Hospital Preparedness Questionnaire Quarter 2 (Nov, Dec, Jan 2010) DUE FEBRUARY 15TH 2010

1. Default Section

These next few questions are to ensure that every hospital in the Trauma Service Area - L region has met the FY10 Hospital Preparedness Program requirements. Since all hospitals have verified they have met all 14 NIMS Elements and are NIMS compliant, those questions have been removed from this survey. By completing this survey, you are acknowledging your hospital is NIMS compliant. Please fill out the questions below so that the CTRAC will know the level of preparedness at your hospital and to ensure we meet the needs of your hospital. Thank you for your coordination and support.

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1. Contact Information

Contact Information Name of Person Completing Report:
Hospital Name:
Address:
City/Town:
State:
ZIP/Postal Code:
Email Address:
Phone Number:

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2. Interoperable Communications:

Can your hospital communicate between other hospitals, local first responders, and/or the City/County EOC utilizing EMResource (EMSystem) and/or WebEOC?

Interoperable Communications: Can your hospital communicate between other hospitals, local first responders, and/or the City/County EOC utilizing EMResource (EMSystem) and/or WebEOC? Yes

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3. Interoperable Communications:

Can your hospital demonstrate sustained two-way communications capability with the local City/County EOC and the other hospitals in the region during an exercise or incident?

Interoperable Communications: Can your hospital demonstrate sustained two-way communications capability with the local City/County EOC and the other hospitals in the region during an exercise or incident? Yes

4. Does your hospital have access to the Regional online Inventory System (EM Asset Tracker)?

Does your hospital have access to the Regional online Inventory System (EM Asset Tracker)? Yes

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5. Hospital Mass Fatality Plan:

Definition-The Medical Surge Capacity and Capability (MSCC) Handbook Tier 1 (hospital) plans should include, at a minimum, current information on (a) trained and available personnel, (b) equipment, supplies, facilities and other material resources, including but not limited to temporary refrigerated storage of human remains, and (c) the operational structure and standard operating procedures for disposition of the deceased.

Please select the type of Hospital Mass Fatality Plan currently in place at your facility:

Hospital Mass Fatality Plan: Definition-The Medical Surge Capacity and Capability (MSCC) Handbook Tier 1 (hospital) plans should include, at a minimum, current information on (a) trained and available personnel, (b) equipment, supplies, facilities and other material resources, including but not limited to temporary refrigerated storage of human remains, and (c) the operational structure and standard operating procedures for disposition of the deceased. Please select the type of Hospital Mass Fatality Plan currently in place at your facility: A Completed Draft plan for mass fatality (Plan that has not been submitted for senior management approval)

A Finalized Written plan for mass fatality (Plan that has received senior management approval)

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6. Hospital Mass Fatality Plan:

Number of Dead bodies your hospital could handle in cold storage capacity (above average daily census):

Hospital Mass Fatality Plan: Number of Dead bodies your hospital could handle in cold storage capacity (above average daily census): None

Quantity

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7. Hospital Mass Fatality Plan:

Number of Dead bodies your hospital could handle in regular storage capacity (above average daily census-NOT COLD STORAGE):

Hospital Mass Fatality Plan: Number of Dead bodies your hospital could handle in regular storage capacity (above average daily census-NOT COLD STORAGE): None

Quantity

8. Describe the progress toward increasing resource capacity for the temporary disposition of the deceased at the MSCC Tier 1, 2, or 3 (hospital, community, and jurisdictional) level.

Describe the progress toward increasing resource capacity for the temporary disposition of the deceased at the MSCC Tier 1, 2, or 3 (hospital, community, and jurisdictional) level.

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9. Hospital Evacuation Plan:

Definition-Tier 1 (hospital) plans should include, at a minimum current information on (a) personnel training in evacuation procedures; (b) tranpsortation means, equipment, supplies, and alternative facilities, and (c) the operational structure and standard operating procedures for moving patients as appropriate.

Please select the type of Hospital Evacuation Plan currently in place at your facility:

Hospital Evacuation Plan: Definition-Tier 1 (hospital) plans should include, at a minimum current information on (a) personnel training in evacuation procedures; (b) tranpsortation means, equipment, supplies, and alternative facilities, and (c) the operational structure and standard operating procedures for moving patients as appropriate. Please select the type of Hospital Evacuation Plan currently in place at your facility: A Completed Draft Evacuation Plan (Plan that has not been submitted for senior management approval)

A Finalized Written Evacuation Plan (Plan that has recieved senior management approval)

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10. Shelter-In-Place Plan:

Does your hospital have a completed Shelter-In-Place plan?

Shelter-In-Place Plan: Does your hospital have a completed Shelter-In-Place plan? Yes

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11. Partnerships/Coalitions:

Does your hospital have a designated representative that attends the CTRAC monthly Emergency Preparedness & Response committee meetings?

Partnerships/Coalitions: Does your hospital have a designated representative that attends the CTRAC monthly Emergency Preparedness & Response committee meetings? No

Yes (enter name of representative)

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12. Partnerships/Coalitions:

Has your hospital signed onto the Regional Medical Operations Center (RMOC) compact? (This agreement facilitates sharing of assets, personnel, and information during disasters).

Partnerships/Coalitions: Has your hospital signed onto the Regional Medical Operations Center (RMOC) compact? (This agreement facilitates sharing of assets, personnel, and information during disasters). Yes

No (comment if needed)

13. Alternate Care Sites:

How many Alternate Care Site locations that are considered FIXED sites do you currently have listed in your hospital emergency plan? (Example: Hotels, Churches, Schools, Stadiums, Clinics, etc.)

Alternate Care Sites: How many Alternate Care Site locations that are considered FIXED sites do you currently have listed in your hospital emergency plan? (Example: Hotels, Churches, Schools, Stadiums, Clinics, etc.) Please enter number of FIXED sites:

14. Alternate Care Sites:

How many Alternate Care Site locations that are considered MOBILE sites do you currently have listed in your hospital emergency plan? (Example: Trailers, Tents, Etc.)

Alternate Care Sites: How many Alternate Care Site locations that are considered MOBILE sites do you currently have listed in your hospital emergency plan? (Example: Trailers, Tents, Etc.) Please enter number of MOBILE sites:

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15. Alternate Care Sites:

List the name and location (name of building and city) of each Alternate Care Site identified for your facility. Include Fixed and Mobile Alternate Care Sites.

Alternate Care Sites: List the name and location (name of building and city) of each Alternate Care Site identified for your facility. Include Fixed and Mobile Alternate Care Sites. 1.
2.
3.
4.
5.
6.
7.

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16. Alternate Care Sites:

How many Alternate Care Site beds would be available at your Alternate Care Site locations? Enter number of Alternate Care Site beds for each location: (Correlate these numbers to the list given in the previous question-Question 15)

Alternate Care Sites: How many Alternate Care Site beds would be available at your Alternate Care Site locations? Enter number of Alternate Care Site beds for each location: (Correlate these numbers to the list given in the previous question-Question 15) 1.
2.
3.
4.
5.
6.
7.

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17. Alternate Care Sites:

Does your hospital have any agreements with local agencies to use a Building of Opportunity? (a building with enough space that could be turned into an Alternate Care Site)

Alternate Care Sites: Does your hospital have any agreements with local agencies to use a Building of Opportunity? (a building with enough space that could be turned into an Alternate Care Site) Yes

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18. Alternate Care Sites:

Describe the level of care to be provided or type of patients that can be cared for at your Alternate Care Site

Alternate Care Sites: Describe the level of care to be provided or type of patients that can be cared for at your Alternate Care Site

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19. Alternate Care Sites:

Provide a summary of plans for staffing, supply and re-supply of resources for the Alternate Care Site

Alternate Care Sites: Provide a summary of plans for staffing, supply and re-supply of resources for the Alternate Care Site

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20. Alternate Care Sites:

Has your hospital identified the following internal assets to support the alternate care site(s) identified above?:

Alternate Care Sites: Has your hospital identified the following internal assets to support the alternate care site(s) identified above?: Staffing

Supplies

None of the above

Other (please specify)

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21. Pharmaceutical Cache:

Does your hospital have local or regional access to readily-available pharmaceutical caches of ANTIBIOTICS sufficient to cover hospital personnel, hospital-based emergency first responders and their family members for a 72-hour period?

Pharmaceutical Cache: Does your hospital have local or regional access to readily-available pharmaceutical caches of ANTIBIOTICS sufficient to cover hospital personnel, hospital-based emergency first responders and their family members for a 72-hour period? Yes

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22. Pharmaceutical Cache:

Does your hospital have local or regional access to readily-available pharmaceutical caches of ANTIVIRALS sufficient to cover hospital personnel, hospital-based emergency first responders and their family members for a 72-hour period?

Pharmaceutical Cache: Does your hospital have local or regional access to readily-available pharmaceutical caches of ANTIVIRALS sufficient to cover hospital personnel, hospital-based emergency first responders and their family members for a 72-hour period? Yes

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23. Pharmaceutical Cache:

Does your hospital have a completed distribution plan for pharmaceutical cache (plan in place to disseminate prophylaxis to essential hospital personnel, hospital-based emergency first responders and their family members)?

Pharmaceutical Cache: Does your hospital have a completed distribution plan for pharmaceutical cache (plan in place to disseminate prophylaxis to essential hospital personnel, hospital-based emergency first responders and their family members)? Yes

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24. Pharmaceutical Cache:

Has anyone at your hospital recieved training on the Strategic National Stockpile (SNS)or the CHEMPACK Program during the quarter?

Pharmaceutical Cache: Has anyone at your hospital recieved training on the Strategic National Stockpile (SNS)or the CHEMPACK Program during the quarter? Yes

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25. Personal Protective Equipment (PPE):

Does your hospital have the minimum level (at least 12 sets of Level-C) of Personal Protective Equipment (PPE) on hand?

Personal Protective Equipment (PPE): Does your hospital have the minimum level (at least 12 sets of Level-C) of Personal Protective Equipment (PPE) on hand? Yes

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26. Personal Protective Equipment (PPE):

Does your hospital have a written plan in place for disseminating and maintaining appropriate PPE for staff?

Personal Protective Equipment (PPE): Does your hospital have a written plan in place for disseminating and maintaining appropriate PPE for staff? Yes

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27. Decontamination:

Can your hospital decontaminate ambulatory and non-ambulatory patients?

Decontamination: Can your hospital decontaminate ambulatory and non-ambulatory patients? Yes

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28. Decontamination:

How many AMBULATORY patients can be decontaminated per hour at your hospital? (Quantity)

Decontamination: How many AMBULATORY patients can be decontaminated per hour at your hospital? (Quantity) Enter Number:

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29. Decontamination:

How many NON-AMBULATORY patients can be decontaminated per hour at your hospital? (Quantity)

Decontamination: How many NON-AMBULATORY patients can be decontaminated per hour at your hospital? (Quantity) Enter Number:

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30. Decontamination:

Does your hospital have sufficient and appropriate decontamination equipment in place to decontaminate ambulatory and non-ambulatory patients?

Decontamination: Does your hospital have sufficient and appropriate decontamination equipment in place to decontaminate ambulatory and non-ambulatory patients? Yes

Comment

31. Labs:

How many hospital-based lab personnel (medical and clinical laboratory technologists) are there in your hospital?(provide number).

Labs: How many hospital-based lab personnel (medical and clinical laboratory technologists) are there in your hospital?(provide number).

32. Labs:

How many hospital-based lab personnel (medical and clinical laboratory technologists) are trained in the protocols for referral of clinic samples and associated information to public health labs?(provide number).

Labs: How many hospital-based lab personnel (medical and clinical laboratory technologists) are trained in the protocols for referral of clinic samples and associated information to public health labs?(provide number).

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33. NIMS:

Number of Hospital personnel IDENTIFIED that require ICS training (TOTAL IN ENTIRE HOSPITAL EVEN IF THEY HAVE ALREADY BEEN TRAINED)(QUANTITY)

NIMS: Number of Hospital personnel IDENTIFIED that require ICS training (TOTAL IN ENTIRE HOSPITAL EVEN IF THEY HAVE ALREADY BEEN TRAINED)(QUANTITY) # of all positions IDENTIFIED that require ICS-100 training (in the entire hospital)
# of all positions IDENTIFIED that require ICS-200 training (in the entire hospital)
# of all positions IDENTIFIED that require ICS-300 training (in the entire hospital)
# of all positions IDENTIFIED that require ICS-400 training (in the entire hospital)
# of all positions IDENTIFIED that require ICS-700 training (in the entire hospital)
# of all positions IDENTIFIED that require ICS-800 training (in the entire hospital)

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34. NIMS:

Number of Hospital staff trained in the following courses during this quarter.
(November 01, 2009-January 31, 2010)(QUANTITY)

NIMS: Number of Hospital staff trained in the following courses during this quarter. (November 01, 2009-January 31, 2010)(QUANTITY) ICS-100
ICS-200
ICS-300
ICS-400
ICS-700
ICS-800.B

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35. Drills/Exercises:

Did your hospital conduct or participate in a drills/exercises/actual events that included a component(s) that tested NIMS concepts and principles during this quarter? (November 01, 2009-January 31, 2010)

Drills/Exercises: Did your hospital conduct or participate in a drills/exercises/actual events that included a component(s) that tested NIMS concepts and principles during this quarter? (November 01, 2009-January 31, 2010) No

Yes, how many drills/exercises/actual events tested parntership/coalition agreements, MOUs or MOAs during the quarter?

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36. Drills/Exercises:

Did your hospital conduct or participate in a drills/exercises/actual events that included a component(s) that tested Partnership/Coalition Agreements, MOUs, MOAs during this quarter? (November 01, 2009-January 31, 2010)

Drills/Exercises: Did your hospital conduct or participate in a drills/exercises/actual events that included a component(s) that tested Partnership/Coalition Agreements, MOUs, MOAs during this quarter? (November 01, 2009-January 31, 2010) No

Yes, how many drills/exercises/actual events tested parntership/coalition agreements, MOUs or MOAs during the quarter?

37. Did your hospital conduct or participate in a drills/exercises/actual events that tested the following component during this quarter? (November 01, 2009- January 31, 2010)Check each component that was tested.

	Components Tested
Incorporated NIMS concepts and principles	*Did your hospital conduct or participate in a drills/exercises/actual events that tested the following component during this quarter? (November 01, 2009- January 31, 2010)Check each component that was tested. Incorporated NIMS concepts and principles Components Tested
Interoperable Communications	Interoperable Communications Components Tested
Redundant Communication	Redundant Communication Components Tested
ESAR-VHP	ESAR-VHP Components Tested
Fatality Management	Fatality Management Components Tested
Medical Evacuation	Medical Evacuation Components Tested
Shelter-in-place Plan	Shelter-in-place Plan Components Tested
Tracking of Bed Availability	Tracking of Bed Availability Components Tested
Use or operation of hospital decontamination equipment	Use or operation of hospital decontamination equipment Components Tested
Resource Request	Resource Request Components Tested

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38. Drills/Exercises:

What is the total number of hospital staff that participated in exercises/drills during the quarter?

Drills/Exercises: What is the total number of hospital staff that participated in exercises/drills during the quarter?

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39. Drills/Exercises:

If your hospital participated in an exercise/actual event, did you submit an After Action report within 60 days of the event to the RAC?

Drills/Exercises: If your hospital participated in an exercise/actual event, did you submit an After Action report within 60 days of the event to the RAC? Yes

Does Not Apply

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40. Drills/Exercises:

If your hospital participated in an exercise/actual event during this quarter, did you develop corrective actions/improvement plans (related to your After Action Report)?

Drills/Exercises: If your hospital participated in an exercise/actual event during this quarter, did you develop corrective actions/improvement plans (related to your After Action Report)? Yes

Does Not Apply

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41. Have hospital personnel from your facility met at least once during this quarter with emergency management and/or public health partners to discuss integration of your responsibilities related to SPECIAL NEEDS individuals?

Have hospital personnel from your facility met at least once during this quarter with emergency management and/or public health partners to discuss integration of your responsibilities related to SPECIAL NEEDS individuals? Yes

Comment:

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42. Who is the hospital point of contact for EMResource Bed Poll Reporting?

Who is the hospital point of contact for EMResource Bed Poll Reporting? Name:
Email Address:
Phone Number:

43. Number of staffed ADULT INTENSIVE CARE UNIT (ICU) hospital beds in your facility. (You may provide an average or estimated number).

Number of staffed ADULT INTENSIVE CARE UNIT (ICU) hospital beds in your facility. (You may provide an average or estimated number).

44. Number of staffed MEDICAL/SURGICAL (MED/SURGE) hospital beds in your facility. (You may provide an average or estimated number).

Number of staffed MEDICAL/SURGICAL (MED/SURGE) hospital beds in your facility. (You may provide an average or estimated number).

45. Number of staffed hospital BURN beds in your facility. (You may provide an average or estimated number).

Number of staffed hospital BURN beds in your facility. (You may provide an average or estimated number).

46. Number of staffed PEDIATRIC ICU (PICU) hospital beds in your facility. (You may provide an average or estimated number).

Number of staffed PEDIATRIC ICU (PICU) hospital beds in your facility. (You may provide an average or estimated number).

47. Number of staffed PEDIATRIC hospital beds in your facility. (You may provide an average or estimated number).

Number of staffed PEDIATRIC hospital beds in your facility. (You may provide an average or estimated number).

48. Number of staffed PSYCHIATRIC (PYSCH) hospital beds in your facility. (You may provide an average or estimated number).

Number of staffed PSYCHIATRIC (PYSCH) hospital beds in your facility. (You may provide an average or estimated number).

49. Number of staffed NEGATIVE PRESSURE ISOLATION hospital beds in your facility. (You may provide an average or estimated number).

Number of staffed NEGATIVE PRESSURE ISOLATION hospital beds in your facility. (You may provide an average or estimated number).

50. Number of staffed OPERATING ROOM hospital beds in your facility. (You may provide an average or estimated number).

Number of staffed OPERATING ROOM hospital beds in your facility. (You may provide an average or estimated number).

51. TOTAL Number of staffed hospital beds in your facility. (You may provide an average or estimated number).

TOTAL Number of staffed hospital beds in your facility. (You may provide an average or estimated number).

52. Number of hospital employees (including hospital-based EMS):

Number of hospital employees (including hospital-based EMS):

53. What type of preparedness related training would be beneficial to your hospital and staff?

What type of preparedness related training would be beneficial to your hospital and staff?

54. What general items does your facility need assistance in funding RELATED to the OASPR/HPP Yr 8 grant deliverables (NIMS,Education & Preparedness Training/Exercises, Special Needs populations, Interoperable Communications, Tracking of Bed Availability, ESAR-VHP, Fatality Management, Medical Evacuation, Alternate Care Sites, Mobile Medical Assets, Pharmaceutical Caches, PPE, Decontamination)?

What general items does your facility need assistance in funding RELATED to the OASPR/HPP Yr 8 grant deliverables (NIMS,Education & Preparedness Training/Exercises, Special Needs populations, Interoperable Communications, Tracking of Bed Availability, ESAR-VHP, Fatality Management, Medical Evacuation, Alternate Care Sites, Mobile Medical Assets, Pharmaceutical Caches, PPE, Decontamination)?

55. Please list any suggestions, concerns, or ideas the CTRAC Emergency Preparedness & Response (EPR) Committee can utilize to improve coordination and/or preparedness planning throughout the region:

Please list any suggestions, concerns, or ideas the CTRAC Emergency Preparedness & Response (EPR) Committee can utilize to improve coordination and/or preparedness planning throughout the region:

Hospital Preparedness Questionnaire Quarter 2 (Nov, Dec, Jan 2010) DUE FEBRUARY 15TH 2010

1. Default Section

*1. Contact Information

*2. Interoperable Communications:Can your hospital communicate between other hospitals, local first responders, and/or the City/County EOC utilizing EMResource (EMSystem) and/or WebEOC?

*3. Interoperable Communications:Can your hospital demonstrate sustained two-way communications capability with the local City/County EOC and the other hospitals in the region during an exercise or incident?

4. Does your hospital have access to the Regional online Inventory System (EM Asset Tracker)?

*6. Hospital Mass Fatality Plan:Number of Dead bodies your hospital could handle in cold storage capacity (above average daily census):

*7. Hospital Mass Fatality Plan:Number of Dead bodies your hospital could handle in regular storage capacity (above average daily census-NOT COLD STORAGE):

8. Describe the progress toward increasing resource capacity for the temporary disposition of the deceased at the MSCC Tier 1, 2, or 3 (hospital, community, and jurisdictional) level.

*10. Shelter-In-Place Plan:Does your hospital have a completed Shelter-In-Place plan?

*11. Partnerships/Coalitions:Does your hospital have a designated representative that attends the CTRAC monthly Emergency Preparedness & Response committee meetings?

*12. Partnerships/Coalitions:Has your hospital signed onto the Regional Medical Operations Center (RMOC) compact? (This agreement facilitates sharing of assets, personnel, and information during disasters).

13. Alternate Care Sites:How many Alternate Care Site locations that are considered FIXED sites do you currently have listed in your hospital emergency plan? (Example: Hotels, Churches, Schools, Stadiums, Clinics, etc.)

14. Alternate Care Sites:How many Alternate Care Site locations that are considered MOBILE sites do you currently have listed in your hospital emergency plan? (Example: Trailers, Tents, Etc.)

*15. Alternate Care Sites:List the name and location (name of building and city) of each Alternate Care Site identified for your facility. Include Fixed and Mobile Alternate Care Sites.

*16. Alternate Care Sites:How many Alternate Care Site beds would be available at your Alternate Care Site locations? Enter number of Alternate Care Site beds for each location: (Correlate these numbers to the list given in the previous question-Question 15)

*17. Alternate Care Sites:Does your hospital have any agreements with local agencies to use a Building of Opportunity? (a building with enough space that could be turned into an Alternate Care Site)

*18. Alternate Care Sites:Describe the level of care to be provided or type of patients that can be cared for at your Alternate Care Site

*19. Alternate Care Sites:Provide a summary of plans for staffing, supply and re-supply of resources for the Alternate Care Site

*20. Alternate Care Sites:Has your hospital identified the following internal assets to support the alternate care site(s) identified above?:

*21. Pharmaceutical Cache:Does your hospital have local or regional access to readily-available pharmaceutical caches of ANTIBIOTICS sufficient to cover hospital personnel, hospital-based emergency first responders and their family members for a 72-hour period?

*22. Pharmaceutical Cache:Does your hospital have local or regional access to readily-available pharmaceutical caches of ANTIVIRALS sufficient to cover hospital personnel, hospital-based emergency first responders and their family members for a 72-hour period?

*23. Pharmaceutical Cache:Does your hospital have a completed distribution plan for pharmaceutical cache (plan in place to disseminate prophylaxis to essential hospital personnel, hospital-based emergency first responders and their family members)?

*24. Pharmaceutical Cache:Has anyone at your hospital recieved training on the Strategic National Stockpile (SNS)or the CHEMPACK Program during the quarter?

*25. Personal Protective Equipment (PPE):Does your hospital have the minimum level (at least 12 sets of Level-C) of Personal Protective Equipment (PPE) on hand?

*26. Personal Protective Equipment (PPE):Does your hospital have a written plan in place for disseminating and maintaining appropriate PPE for staff?

*27. Decontamination:Can your hospital decontaminate ambulatory and non-ambulatory patients?

*28. Decontamination:How many AMBULATORY patients can be decontaminated per hour at your hospital? (Quantity)

*29. Decontamination:How many NON-AMBULATORY patients can be decontaminated per hour at your hospital? (Quantity)

*30. Decontamination:Does your hospital have sufficient and appropriate decontamination equipment in place to decontaminate ambulatory and non-ambulatory patients?

31. Labs: How many hospital-based lab personnel (medical and clinical laboratory technologists) are there in your hospital?(provide number).

32. Labs: How many hospital-based lab personnel (medical and clinical laboratory technologists) are trained in the protocols for referral of clinic samples and associated information to public health labs?(provide number).

*33. NIMS:Number of Hospital personnel IDENTIFIED that require ICS training (TOTAL IN ENTIRE HOSPITAL EVEN IF THEY HAVE ALREADY BEEN TRAINED)(QUANTITY)

*34. NIMS:Number of Hospital staff trained in the following courses during this quarter.(November 01, 2009-January 31, 2010)(QUANTITY)

*35. Drills/Exercises:Did your hospital conduct or participate in a drills/exercises/actual events that included a component(s) that tested NIMS concepts and principles during this quarter? (November 01, 2009-January 31, 2010)

*36. Drills/Exercises:Did your hospital conduct or participate in a drills/exercises/actual events that included a component(s) that tested Partnership/Coalition Agreements, MOUs, MOAs during this quarter? (November 01, 2009-January 31, 2010)