SUBJECT: Emergency Management REFERENCE: MCLNO Code Grey Revised: 5/07, 3/08, 6/09, 5/13 DEPARTMENT: Medical Staff and GME Page 1 of 7

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1 DEPARTMENT: Medical Staff and GME Page 1 of 7 POLICY: When a situation occurs requiring activation of the Interim LSU Public Hospital (ILH)organizationwide Emergency Management Plan, the Medical Staff Office will implement the following procedures to ensure proper coverage for Medical Staff and House Staff: SITES COVERED: University Hospital Butterworth Building Delgado Building PROCEDURES: 1. Upon declaration of a Code Grey, the administration of ILH will notify the Medical Director of Medical Staff Affairs and GME of Emergency preparations. 2. The Medical Director of Medical Staff Affairs will inform/contact the Administrative Director of Medical Staff Services to initiate the Emergency Management Plan: a. Severe Weather Watch: i. Contact LSU and Tulane Schools of Medicine departments for a list of physicians on Code Grey activation. ii. Send information to Medical Director s office for Administrative Council meeting to be scheduled by CEO. b. Severe Weather Warning: i. Medical Director of Medical Staff Affairs will contact programs requesting voluntary discharge of stable patients as necessary. c. Activation Emergency Management and Facilities Departments will: i. Register all physicians ii. Issue parking passes iii. Assign call rooms and issue call room keys iv. Maintain list of physicians, by department/school, present during activation v. Act as command station for physicians

2 DEPARTMENT: Medical Staff and GME Page 2 of 7 3. PHYSICIAN DISASTER PLAN CODE GREY Procedures a. The Medical Director of MSA will notify Deans/Department Chairs via , fax or direct contact b. Department chairs will notify Chief Residents/Assigned Staff i. Chief Residents will be responsible for identifying on-call teams and will provide the information to the Medical Director of MSA via fax, or via phone. ii. The Chief Resident (or his/her designee) of each service will be expected to be in-house when the code is called and during the entire disaster. iii. The Medical Director for Medical Staff Affairs office will notify the assigned Staff/Chief Residents of the change to Code Grey status. iv. Chief Residents are expected to notify all assigned House Staff of the need to report to the hospital. v. All staff and house staff are to check in with Emergency Command Center upon their arrival. (Parking passes will be distributed to Chief Residents. No one will be allowed entry to the parking garage without a pass) vi. Arm bands for on-call physicians are to be obtained from the Emergency Command Center at registration (No one will be allowed to remain in on-call quarters without an arm band.) vii. During a CodeGrey status, the Medical Director of MSA has the final authority and responsibility for all assignments for all Medical Staff. viii. Call Rooms are assigned by the Emergency Command Center. ix. Assigned physicians will be allowed to park only one vehicle on campus. x. Activation physicians are not allowed guests/family members. xi. Absolutely NO PETS are allowed. xii. Food, clothing, medications, blankets, pillows, and water are the responsibility of each individual. xiii. Medical Students are not allowed in hospital during Code Grey.

3 DEPARTMENT: Medical Staff and GME Page 3 of 7 xiv. In-house teams include the following: Code Grey Coverage 2013 Department School Staff Residents Total Medicine LSU Tulane Cardiology one team /alternate schools Emergency Medicine LSU Nephrology Dr. Hamm will be covering at Tulane Pulmonary Critical Care one team /alternate schools Anesthesia LSU 1 6 CRNAs 1 Ob/Gyn one service/alternate schools Trauma Surgery LSU/Tulane 1 3 ( 1 for TICU) 4 Cardiothoracic Surgery LSU 1 1 Neurosurgery LSU Orthopaedic Surgery LSU/Tulane will alternate schools Neurology LSU/Tulane schools alternate months for coverage Psychiatry LSU- UH LSU- Depaul 1 2 Radiology LSU Pathology LSU Opthalmology LSU/Tulane No resident or faculty for Urology, GI, Vascular Surgery, ENT Chief Medical Officer 1 Medical Director of Medical Staff 1 71

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5 DEPARTMENT: Medical Staff and GME Page 5 of 7 EMERGENCY / DISASTER PRIVILEGES Policy: In accordance with the MCLNO Medical Staff Rules and Regulations, the following procedure will be followed: A. In the event of an emergency, any practitioner, to the degree permitted by his/her professional license regardless of Medical Staff status or lack thereof, will be permitted and assisted to save the life of a patient at MCLNO. B. When the emergency management plan has been activated and MCL Staff is unable to handle immediate patient needs, the Chief Executive Officer, Medical Director, or Medical Staff President or his designee may grant emergency privileges to volunteer practitioners. In order for volunteers to be considered eligible to act as licensed independent practitioners, the organization obtains for each volunteer practitioner at a minimum, a valid government-issued photo identification issued by a state or federal agency (e.g., driver s license or passport) and at least one of the following: i. A current picture hospital ID card that clearly identifies professional designation ii. A current license to practice iii. Primary source verification of the license iv. Identification indicating that the individual is a member of a Disaster Medical Assistance Team (DMAT), or MRC, ESAR-VHP, or other recognized state or federal organizations or groups. v. Identification indicating that the individual has been granted authority to render patient care, treatment, and services in emergency/disaster circumstances, such authority having been granted by a federal, state, or municipal entity. vi. Identification by current hospital or medical staff member(s) who possesses personal knowledge regarding volunteer s ability to act as a licensed independent practitioner during a disaster. C. The activities of these emergency practitioners will be managed in accordance with the Hospital Emergency Incident Command System (HEICS). D. Practitioners granted Emergency/Disaster Privileges will be supervised and monitored through direct observation when possible and concurrent clinical record review by a MCLNO Clinical Medical Staff member. The MCLNO Medical Staff are responsible for oversight of the volunteer practitioner s professional performance. E. Primary source verification of licensure begins as soon as the immediate situation is under control, and is completed within 72 hours from the time the volunteer situation is under control, and is completed within 72 hours from the time the volunteer practitioner presents to the organization. If primary source verification cannot be obtained due to extraordinary circumstances such as no means of communication or lack of resources, it is expected to be completed as soon as possible. The reason for lack of primary source verification within 72 hours and evidence of demonstrated ability to continue to provide adequate care, treatment and services is documented; and an attempt to rectify the situation as soon as possible is expected F. MCLNO will monitor the volunteer practitioner s performance and evaluate (based on information obtained regarding the professional practice of the volunteer) within 72 hours related to the continuation of the emergency/disaster privileges initially granted. G. The MSO will use the Emergency and Temporary Privilege Form to register all practitioners requiring Emergency/Disaster Privileges. (See Exhibit A last page) Click here for form

6 DEPARTMENT: Medical Staff and GME Page 6 of 7 5. RECOVERY PLAN a. The Medical Staff Office Administrative Director will contact the recovery team to resume responsibilities of the Medical Staff Office/GME. b. The Medical Director for Medical Staff Affairs will contact Department Chairs and Program directors of LSU and Tulane Medical Schools to resume normal call schedules.

7 DEPARTMENT: Medical Staff and GME Page 7 of 7 Policy: EMERGENCY / DISASTER PRIVILEGES FORM In accordance with the MCLNO Medical Staff Bylaws, Rules and Regulations, the following procedure will be followed: A. In the event of an emergency, any practitioner, to the degree permitted by his/her professional license regardless of Medica thereof, will be permitted and assisted to save the life of a patient at MCLNO. B. When the emergency management plan has been activated and MCL Staff is unable to handle immediate patient needs, Officer, Medical Director, or Medical Staff President or his designee may grant emergency privileges to volunteer practitioners. In to be considered eligible to act as licensed independent practitioners, the organization obtains for each volunteer practitioner at government-issued photo identification issued by a state or federal agency (e.g., driver s license or passport) and at least one of th i. A current picture hospital ID card that clearly identifies professional designation ii. A current license to practice iii. Primary source verification of the license iv. Identification indicating that the individual is a member of a Disaster Medical Assistance Team (DMAT), or MRC, ESAR-VHP, state or federal organizations or groups. v. Identification indicating that the individual has been granted authority to render patient care, treatment, and services in circumstances, such authority having been granted by a federal, state, or municipal entity. vi. Identification by current hospital or medical staff member(s) who possesses personal knowledge regarding volunteer s ability independent practitioner during a disaster. C. The activities of these emergency practitioners will be managed in accordance with the Hospital Emergency Incident Command D. Practitioners granted Emergency/Disaster Privileges will be supervised and monitored through direct observation when possib clinical record review by a MCLNO Clinical Medical Staff member. The MCLNO Medical Staff are responsible for oversig practitioner s professional performance. E. Primary source verification of licensure begins as soon as the immediate situation is under control, and is completed within 72 hou volunteer situation is under control, and is completed within 72 hours from the time the volunteer practitioner presents to the orga source verification cannot be obtained due to extraordinary circumstances such as no means of communication or lack of reso to be completed as soon as possible. The reason for lack of primary source verification within 72 hours and evidence of dem continue to provide adequate care, treatment and services is documented; and an attempt to rectify the situation as soon as pos F. MCLNO will monitor the volunteer practitioner s performance and evaluate (based on information obtained regarding the prof the volunteer) within 72 hours related to the continuation of the emergency/disaster privileges initially granted. Name: Contact # The following documentation has been provided by the volunteer practitioner listed above: ITEM CURRENT PICTURE HOSPITAL ID CURRENT MEDICAL LICENSE RECEIVED/Verified State Expiration Date DMAT IDENTIFICATION FEDERAL/STATE/ MUNICIPAL EMERGENCY ID ID BY CURRENT MEDICAL STAFF/MCLNO STAFF ID # ISSUED: Medical Staff Office Representative Date