontamination area
to make the final triage assessment and disposition to the appropriate
treatment section \-- Red, Yellow, Green or Black. (PPE not required in
this area).

10\) Identify need and persons involved in chain-of-evidence collection.

6\. ***Response/Recovery from the Event/Threat***.

a\. Hazard Control Strategies and Resource Issues.

1\) Implement mitigation strategies.

2\) Have additional staff ready and available to relieve triage teams,
as needed.

b\. Hazard Monitoring Strategies**.**

1\) Monitor the time staff are in PPE triaging. The time when each team
member is completely donned in his or her PPE is written on the back of
his or her PPE suit. This allows the safety officers and other team
members an opportunity to help identify times for changing out staff.
Time limitations for staff to be in PPE performing triage or
decontamination depend on or may change due to level of PPE, weather
conditions and/or response of staff to the stress level of the event.

2\) Each team is responsible for monitoring the condition of their
fellow team member. This allows the team to identify when one member may
be having physical problems not necessarily related to the time in PPE.
By observing the eyes of the team member in PPE, one can identify the
onset of problems and the need to request a replacement triage team.

c\. Recovery Strategies*.*

1\) Clean up/pick-up of equipment, supplies and gathering of staff for
debriefing.

2\) A team debriefing is necessary to allow the team to ventilate,
express their feelings and concerns, and identify things done well and
areas for improvement.

3\) The VAMC uses EMRT psychologists, social workers or Chaplain to lead
the debriefing.

> d\. See Attachment D - Key Activity Management Tool/Structure.

7\. ***External Notification Procedures***.

a\. VA and Other Federal Notification: The triage area would not notify
any federal agencies, but would defer this procedure to the Emergency
Operations Center (EOC).

b\. Community Entities: The VAMC is included in the community emergency
communication system with a "Red Phone" in the Emergency Department to
allow immediate contact with all other Emergency Departments in the
community, Emergency Medical Services and the state health department.
Through this mechanism, the community would be notified of any initial
disaster situation and response effort.

8\. ***Specialized Staff Training***. Awareness Level training is needed
for all medical center clinical staff and any ancillary staff that will
be working in the reception area. The EMRT and Emergency Department
staff that will be in the triage/decontamination area, regardless of the
level of Personal Protective Equipment (PPE) needed, requires an
Operations Level education, specific training and drills.

9\. ***References and Further Assistance***.

a\. VHA Emergency Management Program Guidebook.

> b\. Other Resources for Domestic Preparedness Program - Triage:
>
> <http://www.ojp.usdoj.gov/odp/docs/EmergencyRespGuidelinesRevB.pdf>.
>
> [http://www.fcphp.org/Preparedness%20guide/Homeareyouready.htm](http://www.fcphp.org/Preparedness guide/Homeareyouready.htm).
>
> <http://www.ualbanycphp.org/learning/registration/detail_Terrorism.cfm>.
>
> <http://www.sph.unc.edu/nccphp/training/training_list/>.
>
> <http://www.publichealthgrandrounds.unc.edu/bioter02/webcast.htm>.
>
> <http://hopkins-id.edu/bioterror/info.html>.
>
> [http://www.train.org/DesktopModules/eLearning/CourseDetails/CourseDetailForm.aspx?tabid=62&CourseID=1000442](http://www.train.org/DesktopModules/eLearning/CourseDetails/CourseDetailsForm.aspx?tabid=62&CourseID=1000442).
>
> <http://www.citmt.org/start/default.htm>.
>
> [http://www.jumpstarttriage.com](http://www.jumpstarttriage.com/).
>
> <http://www.citmt.org/start/flowchart.htm>.
>
> <http://www.jumpstarttriage.com/JumpSTARTDownloads.html>.

10\. ***Review Date***.

(Name)

Chief, (Service)

Attachments:

A. HAZMAT Non-Terrorist Incident vs. NBC Terrorist Incident

B. START Triage Systems

C. JumpSTART Pediatric Triage System

D. Key Activity Management Tool/Structure

*Sample 6.3.3.5*

*(Note: This SOP contains some intricate clinical information. For
additional clinical information or clarification, you may contact Dr.
Margie Scott or Dr. Linda H. Williams via the VA Global Address in
Outlook, or your local trauma/ER specialist.)*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Trauma Management in a Mass Casualty Event -- All Hazards
Considerations**

1\. ***Description of the Threat/Event***.

a\. **Trauma and the Mass Casualty Incident (MCI) in the US.** Traumatic
injuries are treated daily by many physicians throughout the US.
However, relatively few physicians have been in the position of managing
a mass casualty event with multiple trauma victims. Even fewer
physicians in the US have been involved in the management of a mass
casualty event with living victims as extensive as would have occurred
had the outcome of September 11 (2001) resulted primarily in injuries
rather than fatalities, or if the tsunami which struck India, Sri Lanka
and other nations (2004) had hit the western or eastern coastline of the
US.

Multiple trauma victims may present from a Mass Casualty Incident (MCI)
as a result of either terrorism or natural phenomena. The use of
explosives is a frequent weapon of choice for terrorists. Military
physicians may be skilled in diagnosis and treatment of the resulting
blast injuries, but many civilian practitioners are unfamiliar with the
management of bomb-blast victims. Earthquakes, hurricanes, tornados,
tsunamis and other natural disasters may result in hundreds to
hundreds-of-thousands of trauma victims. With the increasing population
density in certain areas of the country, the possibility of a disaster
with overwhelming numbers of trauma casualties is rising. The risk of
terrorism is also increasing. The national capacity to manage events
with trauma patients must increase as this risk of terrorism and the
population density in the United States increases.

An MCI is any event in which the number of patients and the severity of
injuries exceed the resources of the healthcare facility. The imbalance
of needs to resources may be due to the large number of patients, to the
number or severity of the injuries, to limited equipment, supplies or
staff, or to the presentation of victims with conditions beyond the
medical capability of staff that are present. Accurate pre-hospital
triage and transport of trauma victims to the hospital of the
appropriate trauma level mitigate this problem in daily events.
Transportation directly to the site where definitive trauma care can be
provided is the first delivery-site priority of Emergency Medical
Service (EMS) transport for trauma patients. However, in a true mass
casualty event, all appropriate designated trauma level institutions may
be completely overwhelmed and other healthcare facilities, which do not
routinely provide trauma care, may receive victims out of dire
necessity.

Additionally, non-trauma hospitals may receive trauma patients through
self-referral, delivery by privately owned vehicle, and by default when
transportation routes to the usual sites of trauma care are blocked.
Thus, these non-designated facilities will become defacto triage and
emergency treatment areas. Life saving measures must not be denied for
arrivals simply because the facility is not designated as a Trauma
facility. Provision of emergency care and stabilization until transport
to the appropriate site is possible may be lifesaving. Although this SOP
addresses such a contingency, in **no** situation should the victim be
transported to a non-trauma or lower level facility when access to the
appropriately designated facility or a facility with more appropriate
resources is available. Activation of this SOP will occur primarily in
response to a Mass Casualty Incident. (*Note to Writer: Refer to the
sample Mass Casualty Incident SOP in the Emergency Management Program
Guidebook, Section 6.3.3.9*.)

This sample Trauma SOP is a component of the sample Trauma Readiness for
All-Hazards Disaster Response (TRADR) Plan, which is a component of the
VA Medical Center (VAMC) Emergency Management Plan (EMP). The VAMC
Emergency Operating Plan (EOP) is structured to use the Incident Command
System (ICS), and implement the Trauma SOP for any specific disaster
that is likely to involve mass casualty trauma victims.

b\. **Goal of Trauma Care and the Critical Timing of Intervention**.
Following acute trauma, three peaks in death occur over time. The first
peak occurs within seconds to minutes following the trauma, and salvage
of the victim is unlikely due to the severity of injury. The second peak
in deaths occurs within the next few minutes to two to three hours
following the trauma. Rapid intervention can mitigate this second peak,
and has given rise to the concept of the "golden hour" of trauma care
delivery. The major goal of an effective trauma response plan is to
improve the outcome of injured victims through the timely provision of
the most appropriate care available. Component goals are to stabilize
the patient with minimization of morbidity and mortality through the
provision of safe and effective treatment at the earliest possible time
until definitive care is available, and to maximize the efficiency of
patient transfer and transport to the appropriate facility where
definitive care can be provided. Efforts directed toward these goals can
mitigate the second peak in deaths through the immediate saving of life.
Additionally, effective rapid trauma intervention will mitigate the
third peak in deaths which occurs between three and five weeks
post-trauma through reducing the time spent in hypotension-related organ
hypo-perfusion and reducing the risk of infection.

Effective internal and external communication pathways must be
incorporated into the plan to achieve these goals. The VAMC utilizes the
ICS to affect these communication pathways. Ongoing local needs analysis
and situation status reports are utilized to enhance response
efficiency.

VAMC facilities must have trauma control policies in place authorizing
the appropriate staff to rapidly implement appropriate measures in
response to a potential or actual event. A community emergency
department communication system, with a pre-event Memorandum Of
Understanding (MOUs) between all community medical facilities and a
clearly-developed overall community transfer coordination center are
essential in achieving the maximum patient outcome from a community or
larger mass casualty event.

c\. **Characteristics of Trauma and Event Mitigation**. Important
characteristics of trauma include the mechanism of injury; the severity,
type and extent of injury; prior health status or special
characteristics of the victim (i.e., pregnancy, pediatric or geriatric
patient, underlying medical conditions, etc.), and the status of wound
contamination. Management of an event with multiple trauma victims
necessitates an understanding of the epidemiology of patient
presentation. The availability of effective trauma response protocols
will serve as a major mitigation strategy. Sufficient personnel and
equipment, along with the availability of decontamination, and an
understanding of when it is indicated, is critical to a safe and
effective response plan. A cooperative response plan including the
Medical Center surgical team, emergency department providers, primary
care and medical providers, along with clinical leadership, hospital
administration and clinical support services working together as a team,
make an effective trauma response plan possible.

In an event requiring activation of the TRADR Plan, the internal
communication network must include the hospital Director, Police, Chief
of Staff, Chief of the Emergency Department, Chief of Surgery and
surgical subspecialty chiefs, Chief of Anesthesiology, Operating Room
personnel, Chief of Medicine, all other clinical and administrative
service chiefs, healthcare providers, Blood Bank and clinical Laboratory
personnel, Radiology personnel, Chaplain Service, Social Work Service,
Acquisition and Materiel Management Service, Public Affairs Officer,
hospital Safety, Engineering and Environmental Management Services.
External notification will include the Network Director, and may be
extended to include the Federal Bureau of Investigation (FBI) field
office, the American Red Cross Blood Bank, burn centers and organ
transplantation affiliates.

Commitment to periodic disaster preparedness drills is necessary to
assure operative capability. The use of both mini-component testing
drills and major full-scale drills provide testing of program
effectiveness and improvement in readiness and response capacity. In
addition, encouragement of participation by physicians and nurses in
specific training in trauma management will improve the ability to
minimize morbidity and mortality in such events.

Community response and panic reduction will be facilitated through
skillfully disseminated information. On-going communication with other
local medical facilities will be necessary to ensure appropriate
transfer of the victims at the proper time.

d\. **Psychological Aspects of Trauma**. The personal response to an
event involving trauma is likely to be one of anxiety, fear and panic.
The psychological management of patients, staff, family and members of
the community is pivotal in reducing long-term effects of psychological
stress. (*Note to Writer: Please refer to further discussion of this in
the sample TRADR Readiness Plan in the Emergency Management Program
Guidebook, Section 5, Part 5*.)

e\. **Trauma and Contamination**. Whenever patients present from a mass
casualty incident, the possibility of terrorism with secondary
contamination must be considered. Identification of involvement of
contamination in an event will be facilitated by appropriate inquiry
upon initial facility contact regarding a potential event and by
appropriate inquiry and screening at the point of perimeter entry upon
arrival of victims. Signs of involvement with a chemical event may
include notation of chemical warning placards or identifiers in the
vicinity of the event, characteristic or peculiar odors in the vicinity,
the sudden onset of symptoms and signs not related to the trauma,
notation of dead birds/animals/foliage in a pattern which would not be
anticipated from the event itself, and other patients presenting with a
cluster of similar signs and symptoms who were not close enough to be
involved in the trauma. Signs of involvement in a radiation event
include patients presenting with a cluster of symptoms including nausea
and vomiting, diarrhea, red skin, notation to radiation warning symbols
in the area, contact with or observation of a metal cylindrical object
or objects in the area, headaches and confusion. Radiation screening at
the point of perimeter entry with a standard radiation survey meter will
aid in early identification of contamination with radioactive material.
(*Note to Writer: Please refer to the Section 5 in the Emergency
Management Program Guidebook for further information on decontamination,
biological, chemical and radiological event detection and management*.)
When the trauma is accompanied by chemical contamination,
decontamination takes precedence to avoid contamination of personnel and
the facility, which will result in the facility being unavailable for
reception of patients. When the trauma occurs from an explosion
involving radioactive materials, treatment of traumatic injuries
[always]{.underline} takes precedence over concerns of radiation. This
SOP is intended to cover the aspects of such an event that is related to
trauma. \[*Note to Writer: Please refer to the sample Radiological Event
and Terrorism Readiness Plan (Section5, Part 3) and sample Trauma
Readiness for All-Hazards Disaster Response Plan (Section 5, Part 5) of
the Emergency Management Program Guidebook for management of these
additional problems*.\]

Factors that must be considered in implementation of the response plan
include:

> How many victims are involved?
>
> What is the type of event and the anticipated types of injuries? (See
> Attachments A, B and C.)
>
> Is it likely from the estimated number of victims that the VAMC will
> need to receive trauma victims and provide emergency care and
> stabilization until another facility can accept them for definitive
> care or until the definitive care can be made available at the VAMC?
>
> Are the involved victims also contaminated?
>
> If victims are contaminated, what is the contaminant?
>
> What victim-specific factors must be considered? Is a special
> population involved, such as infant, pregnant, elderly or frail
> victims, etc?

The number of victims and mechanism of injuries (i.e., degree of
explosive force if blast involved) will be the prime determinant of the
extent of response required. An MCI (such as a transportation accident
involving explosive materials, detonation of an improvised nuclear
weapon or the structural collapse of a stadium during a tornado) may
require activation of the facility and community disaster plans.

f\. **Legal Aspects of an MCI with Trauma**. The importance of
maintaining the legal chain-of-custody in these procedures must be
recognized. (*Note to Writer: For additional information, please refer
to the sample Chain-of-Custody Readiness Plan, Section 5, Part 6A, in
the Emergency Management Program Guidebook*.) Exclusions to the
Emergency Medical Treatment and Active Labor Act (EMTALA) may apply when
an MCI/disaster has occurred.

2\. ***Impact on Mission Critical Systems***. A mass casualty incident
with trauma may quickly overwhelm several mission-critical systems
including staffing, critical supplies (i.e., ventilators, blood supply,
antibiotics) and operational space. If the incident is due to terrorism
and contamination is involved, all the risks related to the type of
contamination must be mitigated. (*Note to Writer: Please refer to the
appropriate sections of the Emergency Management Program Guidebook when
contamination is involved*.)

3\. ***Operating Units and Key Personnel with Responsibility to Manage
this Threat/Event***. The facility Emergency Medical Response Team
(EMRT) should be a component of the TRADR Plan. Use of the all-hazards
approach to disaster management, with screening for chemical and
radiation contamination in any potentially deliberate incident, should
be considered. The Radiation Safety Officer (RSO) is a critical member
of the team responding to an incident involving radiation, and
involvement with the existing facility disaster response team rather
than establishing a separate team should be considered.

4\. ***Responsibilities***.

*Medical Center Director or Designee i*s responsible to act as the
Incident Commander/Manager (IC), and is responsible for all VAMC
response planning and actions.

*Emergency Program Coordinator (EPC)* is responsible to ensure that the
EOP is current, assists the IC with internal (Key Operations Managers)
and external (community or agency) coordination.

*Chief of Staff* is responsible for providing proper medical, health and
treatment care services.

*Associate Director* is responsible for monitoring and ensuring VAMC
operations and services as they relate to patient services are
implemented.

*Emergency Department Director* is responsible for ensuring Emergency
Department personnel are familiar with the TRADR Plan and SOP, and
participate in trauma-related educational endeavors and drills to assure
ability to respond to an MCI with trauma. Key role in developing and
maintaining functional trauma procedures/protocols in conjunction with
Chief of Surgery for an MCI with trauma.

*Emergency Room Personnel* - Key role in patient reception, triage,
stabilization, treatment and disposition. Key role in ensuring that all
other medical emergency capabilities (i.e., cardiac emergencies) are
maintained and operational.

*Chief of Surgery* is responsible for developing and maintaining
functional trauma procedures/protocols in conjunction with the Emergency
Department Director.

*Chief of Anesthesiology/Anesthesiology Staff* are responsible for
providing supportive services to assist with intubation and airway
access, intravenous access and anesthesiology services as indicated.

*Chief of Medicine* is responsible for assuring ongoing patient care,
providing appropriate medical services as needed in support of patients
from the event, for collaborating with the Emergency Department Director
and Chief of Surgery as needed to assure optimum patient support.

*Medical Service* - Key role in clinical care of patients in conjunction
with Surgery Service to assure timely and appropriate stabilization and
treatment of patients. Key role in maintaining continuity of patient
care operations and monitoring clinical patient workload. Key role in
identifying clusters of clinical signs or symptoms that could indicate
exposure to a chemical, biological or radioactive contaminant in the
incident.

*Chief of Nursing/Nursing Service -* Key role in tracking patient
census, staffing utilization and need for additional staff. Encourages
nursing staff in educational endeavors on trauma management.

*Chief of Radiology/Radiology Staff* are responsible for providing
radiological support services. In MCIs with trauma, the number of
functional x-ray machines and the rate of processing may be the limiting
factor in the processing of victims. Interventional Radiology services
will probably be needed to assist with line placement and diagnostic
testing. CT and Ultrasound services will have key roles in patient
assessment.

*Infection Control Team* - Provides information as needed, for
healthcare providers, employees and patients regarding concerns related
to infection control, with emphasis on any staff exposed to blood and
body fluids.

*Clinical Laboratory* - Provides collection and analysis of biological
specimens as needed to support clinical care. Blood Bank plays a key
role in providing cross-matching and blood components as indicated.

*Safety Officer* is responsible for monitoring and initiating actions to
ensure safe actions are taken during the emergency event.

*Safety Officer/Industrial Hygienist* - When potential or actual
contamination is involved, key role as the point of contact with HAZMAT
agencies in substance sampling or environmental sampling. Key role in
monitoring and proper use of specialized PPE resources as needed.

*Public Affairs* will act as the point of contact for the media and
other governmental agencies that may request information concerning the
incident and its impact upon patients, staff and facility.

*Police Chief* ensures that lockdown and police procedures; traffic and
crowd control; crime scene and investigation; and perimeter control are
implemented.

*Police Service* is responsible for perimeter control and incident site
access. Key role in maintaining chain-of-custody for all potential
evidence during investigation of potential terrorist events within the
VAMC or when victims of the incident enter the VAMC.

*Occupational/Employee Health* - Key role in monitoring occupational
health conditions/risks, employee concerns and prophylactic therapy as
needed. Tracks and provides care and documentation for any employee
exposed to blood or body fluids.

*Chief Engineer* is responsible for protecting, repairing and
maintaining plant utility systems, communications and medical equipment
necessary for patient care and VAMC operation.

*Chief A&MMS* is responsible for logistical function as it relates to
providing facilities, transportation, supplies, equipment, services,
etc.

*Chief Fiscal* is responsible for providing funding and tracking
expenses that relate to VAMC response to the emergency event.

*Social Work -* Coordinates information between victims and their
significant other and family.

*Chaplain* - Provides spiritual counsel and comfort to the victims and
their significant other and family, with special emphasis on those
victims who are terminal.

*Human Resource Management* - In a Mass Casualty Incident involving the
community, provides information to significant others or family of
workers on site and acts as liaison during an extended event in
coordination with Public Affairs.

5\. ***Mitigation/Preparedness Activities for the Threat/Event***.

a\. *Hazard Reduction Strategies and Resource Issues*. N/A.

b\. *Preparedness Strategies and Resource Issues*. Develop a basic
capability to organize a response to an MCI with trauma. Pre-event
education and planning may include:

1\) Staff Training: Train staff on the principles of trauma management
(e.g., triage, first aid, stabilization and emergency treatment of the
trauma victim, appropriate transfer and transport, and psychological,
ethical and legal issues).

2\) Provider Training: Encourage providers to pursue training in trauma
management through recognized courses, such as:

> a\) Advanced Trauma Life Support for Doctors (American College of
> Surgeons).
>
> b\) Advanced Trauma Course for Nurses (Society of Trauma Nurses).
>
> c\) Pre-hospital Trauma Life Support course (National Association of
> Emergency Medical Technicians).
>
> d\) Basic Disaster Life Support.
>
> d\) Advanced Burn Life Support Pre-Hospital Course
> (<http://www.ameriburn.org/ABLSCourseDescriptions.htm>.
>
> f\) Advanced Disaster Life Support.
>
> g\) Community Emergency Response team (CERT) Training (Federal
> Emergency Management Association).

3\) Protocol Development: Encourage development of appropriate
cooperative inter-departmental protocols for management of overwhelming
numbers of patients from an MCI with trauma. Determination of which
screening and assessment tools the facility will have available for use
for rapid patient intake, assessment and tracking prior to an event is
important.

4\) Development of lists of closest referral centers (local, regional,
state and national) and their referral procedures:

> a\) Trauma centers.
>
> b\) Burn centers.
>
> c\) Micro-vascular replantation centers.
>
> d\) Dialysis centers.

5\) MOU and Mutual Aid: Encourage development of appropriate Memorandum
Of Understanding for mutual aid with area healthcare facilities.
Participate with the Emergency Medical Transport Services and community
healthcare facilities in community-wide drills with simulated patients.

6\) Contingency Provider Resource Development: Encourage development of
appropriate policies and procedures to allow development of a
contingency list of surgeons trained in trauma in the community who
would provide services in the facility on an emergency basis in the
event of an MCI with trauma. Develop the list; obtain their credentials;
and maintain them up-to-date.

7\) Equipment Readiness: Have ready the basic equipment that may be
necessary (e.g., command vests, signage, forms/tags, backboards, crash
cart, oxygen, ventilators, IV fluids, thoracotomy trays, chest tubes,
cricothyroidotomy kits, Dopplers, ultrasound units, etc.). Pre-stocked
disaster/trauma carts are helpful.

6\. ***Response/Recovery from the Threat/Event***.

a\. *Hazard Control Strategies*: Preparation for Patient Arrival and
Reception.

> 1\) Receive/Verify Notification*:* Receive and confirm the information
> that an MCI with multiple trauma victims has occurred by a callback to
> the source, unless the source is verified at the time the call is
> received.
>
> 2\) Provide Internal Notification: Alert the VAMC Director, Police,
> Chief of Staff, Chief of the Emergency Department, Chief of Surgery
> and surgical subspecialty chiefs, Chief of Anesthesiology, Operating
> Room personnel, Chief of Medicine, Chief of Nursing, all other
> clinical and administrative service chiefs, healthcare providers,
> clinic supervisors, Blood Bank and clinical Laboratory personnel,
> Radiology personnel, Infection Control, Chaplain Service, Social Work
> Service, Acquisition and Materiel Management Service, the Public
> Affairs Officer, hospital Safety, Engineering and Environmental
> Management Service to prepare for the arrival of casualties.
>
> 3\) Facility Lockdown and Restricted Access: Alert Police to establish
> traffic and access control procedures, including facility lockdown,
> when appropriate. If contamination is considered possible or if it is
> an intentional act, consider activation of the hospital
> decontamination program until contamination can be ruled out.
>
> 4\) Staff briefing: Brief the nurses and other involved personnel on
> the anticipated arrival of trauma victims. The physicians most
> skilled/experienced in trauma and emergency medicine at the facility
> should report to the Emergency Department, and roles clarified.
>
> 5\) Designate Triage and Treatment Areas: Prepare the areas by having
> pre-stocked disaster or trauma treatment carts delivered to the area.
> Each designated Treatment Area should have equipment prepared and
> ready to use to allow proper airway access such as laryngoscopes, ET
> tubes, LMA and/or Combitubes. Crash carts, oxygen, IV fluids (warmed
> Ringer's lactate or Normal Saline), thoracotomy trays, chest tubes,
> cricothyroidotomy kits and Dopplers should be immediately available.

b\. *Patient Reception*.

1\) General Triage. Triage, the sorting of victims according to the
severity of injury and need for treatment, will have been initiated in
the pre-hospital setting if the patient is transported by Emergency
Medical Service transportation. However, many victims arrive by private
conveyance and have not received any medical screening. All patients
will need to receive triage immediately upon arrival; repeat triage for
those arriving by medical transport, and initial triage for the others.
This should not take over 1 minute per patient. The triage method and
tagging system used may vary according to local facility practices.
(*Note to Writer: Refer to sample Trauma Readiness for All-Hazards
Disaster Response Plan, Section 5, Part 5, of the Emergency Management
Program Guidebook*.)

An understanding of the "upside down" presentation of disaster victims
is necessary to avoid delay in attention to critical arrivals that may
result from early congestion of treatment rooms by the "walking
wounded." In a mass casualty incident, the less severely injured will
present themselves initially to the closest hospitals at which they can
obtain care, with subsequent arrival of the more severely injured. Plans
must be in place to anticipate these later arrivals with greater
injuries, and provide appropriate access to the needed level of care.

2\) Prioritization of Patients. Patients triaged as Immediate should be
transported directly to the prepared treatment areas and the Primary
Survey performed. Patients triaged as Urgent should be monitored with
close observation and ongoing reassessment for destabilization and the
need to redesignate their status.

3\) Estimation of Casualties for Needs Assessment. Following an event
that involves blast trauma, approximately half of the initial casualties
are expected to seek medical care within the first hour.

c\. *Patient Stabilization and Treatment*. A general principle to follow
with [all]{.underline} trauma patients is that continued re-evaluation
of the patient is necessary to identify all injuries. Regardless of the
type or mechanism of injury, the following sequential approach is
helpful in assuring the most rapid provision of optimum care:

1\) Primary Survey: The following sequential assessment, which may be
performed simultaneously, constitutes the Primary Survey. During the
primary survey, **life-threatening conditions are treated as they are
identified**.

> A Airway establishment/maintenance with cervical spine protection.
>
> B Breathing and ventilation.
>
> C Circulation and Control of hemorrhage:
>
> Level of consciousness (LOC).
>
> Skin color.
>
> Pulse.
>
> D Disability/Neurological status.
>
> E Exposure and Environmental Control.
>
> Specific points to note regarding the Primary Survey:
>
> a\) Any patient with multi-system trauma should be assumed to have a
> cervical spine injury, and the neck must be stabilized and remain so
> until ruled out with cervical spine x-rays. These x-rays may be
> obtained as soon as life-threatening conditions have been sufficiently
> stabilized. Cervical Spine X-rays or other imagings are required
> unless the history is not suggestive of neck trauma. The neurological
> examination alone will [not]{.underline} exclude a cervical spine
> injury.
>
> b\) Airway compromise: Adequate speech usually indicates adequate
> airway patency; this can deteriorate, so reassessment is mandatory.
>
> c\) Assess the airway for foreign bodies, ENT fractures.
>
> d\) Auscult the chest for adequacy of ventilation. Percuss the chest
> for evidence of pneumothorax (increased resonance) or internal
> bleeding (dullness).
>
> d\) Inspect the chest visibly and by palpation for flail chest, rib
> fractures, major hematomas.
>
> f\) Identify and control external hemorrhage in the primary survey.
> Assume low blood pressure indicates blood loss until this is ruled
> out. Signs which may indicate significant hypovolemia include:

Reduced LOC.

Ashen, grey, or white skin.

Loss of femoral or carotid arterial pulses.

Loss of peripheral pulses.

Rapid thready pulse (other etiologies also).

> g\) Control visible hemorrhage with direct pressure on the wound
> and/or primary pressure points. Do [not]{.underline} use tourniquets
> except in extreme cases such as traumatic amputation; they promote
> tissue loss.
>
> h\) Rapid Neurological Examination:

-   Mental Status: AVPU ([A]{.underline}lert, [V]{.underline}erbal,
    [P]{.underline}ain response, [U]{.underline}nresponsive).

-   Consider performance of the Glasgow Coma Scale (GCS), this may be
    deferred to the Secondary Survey. (See Attachment E.)

-   Check pupillary size, reactivity and equality; check for
    lateralizing signs, and check for spinal cord injury level. If
    closed head injury has occurred, frequent reassessment [is
    necessary]{.underline} with rapid consultation with a Neurosurgeon
    if neurological level deteriorates.

> i\) Exposure: Clothing should be entirely removed from each patient
> and a quick but thorough head-to-toe examination for injuries
> performed.
>
> j\) Environmental Control: Hypothermia is a major life-threatening
> risk to trauma patients. Use warming blankets with attention to the
> warming of infusing solutions in most situations.
>
> k\) Patient factors may obscure appropriate diagnosis (i.e., Beta
> Blockaid may mask tachycardia as a sign of blood loss).

2\) Trauma Resuscitation: Follow standard treatment practices for the
resuscitation of the trauma patient. Specific points include:

a\) Provide supplemental oxygen to all patients with significant trauma.

b\) Establish a definitive airway if maintenance of airway integrity is
in question or the level of consciousness is reduced with a risk of
aspiration, with caution to [maintain cervical spine
stability]{.underline}. Use a CO~2~ monitor with all endotracheal tubes
to detect incorrect placement or dislodgement. Note: These do
[not]{.underline} verify correct placement.

c\) Insert a minimum of 2 large bore IV catheters and obtain lab. Lab
should include blood for type and cross match, CBC, basic metabolic
studies including electrolytes and renal function, and clotting
functions. Include a pregnancy test in all females of childbearing age,
and a fibrinogen and Rh factor test in all pregnant patients.

d\) Control bleeding by direct pressure or operative intervention.

e\) Administer warmed (98.6-104°F/37-40°C) IV fluid rapidly, preferably
Ringer's lactate. Large volumes may be required in the adult patients,
such as 2-3 liters of solution.

> f\) If hypovolemia persists, give blood:
>
> 1^st^ choice - cross-matched blood.
>
> 2^nd^ choice - type-specific uncross-matched blood.
>
> 3^rd^ choice - O negative blood.

g\) Control continued hemorrhage by operative intervention. Avoid
vasopressor use for control of hypovolemic hypotension.

> h\) Hypothermia may develop rapidly, be lethal, and should be avoided.

i\) Monitor the EKG in all trauma patients. (See Attachment F -
Dysrhythmias in the Trauma Patient.)

> j\) Check Arterial Blood Gases (ABGs) in all trauma patients.
>
> k\) Monitoring of pulse oximetry is indicated in most trauma patients.
> However, this should [not]{.underline} replace a check of the Arterial
> Blood Gases (ABGs).

l\) Perform a rectal and genitourinary examination, and consider
placement of a urinary catheter unless urethral injury is suspected, in
which case obtain a retrograde urethrogram. Signs of possible urethral
injury include: Hematuria, blood in the penile meatus, blood in the
scrotum, pelvic fracture, or a non-palpable or very high prostate.

> m\) If gastric distension is present, consider decompression with a
> nasogastric tube. Do [not]{.underline} use a nasogastric tube if a
> cribiform plate fracture is suspected (tube may go intracranially).

3\) Diagnostic Studies in the Trauma Patient:

a\) Obtain a Stat portable AP CXR, lateral cervical spine film, AP
pelvic x-ray as soon as possible during the Initial Survey without
interfering with resuscitation measures. Note: CXR should be obtained
regardless of pregnancy.

b\) Other techniques that may be indicated depending upon the skill of
the provider and the clinical situation are diagnostic peritoneal lavage
(DPL) and abdominal ultrasonography; but these are generally performed
during the Secondary Survey.

c\) Other diagnostic studies such as CT scanning and MRI may be
indicated at a later point in patient evaluation, but are usually
accomplished the Secondary Survey.

4\) *Secondary Survey*:

> a\) The Secondary Survey is done [after]{.underline} completion of the
> primary survey and after resuscitation efforts are stabilizing the
> patient.
>
> b\) The Secondary Survey consists of the complete history and physical
> and includes:

[1]{.underline}. Complete history including allergies, current
medications, past medical history, pregnancy and ob-gyn history, time of
the last meal, and history of the events and environment related to the
trauma with specific questioning for contaminants and exposure to
chemicals, biologicals, and radioactive materials.

> [2]{.underline}. Complete examination or re-examination of the entire
> body.
>
> [3]{.underline}. Complete neurological examination.
>
> [4]{.underline}. Glasgow Coma Scale, if not done earlier.

5\) Diagnostic Procedures Following the Secondary Survey: Following the
Secondary Survey and stabilization of the patient, further diagnostic
studies may be obtained as indicated.

6\) Re-evaluation and Pain Control: Ongoing re-evaluation is necessary
in trauma patients, with attention to the emergence of previously
unrecognized problems as they appear. Continuous monitoring of vital
signs, pulse oximetry for the critical patient, end-tidal carbon dioxide
monitoring for the intubated patient, EKG monitoring in the critical
patient, and urinary output is indicated. Target urine output in the
adult patient is 0.5ml/kg/hour. Target urine output in the pediatric
patient older than 1 year is 1ml/kg/hour.

7\) Transfer and Definitive Care Issues: As soon as the physician
determines that the patient will require more resources than are
available at the facility, arrangements for transfer to an institution
with an appropriate level of care can be started. Administrative
personnel can begin these arrangements, but direct communication from
transferring physician to receiving physician is essential.

8\) Legal Issues:

> a\) Careful record keeping and documentation is essential.
>
> b\) Informed consent should be obtained prior to treatment if
> possible. However, life-saving treatment should be provided with the
> presumption of consent in a life-threatening emergency.

9\) Immunization: If the wound is clean, non-punctured, adequately
debrided, and the patient has had at least 3 prior doses of adsorbed
tetanus toxoid, no tetanus prophylaxis is needed if the last dose was
given in less than 10 years for non-tetanus prone wounds or less than 5
years for tetanus-prone wounds (CDC). Regardless of the wound, if less
than 3 prior doses have been given, then Td prophylaxis is recommended.
If the wound is tetanus-prone (puncture or question regarding adequacy
of debridement) and less than 3 prior tetanus immunization doses have
been received, then passive immunization with 250 units of human tetanus
immune globulin (TIG) should be given IM. For patients over the age of 7
years, Td (tetanus and diphtheria toxoids, absorbed) are preferred to
Tetanus Toxoid alone.

10\) Follow-up: Appropriate discharge includes identifying appropriate
follow-up and providing instructions appropriate to the specific injury.
Many, if not most, trauma patients will require discharge to a situation
where they are checked at appropriate intervals by another person who
can identify a need for attention, should signs of further injury or
complications develop. The caregiver should be provided with specific
instructions on symptoms and signs that would indicate the need to
return. Similarly, the time and site for follow-up of injuries should be
specified. Wounds and injuries of the head, eye or ear, as well as
stress-related complaints, should have close follow-up.

d\. *Other Issues in Management of the Trauma Patient*.

1\) If Radioactive Contamination Is Discovered After Patient Has Been
Admitted - Continue attending to the patient\'s medical needs. Secure
entire area where victim and attending staff have been. Do not allow
*anyone* or *anything* to leave the area until cleared by the Radiation
Safety Officer. Establish control lines, and prevent the spread of
contamination. Completely assess the patient\'s radiological status.
Personnel should remove contaminated clothing before exiting area; they
should be surveyed; shower, dress in clean clothing and be re-surveyed
before leaving area. (*Note to Writer: Refer to sample SOP, Section
6.2.3.3, Patients with Radiation Exposure or Radioactive Contamination,
in the Emergency Management Program Guidebook for further details*.) See
specific information on the necessity of primary wound closure for all
wounds in the irradiated patient and on the early timing of operative
intervention.

2\) If Chemical Contamination Is Discovered After Patient Has Been
Admitted - Immediately notify the Safety Officer and HAZMAT Team; follow
appropriate notification procedures and facility protocol for dealing
with a HAZMAT Incident. If the type of chemical is known, immediately
consult with the Safety Officer/Industrial Hygienist and check the
Material Safety Data Sheet or with Poison Control for determination of
toxicity and the need for evacuation, decontamination or other actions.
(*Note to Writer: Refer to the Emergency Management Program Guidebook,
Section 5, for further information on sample Decontamination, Chemical,
Biological and Radiological Emergency Response Readiness Plans.)*

e\. *Special Considerations for Specific Trauma Types*. Detailed
discussion is beyond the scope of this SOP. A few major considerations
are mentioned here. Please refer to provided references and pursue
further study.

> 1\) Blast Injuries.
>
> a\) Components of Blast Injury:
>
> Compression wave.
>
> Thermal wave.
>
> Flying debris.
>
> Structural Collapse.
>
> Psychological Trauma.
>
> Physical Exertion (Escape or rescue efforts).
>
> b\) Blast injuries associated with a bomb or explosion are classified
> into 3 types:
>
> Primary blast injuries result from the pressure wave produced by the
> blast and result in greatest injury to the gas-containing organs.
>
> Secondary blast injuries result from flying debris.
>
> Tertiary blast injury results from the person being thrown against an
> object or the ground.

c\) Greater morbidity and mortality occur when explosions occur within a
confined space or when structural collapse occurs.

d\) Tympanic membrane (eardrum) rupture is a sensitive indicator of the
force of the Primary Blast Wave and may rupture at a pressure exceeding
2 atmospheres. Thus, examination of the tympanic membrane should be done
in all victims presenting from a blast injury. However, tympanic
membrane rupture alone is not a predictor of mortality.

e\) Injuries from the secondary blast effects are typical of penetrating
trauma.

f\) Injuries from the tertiary blast effects are typical of blunt
trauma.

g\) Traumatic amputation in association with a blast injury is a
predictor of mortality.

h\) Blast injury produces certain specific organ injuries:

[1]{.underline}. Blast Lung:

> Is the most common fatal injury in initial survivors, and presents
> immediately and up to 48 hours post-blast.
>
> Symptoms are dyspnea or apnea, cough, hemoptysis or chest pain.
>
> Clinical Triad - Apnea, bradycardia and hypotension.
>
> CXR (obtain in all blast victims): Classic "butterfly" pattern.
>
> Chest tube recommended prior to general anesthesia or air transport.
>
> Results from bleeding into the lung tissue, ranging from scattered
> petechiae to frank hemorrhage, resulting from the pressure wave.

[2]{.underline}. Blast Abdomen:

> May present immediately or only later after complications arise.
>
> Symptoms are abdominal pain, nausea, vomiting, hematemesis, rectal
> pain, testicular pain and tenesmus.
>
> Clinical Findings - Any suggesting an acute abdomen, unexplained
> hypovolemia.
>
> Results from bowel perforation/rupture, abdominal/intestinal
> hemorrhage (as in blast lung), lacerations of the solid organs,
> mesenteric shear injuries, testicular rupture.

[3]{.underline}. Blast Brain Injury:

> Traumatic Brain Injury may be minimal or major.
>
> If minimal, may mimic Post Traumatic Stress Disorder (PTSD).
>
> Symptoms are headache, fatigue, lethargy, depression, anxiety, poor
> concentration and insomnia.
>
> Results from the primary blast wave.

i\) Other Blast Complications:

> [1]{.underline}. Air Embolism:
>
> Presentation - stroke, MI, acute abdomen, spinal cord injury,
> blindness, deafness, claudication.
>
> Consider hyperbaric oxygen; may be effective.

[2]{.underline}. Inhaled Toxins:

> Carbon Monoxide, cyanide, chemicals released secondary to associated
> fires.
>
> Check for methemoglobinemia:
>
> \-- Treatment includes high concentration oxygen.
>
> \-- When cyanide is involved, the Cyanide Antidote Kit can be life
> saving.

[3]{.underline}. Hearing Impairment:

> Sudden temporary or permanent deafness may occur. Tinnitus (ringing in
> the ears) may occur.
>
> May have to communicate in writing to obtain history and provide
> instructions.

[4]{.underline}. Wound Contamination:

> Consider delayed primary closure for contaminated wounds
> [unless]{.underline} patient is a victim of significant radiation.
>
> Assess the need for tetanus prophylaxis.
>
> Assess the need for antibiotic prophylaxis.
>
> In radiation events with significant irradiation of the patient,
> [all]{.underline} wounds should be closed primarily if at all
> possible. (*Note to Writer: Refer to sample Radiation SOP, Section
> 6.2.3.3. in the Emergency Management Program Guidebook*.)

j\) For further information, refer to: Centers for Disease Control and
Prevention publication *Explosions and Blast Injuries: A Primer for
Clinicians* (<http://www.bt.cdc.gov/masstrauma/explosions.asp>).

2\) Burns.

a\) Respiratory tract burns should be suspected if:

> Soot is noted in the nose, mouth or sputum; may also appear inflamed.
>
> The eyebrows, nasal or facial hair is singed.
>
> Face or neck is burned.
>
> Hoarseness is noted.
>
> History of confinement in a burning area.
>
> Greater than 10% carboxyhemoglobin level after a fire.

b\) Respiratory tract burns require immediate care including airway
support; and transfer to a burn center is indicated.

c\) If stridor is present, [immediate]{.underline} intubation is
indicated.

d\) Early intubation is indicated in any patient with circumferential
neck burns due to the risk of airway compression from progressive tissue
swelling.

e\) Burns of the eyes require urgent examination before swelling
prevents adequate examination.

f\) IV fluid support is indicated for any patient with more than a 20%
BSA burn area, unless the burn is only first degree. Place Foley
catheter for hourly measurement of urinary output. (See Management
portion below.)

g\) Estimation of the percent of Body Surface Area burned is essential.
The rule of nines is useful in the adult patient.

h\) Assessment of the depth of the burn is also essential.

> Third degree, full-thickness burns are painless and usually dry; may
> be red but does not blanch; may appear dark and leathery or waxy white
> or mottled.
>
> Second degree, partial-thickness burns are very painful, appear red or
> mottled with blistering and swelling; may be weeping and wet.

First degree, relatively minor burns (i.e., sunburn) have varying
degrees of pain; are red and dry; do not have blisters; are not life
threatening and do not require fluid resuscitation.

i\) Management of **thermal** burns includes following the primary and
secondary trauma survey protocols, [and]{.underline}:

> High-flow oxygen by non-rebreathing mask (facilitates CO removal).
>
> Fluid resuscitation for 2^nd^ and 3^rd^ degree burns (need is greatest
> for 3^rd^ degree burns):
>
> [1]{.underline}. Burn Resuscitation Formula: 2-4ml Ringer's Lactate x
> body wt (kg) x % BSA with 2^nd^ and 3^rd^ degree burns = total volume
> to give [within]{.underline} the first 24 hours from the time of burn
> (TOB). Give ½ of this total calculated volume within the first 8 hours
> from TOB; give the remaining ½ calculated fluid volume over the next
> 16 hours.
>
> [2]{.underline}. For 3^rd^ degree burns, begin with 4ml/kg/% burn and
> reduce quantity as indicated clinically.
>
> [3]{.underline}. Urine output goal: Adults: 0.5-1.0ml/kg/hour
>
> Children less than 30kg: 1.0ml/kg/hour

Place Foley catheter for hourly measurement of urinary output.

-   Frequently monitor electrolytes to avoid electrolyte imbalance.

-   Provide continuous EKG monitoring.

-   Airway management as indicated and as discussed above.

-   Initiate a burn management flow sheet upon admission.

-   Obtain lab as discussed for trauma patients, with carboxyhemaglobin.

-   Remove all jewelry from burned areas.

-   Assess for peripheral pulses (Doppler if available) and intact
    sensation, with repetitive reassessment to monitor for development
    of a compartment syndrome and need for fasciotomy or escharotomy.

-   Pain management should be by small frequent intravenous doses, not
    the intramuscular route; for example, Morphine Sulfate 2mg IV every
    5 minutes until pain relieved. To avoid respiratory depression,
    follow pulse oximetry and respiratory rate.

-   Cover burns with clean linen to relieve pain; do not apply ointment,
    unless advised by Burn Center. Maintain blisters intact.

-   Provide tetanus prophylaxis.

-   With burns over 20% BSA, insert a gastric tube to suction.

-   Reserve antibiotics for treatment of infection.

-   Contact the local or regional burn center to discuss criteria for
    transfer. (See Attachment G, Burn Center Transfer Guidelines.)

j\) Management of **chemical** burns includes following the primary and
secondary trauma survey protocols [and]{.underline}:

-   Do [not]{.underline} flush dry chemicals with liquid;
    [brush]{.underline} them away first. Some chemicals ignite with
    water, such as white phosphorus.

-   Flush with large amounts of water for 20-30 minutes, longer for
    alkali burns.

-   Continuously irrigate the eye in the case of alkali burn for 8
    hours.

-   Do [not]{.underline} replace fluid by the Burn Formula. Fluid loss
    in a chemical burn is less than for thermal burns. Use of the
    standard burn formula for IV fluid replacement in a chemical burn
    patient may result in fluid overload and pulmonary edema.

3\) Fractures.

a\) Fractures of the long bones and pelvis indicate that major force was
involved in the trauma and that other injuries should be sought.

b\) Long bone and pelvic fractures can result in major hemorrhage, which
may result in shock. Several units of blood can be lost into the
surrounding tissue space. Pelvic fractures have the potential for 1 to
more than 5 liters (L) of blood; femur fractures, 1-4 L; spine
fractures, 1-2 L; leg fractures 0.5-1 L; and arm fractures, 0.5-0.75 L.

c\) Initial fracture splinting and immobilization will:

> Reduce motion, thus reducing further tissue damage.
>
> Assist with hemorrhage control.
>
> Reduce pain.

Assist in realignment toward an anatomic position.

d\) Hemorrhage in an open fracture can usually be controlled by
application of a sterile dressing.

e\) Physical examination should include notation of:

> Perfusion (color, capillary refill, pulses).
>
> Deformity (position, rotation or angulation, shortening).
>
> Sensation (verification of intact nerve supply).
>
> Edema.
>
> Bruising or open wounds.
>
> Palpation for areas of tenderness, especially focal point tenderness
> over bone, which frequently indicates a fracture.
>
> Cautious range of motion testing and checks for ligamentous
> instability.

f\) Cervical or spine fractures should be evaluated by a lateral C-spine
x-ray if possible during the primary survey and followed by a full
C-spine series during the secondary survey. The C-spine or portion of
the spine with possible fracture must be immobilized until fully
assessed.

g\) All open fractures require surgical exploration and debridement.

h\) With hemorrhage and swelling from a fracture involving an extremity,
pulses and sensation must be monitored for development of a compartment
syndrome and the need for decompression with a fasciotomy.

i\) Pelvic fractures may be associated with genitourinary system injury.

j\) Fat embolization can result in hypoxia and Central Nervous System
(CNS) impairment.

k\) Consult with Orthopedics for further management.

4\) Crush Injuries (Traumatic Rhabdomyolysis).

a\) Characteristics - Hemorrhage into soft tissue with massive swelling,
bruising and hematoma formation.

b\) Major history point - How long was the tissue crushed prior to
removal of the crushing object?

c\) Crush injury to the chest may produce traumatic asphyxia. Petechiae,
swelling (may include cerebral edema) and redness from vascular
congestion may be present over the face, arms and upper body due to
compression of the superior vena cava.

d\) Risk of compartment syndrome, neurovascular damage, rhabdomyolysis
and tissue necrosis, hyperkalemia, myoglobinuria, acute renal failure
(may require dialysis), hypocalcemia, metabolic acidosis, hypovolemia,
and disseminated intravascular coagulation (DIC).

e\) Testing - Follow serum creatine phosphokinase (CK), potassium (K),
acid-base status; check urine for myoglobulin; urine will appear dark
amber and hemoglobin test will be positive.

f\) Prevention of Renal Failure - Usual goal for urine output is 100
ml/hour; may alkalinize urine with sodium bicarbonate to prevent
precipitation of myoglobin.

g\) Prevention of Limb Loss - Aggressive monitoring for compartment
syndrome with fasciotomy for circulatory compromise.

h\) Crush injuries in children may involve the growth areas of the bones
and result in abnormal growth and development.

5\) Traumatic Amputation.

a\) Do [not]{.underline} let this divert your attention from more
life-threatening injuries, which may be missed while attending to the
amputation.

b\) Immediate Care - control bleeding with direct pressure and
elevation; re-establish normal intravascular volume; gently cleanse the
wound and cover with a sterile dressing; immobilize extremity until
evacuation; reduce dislocations and angular deformities with monitoring
of neurovascular status; obtain early surgical debridement. Use
tourniquets [only]{.underline} for life-threatening bleeding when other
methods of control have failed, due to risk of distal tissue loss.

c\) Intervening care in event of delayed definitive treatment -
antibiotics (parenteral cephalosporin, such as cefazolin 1 gram IV,
unless allergic), tetanus prophylaxis; limited open wound irrigation and
debridement; splint or cast extremities; monitor for compartment
syndrome; consider other complications, such as deep vein thrombosis,
osteomyelitis and fat embolus syndrome.

d\) Limb loss may be considered as a severe type of open fracture.

e\) Severe open fractures may result in amputation when limb cannot be
salvaged, due to prolonged ischemia and severe tissue injury.

f\) Vascular injuries to a limb must be repaired within 6 hours to avoid
tissue necrosis and potential limb loss.

g\) Psychological, as well as physical, trauma; anticipate grief
reaction from loss.

h\) Reimplantation:

-   Is [not]{.underline} indicated in the critical patient with multiple
    injuries requiring resuscitation or surgery for other injuries, or
    in the patient with pre-existing major systemic disease.

-   Is [not]{.underline} indicated when the amputated limb has been
    severely crushed.

-   [May]{.underline} be indicated in a clean, sharp amputation of an
    extremity (sharp guillotine injuries are best candidates).

-   Amputated limb care:

> i\. Avoid freezing; do [not]{.underline} use dry ice; do
> [not]{.underline} allow direct contact of ice with tissue.
>
> ii\. Do [not]{.underline} soak limb in container of solution.
>
> iii\. Wash well in isotonic solution (Ringer's Lactate or Normal
> Saline); wrap in sterile gauze soaked in the solution containing
> 100,000 units of aqueous penicillin per 50 ml of isotonic solution (if
> [not]{.underline} Penicillin allergic); then wrap in sterile towel
> moistened with the same solution; place in plastic bag; transport
> (preferably with the patient) in an ice chest (use crushed wet ice,
> [not]{.underline} dry ice) or in a refrigerated container at 4°C (\~
> 40°F).

-   Immediate cooling may increase the time of amputated limb salvage
    from the usual 6 hour maximum to 12-24 hours.

6\) Abdominal Wounds with Evisceration.

a\) Do not replace exposed organs into the abdominal cavity.

b\) Cover with gauze wet with normal saline.

c\) Obtain surgical consultation immediately.

7\) Sucking Chest Wounds.

a\) Do not place a chest tube through the site of the wound.

b\) Occlude the wound with Vaseline impregnated gauze, plastic wrap or
other occlusive dressing taped on 3 sides. This allows the dressing to
seal the wound with inspiration, and lets the leaking air escape with
exhalation. Occluding on all 4 sides with[out]{.underline} a chest tube
inserted may allow the leaking air to accumulate in the chest, producing
a tension pneumothorax.

c\) Placement of a chest tube through uninvolved skin is indicated by an
experienced practitioner.

8\) Closed Chest Trauma.

a\) Evaluate for signs of a pneumothorax or hemothorax. Respiratory
distress and if unilateral decreased breath sounds with increased
resonance on percussion, r/o pneumothorax; with decreased resonance on
percussion, r/o hemothorax.

b\) Immediately obtain pulse ox, ABGs, chest x-ray. Do not delay
intervention for results in a life-threatening situation when the
clinical diagnosis warrants immediate intervention.

c\) Recognize signs of Tension Pneumothorax: chest pain, respiratory
distress, absent breath sounds with hyper-resonance on the affected side
of the chest, hypotension, tracheal deviation, may have jugular venous
distention. If tension pneumothorax is diagnosed, immediate
decompression is indicated. Inset a large-bore needle in the second
intercostal space in the mid-clavicular line on the affected side.
Follow when indicated (in most cases) with chest tube insertion, usually
just anterior to the mid-clavicular line in the 5^th^ intercostals
space.

d\) Recognize signs of Cardiac Tamponade: The classic triad is jugular
venous distension plus muffled heart sounds plus reduced blood pressure.
However, these signs are not specific and may be absent. Electrical
Alternans is an infrequent but diagnostic sign; the QRS complex on the
EKG alternates between positive and negative. Also on the EKG, the QRS
voltage may be low (less than 5 mm in amplitude).

f\. *Special Considerations in Specific Trauma Patients*. In no
situation when other more appropriate resources are available should
pregnant trauma patients or pediatric trauma patients be transported to
or treated at the VAMC. However, when such patients arrive, every effort
should be made to minimize morbidity and mortality by providing
emergency care and stabilization until more appropriate care is
available. Two methods of obtaining this care are possible: the
preferable solution is the rapid transfer of the patient to an
appropriate facility; a less optimal contingency that should be
considered is establishment and maintenance of a credentialing file of
Obstetricians and Pediatricians who can be called to report to the
hospital when indicated in a Mass Casualty Incident. Consideration
should be given to developing a contingency plan that includes pre-event
identification and credential verification for qualified Obstetricians,
Surgeons and Pediatricians skilled in management of obstetric and
pediatric trauma patients who would plan to report to the facility
Emergency Department for activation of temporary privileges when the EOP
and Trauma SOP are activated due to an event, and local pediatric
facilities are overwhelmed or inaccessible.

1\) The Pregnant Trauma Patient:

a\) Pregnancy should be considered in girls and women between the ages
of 10 and 50 years of age, and pregnancy testing should be considered in
females in this age range. Inquiry into the menstrual history will
assist in excluding this possibility in younger and older patients.

b\) Two patients are being assessed and treated: both the mother and the
unborn. The life of the unborn depends upon the mother's health; thus,
direct initial management toward maternal resuscitation.

c\) The best initial care for the unborn is the provision of optimum
resuscitation and care for the mother and early assessment of the
unborn.

d\) Order of care should be: Initial Survey and Resuscitation for the
Mother; Fetal Assessment; Secondary Survey of the Mother to include
Pelvic Examination preferably by an Obstetrician. Fetal heart rate
monitoring is indicated at greater than 20-24 weeks gestation.

e\) Pregnancy produces changes in both anatomy and physiology that alter
both injury patterns and the response to trauma.

f\) Significant change includes increased oxygen consumption, thus early
provision of supplemental oxygen is indicated and hypervolemia of
pregnancy indicating the need for early fluid resuscitation.

g\) Early consultation with both a qualified Obstetrician and a Surgeon
should be obtained in all pregnant trauma patients.

h\) Full discussion of this is beyond the scope of this document, and
qualified medical practitioners must attend to these patients as soon as
possible. (See Attachment D for a summary of some of the considerations
in management of the pregnant trauma patient.) Some conditions of
concern include uterine rupture, abruption placenta or placental
separation, amniotic fluid embolization, disseminated intravascular
coagulation and fetal loss.

i\) Peri-mortem Cesarean Section within 4-5 minutes of maternal cardiac
arrest may be successful, unless the mother has been hypovolemic. In
cases of hypovolemia, this is unlikely to be successful due to prolonged
fetal compromise.

j\) Disseminated intravascular coagulation (DIC) may occur rapidly in
the pregnant trauma patient. Findings include low fibrinogen (less than
250mg/dl), low platelet count and reduction in other coagulation
factors. Management includes urgent uterine evacuation and management of
the depleted factors.

k\) Consider Rh immunoglobulin therapy within 72 hours in
[all]{.underline} Rh-negative pregnant trauma patients with possible
fetomaternal hemorrhage (any degree of trauma of the abdomen or thorax)
to avoid Rh sensitization.

2\) The Pediatric Trauma Patient. Treatment of the pediatric patient
requires specialized knowledge of normal developmental stages,
pharmacology with calculation of drug dosages on a weight basis and
avoidance of specific drugs, and specialized knowledge of Pediatric
Advanced Life Support. Consideration should be given to developing a
contingency plan that includes pre-event identification and credential
verification for qualified Pediatricians and Surgeons skilled in
management of pediatric trauma patients who would plan to report to the
facility Emergency Department for activation of temporary privileges in
an event when the EOP and Trauma SOP are activated, and when local
pediatric facilities are overwhelmed or inaccessible. Sources must be
identified for rapid availability of pediatric supplies and equipment,
and these must rapidly be obtained as soon as such a situation is
recognized.

3\) The Elderly Trauma Patient. Fatality rates with trauma are increased
in the elderly patient, but no good criteria exist to determine which
factors are determinants of mortality. Aggressive early treatment has
been shown to improve survival in the elderly trauma patient. Many of
these patients return to their pre-injury level of function after
recovery. Ethical considerations warrant that the patient's right to
self-determination as expressed in pre-existing Advance Directives
should be considered in the massively injured elderly patient. It is
inappropriate to withhold care based upon consideration of age.
Consideration of age-related changes in physiology and reduced reserve
capacity is necessary to provide optimal care.

g\. *Event Monitoring Strategies*. Police should coordinate with local
authorities and monitor the progress and duration of the event. Nursing,
Chief of Staff, Hospital Director and Clinical Services should document
clinical data and assist in patient tracking and disposition.

h\. *Recovery Strategies and Resource Issues*. An assessment of
mission-critical systems, medical resources, and personnel needs should
be conducted every 12 to 24 hours during the event and forwarded to the
Emergency Operations Center (EOC) so that a Situation Report (SITREP)
can be compiled.

7\. ***Notification Procedures***.

> Provide notification and situation reports (SITREPS) to the Network
> Director.
>
> Contact secondary VA Medical Centers, if necessary.
>
> Coordinate with local, county and state emergency response agencies as
> appropriate.
>
> State/Local Office of Emergency Services.

Coordinate with local, county and state emergency response agencies as
appropriate.

8\. ***Specialized Staff Training***.

a\. Train staff on the principles of trauma management (e.g., triage,
first aid, stabilization and emergency treatment of the trauma victim;
appropriate transfer and transport; and psychological, ethical and legal
issues).

b\. Encourage providers to pursue training in trauma management through
recognized courses, such as:

> Advanced Trauma Life Support for Doctors (American College of
> Surgeons).
>
> Advanced Trauma Course for Nurses (Society of Trauma Nurses).
>
> Pre-hospital Trauma Life Support course (National Association of
> Emergency Medical Technicians).
>
> Basic Disaster Life Support.
>
> Advanced Disaster Life Support.

Community Emergency Response Team (CERT) Training (Federal Emergency
Management Association).

c\. Conduct tabletop exercises to evaluate response readiness.

d\. Participate in community-wide exercises.

e\. Conduct drills and mini-drills.

9\. ***References and Resources***.

a\. *Advanced Trauma Life Support for Doctors* Student Course manual
7^th^ Edition; 2004 American College of Surgeons; ISBN 1-880696-14-2.

b\. The American Association for the Surgery of Trauma Web net
**(**<http://www.aast.org/> and
<http://www.aast.org/injury/injury.html>).

c\. Centers for Disease Control and Prevention, *Mass Trauma Data
Instrument,*
<http://www.bt.cdc.gov/masstrauma/pdf/rapidassessmentform.pdf>.

d\. Centers for Disease Control and Prevention, *Coping With a Traumatic
Event;* More about post-traumatic stress disorder & what you can do.
(<http://www.bt.cdc.gov/masstrauma/copingpub.asp>).

e\. Centers for Disease Control and Prevention, *Explosions and Blast
Injuries: A Primer for Clinicians*
(<http://www.bt.cdc.gov/masstrauma/explosions.asp>).

f\. Centers for Disease Control and Prevention, *Traumatic Incident
Stress: Information For Emergency Response Workers*.
(<http://www.cdc.gov/niosh/unp-trinstrs.html>).

g\. Center for Mental Health Services/Division of Prevention, Traumatic
Stress, and Special Programs/Emergency Mental Health and Traumatic
Stress Services Branch, *Emergency Mental Health and Traumatic Stress
(*<http://www.mentalhealth.org/cmhs/EmergencyServices/links.asp>).

h\. Community Emergency Response Team (CERT) Training, March 2004,
Module 4: *Disaster Medical Operations,* Lesson 15: *Patient Assessment
and Treatment.* Self-Assessment and Study Guide; FEMA
(<http://training.fema.gov/EMIWeb/downloads/is31715PatientAssess.pdf>).

i\. *Current Emergency Diagnosis and Treatment*; Stone KC, Humphries RL;
2004 5^th^ edition; Lange Medical Books/McGraw-Hill.

j\. National Center for Post Traumatic Stress Disorder (PTSD),
Department of Veterans Affairs (<http://www.ncptsd.org/>).

k\. Disaster Mental Health: Dealing with the Aftereffects of Terrorism.
Brief Information for the Public and the Professional. National Center
for PTSD, Veterans Affairs (<http://www.ncptsd.org/disaster.html>).

l\. VHA Emergency Management Program Guidebook.

m\. *ER Trauma Guide*, (1^st^ Edition), 2004, Stanford, CT, MIS Inc.
(This is a pocket card.)

n\. Lekawa, ME; *Trauma in Surgery*; Wilson SE (ed); Current Clinical
Strategies Publishing, Laguna Hills, CA, 6^th^ Edition, 2005; ISBN
1929622-57-0.

o\. Livingston, DH; Hauser, CJ; Trauma to the Chest Wall and Lung; in
*Trauma*; McGraw-Hill Medical Publishing Division, New York, NY; 5^th^
Edition, 2004; ISBM 0-07-137069-2.

p\. *The Mont Reid Surgical Handbook*; Fischer, DR, Kelly, BS (eds);
Elsevier Mosby Publisher, Cincinnati, OH; 5^th^ Edition, 2005.

q\. *Trauma*; Moore, EE; Feliciano, DV; Mattox, KL (eds); McGraw-Hill
Medical Publishing Division, New York, NY; 5^th^ Edition, 2004; ISBM
0-07-137069-2.

10\. ***Review Date***.

(Name)

Chief, (Service)

Attachments:

A. Common Trauma in Natural Disasters

B. Common Trauma in Non-Natural Disasters

C. Secondary Effects of Disasters

D. Special Considerations in the Pregnant Trauma Patient

E. Assessment of the Unborn and Uterine Injury

F. Dysrhythmias in the Trauma Patient

G. Key Activity Management Tool/Structure

*Sample 6.3.3.6*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **VHA Pharmaceutical Cache**

1\. ***Introduction.*** The VA Pharmaceutical Cache Program was
conceived in October 2001 as a means for VA to maintain its healthcare
delivery capability in the event of a natural disaster or attack. VHA
Directive 2002-026 covers all requirements for storage, inspection and
use of the cache.

2\. ***Description of the Threat/Event.*** Mass casualties from a
natural event or terrorist attack can rapidly overload any healthcare
system. Events fall into four major types: 1) conventional explosive; 2)
biological agents; 3) chemical agents, and 4) radiological agents.
Casualties from a conventional weapon incident may present with trauma,
burn, crush, laceration and physiological injuries. Biological events
usually have little immediate effect, but subsequent rapid peaks and
symptom development can quickly overwhelm the emergency response and
healthcare system. Casualties from a chemical exposure may exhibit
respiratory distress, convulsions, contamination of skin and clothing,
massive blistering, burns and, in addition, present a contamination
hazard to healthcare providers and the healthcare facility. They must be
decontaminated prior to entry. Radiological incidents include nuclear
explosion, but the most likely radiological event would be atmospheric
contamination. A nuclear "dust" incident or reactor "meltdown" accident
would likely cause respiratory damage, irradiation injuries for those
directly exposed and contamination of clothing and skin requiring
decontamination prior to entry into a healthcare facility.

3\. ***Impact on Mission Critical Systems.*** Most VA facilities
maintain limited stocks of pharmaceuticals, fluids and other items
needed for a terrorist attack. Even with the activation of the Strategic
National Stockpile (SNS), there will be a minimum of 1 to 2 days for
effective re-supply. Since VA Medical Centers may find themselves in the
position of receiving casualties from a weapons of mass destruction
(WMD) event, they must be prepared to provide care.

4\. ***Operating Units and Key Personnel to Manage the Cache During an
Event.*** The type of event will dictate the components and the amount
of the cache that will be deployed. The Incident Commander will provide
cache deployment information to the Chief of Pharmacy. The operating
units involved in the deployment may include:

> Medical Center Director
>
> Incident Commander
>
> Chief of Police
>
> Chief Transportation
>
> Chief EMS
>
> Emergency Management
>
> Safety
>
> Chief of Pharmacy

Chief of Staff

5\. ***Mitigation/Preparedness Activities for the Cache***. The cache
will be stored, inspected and secured in accordance with VHA Directive
2002-026, and in compliance with criteria issued by Pharmacy Benefits
Management Strategic Healthcare Group (PBMSHG) (see Attachment A of VHA
Directive 2002-026). Each VA Medical Center will prepare a written
emergency plan that covers the activation of the cache. All affected
staff will receive training in cache requirements. Annual exercises will
involve the deployment and activation of the cache for simulated
external chemical, biological, radiological, nuclear and explosive
(CBRNE) events.

6\. ***Response/Recovery of the Cache.*** The VA Medical Center
emergency plan will address:

> Activation of the cache by the Medical Center Director.
>
> Notification of the Pharmacy Representative parts of the cache is
> required.
>
> Activation of responding units to move cache.
>
> Transportation of the cache to and from the required secure location,
> including:
>
> How the cache will be moved to the required location.
>
> Special considerations when moving the cache.
>
> Personnel designated to move the cache.
>
> Security of the cache while in transit.
>
> Transportation requirements for moving the cache back to secure
> storage location using the same concerns listed above.

Inventory of all items used during the emergency.

Replacement of cache supplies.

7\. ***References.***

a\. VHA Directive 2002-026.

b\. VHA Directive 2004-046, Inspection of VHA Pharmacy Caches by the
Emergency Management Strategic Healthcare Group (EMSHG), August 24,
2004.

8\. ***Review Date.***

(Name)

(Title)

*Sample 6.3.3.7*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Evacuation (Total)**

1\. ***Description of the Threat/Event*.** Total evacuation of all or
parts of a VA Medical Center may be the result of sudden or expected
internal or external emergency events that may impact the safety and
well being of patients, employees and all other occupants. Evacuation
begins with understanding the type of patients (physical and mental
limitations), resources available, transportation assets, and knowing
what alternative care sites are available. Depending upon the type of
events causing evacuation, other resultant emergencies may impact the
successfulness of evacuation. For example, an explosion within the
facility may have affected the Heating, Ventilation and Air Conditioning
(HVAC), communications, lighting and oxygen systems. Inclement weather
may also hamper efforts, thereby impacting location of staging areas and
access to transportation assets.

2\. ***Impact on Mission Critical Systems.*** Typically the reason for
evacuation is that critical systems have been; or will, be adversely
impacted. The Operating Unit templates must address the back-up plans
should the facility experience a loss of these mission-critical systems.

3\. ***Operating Units and Key Personnel with Responsibility to Manage
this Threat/Event.*** This activity will in most cases require full
activation of the Incident Command System (ICS). The operating units
involved may include:

> Medical Center Director's Office
>
> Incident Manager
>
> Planning and Intelligence
>
> Logistics
>
> Finance and Administration
>
> Operations
>
> Business Continuity
>
> Plant and Utility Systems
>
> Safety and Security
>
> Health and Medical

4\. ***Mitigation/Preparedness Activities for the Threat/Event***.

> a\. Identify typical number and locations of ambulatory and
> non-ambulatory patients.
>
> b\. Identify patients that require special needs and assistance, such
> as those with dementia.
>
> c\. Identify employees with physical limitations or those who may have
> emotional, cognitive or learning difficulties during sudden and
> unusual activities, such as emergencies and evacuation.
>
> d\. Develop written evacuation procedures that include horizontal and
> vertical evacuation within the facility and total evacuation to the
> outside.
>
> e\. Identify services or departments responsible for overseeing and
> conducting evacuation.
>
> f\. Identify means to evacuate patients, employees and visitors who
> have physical and/or mental health limitations. *Note: Examples of
> devices, equipment or procedures that may assist in evacuation include
> Evacuation Chairs, Evacusleds, procedures involving Assist-O-Kinetics,
> and working with professional emergency responders.*
>
> g\. Establish a Memorandum of Understanding (MOU) with nearby
> hospitals and other alternative healthcare facilities.
>
> h\. Develop early discharge procedures.
>
> i\. Inventory/procure adequate number of stretchers, wheelchairs, etc.
>
> j\. Develop patient medical and tracking records in paper form in the
> event that automated information is not accessible.
>
> k\. Identify and establish agreements with local and statewide
> ambulance services, mass transport carriers (vans and buses) and state
> assets, such as National Guard Units, local military bases, etc.
>
> l\. Pre-designate staging areas, factoring in possible inclement
> weather. Develop simple blueprint of building areas indicating what
> units are staging where.
>
> m\. Identify supply and medical needs with local vendors.
>
> n\. Estimate number and types of staff needed and how to recall 24/7.

o\. Conduct drills and exercises to validate evacuation procedures.

5\. ***Response/Recovery from the Event or Threat*.**

a\. *Hazard Control Strategies/Resource Issues.*

-   Activate internal disaster plan.

-   Communicate with all Operating Units on actions to be taken, and
    verify their status.

-   Verify use of back-up communications (radio, cellular, etc.).

-   Verify alternate care sites are available. (*Note to Writer:* *See
    sample SOP for Alternate Care Sites, Section 6.3.3.1. in the
    Emergency Management Program Guidebook.*)

-   Track and account for patients and procedures for emergency medical
    response.

-   Ensure medical record information is being handled and/or
    communicated properly.

-   Verify collection and transport of medical and other waste materials
    while awaiting transport to be accomplished.

-   Verify patient transport/destination has been accomplished.

-   Monitor and evaluate critical plant systems operations.

b\. *See Attached Charts: Key Activity Management Tool/Structure.*

6\. ***Notification Procedures.***

a\. *Within VA.*

> Provide notification and situation reports (SITREPS) to the Network
> Director.

Contact secondary VA Medical Centers, if necessary.

b\. *Other Federal Agencies.*

> OSHA - Notify within eight (8) hours of one (1) employee fatality, or
> three (3) employee hospitalizations resulting from a single incident.

Coordinate with local, county, and state emergency response agencies as
appropriate.

7\. ***Specialized Staff Training.***

> a\. Conduct training for nursing and other staff in proper patient
> evacuation strategies and techniques. Example - how to evacuate
> vertically using Assist--O-Kinetics and demonstrate use.

b\. Conduct tabletop exercises to evaluate response readiness.

8\. ***References and Further Assistance.***

a\. VHA Emergency Management Program Guidebook.

b\. All Operating Units must review their operating unit templates for
response/recovery activities.

9\. ***Review Date.***

(Name)

(Title)

Attachments:

> A. Key Activity Management Tool
>
> B. Key Activity Management Structure

*Sample 6.3.3.8*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Fatality Management**

1\. ***Description of the Threat/Event*.** This procedure outlines steps
that a VA Medical Center should follow in the management of a large
number of fatalities as a result of an internal or external event. The
local Coroner's office is responsible for determining the cause of death
for all fatalities within a County (or Parish); although in some cases,
support from the Coroner's office may be delayed several hours to
several days.

2\. ***Impact on Mission Critical Systems.*** N/A.

3\. ***Operating Units and Key Personnel with Responsibility to Manage
this Threat/Event.***

> Director's Office

Chief of Staff, etc.

4\. ***Mitigation/Preparedness Activities for the Threat/Event*.**

a\. *Hazard Reduction Strategies and Resource Issues.* N/A.

b\. *Preparedness Strategies and Resource Issues.*

> 1\) The Medical Center maintains supplies for the identification and
> containment of human remains. If extra quantities are not available,
> other materials should be substituted.
>
> 2\) Contact the local Coroner's office to discuss this situation and
> make adjustments to this standard operating procedure.

3\) Temporary storage of human remains is usually handled through the
rental of refrigerated trucks. Several such vendors should be part of
the resource inventory.

5\. ***Response/Recovery from the Threat/Event.***

a\. *Event Control Strategies.*

> 1\) Bodies should not be moved prior to notification of the local
> Coroner's office. If, upon notification, the Coroner's office states
> their response will be delayed, seek instructions on how to manage the
> situation.
>
> 2\) If guidance is lacking, do the following:

-   Bodies should not be moved until the scene is adequately documented
    (e.g., Police and Security should sketch and photograph the area).

-   Identification and personal effects on the body should be collected,
    and the body placed in a body bag or other suitable container.

-   The bodies should be stored in a refrigerated area until the
    Coroner's office can accept them.

b\. *Event Monitoring Strategies*. The Chief of Staff will monitor
fatality management.

c\. *Recovery Strategies and Resource Issues*. Employees participating
in the response to a mass fatality event may benefit from stress
counseling.

6\. ***External Notification Procedures.***

a\. *Within VA.* VISN will be notified when the Medical Center
implements its plan.

b\. *Other Federal Agencies*. Support from other Federal agencies, such
as GSA, should be considered. OSHA -- Notify within eight (8) hours of
one (1) employee fatality, or three (3) employee hospitalizations
resulting from a single incident.

c\. *Community Entities and Local Governments*.

> Local Emergency Management Agency
>
> Local Hospital Association.

7\. ***Specialized Staff Training.*** Police and Security staff
education should address fatality management procedures.

8\. ***References and Further Assistance.*** N/A.

9\. ***Review Date.***

(Name)

(Title)

*Sample 6.3.3.9*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Mass Casualty Incident**

1\. ***Description of the Threat/Event*.** A mass casualty incident
(MCI) is defined as a type of significant medical incident that may fall
into the following categories:

> Extended - An incident for which local medical resources are available
> and adequate to provide for field medical triage and stabilization;
> and, for which appropriate local definitive care facilities are
> available and adequate for further diagnosis and treatment.

Major - An incident producing large numbers of casualties, for which
routinely-available regional or multi-jurisdictional medical mutual aid
is necessary and adequate for field medical triage and stabilization
and/or for further diagnosis and treatment.

(This SOP assumes the MCI is external to the Medical Center, causing no
damage to mission-critical systems, and that casualties arrive outside
the formal Emergency Medical Services (EMS) system (e.g., even though
most VA Medical Centers are not disaster-receiving stations for the
community, the disaster research has shown that injured victims will not
wait for EMS to arrive and will go to any hospital for treatment,
especially those near the disaster site.)

2\. ***Impact on Mission Critical Systems.*** N/A.

3\. ***Operating Units and Key Personnel with Responsibility to Manage
this Threat/Event.***

> Medical Center Director

Medical Service, etc.

4\. ***Mitigation/Preparedness Activities for the Threat/Event*.**

a\. *Hazard Reduction Strategies and Resource Issues*. N/A.

b\. *Preparedness Strategies and Resource Issues*. Develop a basic
capability to organize a response to an MCI. Actions include:

> 1\) Train staff on the principles of MCI management (e.g., triage,
> first aid, etc.).

2\) Have ready the basic equipment that may be necessary (e.g., command
vests, signage, forms/tags, backboards, crash cart, oxygen, etc.).

5\. ***Response/Recovery from the Threat/Event.***

a\. *Hazard Control Strategies.*

> Receive/verify notification from local authorities that an MCI
> occurred.
>
> Alert Clinic Supervisors to prepare for the arrival of casualties.
>
> Alert Security to establish traffic and access control procedures.

Alert Medical Center Director's Office and Public Affairs.

b\. *Event Monitoring Strategies**.*** Police and Security will
coordinate with local authorities and monitor the progress and duration
of the event.

c\. *Recovery Strategies and Resource Issues.* An assessment of
mission-critical systems will be conducted every 12 hours during the
event.

d\. *See Attached Charts: Key Activity Management Tool/Structure.*

6\. ***External Notification Procedures.***

a\. *Within VA.* VISN will be notified when the Medical Center
implements its plan.

b\. *Other Federal Agencies*. Severe weather planning should include
other Federal agencies, as appropriate. OSHA -- Notify within eight (8)
hours of one (1) employee fatality, or three (3) employee
hospitalizations resulting from a single incident.

c\. *Community Entities and Local Governments.*

> Local Emergency Management Agency
>
> Local Hospital Association

National Weather Service

7\. ***Specialized Staff Training*.** Staff and education should address
principles of MCI management.

8\. ***References and Further Assistance.*** ASTM 1288-90, Standard
Guide for Planning for and Response to a Multiple Casualty Incident.

9\. ***Review Date.***

(Name)

(Title)

Attachments:

> A. Key Activity Management Tool
>
> B. Key Activity Management Structure

*Sample 6.3.3.10*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Outreach**

1\. ***Description of the Threat/Event*.** Outreach to Veterans in the
service area of a VA Medical Center is a necessary activity prior to,
during, and after a major emergency occurs, especially the home-based
patients. The purpose of Outreach is to ensure continuity of care and to
help prevent losses due to disasters.

2\. ***Impact on Mission Critical Systems.*** N/A.

3\. ***Operating Units and Key Personnel with Responsibility to Manage
this Threat/Event.***

> Medical Center Director

Chief of Staff, etc.

4\. ***Mitigation/Preparedness Activities for the Threat/Event.***

a\. *Hazard Reduction Strategies and Resource Issues.* N/A.

b\. *Preparedness Strategies and Resource Issues.* Contact information
should be maintained on all Veterans in the service area who are, or
have been, patients at the Medical Center. Inquiry should be made to
determine if the Veteran would like to have emergency preparedness
services. Emergency preparedness services include:

1\) Assessment of dependency on utilities.

2\) Family disaster education and planning.

3\) Location of occupancy (e.g., in flood plain, etc.).

4\) Special patient management requirements.

5\. ***Response/Recovery from the Threat/Event.***

a\. *Hazard Control Strategies.*

> 1\) Events with warning:
>
> Verify status of patients and availability of medicines, support
> systems, etc.
>
> Answer questions, offer assistance.
>
> 2\) Events without warning:
>
> Verify status of patients and availability of medicines, support
> systems, etc.
>
> Respond to needs generated by the event.

b\. *Event Monitoring Strategies**.*** The Chief of Staff will monitor
outreach activities.

c\. *Recovery Strategies and Resource Issues.* Veterans in need of
recovery assistance should be referred to the appropriate authorities
(e.g., Local Emergency Management Agency, etc.).

6\. ***External Notification Procedures.***

a\. *Within VA.* VISN will be notified when the Medical Center
implements its plan.

b\. *Other Federal Agencies.* Support from other Federal agencies, such
as GSA, should be considered. OSHA -- Notify within eight (8) hours of
one (1) employee fatality, or three (3) employee hospitalizations
resulting from a single incident.

c\. *Community Entities and Local Governments.*

> Local Emergency Management Agency
>
> Local Hospital Association
>
> Local Visiting Nurses Association

7\. ***Specialized Staff Training*.** Staff and education should address
family disaster planning concepts.

8\. ***References and Further Assistance.*** N/A***.***

9\. ***Review Date.***

(Name)

(Title)

*Sample 6.3.4.1*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Alerting and Warning Systems**

1\. ***Description of the Threat/Event*.** Steps that the Medical Center
should follow in developing an alerting and warning system for
emergencies and disasters.

2\. ***Impact on Mission Critical Systems.*** N/A.

3\. ***Operating Units and Key Personnel with Responsibility to Manage
this Threat/Event.***

Medical Center Director.

Chief of Staff, etc*.*

4\. ***Mitigation/Preparedness Activities for the Threat/Event.***

> a\. *Hazard Reduction Strategies and Resource Issues.* N/A.
>
> b\. *Preparedness Strategies and Resource Issues.*

The Medical Center should designate a warning point (e.g., a function
staffed 24 hours a day, 7 days a week, such as Police and Security).

5\. ***Warning Systems.***

> a\. *External Warning Systems* - Medical Center warning point
> Supervisors should contact the State and Local Police's warning
> point(s), become familiar with the various community warning systems
> (e.g., tornado sirens, chemical industry alarms, dam failure/stream
> flow alarms, etc.), and which of them the Medical Center should be
> connected to.
>
> b\. *Internal Warning Systems* - The Medical Center's internal warning
> systems include fire, theft and other systems.

6\. ***Alerting Systems*.**

> a\. *External Alerting Systems* - In many locations, no fixed external
> alerting systems exist. In these cases, loudspeakers on Police
> vehicles can be used to alert and warn those out-of-doors.
>
> b\. *Internal Alerting Systems.*

1\) Organization-wide. Pre-scripted messages for use over the public
address system for common problems (e.g., severe weather, evacuation due
to fire, etc.) should be developed.

2\) Key Individuals. Current contact information should be maintained on
all key individuals. Procedures should be developed for who should be
called for what type of situations and where they should report.

7\. ***Response/Recovery from the Threat/Event.***

a\. *Event Control Strategies.*

> 1\) Warning messages received from unofficial sources should be
> verified with official sources prior to taking action on the threat
> (*Note to Writer: For an exception, see sample SOP for Bomb Threat,
> Section 6.2.2.1. in the Emergency Management Program Guidebook*).
>
> 2\) The warning point should follow procedure in alerting and warning
> organization-wide and/or key individuals*.*

b\. *Event Monitoring Strategies.* Police and Security is responsible
for warning-point operations.

c\. *Recovery Strategies and Resource Issues.* Procedures should be
revised based upon experience gained in actual events or drills.

8\. ***External Notification Procedures.***

a\. *Within VA.* VISN will be notified when the Medical Center
implements its plan.

b\. *Other Federal Agencies*. Support from other Federal agencies, such
as GSA, should be considered. OSHA **-** Notify within eight (8) hours
of one (1) employee fatality, or three (3) employee hospitalizations
resulting from a single incident.

c\. *Community Entities and Local Governments.*

Local Emergency Management Agency.

Local Hospital Association.

Local and State Police Agencies.

9\. ***Specialized Staff Training.*** Police and Security staff
education should address alerting and warning procedures.

10\. ***References and Further Assistance.*** N/A.

11\. ***Review Date.***

(Name)

(Title)

*Sample 6.3.4.2*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Facility Access Control**

1\. ***Description of the Threat/Event.*** To ensure a safe and orderly
operation of the Medical Center, a plan(s) must be developed to inform
the public of normal operating hours and how to obtain emergency
assistance during irregular hours. In addition, the Medical Center staff
must know, understand, and comply with policies and procedures in place
for securing facilities and property gates to ensure the safety and
security of patients, visitors, staff and for the safeguarding of
government property.

2\. ***Impact on Mission Critical Systems.*** Failure to properly secure
facilities and safeguard critical Government property could result in
serious consequences and negatively impact direct patient care. Persons
intending to commit criminal acts or cause harm to patients, visitors,
or staff will exploit every opportunity to take advantage of weak access
control to property and facilities, particularly during irregular hours
or in areas where the staff employs poor security controls and
management techniques.

3\. ***Operating Units and Key Personnel with Responsibility to Manage
this Threat/Event.***

> Medical Center Director.
>
> Chief, Police and Security.
>
> All Program Managers.
>
> All Employees.

4\. ***Mitigation/Preparedness Activities of the Threat/Event.***

a\. *Hazard Reduction Strategies and Resource Issues.*

b\. *Preparedness Strategies and Resource Issues.*

5\. ***Response/Recovery from the Event/Threat.***

a\. *Hazard Control Strategies and Resource Issues.*

1\) Establish Medical Center business hours for routine medical care and
how and where to obtain care during other than posted business hours.
Establish and post visiting hours. Consideration should also be given to
posting hours for routine delivery and accepting of supplies, etc., from
vendors.

2\) Restrict access to VA property and facilities to on-duty employees
and persons having a legitimate need to be on VA property during
irregular hours. The wearing of employee ID badges should be mandatory.

3\) Persons other than scheduled duty employees and those persons or
groups specifically authorized by the Medical Center Director who will
be within Medical Center buildings after normal business or visiting
hours are required to present a valid reason for their presence and to
record their presence on a Visitor Log, VA Form 4793. When at all
possible, the VA Police should control and maintain visitor sign-in
logs.

4\) Where use of visitor log-in procedures are not practicable, the
staff on duty where the visitor will be going should document the visit
and monitor the visitor\'s activity while on the property.

5\) Persons not having a legitimate reason for being on VA property,
particularly during irregular hours, should be asked to leave or be
removed by the VA Police.

6\) The VA Police may be tasked with developing procedures to lock
Medical Center doors, property gates, etc., to provide security to
facilities and grounds during non-business hours. Lock-downs can be
accomplished manually or through electronic means.

7\) VA Police will provide aggressive foot and mobile patrol coverage of
facilities and property 24 hours a day. Special emphasis should be given
to building checks during irregular hours, particularly at night and to
buildings located in isolated areas. Such checks should be adequately
documented.

8\) All employees should be trained and held accountable for securing
their work centers/facilities to prevent the unauthorized removal or
theft of Government property.

b\. *Preparedness Strategies and Resource Issues.*

1\) The Medical Center Director will establish business hours and
visiting hours.

2\) Police and Security may manage the Facility Access Control Program
for the Medical Center and may develop internal operating procedures
pertaining to visitor sign-in procedures/policy, building/property
security (locking buildings, doors, gates, etc.), building checks, and
foot/mobile patrol coverage, etc.).

3\) Program Managers may develop internal procedures for securing their
assigned work centers and Government property when their areas are not
staffed, or when closed for business.

6\. ***External Notification Procedures.***

a\. It is good practice for Program Managers to notify VA Police when
identifying a security deficiency (i.e., door unsecured during irregular
hours, Government property left unsecured and unattended and vulnerable
to theft, etc.).

b\. Police and Security may consider sending \"Security Deficiency
Letters\" through the Medical Center Director to Program Managers who
repeatedly have work centers left unsecured or unattended leaving
valuable equipment vulnerable to theft; thereby, impacting patient care
programs. Deficiency letters may require a response to VA Police,
through the Medical Center Director, stating what actions were taken to
prevent further occurrences.

7\. ***Specialized Staff Training.*** Training of all personnel on the
importance of securing work centers to prevent theft of government
property and/or tampering with medical records.

8\. ***References.*** N/A.

9\. ***Review Date.***

(Name)

(Title)

*Sample 6.3.4.3*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Lockdown-Heightened Security Procedures**

1\. ***Description of the Lockdown-Heightened Security Event.*** In the
event of a lockdown-heightened security event, medical center personnel
must be notified and additional security measures must be considered or
implemented. Emergency events that may require immediate activation or
lockdown procedures include those where imminent threats or an emergency
such as an explosion, release of a hazardous or Chemical, Biological,
Radiological, Nuclear or Explosive (CBRNE) material occur.
Lockdown-heightened security measures must be implemented in a fashion
that can be sustained for short or indefinite periods of time. Actions
taken need to provide for increased safety and security of patients,
visitors, and staff. Any actions taken should be accomplished in a calm,
orderly, and professional manner so as not to cause unneeded
alarm/concern or increased anxiety among the Medical Center population.
In the event of activation for an extended period of time concerning
heightened security, the Network Director shall be notified.

2\. ***Impact on Mission Critical Systems.*** Implementation of
lockdown-heightened security measures may have an adverse impact on
patients, visitors and staff. However, not implementing lockdown
procedures during hazardous material and CBRNE events may cause the
Medical Center, its staff, patients and facilities to become
contaminated. An effective lockdown procedure will prevent this. The
process of identification checks, bag checks/inspections, checking
incoming mail and supply shipments, etc., may result in delays in
medical center daily normal activities.

3\. ***Operating Units and Key Personnel with Responsibility to Manage
Heightened Security Events.***

> Medical Center Director
>
> Associate Director
>
> Chief of Staff
>
> VA Police
>
> AOD
>
> Safety Office
>
> Logistics Program Manager
>
> Facilities Management
>
> Others as warranted
>
> Etc.

4\. ***Mitigation/Preparedness Activities of the Lockdown-Heightened
Security Event***. Conduct a vulnerability assessment of medical centers
and ancillary facilities, including outpatient centers and Consolidated
Mail Outpatient Pharmacies (CMOPs) to include the following:

a\. Infrastructure doors, locking mechanism/devices.

b\. Window openings, locking mechanisms/devices.

c\. Physical security vulnerability assessments of medical center
including grounds and roadways.

d\. Physical Security vulnerability assessments of Community Based
Outpatient Clinics (CBOCs) and Outpatient Clinics.

e\. Plans and polices to conduct identification checks.

f\. Plans and procedures to secure doors and windows in a methodical
fashion when warranted (checklist).

Note: Life Safety Code requirements must be closely monitored for
compliance during heightened security events. Interim Life Safety Code
Measures (ILSM) must be considered in the events and planning of
heightened security, if Life Safety Code regulations are compromised.

5\. ***Response/Recovery from the Event/Heightened Security.***

a\. *Hazard Control Strategies and Resource Issues.*

**Lockdown-Heightened Security Alert Level 1:** Lockdown-heightened
security and circumstances that do not justify full implementation of
Alert Level 2 or 3.

> Staffing: Normal staffing levels will be maintained; however, a
> heightened state of alertness and readiness will be paramount.

**Lockdown-Heightened Security Alert Level 2:** An increased and more
predictable lockdown-heightened security activity exists. Actions taken
must be capable of being maintained for extended period of time without
significantly affecting day-to-day operations. (See Attachment A.)

> Staffing: Staffing may need to be increased (all at the discretion of
> the Medical Center Director).

**Lockdown-Heightened Security Alert Level 3:** An incident/event occurs
or intelligence is received indicating some form of lockdown-heightened
security actions are highly likely. Actions to be taken may affect
day-to-day operations and increase operating costs. (See Attachment A.)

> Staffing: Mandatory additional shifts may be implemented. Police
> Officers working in operational positions may also be asked to work
> additional shifts (all at the discretion of the Medical Center
> Director and VA Chief of Police).

**Lockdown-Heightened Security Alert Level 4:** A critical event has
occurred or intelligence is received that a terrorist action against a
specific location or person is imminent. (See Attachment A.)

> Staffing: Mandatory additional shifts may be implemented. Police
> Officers working in operational positions may also be asked to work
> additional shifts (all at the discretion of the Medical Center
> Director and VA Chief of Police).

b\. *Hazard Monitoring Strategies and Resource Issues.*

-   Continue to monitor heightened-alert conditions.

-   Continue to participate in Medical Center Emergency Operations
    Center (EOC) operations when activated for the purpose of
    heightened-security event.

-   Maintain routine contact with local and federal law enforcement
    agencies as warranted.

c\. *Recovery Strategies.*

-   Provide EOC or top management updates on current status of
    heightened security and the impact it is having on Medical Center
    operations.

6\. ***External Notification Procedures.***

-   VISN Director

-   Local U.S. Marshal Service

-   Federal Bureau of Investigation (FBI)

-   Federal Protective Service

-   Deputy Assistant Secretary for Security and Law Enforcement,
    Washington, DC

7\. ***Specialized Staff Training.***

-   Key Medical Center personnel must be adequately trained on
    procedures for implementing Command Post Operations, specific to
    heightened-security activation.

-   Ensure the VA Police and augmentation staff (VA employees other than
    VA Police) are adequately trained and equipped to provide
    heightened-security measures that would be perceived as a viable
    obstacle to heightened-security components.

8\. ***References.***

a\. VHA Emergency Management Program Guidebook (latest revision).

b\. All Operating Units in the medical center should review their
emergency preparedness operating unit templates for heightened-security
activities.

c\. VA Police Handbook 0730.

9\. ***Review Date.***

(Name)

Chief, (Service)

Attachment:

A. Heightened-Security Alert Levels and Tasking

*Sample 6.3.4.4*

S A M P L E

VA Medical Center

(Location)

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Fire Suppression Systems Failure**

1\. ***Description of the Threat/Event.*** Fire suppression systems at
VA Medical Centers refer to sprinklers. Failure of these systems will
trigger activation of Interim Life Safety Measures (ILSM), which should
be detailed for each Medical Center.

2\. ***Impact on Mission Critical Systems.*** The failure of the fire
suppression system will impact Safety, which is responsible for
activating ILSMs; staff who participate in ILSMs; Engineering staff who
recover and maintain critical systems; Security, for crowd and traffic
control; Logistics for acquiring replacement equipment and/or services.

3\. ***Operating Units and Key Personnel with Responsibility to Manage
this Threat/Event.***

> Medical Center Director.
>
> Facilities Engineering.
>
> Safety Office.
>
> VA Police.
>
> VA Fire Department.
>
> Logistics.

4\. ***Mitigation/Preparedness Activities of the Threat/Event.***

a\. *Hazard reduction strategies and resource issues.* Testing and
maintenance of all components of fire suppression system.

b\. *Preparedness Strategies and Resource Issues.* Frequent review and
update of ILSMs and other Life Safety program activities.

5\. ***Response/Recovery from Failure of Fire Suppression System.***

a\. *Hazard Control Strategies.* Activate ILSMs.

b\. *Hazard Monitoring Strategies.* Activate and monitor effectiveness
of ILSMs.

c\. *Recovery Strategies.* Contain/secure affected areas.

d\. *See attached charts:* Key Activity Management Tool/Structure.

6\. ***External Notification Procedures.***

a\. *Within VA.* VISN Safety staff is usually notified by the Medical
Center Safety Officer when fire suppression capability fails and when
restored.

b\. *Other Federal Agencies.*

> OSHA -- Notify within eight (8) hours of one (1) employee fatality, or
> three (3) employee hospitalizations resulting from a single incident.
> The name and phone number for the nearest Federal OSHA office should
> be inserted here for use by the Safety Officer or designee.

7\. ***Specialized Staff Training.***

a\. Training of all staff (especially Safety and VA Police) on ILSMs for
failure of fire suppression systems.

b\. Training of Engineering staff (or contractors) on maintenance/repair
of fire suppression systems.

8\. ***References and Further Assistance.***

a\. VHA Emergency Management Guidebook.

b\. VHA Fire Safety Guidebook, VHA Environment of Care Guidebook,
National Fire Protection Association (NFPA) Life Safety Code.

c\. Operating Units in the medical center should review their operating
unit templates for mitigation, response and recovery activities.

9\. ***Review Date.***

(Name)

(Title)

Attachments:

> A. Key Activity Management Tool
>
> B. Key Activity Management Structure

*Sample 6.3.4.5*

S A M P L E

VA Medical Center

(Location

Emergency Management Program (Date)

Standard Operating Procedure No. ( )

Subject: **Clinical Laboratory Biosafety and Biosecurity**

1\. ***Description of the Threat/Event***. Clinical laboratories have
been under strict operational oversight for over 30 years with
progressive regulatory requirements for increasing levels of clinical
patient care responsibilities. Large portions of these requirements are
in place to ensure the operational safety for employees and both
diagnostic safety and quality testing for patients. A common component
of laboratory operation deals with handling, processing, testing and
shipping of biologic substances. Routine clinical microbiology
laboratories work with BSL-2 level agents that pose no increased level
of respiratory threat to the employee or the environment. A small
percentage of laboratories maintain a clinical BSL-3 level laboratory,
mostly for the sole purpose of culturing and identification of
mycobacterial organisms, including the respiratory pathogen
mycobacterium tuberculosis. Intentional handling, culturing and
identification of CDC-defined select agents are not routine operations
for clinical laboratories. There is, however, a remote chance that a
select agent could be isolated from a direct patient specimen submitted
to the laboratory for evaluation. (Note: Research laboratories have
multiple regulatory agencies to which they report, and separate
inspection and reporting requirements. In general, the safety and
security requirements are more stringent for research laboratories
simply due to the nature of the agents handled in these laboratories.)

Prior to 2001 safety and security principles in the clinical
laboratories have focused solely on operational and employee safety.
Since the September 11, 2001 intentional mailing of concentrated anthrax
spores, it has become apparent that laboratories, particularly BSL-3 and
BSL-4 facilities represent a potential risk for the origin of biologic
agents that could be used against the general public if placed in the
wrong hands. Although routine clinical laboratories pose limited risk,
they must also operate at higher level of biosafety and biosecurity than
ever before. The US Public Health Service and the Office of the
Inspector General have placed a high level of responsibility on medical
centers to ensure that laboratories have taken steps to mitigate the
potential for select agent dissemination. (Please note that VHA does not
permit operation or construction of BSL-4 laboratories.)

2\. ***Supporting Documents, Regulations and Guidelines.***

a\. VHA 1106.1, Pathology and Laboratory Medicine Service (P&LMS)
Handbook.

b\. VHA 1106.2, P&LMS Biosecurity and Biosafety Handbook.

c\. VHA Directive 2005-003, Requirements for Submittal and Approval of
Biosafety Level-3 (BSL-3) Research Laboratory Construction and
Renovation.

d\. Public Law 108-188, Public Health Security and Bioterrorism
Preparedness Response Act (June 2002).

e\. Code of Federal Regulations (CFR) 42 Parts 73 and 1003.

f\. *Biosafety in Microbiological and Biomedical Laboratories*, BMBL
Manual, Centers for Disease Control and Prevention (CDC) and National
Institutes of Health (NIH), 4^th^ edition.

g\. Clinical Laboratory Improvement Act (CLIA).

h\. Clinical Laboratory Accreditation and Oversight Agency Regulations:

-   Joint Commission on Accreditation of Healthcare Organizations
    (JCAHO).

-   College of American Pathologists (CAP).

-   American Association of Blood Banks (AABB).

-   Commission on Office Laboratory Accreditation (COLA).

-   Food and Drug Administration (FDA).

-   Occupational Safety and Health Administration (OSHA).

-   Department of Transportation (DOT).

-   HHS Centers for Disease Control and Prevention (CDC).

-   Nuclear Regulatory Commission (NRC).

3\. ***Impact on Mission Critical Systems***. The accidental release of
a biologic agent into the clinical laboratory may result in
contamination of the immediate laboratory space, adjacent areas of the
medical facility and the Heating, Ventilation and Air Conditioning
(HVAC) system, in addition to potential infection of exposed employees.
Clinical laboratories do not routinely work with CDC-defined select
agents, so the potential for one of these agents to be spilled or stolen
is extremely low. In the event that a select agent is isolated from a
patient sample, it is possible that there could be an accidental spill
of the sample, if inappropriately prepared for shipping and transport to
the laboratory response network.

4\. ***Operating Units and Key Personnel with Responsibility to Manage
this Threat/Event***.

a\. *Medical Center Director and Chief of Staff* - Key role in ensuring
that all medical center laboratories meet and maintain an appropriate
level of accreditation for the patient care services provided and meet
all regulatory safety requirements.

b\. *Chief Pathology and Laboratory Medicine Service and/or Laboratory
Director* - Key roles include the following:

-   Ensure that the laboratory maintains all regulatory requirements
    needed for safe laboratory operations.

-   Ensure that laboratory employees are trained at appropriate levels
    in handling, processing, shipping and tracking of biohazardous
    material, including waste.

-   Ensure that quality laboratory operations are maintained.

-   Approve all laboratory standard operating procedures prior to
    implementation.

-   Review all quality control measures to ensure quality patient care.

-   Review all proficiency testing results and aggregate data to ensure
    quality care.

-   Ensure that P&LMS is represented on key hospital safety committees
    and workgroups, such as the Infection Control Committee.

-   Ensure that equipment is operated and maintained in proper working
    condition.

-   Ensure that appropriate notification occurs in the event of a
    laboratory accident, a potential accidental release or event, and
    isolation of reportable pathogens.

c\. *Infection Control Team* - Key role in tracking and reporting of
reportable biologic pathogens detected by laboratory testing methods.
Responsible for facility-wide biosafety educational activities.

d\. *Safety Officer/Industrial Hygienist* - Key role in ensuring ongoing
monitors, as needed, to verify proper operational status of biologic
safety cabinets and other engineering and equipment controls. Ensure
that the disposition of biohazardous materials is in compliance with all
regulatory requirements.

e\. *Occupational/Employee Health* - Key role in ensuring that employees
are offered appropriate levels of infectious disease prevention and
screening measures for the areas in which they work, such as Hepatitis B
vaccine, Influenza vaccine, Neisseria meningitis vaccine and TB skin
testing.

Note: TB skin testing is recommended every 6 months for employees
working in BSL-3 laboratories culturing 6 or more mycobacterium
tuberculosis isolates per year.

f\. *Environmental Management Service* - Key role in ensuring that
Environmental Management staff are trained appropriately to safely
handle biohazardous laboratory waste.

5\. ***Mitigation/Preparedness Activities of the Threat/Event***.

a\. Education of all employees in safe laboratory operations,
appropriate levels of personal protective equipment (PPE) and reporting
mechanisms during service level orientation. This applies to all VA
Medical Center services dealing with biohazardous materials.

b\. Requirement for all employees to be cleared for medical record and
physical access through cybersecurity training and pre-employment
background checks.

c\. Maintain safe operations of clinical microbiology laboratory by
restricting access to appropriate Medical Center personnel (laboratory
technologists, clinicians, Environmental Management Service,
Engineering, etc.).

d\. Ensure that BSL-2 laboratories are physically locked and secure when
personnel are not in the laboratory.

e\. Ensure that BSL-3 laboratories are physically locked at all times of
operation. Strict limitation of BSL-3 laboratory access is in place.

f\. Maintain physical security and safety features specific to BSL-3
laboratories, such as:

-   Solid ceilings and floors that prevent alternate access entrance and
    allow decontamination of laboratory space, should a spill occur.

-   Secure ceiling crawl spaces (that do not allow access from above the
    room).

-   Appropriate level of locks to ensure that no unauthorized access
    occurs.

-   Room air exchange differential rate monitors and/or alarms.

-   Appropriate sealed centrifuges, biosafety cabinets, incubators for
    BSL-3 operations.

-   Dedicated external exhaust.

-   Ability to isolate HVAC for BSL-3 areas of the facility.

-   Backup emergency power to BSL-3 facilities to ensure that a power
    outage does not result in airflow disturbances.

g\. Maintain all stock cultures in locked room and/or locked freezer.
(It is also recommended to keep the stock culture inventory in a safe
location, not posted on the wall or freezer.)

h\. VA laboratories that test patients for the diagnosis, treatment and
prevention of disease must meet the applicable clinical laboratory
requirements for handling select agents defined in 42 CFR 73 and 1003.
These requirements are defined under subsection 73.6.

i\. Maintain ongoing operational environmental controls, and work
jointly with Engineering Service and hospital Safety Officer.

j\. Maintain ongoing safety of equipment controls by ensuring timely
preventive maintenance checks, as outlined by manufacturers' guidelines
and regulatory agencies; work jointly with Engineering and Biomedical
services.

k\. Use of and adherence to laboratory standard operating procedures, as
approved by the Chief, P&LMS.

l\. Participation in internal and external safety inspections and
environmental rounds.

m\. Designation of a laboratory Safety Officer to coordinate with
multidisciplinary facility workgroups, hospital Safety Officer and
Infection Control team.

n\. Maintain communications with external support services, such as the
public health laboratory and the Laboratory Response Network.

o\. Report any suspicious activities or unauthorized laboratory access
to immediate supervisor.

6\. ***Response/Recovery from the Event/Threat***.

a\. Rapid notification of event or potential events to Chief, P&LMS.

b\. Decontamination procedures as outlined in standard operating
procedures, working in coordination with hospital Safety Officer.

c\. Maintain appropriate levels of resources for ongoing operations.

7\. ***External Notification Procedures***.

a\. Within VA: Veterans Integrated Service Network (VISN); VA Central
Office (VACO).

b\. Other Agencies: Local Public Health Service, Centers for Disease
Control and Prevention (CDC), Occupational Safety and Health
Administration (OSHA).

OSHA - Notify within 8-hours of one (1) employee fatality, or three (3)
employee accident-related illnesses.

c\. Community Entities. These may include, as needed, neighboring
hospitals, emergency response systems \[Police, Emergency Management
System (EMS), etc.\].

8\. ***Specialized Staff Training***.

a\. Biosafety training appropriate to the job duties of each employee.

b\. Shipping and handling training and certification, as required by the
College of American Pathologists (CAP) and Department of Transportation
(DOT).

c\. Bioterrorism Awareness Training.

9\. ***Review Date***.

(Name)

Chief, (Service)