DEAS 1118 : 2022 
ICS 13. 200 
 
© EAC 20 22                                                                                                                          First Edition 20 22 
 
 DRAFT EAST AFRICAN STANDARD  
Emergency management — Evacuation for healthcare facilities — 
Guidelines  
EAST AFRICAN COMMUNITY  
 
 
 
 
 
  DEAS 1118:2022  
© EAC 20 22 – All rights  reserved  ii 
 Copyright notice  
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Reproduction for sales purposes may be subject to royalty payments or a licensing agreement.  Violators 
may be prosecuted.  DEAS 1118:2022  
© EAC 20 22 – All rights  reserved  iii 
 Foreword   
Development of the East African Standards has been necessitate d by the need for harmonizing requirements 
governing quality of products and services in the East African Community. It is envisaged that through 
harmonized standardization, trade barriers that are encountered when goods and services are exchanged within 
the Community will be removed.  
The Community has established an East African Standards Committee (EASC)  mandated to develop and issue 
East African Standards (EAS).  The Committee is composed of representatives of the National Standards Bodies 
in Partner States, together with the representatives from the public and private sector organizations in the 
community.  
East African Standards are developed through Technical Committees that are representative of key 
stakeholders including government, academia, consu mer groups, private sector and other interested parties. 
Draft East African Standards are circulated to stakeholders through the National Standards Bodies in the Partner 
States. The comments received are discussed and incorporated before finalization of st andards, in accordance 
with the Principles and procedures for develop ment of East African Standards.  
East African Standards are subject to review, to keep pace with technological advances. Users of the East 
African Standards are therefore expected to ensur e that they always have the latest versions of the standards 
they are implementing . 
The committee responsible for this document is Technical Committee EASC/TC 07 6, Services.  
Attention is drawn to the possibility that some of the elements of this document may be subject of patent rights. 
EAC shall not be held responsible for identifying any or all such patent rights.  DRAFT EAST AFRICAN STANDARD  DEAS 1118:2022  
 
© EAC 20 21 – All rights  reserved  4 
 Emergency management — Evacuation for healthcare facilities —
Guidelines  
1. Scope  
This draft East African Standard provides guidelines to help healthcare facilities in the development/updating of a 
facility specific evacuation plan containing detailed information, instructions, and procedures that can be engaged 
in any emergency situation necessitating either full or partial hospital evacuation, as well as sheltering in place.  
2.   Normative references  
There are no normative references in this document . 
3.  Terms and definitions  
For the purposes of this document, the following terms and definitions apply . 
ISO and IEC maintain terminological databases fo r use in standardization at the following addresses:  
— IEC Electropedia: available at http://www.electropedia.org/  
— ISO Online browsing platform: available at http://www.iso.org/obp  
3.1 
Shelter  in Place  (SIP)  
a procedure used to  take immediate  shelter  in a current  location  
 
3.2 
evacuation  
the movement of  patients  and personnel  from  a dangerous location to  one of relative safety  
 
3.4 
horizontal  evacuation  
evacuation  on the same floor, often to  the other  side of  a set of fire barrier or smoke  compartment doors  
 
3.5 
vertical  evacuation  
evacuation to  a safe place  on another floor, can  be upward  or downward  
 
3.7 
emergency  evacuation  
urgent  immediate  egress  for escape of  people away  from  an area that contains an  imminent,  ongoing threat  
or a hazard  to lives  or property.  
 
3.9 
refuge  area DEAS 1118:2022  
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 a location within  a building  that is identified  as having  relative  safety  
 
3.10 
assembly  point  
a pre -identified area outside of  the building where departments will assemble upon evacuation from the                 facility  
3.11 
surge  capacity  
the ability  to evaluate  and care for a markedly  increased  volume  of patients  one that challenges  or exceeds  
normal  operating  capacity  
 
3.12 
Hazard  Vulnerability  Analysis/Assessment  (HVA)  
a systematic  approach to  identifying all hazards  that may affect an organization and/or its community,  
assessing the risk (probability of hazard occurrence and the consequence for the organization) associated  with 
each  hazard,  and analysing the findings  to create  a prioritized comparison  of hazard  vulnerabilities  
 
3.13 
Hospital  Incident  Command  System  (HICS)  
a standardized  management  system  that consists  of a flexible  organization  structure  and time-proven  
management  principles  
 
3.14 
Incident  Command  System  (ICS)  
a standardized on -scene emergency management construct specifically designed to provide for the adoption  
of an integrated organizational structure that reflects the complexity and demands of single or multiple  
incidents,  without  being  hindered  by jurisdictional  boundaries  
 
   3.15 Incident Management Team (IMT)  
group of trained personnel that respond to an emergency   
 
4. General  plan/policy  guidelines  
4.1 General  
 
4.1.1  The purpose of  this plan is: 
 
a) To direct the  activities required to implement sheltering ‐in‐place, partial evacuation/internal 
relocation or  full evacuation.  
 
b) To outline  the responsibilities  of individuals  and departments  during  shelter‐in‐place,  partial  
evacuation/relocation, and  full evacuation.  
 
c) To prioritize response requirements and establish an orderly shelter, relocation, or evacuation 
process  using  the Incident  Command  System  (ICS)  
4.1.2  During an actual evacuation, action plans should be made by the unit leaders and communicated to  all 
staff on site. Communication should be done in a proper manner to assure clarity of communication and  
incident  tracking  capability  DEAS 1118:2022  
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4.1.3  This plan should in cooperate staff roles and responsibilities essential to this process. Staff training  for 
employees  on the evacuation  plan will include  techniques  for lifting  and carrying  patients  and knowledge  
of alternative evacuation routes. The expectations will be that staff will accompany patients and work at  
receiving  facilities  subject  to receiving  proper  emergency  credentials.  Drills  and reviews  shall be 
conducted  to ensure that the plan is workable. The plan shall include back up measures for all components 
and shall be  integrated with pertinent protocols in the facility’s comprehensive emergency plan such as 
activation of  hospitals  incident  command  system.  
 
4.1.4  Sheltering ‐in‐place,  relocation,  and evacuation  activities  may:  
 
a) occur  as stand -alone response.  
 
b) be implemented  in a progression, if  necessary, as  the incident  evolves.  
 
c) be implemented  in a proactive response to  impending  hazards.  
 
d) be implemented  in response to an acute incident.  
 
4.1.5  The following are examples of factors that could lead to activation of the shelter ‐in place / relocation /  
evacuation  plan:  OR insert  results  of your HVA 
a) Loss of environmental support services including heating, water, air conditioning, sterilization, 
electrical  power,  and medical  gases.  
b) Internal  emergencies such  as fire, smoke,  hazardous materials  release,  or active  shooter or  threat.  
 
c) External  emergencies  including  natural  and manmade  disasters  such as earthquake,  urban  
and wildfires,  flood,  power  outage,  civil disturbance,  terrorism,  hazardous  materials  spills,  
contaminated  victims/toxic  agents,  radiation exposure,  explosions  and police  actions.  
 
The evacuation  of the facility  shall only be initiated  as a last resort  in response  to disruption  of 
services     caused by  an internal  or external  disaster.  
 
4.2.1   Supporting  plans  
If necessary,  based  on the incident,  any or all of the following  plans  may also be activated  in support  of the 
evacuation /  shelter  in place  plan:  Emergency  operations  plan (EOP)  
 
a) Command center operations  
 
b) Department ‐specific  evacuation  plans  
 
c) Lockdown procedures  
 
d) threat  specific  plan 
 
e) Facility  closure,  restoration  and start up 
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 f) Business  continuity.  
 
5. Plan Activation  
 
5.1 The responsible individual for the activation and implementation of this plan is the head and/or   
healthcare facility  designee.  
  
5.2 The decision to implement whole or parts of the evacuation plan should be determined based on the  
incident  assessment,  information  and/or  recommendations  from other  facility  personnel  or community  
response partners  such as  the local fire or police  department.  Decision  making  resources available  are: 
 
a) Decision Tree ―  Annex A,  
 
b) Decision  Matrix  ― Annex B  
 
c) Incident  Assessment  Worksheet,  ― Annex  C 
 
6. Incident  management  
 
6.1 Establish  Command  and Control  
 
6.1.1  The overall management of incident response and recovery is the responsibility of the Incident  
Commander  as designated  in the Emergency  Management  Plan.  
 
a) All personnel are authorized to take immediate patient/resident relocation or sheltering 
actions in  response  to a life safety emergency.  
 
b) Every  department  is responsible  for implementing  their activities within  the evacuation  plan.  
 
6.1.2  The Incident Commander  will notify  and activate:  
 
a) Activate  Code  [internal].  
 
b) Activate  ICS Incident Management Team  members  as needed  by the incident.  
 
c) Activate the  Command post.  If the primary  location  is not available,  notification  shall 
include  the new alternate  location.  
 
6.1.3  ICS and Command post operations shall be  guided  by: 
 
a) This plan,  and other  plans  activated  in support  of this incident.  
 
b) ICS Job Action  Sheets.  
 
c) Including  the following evacuation  related  forms:  DEAS 1118:2022  
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1) HICS  254: Disaster  Victim/Patient  Tracking  Form  
 
2) HICS 255:  Master Patient Evacuation  Tracking  Form  
 
3) HICS  259: Hospital  Casualty/Fatality  Report  
 
4) HICS 260: Patient  Evacuation  Tracking  Form  
 
6.1.4  All information  related  to the incident  shall be coordinated  and released  through  the Command       
Center . 
 
6.1.5  The Command centre  will coordinate with outside agencies, other healthcare facilities and facility  
administration  regarding  facility  status,  evolving  situational  needs,  and overall  status  of the 
evacuation/shelter  in place  process.  
 
6.2 Roles  and responsibilities  
 
6.2.1  General  
 
In addition to the use of the position Job Action Sheets, the following identifies some key activities and  
responsibilities for certain  ICS IMT members  and all  personnel.  Additional  resources available:  
 
a) Initial  critical  action sheet  for an  emergency  evacuation and shelter  in place.  
 
b) Defend in place for active  threat/shooter.  
 
c) Command  personnel  checklist  for shelter,  relocation,  and evacuation.  
 
d) Evacuation incident  response  guide.  
 
6.2.2  Incident  commander  
 
The incident commander has the full authority and responsibility for the decision making processes for this  
response.  
 
6.2.3  Public  information  officer  
 
Coordinate  media  communications regarding the  status of the  facility,  including the need  to evacuate.  
 
Establish a family information center to notify and respond to queries from family members regarding the  
status and location of patients who have been evacuated.  Utilize the tracking information provided to the  
Command  post by the  Planning  Section  Chief.  
 
Assign personnel to  notify  the patients/residents  emergency  contact  person.  
 
6.2.4  Liaison  officer  DEAS 1118:2022  
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Notify local agencies that you are experiencing an adverse incident that requires sheltering or evacuation  
and update  your operational  status  (capabilities,  resources  needs,  etc.).  
 
Notify  relevant  community  response  partners,  
 
6.2.5  Safety  officer  
 
a) Oversee  the immediate  stabilization of the  facility;  
 
b) Recommend  areas  for immediate  evacuation  to protect life;  
 
c) Ensure  the safe evacuation of  patients, staff  and visitors;  
 
d) Conduct initial and ongoing analysis of existing evacuation practices for health and safety 
issues  related to  personnel,  patients,  and facility,  and implement  corrective  actions  to 
address.  
 
6.2.6  Operations  section  chief  
 
a) Coordinate the processes necessary  to safely  evacuate a  portion or  all of the facility.  
 
b) Identify appropriate staging areas for the receipt and movement of patients/residents, 
personnel and  visitors.  
 
c) Work with the medical care branch director to identify (number and acuity levels), prioritize, 
and       evacuate  patients  in a systematic  and orderly  manner.  
 
d) Communicate  with the  infrastructure branch  director  to determine  the need  for and  orderly  
 
e) implementation of the operational reliability and/or shut down of utilities and structural 
support  systems.  
 
f) Coordinate  with the Infrastructure  Branch  Director  to determine  and supply  necessary  utilities  
and   medical  gases  to the sheltering  or evacuation  assembly points.  
 
g) Coordinate  with the Liaison  Officer  to determine  the number  and type of transportation  vehicles  
that       will be necessary  to evacuate  patients  to alternate  care sites.  
 
h) Work  with the Security  Branch  Director  to establish  access  and control  of key areas  of the 
facility  and campus  during  the evacuation.  
 
i) Interface  with the Business  Continuity  Branch  Director  to assure  that the security  and availability  of 
vital patient/resident  health  record,  and other  key information  is maintained.  
 
6.2.7  Planning  section  chief  
 DEAS 1118:2022  
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 Establish  and implement  processes  to track  the location  of patients/residents,  personnel  and resources  who have 
been  moved  from one location  to another  including evacuation  to alternate  sites of care.  
 
6.2.7  Logistics  section  chief  
 
a) Work  with the Operations  Section  Chief  to provide  the necessary  medical  equipment,  beds,  
medications, and supplies to safely relocate patients to alternate locations. Caches of 
equipment,  supplies, and medications pre ‐ positioned to manage an influx of casualties can be 
used if they are  not required  for their intended  purpose.  
 
b) Assure  an adequate  supply  of personnel  and other  human  resources  to safely  evacuate  
patients/residents  and visitors  to alternate  locations.  
 
c) Ensure that potable water and basic food supplies are brought to the sheltering area or 
assembly  points.  
 
d) Collaborate  with the Operations  and Planning  Section  Chiefs  to identify  and address  both 
internal  and external  transportation  needs.  
 
e) Establishing a family information centre to notify and respond to queries from family members 
of personnel  regarding  the status  and location  of personnel  who have  been  evacuated.  
 
7. Communication  
 
Internal  notification  and external  communications  should  be conducted  according  to the Emergency  Operations  
Plan.  Key communications  for facility  evacuations  include,  but are not limited to:  
 
7.1 Personnel  on duty  
 
Notification  of potentially  unsafe  situation(s)  at the facility.  If evacuation  activities  are possible,  an ‘evacuation 
standby’ notification should be made as soon as possible so that units may begin accessing  appropriate  supplies  
and collecting  belongings  and records.  
 
7.2 Personnel off  duty  
 
Notification of potentially unsafe situation(s) at the facility. Provide guidance on whether personnel should  report  
to duty as  usual  or not. 
 
7.3 Patient  families  
 
Notification  of patient/resident  families  of evacuation  destinations.  
 
7.4 Medical  providers  
 
Notification  of evacuation  destinations.  
 
7.5 Personnel  families  DEAS 1118:2022  
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Notification  of incident  status and  evacuation destinations.  
 
7.6 Public  safety  
 
Communication links to facilitate coordination with public safety agencies (security and traffic control), EMS  and 
other  transport  providers  (buses,  etc), and fire  agencies  (lifting  assistance).  
 
Public information    
Public information  reflecting  the capabilities  of the facility   
 
8. Sheltering  in place procedures  
 
When the threat does not permit safe relocation or evacuation, the following actions may be taken.  Patient  care 
and administrative departments  upon  receiving  directives from  the commander can initiate  these  actions.  
 
8.1 Weather  – wind,  hail, or other  weather  threat  
 
a) Remain calm.  
 
b) Move  patients/residents  and personnel  away  from windows as  possible.  
 
c) Close  drapes/blinds  and exterior  doors/windows.  
 
d) Ensure personnel  and visitors also  advised  of weather  situation.  
 
e) Update incident command on your operational status and impact on patients/ residents, 
personnel,  and visitors.  
 
f) Personnel  will remain  with patients/residents  
 
8.2 Security emergency – bomb threat, individual posing security threat, external civil  
unrest  
 
a) Remain calm.  
 
b) Refer to Active Shooter/Bomb  Threat policy.  
 
c) Implement  department ‐specific access  controls.  
 
d) Close  smoke  compartment doors,  patient/resident room  and office doors,  and perform  other 
take cover  measures  as needed.  
 
e) Ensure  personnel  and visitors are  aware of  the situation.  
 
f) Update incident command on your operational status and impact on patients/ residents, 
personnel,  and visitors.  DEAS 1118:2022  
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g) Personnel  will remain  with patients/residents.  
 
8.3 Hazardous  materials  (HAZMAT)  incident  
 
a) Remain calm.  
 
b) If there is an airborne hazardous materials plume, facilities will shut down air intake  into 
ventilation  system;  security will  implement  access  controls  as needed.  
 
c) Ensure  visitors  and personnel aware  of threat  location  and actions to  take.  
 
d) Update incident command on your operational status and impact on patients/ residents,  
 personnel,  and visitors.  
 
e) Personnel  will remain  with patients/residents.  
 
9. Evacuation  — General  guidelines  
 
9.1 Authority  and decision  making  
 
a) Incident commander or designee can authorise immediate patient/resident relocation actions in  
response  to an immediate  life safety  emergency.  
 
b) Initiation of a vertical or complete evacuation, with the exception of persons in immediate danger, will  
be coordinated  by the Incident  Commander/Command  post.  
 
9.2 Evacuation  priorities  
 
In an emergency:  
 
a) Persons in immediate  danger.  If persons  are not  in immediate  danger,  personnel  shall 
WAIT for  evacuation  orders.  
 
b)       Ambulatory  persons.  
 
c)       Non‐ambulatory  persons.  
 
d) Critical patients will be moved last when the maximum number of personnel and 
equipment is  available.  
 
e) Personnel  will remain  with patients/residents.  
 
f)          Evacuation  shall be completed in a calm  and orderly  fashion.  
 
 
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 9.3 Evacuation routes  
 
Evacuation  and specific  guidance  for travel  route  and in-house  transportation  shall be a systematic  coordinated 
effort in order to remove all patients/residents, visitors, and personnel from affected areas in a  safe and timely  
manner.  
 
a) Evacuation  shall be completed in a calm  and orderly  fashion.  
 
b) When  possible,  horizontal  evacuation  is preferred  over vertical  evacuation.  
 
c) Departments  should  have  pre‐identified  evacuation  routes.  
 
d) Incident  specific  evacuation  routes may  be necessary  and shall be communicated  by the 
command  center  quickly  to affected  areas.  
 
e) Only when absolutely necessary should evacuation result in patient/resident leaving the 
interior of  the facility.  
 
f)          Visitors,  personnel,  and ambulatory patients  should  walk to the designated  assembly point.  If 
vertical evacuation is necessary, stairs not elevators should be used for these individuals. 
Personnel  should be assigned at key points along the evacuation route to direct individuals to 
the assembly  points.  
 
g) Elevators  if operational  are reserved  for transporting  non-ambulatory  patients.  Engineering  / 
maintenance  personnel  should be  assigned to take  operational  control of  the elevators  using  
               the bypass  key to take elevators  directly  to / from the affected  areas.  Do not use elevators  in     
a fire    or earthquake.  
 
h) If elevators are non ‐operational, and vertical evacuation is required, non-ambulatory patients 
will be  carried down  staircase  using  assist  devices,  blanket carry,  or two‐man carry  techniques.  
 
i)           Human Chain can be used if you have large numbers of ambulatory patients.  Two personnel  
members are needed, one in the front  and one in the rear.  Have the first patient put his/her hand 
on the shoulder of  the first personnel member, and everyone else  do the same to the person in 
front.  The last  person  in the chain  should  be the second  personnel  member.  
 
9.4 Return  to facility  
 
Do not re‐enter  the facility  for any reason unless:  
 
a) Assisting  with evacuation of patients/residents,  visitors  or other  personnel/equipment;  
 
b) Authorized  by the Incident  Commander/Command  post;  
 
c) An order to repopulate  / reopen the facility  has been approved  by relevant  authority.  
 
10. Moving  to a safe refuge  — Horizontal  evacuation  DEAS 1118:2022  
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Refuge areas are used for internal evacuation or relocation.  They are internal locations that will receive and  hold 
patients/residents,  personnel and  visitors  for a period  of time until  they can return to  their original  location  or are 
evacuated.  
 
10.1 Procedures  
 
a) Remain  calm.  
 
b) Follow  instructions  of the area  supervisor.  
 
c) Identify  the next  functional  smoke compartment  (i.e., beyond  the next set  of double fire doors).  
 
d) Movement  shall be completed  in a calm and orderly  fashion.  
 
e) Assign personnel to clear obstructions from corridors and control fire/smoke doors and other 
exits as  required.  
f) Move patients/residents, personnel and visitors who are closest to the hazard to the next 
functional  smoke compartment or identified  refuge area.  If you are moving  patients  to 
another floor, follow  instructions  for vertical  evacuation.  
 
g) Ambulatory  patients should  be assisted to  the new location,  and non‐ambulatory  patients  
moved  on beds,  carts,  wheelchairs,  or via blanket  carry.  
 
h) If possible, take with you the necessary patient/resident care equipment and supplies 
from the  hazardous  area.  
 
i) Unless otherwise indicated, evacuation should proceed from patient/resident rooms farthest 
from the  evacuati on route  to closest.  
 
 
j) If time allows, as each room is cleared, lights should be turned off, non ‐essential 
electrical  equipment  should  be turned  off and unplugged.  
 
k) Each room  should  be marked as evacuated.  
 
NOTE  Each  healthcare  facility  should  pre‐determine  how this will be  designated.  
 
l)If an individual requires additional evacuation support than is immediately available, the door should  
be marked  so that returning  responders  know  which  room  to evacuate.  
 
NOTE  Each  healthcare  facility  should  pre‐determine  how this will be  designated.  
 
m) The area supervisor should identify a single individual to sweep the area for remaining 
persons,  ensuring to check  all patient rooms, offices, storage areas, restrooms, etc.  And 
marked  as clear  
 DEAS 1118:2022  
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 NOTE  Each  healthcare  facility  should  pre‐determine  how this will be  designated.  
 
n) Relocation does not involve formal gathering of medical records, unless this relocation is 
part of a  phased  evacuation,  then gather  patient  records.  
 
o) Continue  to care for  all patients/residents  during transport  and relocation.  
 
p) Account  for all patients/residents  and personnel.  Check  off the names of patients/residents  
as they  are evacuated,  and as they arrive  in the new location.  
 
q) Update the  Command Center  on your operational  status  and impact  on patients/ 
residents,  personnel, and visitors, and if any additional individuals need to be evacuated 
or if the area is all  clear.  Receive  and implement  instructions  from the Command  Center.  
 
r) Ensure  personnel and visitors are aware  of the situation.  
 
s) Personnel  will remain  with patients/residents.  
 
10.2 Horizontal  evacuation  — Personnel  responsibilities  
 
10.2.1  Affected  area personnel  
 
Assist with  patient  care and  evacuation  of current  patients/residents  from their area.  
 
 
10.2.2  Unaffected  clinical  area personnel  
 
Minimal  numbers  of clinicians  will remain  with current  patients/residents;  additional  personnel  will report  to unit 
being  evacuated  to assist  – utilize  internal  stairwells.  
 
10.2.3  Nonclinical  personnel  
 
10.2.3.1        All noncritical  functions  will cease and personnel will report to  unit being  evacuated to    assist,  
 
10.2.3.2  Utilize  internal  stairwells.  
 
11. Vertical  evacuation  procedures  
 
Unless  otherwise  indicated by  the Incident  Commander,  the following guideline  should  be used.  
 
11.1 Procedures  
 
a) Remain  calm.  
 
b) Follow  instructions of the area supervisor or fire  department.  
 
c) Identify  evacuation  route and  relocation area.  DEAS 1118:2022  
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d) Assign personnel to clear obstructions from corridors and control fire/smoke doors and other 
exits as  required.  
 
e) Evacuation  shall be completed in a calm  and orderly  fashion.  
 
f) Evacuate  patients/residents,  personnel  and visitors  from the hazard  
 
g) Visitors, personnel, and ambulatory patients should walk to the designated area.  Personnel 
should  be assigned  at key  points  along  the evacuation  route to  direct  individuals  to the area.  
 
h) Elevators if  operational  are reserved  for transporting  non‐ambulatory  patients.  
 
i) Do not use  elevators  in a fire or earthquake.  
 
ii)  If elevators are non -operational, and vertical evacuation is required, non -ambulatory patients   
will be carried  down staircase using specialized evacuation equipment (if available), blanket carry, 
or two‐man carry  techniques.  
 
i) Unless otherwise indicated, evacuation should proceed from patient/resident rooms farthest 
from the  evacuation route  to closest.  
 
j) If time allows, as each room is cleared, lights should be turned off, nonessential electrical 
equipment  should  be turned  off and unplugged.  
 
k)     Each room  should be marked  as evacuated  
 
 
l) If an individual requires additional evacuation support than is immediately available, the door should  
be marked  so that returning  responders  know  which  room  to evacuate.  
 
  NOTE  Each  healthcare  facility  should  pre‐determine  how this will be  designated.  
 
m) The area supervisor  should  identify  a single  individual to  sweep the  area for remaining  
persons,  ensuring to  check  all patient rooms,  offices, storage areas, restrooms,  etc. and 
marked  as clear  
 
  NOTE  Each  healthcare  facility  should  pre‐determine  how this will be designated.  
 
n) Continue  care for all  patients/residents during transport  and at  the assembly  point.  
 
o) Account  for all patients/residents  and personnel.  Check  off the names of patients/residents  as 
they are evacuated,  and as they arrive  in the new location.  
 
p) Keep  patient/resident  files and records  with the patient.  
 
q) Account  for all patients/residents  and personnel.  Check  off the names of patients/residents  as DEAS 1118:2022  
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 they are evacuated,  and as they arrive  in the new location.  
 
r)          Update  the Command post  on your operational  status  and impact on  patients/ residents,  
personnel,  and visitors, and if any additional individuals need to be evacuated or if the area is 
all clear.  Receive  and implement  instructions  from the Command  post.  
 
s)         Ensure  personnel  and visitors are aware  of the situation.  
 
t)         Personnel  will remain  with patients/residents.  
 
11.2 Vertical  Evacuation  — Personnel  responsibilities  
 
a) Affected  area personnel  – assist  with patient/resident  care and evacuation  of current  
patients/residents  from  their area 
 
b) Unaffected clinical area  personnel  – minimal numbers of clinicians will remain with 
current  patients/residents; additional personnel will report to unit being evacuated to assist – 
utilize internal  stairwells.  
 
c) Nonclinical personnel – all noncritical functions will cease and personnel will report to 
unit being  evacuated  to assist – utilize internal  stairwells.  
 
 
 
 
12. Complete  Evacuation  Procedures  
 
Unless  otherwise  indicated by  the Incident  Commander,  the following guideline  should  be used.  
 
12.1 Procedures  
 
a) Remain calm.  
 
b) Follow  instructions of the  area supervisor or fire  department.  
 
c) Identify  evacuation  route  and external assembly  point.  
 
 
d) Assign personnel to clear obstructions from corridors and control fire/smoke doors and other 
exits as  required.  
 
e) Evacuation  shall be completed in a calm  and orderly  fashion.  
 
f)        Each  patient  who is evacuated  should have  the following  accompany  them:  
 
i) Their  medical  record  – which  should  remain  in their possession  during  the entire  
evacuation    process.  DEAS 1118:2022  
© EAC 20 22 – All rights  reserved  18 
  
ii) Necessary  medications along  with their medication administration  record.  
 
iii) Their  identification  labels.  
 
iv) Personal  belongings  (if time permits).  
 
NOTE : Ideally , these items should be placed in a large plastic belongings bag and the bag 
marked     with the patient’s  name  and medical  record  number  with indelible  ink. 
 
g) Evacuate patients/residents,  personnel  and visitors  from the hazard  
 
h) Visitors, personnel, and ambulatory patients should walk to the designated area.  Personnel 
should  be assigned  at key  points  along  the evacuation  route to  direct  individuals  to the area.  
 
i)            Elevators if  operational  are reserved  for transporting  non‐ambulatory  patients.  
 
i) Do not use  elevators  in a fire or earthquake.  
 
ii) If elevators are  non-operational,  and vertical  evacuation  is required,  no ambulatory  
patients  will be carried down stairwells using specialized evacuation equipment (if 
available), blanket carry, or       two‐man carry  techniques.  
 
j) Unless  otherwise  indicated,  evacuation  should  proceed  from patient/resident  rooms  farthest  
from the evacuation  route  to closest.  
 
k) If time allows,  as each  room  is cleared,  lights  should  be turned  off, non‐essential  electrical  
equipment  should  be turned  off and unplugged.  
 
l) Each room  should be marked  as evacuated  
 
NOTE  Each  healthcare  facility  should  pre‐determine  how this will be designated.  
 
m) If an individual  requires  additional  evacuation  support  than is immediately  available,  the door 
should  be marked  so that returning  responders  know  which  room  to evacuate.  
 
  NOTE  Each  healthcare  facility  should  pre‐determine  how this will be  designated.  
 
n) The area supervisor  should  identify  a single  individual  to sweep  the area for remaining  
persons,  ensuring to  check  all patient  rooms, offices,  storage  areas,  restrooms, etc.  and marked 
as cleaning.  
 
 
o) Continue  care for all  patients/residents during transport  and at  the assembly  point.  
 
p) Account  for all patients/residents  and personnel.  Check  off the names of patients/residents  as 
they are evacuated,  and as they arrive  in the new location.  
 
q) Keep  patient/resident  files and records  with the  patient.  DEAS 1118:2022  
© EAC 20 22 – All rights  reserved  19 
  
r) Update  the Command  Center  on your operational  status  and impact  on patients/  residents,  
personnel, and visitors.  Receive and implement instructions from the Command post.  Notify the  
Command Center if there are additional individuals that need evacuating  or if the area is all clear,  
and if  you need  additional  staffing, supplies,  or other  resources to  manage  your 
patients/residents.  
 
s) Ensure  personnel  and visitors are  aware of  the situation.  
 
t) Personnel  will remain  with patients/residents.  
 
12.2 Guidelines  for evacuating  specific  patient  care areas  
 
12.2.1  Operating  room,  post  anaesthesia  care unit and haemodialysis  
 
The following personnel  are responsible  for ensuring  the safety  of the patients:  
 
a) Operating  Suite  — The surgeon  in charge  of each  case.  
 
b) ACU  — The covering anesthesiologist  is responsible  to coordinate  care with  the nursing  
personnel.  
 
c) Hemodialysis  — The Nurse  Manager or  designee  and physician  will direct  activities  of the  
personnel.  
 
d) Obtain  equipment  and services  required  for completion of the  procedure.  
 
e) Keep  list of anticipated  supplies and  prepare  to procure additional  supplies  as needed.  
 
f) Patients  on ventilators —when  central  O2 is turned  off, switch  ventilator  to room  air and/or  
obtain  portable O 2 tanks.  If no power  and/or  patients  shall be moved,  patients  shall be 
bagged.  
 
g) Patients  with IVs, arterial  lines and Swan‐Ganz  — Disconnect  transducer  from patient  
cable‐take pressure  bag with patient.  Saline  lock all non‐critical  IV lines.  
 
12.2.2  Intensive  Care  Units  (ICU)  
 
a) The Nurse Manager  or designee shall  evaluate  the ICU patients  with the house officer  to 
determine  possible  transfers  and/or  discharge.  
 
b) Transfer as  many  patients  as possible to medical  surgical or step down  units, if  safe to  do so. 
 
c) Use gurneys/wheeled  stretchers, beds and  evacuation  equipment  to move patients to  refuge 
areas.  
 
d) Collaborate with house officer and respiratory therapists to evaluate appropriate shutoff of 
oxygen,  ventilation  equipment  and other  gases  to preserve  resources.  DEAS 1118:2022  
© EAC 20 22 – All rights  reserved  20 
  
12.2.3  Labour  and delivery,  family  centred  care and  maternity  units  
 
The Nurse Manager  or designee shall  direct the  unit personnel to:  
 
a) Obtain wheelchairs, gurneys, incubators, instruments and supplies needed to complete 
Labor and  Delivery  procedures.  
 
b) Transport  infants  in their mother’s  arms,  if appropriate.  
 
c) Place  multiple  infants into  a single  crib, incubator or  evacuation vest for  transport  by a 
nurse, if  needed.  
 
d) Transport  labouring patients  via bed, gurney  or evacuation equipment, if  safe to  do so. 
 
12.2.4  Neonatal  intensive  care unit, pediatric  intensive  care unit and pediatrics  
 
The Nurse Manager  or designee shall  direct the  unit personnel to:  
 
a) Transport infants in cribs/incubators/specialized evacuation equipment with a nurse in 
attendance  during  the evacuation  
 
b) If necessary  multiple infants  may be placed  into a single  crib or incubator for  transport  by a nurse  
 
c) Older non -ambulatory paediatric patients may be transported by bed, gurney, wheelchair, 
carried or  rolled in a blanket (do not use sheets; they are not strong enough) and dragged to a 
safe location as  needed.  
 
d) Ambulatory paediatric patients may be evacuated together by forming a chain, holding 
hands, and  alternating  the older  and younger  children  in the  line as time and circumstances  
permit.  
 
12.3 Evacuation  of non‐patient  care areas  
 
Overall,  the evacuation of non ‐patient  care areas  will follow  the same  general  guidelines.  
 
a) Remain calm.  
 
a) Recognize local threat or receive evacuation instructions from the Command Center or 
authorized  personnel according  to facility  plan and move  personnel  to the pre‐identified  
assembly  point.  
 
b) Persons in  immediate danger should  evacuate  first. 
 
c) In areas  where  there are visitors,  escort  the visitors  to your department’s  assembly  point.  
 
d) Unless otherwise indicated, evacuation should proceed from offices farthest from the DEAS 1118:2022  
© EAC 20 22 – All rights  reserved  21 
 evacuation  route to  closest.  
 
e) If time allows, as each room is cleared, lights should be turned off, nonessential electrical 
equipment            should  be turned  off and unplugged.  
 
f) Each room  should be marked  as evacuated  
 
g) If an individual requires additional evacuation support than is immediately available, the 
door should  be marked  so that returning  responders  know  which  room  to evacuate.  
 
   NOTE  Each  healthcare  facility  should  pre-determined  how this will be  designated.  
 
h) The department head should identify a single individual to sweep the area for remaining 
persons,  ensuring  to check  all patient  rooms,  offices,  storage  areas,  restrooms,  etc. and 
marked as  clear.  
 
NOTE  Each  healthcare  facility  should  pre-determined  how this will be  designated.  
 
i) Personnel/visitors with disabilities may require assistance.  Each department head  shall 
identify  which of their personnel may have difficulty during an evacuation and pre-plan the 
best way to aid  their movement  to a safe location.  
 
j) Visitors should remain at the assembly point until the Command Center declares an “all 
clear” or  other  directions  are given.  
 
k) Account for personnel at assembly point (conduct roll call).  If you have time, conduct roll 
call prior to  evacuation,  and again  at the assembly  point.  
 
l) Initiate  continuity  of operations plan actions.  
 
m) Update the  Command Center  on your operational status  and impact on  personnel  and 
visitors.  Receive and implement instructions from the Command Center.  Notify the 
Command Center if there  are additional individuals that  need evacuating  or if the area is 
all clear, and if  you need additional  staffing,  supplies,  or other  resources.  Send  personnel  
to the  labor  pool is requested.  
 
n) Ensure  personnel  and visitors are  aware of  the situation.  
 
12.4 Complete  evacuation  — Personnel responsibilities  
 
Since all areas will be affected, all clinical personnel will assist with patient care and evacuation of current  
patients  from their units,  and perform  follow  up care at the assembly point.  
 
Nonclinical  personnel  – all functions  will cease,  and personnel  will evacuate  to their designated  assembly  point,  
and assign  personnel  to the labor  pool for further  instructions.  
 
12.5 Vertical/complete  evacuation  transport  devices  
 DEAS 1118:2022  
© EAC 20 22 – All rights  reserved  22 
 12.5.1  If there is a need to relocate patients horizontally, patients shall be moved using normal patient  
transportation  equipment  and routes  of travel.  
 
The following  resources  can be used in patient evacuation:  
 
a) Wheelchairs  can be used  to move  ambulatory,  minimally  ambulatory  patients  and non -ambulatory  
patients.  Mostly  used  to get to  the stairwell,  and if able to carry  the wheelchair down the stairwell, then  
it can be  used to  move  the patient/resident/personnel  to the assembly  point.  
 
b) Beds/wheeled stretchers: can be used to move non -ambulatory patients, but very difficult for 
vertical  movement.  
 
c) Improvised equipment is only to be used when normal transportation equipment is not available.  
Blanket  drags, multi -person carries, and  utilization of other equipment not ordinarily used for 
transportation may  be needed.  
 
12.5.2  Additional resources may be needed during evacuation flashlights, spotlights, electrical cords, 
water  stations, personal protective equipment, work gloves, portable vent ilators, and other non ‐patient 
related  equipment  may be needed.  
 
12.5.3  Specialized  evacuation  transport  devices  (chairs,  stair stretchers,  sleds,  infant  carry  slings,  
motorized gurneys, blankets) are located within the facility and are intended for use in vertical and 
complete  evacuations.  
 
13. Evacuation  assembly  points  
 
In the event of a complete or total evacuation, patients/residents, personnel and visitors will evacuate to  external  
assembly  points.  Each  department  is pre-identified to  evacuate to  a specific  assembly  point.  
 
13.1 Determining  assembly  points  
 
Assembly points are assigned based on the care provided in the department.  Departments with the most  acute  
patients  will assemble  together  near the emergency  department  where  additional  resources  and ground 
transportation will be the most available.  Departments without patients will evacuate to the remotest  locations.  
 
Non-department  based  assembly  points  are identified  for the Command  Center,  Labor  Pool,  Communications  
post,  and Personnel First  Aid. 
 
13.2 Assembly  point  key activities  
 
a) Roll call of all patients/residents,  personnel  and visitors  
 
b) Patient  assessment  and care 
 
13.3 Assembly  point  resource  needs  
 
Resources may be brought with personnel as they evacuate.  Other resource needs shall be filled by the  DEAS 1118:2022  
© EAC 20 22 – All rights  reserved  23 
 Command  Center  from external  disaster  caches:  
 
a) Food and  water;  
 
b) Communication  devices  for personnel  to keep  updated;  
 
c) Environmental  protection  (tents, umbrellas,  blankets, sheets,  etc.);  
 
d) Chairs,  flashlights/light  sticks,  basic first  aid kits; 
 
e) Medical  supplies  ‐ depending  on the care provided.  
 
 
14. Patient/resident  transfer  to alternate  facilities  
 
14.1 Internal  coordination  
 
Internal  organization  of patients/residents  should  be implemented  concurrently  with the External  Coordination  
procedures.  
 
14.1.1  Organizing  patients/residents  
 
14.1.1.1  Categorize  and physically  organize  patients/residents  as follows:  
 
a) Those who have  their own transportation  and are being  discharged to home;  
 
b) Those who need  to be evacuated  to an alternate  acute care  facility;  
 
c) Those  who need  to be evacuated  to a skilled  nursing facility;  
 
d) Those  who are  being  discharged  home  but require  transportation;  
 
14.1.1.2  Once  the patient’s/resident’s  evacuation  status  has been  determined,  it should  be noted  on 
a sign, sticker, or other mechanism and placed prominently  on the patient/resident.  This tag should remain  on 
the patient/resident  at all times  until the evacuation  destination  is reached.  
 
14.1.2  Patient/resident  information  
 
As each patient/resident is placed in their appropriate category, their medical record (which should have  
accompanied them) should be reviewed to collect information necessary to track and discharge / transfer the  
patient/resident.  
 
14.1.3  Patient/resident  tracking  
 
a) Patient  tracking  information  is to be maintained  in the area with copies  forwarded  to the 
Command  Centre  and kept with the Patient  Tracking  Manager.  
 DEAS 1118:2022  
© EAC 20 22 – All rights  reserved  24 
 b) Standard inter -facility transfer forms are to be completed on each patient/resident sent to an alternate  
care site, along with a copy of the medication administration record, and other pertinent medical record  
information.  
 
c) Patients/residents  discharged  to home  should  be provided with  standard  discharge  instructions.  
 
d) If home  health  follow -up is necessary, send  pertinent  medical  information  home with the patient  as well. 
 
e) Patient Tracking Manager  and/or deputies  will contact alternate care sites to ensure patient arrival 
until all patients  have  been  verified.  
 
14.1.4  Personnel  tracking  
 
a) Establish processes to coordinate personnel who may accompany patients/residents being 
transferred to  alternate care  sites.  
 
b) If personnel are to remain at these sites, then implement the mutual aid agreements established 
with these  facilities.  
c) A record should be maintained  of the name,  title, and the  facility  that they  were  assigned  to. 
 
14.2 External  Coordination  
 
a) If patients need to be transferred to another facility for ongoing medical care, identify available beds  
by the following  procedures:  
 
b) Coordinate  with other facilities in  the same healthcare  system.  
 
c) Hospitals: If the above resources are unavailable or inadequate, request assistance from the Local 
EMS        Agency.  Provide  the number of  patients  by type of  bed (critical care,  medical/surgical, 
pediatrics, etc)  that require  evacuation.  
 
d) Skilled Nursing Facilities: If the above resources are unavailable or  inadequate, request assistance 
from accredited  facilities.  
 
e) Obtain  transportation  resources  by contacting  your contracted  ambulance  providers.  
 
f) Transferred  patients  should  have  medical  records  and medications sent  with them:  
 
i) At a minimum,  use a  triage  tag or Patient  Evacuation  Tracking  form to be  included.  
 
ii) Maintain a log  of transferred  patients.  Can use a combination of  Patient  Evacuation  Tracking  
form in Annex  E and  Master  Patient  Evacuation  Tracking Form  in Annex  F. 
 
14.3 Transportation  resource needs  matrix  
 
Estimate  the type and  quantity  of transportation  resources needed  using  the tool  in Annex  D. Use this  information  
when  requesting  assistance  through  your usual  transportation provider:  DEAS 1118:2022  
© EAC 20 22 – All rights  reserved  25 
  
a) Access needed transportation through the hospital based  Incident Command process, 
recognizing  that this  will most  likely  be organized  regionally  using  available  local and regional  
assets,  
 
b) Be aware  of any Memorandums  of Understanding (MOU)  for transportation,  
 
c) Be aware of the hospital based  transportation resource inventory (vehicles, vans, receiving 
dock  vehicles,  ambulances  etc.),  
 
d) Use relay  system  (stationing  staff at intervals  along the evacuation  route)  if regular  transport  
beds  are used,  
 
e) Take  chart  records  and maintain  with patients  or the local  EMS Agency.  
 
14.4 Evacuation  triaging  and transportation  tag 
 
14.4.1  An evacuation transportation  tag system  shall be  used to  track  patients  who are  evacuated  from the 
facility.  
 
a) Clinical personnel are responsible for patient assessment/triage which will dictate 
mode of  transportation  based  on acuity  and care needs.  
 
b) The assessment/triage  process  and transportation  tag will be completed  prior to 
movement of  patients  from the facility.  
 
c) The tags should be updated and reviewed during triage and transportation to the assembly 
points  and/or  other  healthcare  facilities.  
 
14.4.2  Patient tracking  manager  will be responsible  for: 
 
a) Maintaining a supply  of the evacuation  tags at  each patient  care unit. 
 
b) Coordinating  the distribution  of evacuation tags  during  the incident.  
 
c) Tracking  patients who  are evacuated  from the facility.  
 
15. Closure  of a portion  or all of  the facility  following evacuation  
 
15.1 Introduction  
 
15.1.1  The decision  to close all  or a portion  of the facility  is made  by the Incident  Commander. Closure  of 
the facility  (all or in part) is indicated  if: 
 
15.1.1.1  The facility  ceases the operational  capability  to provide  safe and  adequate care.  
 
15.1.1.2  The environment of  care is  no longer capable of  supporting  safe and  adequate care.  DEAS 1118:2022  
© EAC 20 22 – All rights  reserved  26 
  
15.1.1.3  Closure  has been  directed  by an external agency  having legal  authority  to do so. 
 
15.1.2  Facility operations during an evacuation will be under the direction of the Infrastructure Branch  
Director.  This position will coordinate all facility control operations as needed during an evacuation.  The first  
step in this process is to have the current status of all facility systems evaluated and documented.  From this  
status  report,  the Infrastructure  Branch  Director  may call for additional  support  (e.g.,  local utilities  
companies/vendors).  
 
  NOTE  Each  healthcare  facility  should  pre-determined  how this will be  designated  
 
15.2 General  guidelines  
 
a) Whenever possible, operationally capable areas should continue to provide care, 
treatment, and  service  as long as possible.  
 
b) Affected  / hazardous  areas  should  be closed  first. Once  cleared,  these  areas  should  be locked  
and utilities  to the area shut down.  
 
c) Nonessential  areas  should  be closed  next.  Once  cleared,  these  areas  should  be locked  and 
utilities  to the  area shut down.  
 
d) Patient care areas should be closed based on operational and environmental conditions.  
Closure  should proceed from the most at risk to the least at risk areas.  Once cleared, these 
areas should be  locked and  utilities  to the area shut  down.  
 
e) If time and circumstance permit, patient care areas should b e scavenged for available supplies,  
equipment, medication, beds, transport devices, etc.  These material resources should be 
brought to  appropriate  assembly  points  or as otherwise  directed  by the Command  Center.  
 
f) Information Services should conduct a full backup of all information systems prior to shutting 
down  mainframe computers and network systems.  Individual proprietary systems should be 
backed up to  external  hard drives  for removal  from the facility.  
 
g) If time and circumstances permit, medical records should be boxed and removed and 
transported to  an offsite storage location.  Records should be removed if possible,  from most 
recent admissions  going backward.  
 
h) If time and circumstances permit, personnel records should be boxed and removed from 
human  resou rces and transported  to an off‐site storage  location.  
 
i) Unless safety issues are present, utilities should be maintained until the affected areas are 
fully cleared  and ready  for closure.  At that point,  Engineering  should  implement  standard  
and/or  emergency shutdown procedures as warranted.  Once utilities are shut down, they 
should be locked  out / tagged  out and the area secured  as able.  
 
j) Controlled substances are secured at all times except during administration.  If the facility were DEAS 1118:2022  
© EAC 20 22 – All rights  reserved  27 
 to close, these  items  would be secured  by default.  
 
k) If medications are to be moved or evacuated with patients, they shall be secured with licensed  
personnel.  
 
l) Process to  secure  diagnostic  radiology  areas /  medications  / isotopes  in accordance  with state  
law. 
 
15.3 Securing  the facility  
 
Usual procedures to secure  the facility  will be implemented.  Focus areas  include:  
 
a) Maintaining  general  security,  especially  during  prolong  incidents  or when  resources  are scarce;  
 
b) Establishing a perimeter around the facility, especially patient care areas OR 
establishing a  perimeter  around  affected high  risk area areas  within  the facility;  
 
c) Controlling access  and movement  in and  between  facilities;  
 
d) Maintaining traffic  control  on campus;  
 
e) Ensuring  only authorized  persons  re‐enter the facility  after evacuation;  
 
f) Coordination  with local public  safety,  as needed.  
 
15.4 Stay  team  
 
If the facility  has been  evacuated,  but personnel  need  to remain  to stabilize  the incident  and restore  functionality,  
designate  a Stay Team.  This may include  members  of the Incident  Management  Team  including the Safety 
Officer, emergency management personnel, facilities/engineering, risk management,  human resources,  etc. 
 
16. Recovery:  Restoring the  facility  after  evacuation  
 
16.1 Introduction  
 
 
Ensure that restoration  and reimbursement issues  and planning  for facility  start up  are addressed  through  the 
facility  continuity  of operations  plan or  business  continuity plan.  
 
    NOTE  Each  healthcare  facility  should  pre-determined  how this will be  designated  
 
16.2 General  Guidelines  
 
a) Facilities are determined to be structurally sound and safe, and systems are not compromised, 
for occupancy. If not safe, may require repairs/retrofits/replacements that need to be approved by 
relevant  authorities/authority  having  jurisdiction.  
 DEAS 1118:2022  
© EAC 20 22 – All rights  reserved  28 
 b) Prioritize  which  departments  and personnel  to repatriate.  
 
c) Restoration and testing of infrastructure – water, electricity, Heating Ventilation and Air 
Conditioning  system,  medical  gases.  
 
d) All items  within the facility that  can be affected by spoilage  due to loss of power  and/or  high 
temperatures are tested and repaired/replaced/quarantined, as needed (e.g., food,  medications,  
radioactive  supplies  and equipment,  computerized  diagnostics,  etc.).  
 
e) Procedures  to assess  the need for and  implementing  cleaning and  decontamination.  
 
f)          Certification by  local authorities.  
 
g) Essential  functions  and supplies/supply  chains  (pharmacy,  supplies,  laundry,  etc.) are re- 
established.  
 
h)  Notification  of reopening  to other  hospitals/healthcare  facilities,  EMS  Agency,  patient  families,  media.  
 
i) Procedures  for repatriation  of patients  including:  
 
i) Approval  from relevant authority.  
 
ii)   Patient  transportation  coordination  with sending  hospital/healthcare facility.  
 
iii) Medical  records management . 
 
iv) Transportation  coordination . 
 
v) Patient  care assignments.  
 
vi) Room  assignments.  
 
vii) Patient  re‐registration.  
 
j) For additional  resources, see:  
 
i) Incident  Management  Team  Recovery  Responsibilities  ‐ Annex  F. 
 
ii) Hierarchy  of Repopulation Approval(s)  ‐ Annex  G. 
 
 
iii) General All ‐Hazards Hospital  Repopulation  Factors / Steps  ‐ Annex  H. 
 
17. Training  
 
17.1 General  
 DEAS 1118:2022  
© EAC 20 22 – All rights  reserved  29 
 Determine  the extent  of hospital  based employee training  when  designing training.  If the hospital does  not include 
training  in the following  topics,  then add: 
 
a) Importance  of wearing  hospital identification during an emergency.  
 
b) Importance of assuring that non -clinical staff and non -clinical volunteers are wearing proper  
identification;  and clinical staff  is credentialed  through  a hospital process  
 
c) ‘All Hazards Planning’ to include Incident Command/HICS, hierarchy of roles and chain of  
command  topics.  
 
d) Training staff on Hazard Vulnerability Analysis ( HVA)   
 
e) HICS  training for managers  and needs awareness  training for  staff to include where and  when to  
report  to hospital  if off site when  emergency  occurs.  
 
f) Training/education regarding designated parking locations, hospital entrances, labor pool site and  
check -in process  during  disasters.  
 
g) Enhancement of  call tree to  sort by staff address  and proximity  to hospital  (see Annex  J). 
 
h) Plan to include staff participation in hospital drills so that facility evacuation specific challenges are  
included.  
 
i) A discussion  of the possibility of  two types  of evacuations —an initial  evacuation  to a safe place,  
within the  hospital  or at a local hospital  then a secondary  transfer  to care  at an appropriate  facility:  
 
j) Alternate communication modes available to staff (radios, walkie -talkies, satellite phones, in  
house  wireless communication devices, cell  phones [hospital  or personal], voice over  internet  
etc.).  
 
i) Provide regular training on all modes of communication (i.e., know how to use radios,  
walkie -talkies,  in house  wireless  devices  etc.).  
 
ii) Train staff  to use the  appropriate  radio frequencies designated  for hospital  disaster use.  
 
iii) Know hospital dead zones for  cell phones, radios, and walkie -talkies, in house 
wireless  devices.  
 
iv) Use clear  language  – avoid  code  and industry  specific  nomenclature.  
 
k)Recommendation  that staff plan for at least  four days (96 hours)  of personal  supplies  
(clothing/toiletries/and  medications  if applicable).  
 
17.2 Facility  evacuation  training  
Include  the following  in facility  evacuation  training:  DEAS 1118:2022  
© EAC 20 22 – All rights  reserved  30 
 a) Options and methods to identify unit-based  leaders during an evacuation or incident to include 
use of  hats,  large  ID tags,  vests/  shirts/sashes —whichever  method  is chosen  should  be 
consistent  throughout hospital and be utilized for every drill. This is especially important when 
non-clinical staff  or volunteers are included in an evacuation and who do not know the leaders 
by name or b y reputation].  
 
b) Evacuation routes from unit to safe Area and outside hospital (destination to be determined 
when  scope  of the evacuation  is identified).  
 
c) Review  of evacuation  bag contents and storage locations.  
 
d) Review  method of  designating when  a patient  care room  is empty/cleared.  
 
    NOTE  Each  healthcare  facility  should  pre-determined  how this will be  
designated.  
 
e)  Use of unit Team Leader Job Action sheets, Patient Evacuation Tracking Form in Annex E and  
Incident Message Form in Annex K.  Include in evacuation bags and in departmental disaster plans  
or charge  nurse  resource  binder  pick the forms  and delete the  website.  
 
f) Method  to document  patient  tracking  and family  notification/family  reunification  based  on hospital  
emergency  management  plan.  
 
g) Method  used to  categorize  patients  for evacuation based  on hospital  emergency  management  plan.  
 
h) A communication  directory  to the command  center  and other  important  contact  phone/pager  
numbers  to be maintained  in departmental disaster  plan.  
 
i) Knowledge  of hospital  specific  communication/pager  dead  zones  and planning  for alternate  forms  
of written  or verbal  communication  via runners.  
 
j) Reporting  of pertinent drill  findings and  available  after-action reports.  
 
k) Adding  a coaching component  to hospital  drills.  
 
18. Family  notification  
 
a) Notify  family  as soon  as possible  
 
b) Assign family liaison position to keep families appraised of patient transfer status and location.  Note:  
it is important  to coordinate  this information  with the Public  Information Officer  (PIO).  
 
c) If applicable or  necessary,  have ready  access  to all pertinent transfer consent  forms  
 
19. Supplies  
 
a) Identify  patients  in multiple  ways  as follows:  
 
i) Consider both  standard  ID bands/ID  stickers  on attached  medical  equipment, as  well as 
direct patient marking.  Utilize a surgical marking pen or waterproof marker to write on a DEAS 1118:2022  
© EAC 20 22 – All rights  reserved  31 
 transparent  dressing that  is then applied  to the skin of the patient.  
ii) The preferred  location for this  transparent  dressing  is the abdomen,  with other skin  sites 
considered when the abdomen is not intact and there is an alternative site on the patient’s 
body that  can accommodate  the dressing.  
 
b) The transparent dressing (as described above) that is placed directly on the patient should 
ideally  contain the same information  as the  ID band/ID  sticker: the name of  the patient  
(Mother’s  name in  neonates),  the date of birth and hospital  identification  number.  
 
c) Determine whether evacuation boxes or bags/backpacks are the most appropriate transport 
method  based  on unit storage  capability  and previous  hospital  planning.  
 
d) Place content stickers in and on evacuation boxes/bags and in policy and secure with 
breakaway  lock or closures.  
 
e) Assure  that all  bags can accommodate  even  very low birth  weight  infants  (under  1000  g). 
 
f)          Have one supply  bag/box  per patient  per room  (supply  amount  should be enough for a 
minimum  of 4-6 hours).  
 
g) Move  all available  supplies  and medications  with the patient;  be cognizant  that the 
receiving  hospital/staging area  may not have  the needed  supplies or medications 
immediately  available.  
 
h) Plan for unit based  evacuation  bags  with supplies for  all patients.  
 
i)         Store  supplies  in a low  position  for easy  access and in  a safe room  to avoid contamination.  
 
j)          Consider how to  transport  dietary  needs for  patients.  
 
k) Take  existing  and available medications  along  with Med Boxes if available  
 
i)          Bring  Hats/Blankets/Thermoregulatory  Methods.  
 
20. Equipment  
 
a) Recognize that there are multiple types of evacuation equipment made specifically for different  
patients.  
 
b) Purchase and drill with evacuation supplies and equipment so that staff become familiar with their  
use. 
 
c) Utilize Patient Evacuation Tracking Form in Annex E to document all equipment transported with  
the neonate.  
 
d) Know battery  life/promote  extension  of battery  life by  plugging  in electrical equipment.  
 DEAS 1118:2022  
© EAC 20 22 – All rights  reserved  32 
 e) Charge  all equipment  in emergency  outlets if  power  is available while  preparing  for evacuation.  
 
f) Consider bed batteries  as back  up. 
 
g) Consider  purchase of  back  up batteries  for equipment and a method  to assure charging capabilities  
and testing based on recommendations  of manufacturer  or hospital based Biomedical/Clinical  
Engineering.  
 
h) Syringe  pumps.  
 
i) Drug  box/transport  bag/organized supply  kit. 
 
j) Airway  bag and supplies.  
 
k)Oxygen source and supplies.  
 
l) Portable suction  equipment.  
 
m) Consider taking  a crash cart  if going  to a non-clinical  safe Area  on a horizontal  move.  
 
n) Consider additional  hospital locations  of units crash  carts  that could  easily  be moved to  the 
designated safe area (i.e., additional unit crash cart maintained in an outpatient setting or emergency  
department).  
 
21. Operational  structure/standard  operating  procedures  
 
Consider surge capacity  of a facility  as well as surge capability  of the receiving facility based  on number and  
acuity  of patients  and transport  route,  including how  many patients  can be  transported  in one trip.  
 
22. Receiving  Hospital  
 
a) Receive patient into  facility. Transfer of plan  of care  via communication hand -off. 
 
b) Assign a family liaison position to notify next of kin as soon as possible regarding 
condition of the  patient  and arrival  at their facility.  Instruct family  on communication  and 
visitation  process.  
 
    NOTE  it is important  to coordinate  this information  with the Public  Information  Officer  (PIO).  
 
 
 
 
 
 
 
 DEAS 1118:2022  
© EAC 20 22 – All rights  reserved  33 
  
 
Annex  A 
 
(normative)  
 
Decision  Tree  
When  the decision is  made  to activate, the magnitude  of the emergency  response  shall be  determined.  The 
Incident  Commander  will utilize  the Decision  Tree to determine  what type and  level of response is needed.  
 
 
 
 DEAS 1118:2022  
© EAC 20 22 – All rights  reserved  34 
  
 
 
 
 
 
 
 
 
 
 
 
DEAS 1118:2022  
© EAC 20 22 – All rights  reserved  35 
                      Annex  B 
 
(normative)  
 
Decision  Matrix  
When the decision is made to activate, the magnitude of the emergency response shall be determined. The  
DEAS 1118:2022  
© EAC 20 22 – All rights  reserved  36 
 Incident Commander will utilize the Decision Matrix to determine what type and level or response is needed.  
(Planning  note:  This chart  can be  personalized  to your facility  by adding meaningful  triggers.)  DEAS 1118:2022  
© EAC 20 22 – All rights  reserved  37 
  
 
Annex  C 
(normative)  
 
Incident  assessment  worksheet  
 
Use this worksheet  to assess the impact  that the incident  will have on  the facility.  Sources  of this information  may 
come  from affected  departments,  liaison  officers,  other  community  responsible  partners  ,etc. DEAS 1118:2022  
© EAC 20 22 – All rights  reserved  38 
  
 
  
 
  
 
32 33  
                        Annex  D 
                         
                         (normative)  
 
                                   Transportation  resource  needs  matrix  
 
Use this tool to determine transportation needs when requesting assistance through your usual  transportation 
providers  
 
33  
  
 
Annex  E 
 
(normative)  
 
Patient  evacuation  tracking  form  
 
Completed  by the nurse providing care. The  patient  tracking  manager should  maintain a  transfer summary  
form,  or this form to track  all patients  that are  transferred to  an alternate  care site or discharged.  
 
© EAC 20 22 – All rights  reserved  
  
 Annex F  
 
(normative)  
 
Master patient evacuation tracking form  
 
 
 
 
33  
 Annex  G  
(normative)  
 
Incident  management  team  recovery  responsibilities  
G.1 Command  
 
G.1.1  Incident  Commander  
 
G.1.1.1  Assess if  criteria for  partial or complete  reopening of  the facility  is met, and order  reopening  and 
repatriation of  patients  
 
G.1.1.2  Oversee  restoration  of normal  hospital  operations.  
 
G.1.2  PIO 
 
Conduct final media briefing providing situation status, appropriate patient information and termination of the  
incident.  
 
G.1.3  Liaison  Officer  
 
Notify local emergency management, fire, EMS and Licensing and Certification of termination of the incident  
and reopening  of the facility.  
 
G.1.4  Safety  Officer  
 
Oversee  the safe return to  normal  operations  and repatriation  of patients.  
 
G.2 Operations  
 
G.2.1  Restore  patient care  and management activities.  
G.3  
 
G.3.1  Repatriate  evacuated patients.  
 
G.3.2  Re‐establish  visitation  and non‐essential  services.  
 
G.4 Planning  
 
G.4.1  Finalize  the Incident  Action Plan  and demobilization  plan.  
 
G.4.2  Compile a final  report  of the incident and hospital response  and recovery  operations.  
 
G.4.3  Ensure appropriate  archiving  of incident documentation.  
 
G.4.4  Write  after‐action  report and  corrective  action plan  to include  the following:  
 
G.4.4.1  Summary  of actions  taken.  
 
G.4.4.2  Summary  of the incident.  
G.4.4.3  Actions  that went well. 
 
G.3.4.5  Area  for improvement.  
 
G.3.4.6  Recommendations for future response  actions.  
 33  
  
G.4 Logistics  
 
G.4.1  Implement  and confirm  facility  cleaning  and restoration, including:  
 
G.4.2  Structure.  
 
G.4.3  Medical  equipment  certification.  
 
G.4.4  Provide  debriefing and  mental health  support  services for  personnel and  patients.  
 
G.4.5  Inventory  supplies, equipment, food,  and water,  and return  to normal  levels.  
 
G.5 finance/administration  
 
G.5.1  Compile final  response and  recovery  cost and  expenditure  and estimated  lost revenues  summary  
and submit  to the Incident  Commander  for approval.  
 
G.5.2  Contact  insurance carriers to assist  in documentation of  structural  and infrastructure  damage and  
initiate.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 33  
 Annex  H 
 
(normative)  
 
Hierarchy  of Repopulation  Approval(s)  
 
Dependent upon circumstances, the following sequential steps should be expected prior to the repopulation  
of evacuated  hospital  facilities.  
 
 
 
 
 
 
 
 
 
33  
 Annex  J 
 
(normative)  
 
General  all‐hazards  hospital  re‐population  factors  / steps  
 
The following  factors  / steps should  be considered  as appropriate to the type of  evacuation  
 
 
 
 
 
 
 
33  
  
 
 
Annex K  
 
(normative)  
 
SAMPLE ICU EVACUATION CALL TREE  
 
{INSERT HOSPITAL NAME OR LOGO}  
 
 
 
 
 
 
 
 
41 33  
 Sample ICU evacuation call tree  
 
{INSERT HOSPITAL NAME OR LOGO} (CONT.)  
 
  
 
 
 
 
 
 
 
33  
 Annex L  
 
(normative)  
 
Incident message form