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1 OB Anesthesia Job Action Sheet: L&D: OB Attending +/- Anesthesia Fellows & Residents Mission: Ensure that safe patient care continues in the event of the disaster Date: Start: End: Position Assigned to: Position Reports to: OB Unit Leader (UL) & Assistant Unit Leader (AUL), Hospital Command Center (HCC) H3210 Tel: ( ) **Equipment needed: ID Badge, Stethoscope, Pen, Flashlight *** Immediate (Operational Period 0-2 Hours) Done? Initial Getting Started: 1. Contact MAIN OR (may be only Anesthesia Attending in house at night, etc). If anesthesia attending pulled to Main OR, designate OB Anesthesia role on L&D to a fellow or appropriate resident. 2. Identify which patients have necessary epidurals or procedures running to triage Anesthesia care. 3. Meet with all available on- site MDs, Nursing staff at nursing station. 4. Provide the UL with your best form of communication (phone, texting, pager). 5. Allocate anesthesia staff (fellows/residents/tech) to check machines & equipment. PATIENT CARE 1. Ensure only life sustaining equipment is plugged into RED EMERGENCY PLUGS 2. Communicate with AUL & OBTech after TRAIN Triage to Identify high- risk/injured patients 3. Report emergent/life- threatening conditions to AUL, who reports to Hospital Command. DAMAGES 1. Familiarize self with general condition and needs of the unit. 2. Discuss status of O2 & N2O gas valves with AUL and Tech (only Engineering can turn on). SUPPLIES 1. Gather supplies for Anesthesia GRAB & GO Bag: Keep bag with you to be prepared for rapid evacuation. Intermediate (Operational Period 2-12 Hours) Done? Initial STAFF 1. Meet with UL on the time intervals designated by UL. PATIENT CARE 1. Ensure only life sustaining equipment is plugged into RED EMERGENCY PLUGS. 2. Assist with TRAIN triage: Identify high- risk patients and injured patients. 3. Report emergent/life- threatening conditions to UL, who reports to Hospital Command. COMMUNICATION 1. Communicate with AUL regarding medical status change of any patients. 2. Communicate anesthesia- related updates to patients and family members. SUPPLIES 1. Assess anesthesia medication, equipment, and supply needs for the next 24 to 48 hours. 2. Communicate needs to AUL. 3. Keep Anesthesia GRAB and GO bag with you and be prepared for rapid evacuation. Extended ( >12 Hours or as determined by Command Center) Done? Initial Continue to provide care as directed in the Immediate & Intermediate Plan (See Above).

2 OB Anesthesia Grab & Go list: Airway: Location/Notes: Ambu bag x 2 From epidural cart or on wall in LDR hallway O2 tank x 2 + wrenches Dirty utility room across from LDR 8 (Door code 1234) Laryngoscope & Blade x 2 ETT x 2 NRB mask x 3 Oral airways Proseal LMA #3, #4, #5 Bougie Suction: Portable Suction machine Top of code cart (across from LDR8) Monitors: Propaq + power and monitor cables Anesthesia Tech Rm Portable SpO2 Top of OR C Anesthesia machine IV: IV start equipment NS or LR 1000ml bag x 4 IV blood tubing x 2 Meds : Pyxis Keys 1. Use hammer to break glass. 2. Pull pyxis machine away from wall. 3. Insert both keys into large panel and turn them simultaneously. Clean utility room (across from LDR 8 door code 1234), on wall above pyxis, in red box. 4. Turn lever(s) inside back panel. 5. Retrieve needed drugs from front drawers. 6. Lock back panel and push pyxis machine to wall. 7. Give key to Pharmacist or RN Manager (not Resource RN) Propofol & Succinylcholine Labetalol Pitocin PPH Kit x 2 PACU Pyxis only Emergency meds: Epi / Atropine / Neo / Ephedrine SL NTG Other: 10cc syringe x 20 18g needle x 20 25g needle x 10 Gas Shut- Off Valves: Turn off if smoke or fire present, once off, only Engineering can turn back on LDR rooms: Between break room and double doors to OR OR A: Just outside OR A OR B: Just outside OR B OR C: Just outside OR C

3 PACU-1: O k to Enter? Patient: PACU-2: O k to Enter? Patient: PACU-3: O k to Enter? Patient: 11A: O k to Enter? Patient: Bath- Room Ok?: 11B: O k to Enter? Patient: 11C: O k to Enter? Patient: Elevator Ok?: Ultrasound Rm: Patient: Early Labor Lounge: Patient: # of Visitors: PACU, 11A, & US Tube Station DISASTER BINDER Staff Bathroom: _ Patient Bathroom: _ Exam Room: _ Patient: # of Visitors: Anesthesia Tech Rm: Supply Room: _ Labor Rooms 1-10 OR A OR B Front Desk: : Break Room: OR A: RNs & Patient: # of Visitors: Med Room: OR B: RNs & Patient: DIRTYUTILITY (CODE 1234) O2 TANKS CODE CART Labor Room 4: RN:_ Patient: Labor Room 3: RN:_ Patient: Labor Room 5: RN: Patient: Labor Room 6: RN: Patient: Labor Room 7: RN: Patient: Labor Room 8: RN: Patient: Labor Room 2: RN:_ Patient: BACK HALLWAY: (OFFICES, CALL- ROOMS, & LOCKER ROOMS) Anesthesia Resident: (Code 12768) Labor Room 1: RN:_ Patient: Patient Care Mgr.: (Rm 2774) Community MD: (Code 12766) OB Attending: (Code 1234) Community MD: (Code 12764) DEPARTMENT DAMAGE MAP LABOR & DELIVERY OB Attending: (Code 1234) OB Resident: (Code 12762) DISASTER BOXES CODE CART OR Tech Room: Utility Room: OR C OR C: RNs & Patient: Labor Room 9: RN: Patient: Labor Room 10: RN: Patient: Anesthesia Fellows: (Code 44444) Anesthesia Attending: (Code 1234) Men s Locker Rm: (Code 84980) Women s Locker Rm: (Code 84980) _O k to Enter?

4 SWC attending: RSN: L&D Disaster Roles OB Unit Leaders Location Job Front Desk Meet and assign roles Collect Information Communicate with Command Direct efforts Allocate L&D anesthesia staff Contact MOR to assess hospital needs Assistant unit leaders: OB resident: TL: Roaming Collect department status report Assist with TRAIN triage Collect TRAIN forms Complete census form Hand out orderset/transfer notes Gather anesthesia emergency supplies Techs: Room to Room Facilities check: complete dept Damage Map Report to OB Assistant Unit Leaders Runners Grab and Go Kits USA: Front Desk Distribute JAS with lanyards Copy LDR Census Log o note # of visitors ( comments section) o Document facility to which patients are evacuated ( transferred to column) Print patient records and facesheets Monitor entrance/exit RNs: Patient Care Rooms Plug vital equipment into red outlets Perform OB TRAIN triage (every patient) Complete patient form Prepare for emergent move of patient

5 Anesthesia Meet with UL Check anesthesia equipment Ensure life sustaining equipment are in red plugs ID pts with epidurals in place or undergoing procedures Assist with TRAIN triage Discuss status of 02 and N02 gas values with AUL Gather supplies anesthesia portable emergency supplies(list in Disaster binder) TRANSPORT COORDINATOR: MFM/OB FRONT DESK 1. Coordinate transfer of patients with receiving hospitals and command center PHONE TRIAGE L&D RN FRONT DESK CALL CENTER 1. Provide phone triage for pregnant women 2. Refer all other calls to hospital call center

6 OB Disaster preparedness survey Disaster Planning Committee: including MD, RN and OEM members Management familiar with the Hospital Incident Command System Are your front line staff aware that there is a command center during a disaster Does your staff know when and how to contact the hospital command center? Do you have a current Emergency Operation Plan or policy that is familiar to the staff Are your staff aware of where the emergency equipment is: fire extinguishers, gas shut off valves and how to use them Support staff are included in our disaster planning: Pharmacy, RT, Physicians, and Anesthesiologists Do you have a staffing call tree or similar process for staff (both MDs and RNs) to report for work We have an internal communication process as well as a redundant system Do you have an organizational chart that assigns roles to your staff in a disaster (both day and night time) Job Action Sheets or Role Cards developed to delineate particular roles in an emergency Do you have a policy of expectations of your staff during a disaster and are staff made aware of this policy We have evacuation equipment and every staff member has been trained on how to use them properly (MedSled, Stryker Chair, pocket vests) A plan is in place for patient tracking and family reunification Unit has emergency specific equipment such as: Grab and Go Bags if a delivery has to occur off the unit. Other needed equipment such as flashlights or headlamps, dopplers in an easily accessible box For a vertical evacuation, do you have an evacuation point and alternate point We are conducting training and drills annually to prepare for an emergency event causing an evacuation or medical surge Held discussions and what if scenarios with staff and providers for how to handle clinically challenging patients during a disaster Paper forms for transport purposes (medical records + orders) Triage system to allow rapid discharge or correct transport of low to high risk patients Rapid discharge system for normal postpartum and healthy newborns in coordination with pediatrics Do you have a method to maintain accountability of staff, patients and visitors during an evacuation Yes, we have this No, we don t have this but will do soon No, we don t have this and need advice on how to accomplish it

7 OB Unit Leaders (1 OB MD and 1 RSN per unit): L&D: Stanford OB on call and LD RSN F2: Chief Resident and F2 RSN F1: OB resident on call and RSN Mission: Coordinate Initial activities for Disaster Response Date: Start: End: Position Assigned to: Position Reports to: Administrative Nursing Supervisor Hospital Command Center (HCC) Location if other than H3210: Fax: Other Contact Info: Radio Channel: **Equipment needed: ID Badge, Stethoscope, Pen, Flashlight *** Telephone: (H3210: ) _ Immediate (Operational Period 0-2 Hours) Getting started: 1. Find disaster binder in tube room 2. Send tech to get disaster box from supply room 3. Assign disaster roles using assignment sheet in disaster binder 4. Phone emergent/life-threatening conditions to the Hospital Command Center (phone number above). 5. Hang assignment sheet next to white board 6. Meet with all available on-site MD, Nursing staff at nursing station. 7. Set a predetermined meeting place and set a time schedule of when Assistant Unit Leaders will return for updates (i.e.: every 30 minutes). 8. Assess the conditions of the unit, the actions being taken, and the needs of the unit. 9. Determine best form of on going communication (phone, texting, or runners). 10. Designate a runner if there are communications issues or if the pneumatic tube system is down 11. Notify Hospital Command Center (Operations Section Chief) of Unit Leader Designations. 12. Obtain Disaster equipment: disaster box, headlamps, Open omincell if needed. Instructions in Disaster binder 13. Obtain completed Department Status Report from AUL and complete the form on line or give paper form to the Command Center. This report is found in the Disaster Plan Binder. 14. Obtain census forms from Assistant Unit Leader and report unit status to Administrative Nursing Supervisor (ANS). 15. If notified by Command Center to evacuate: Activate Rapid Discharge via TRAIN. Done?

8 16. If shelter in place contact PICN attending to alert them where we are relocating and request assigned pediatrician to join us for deliveries 17. Consider how to cohort patients 18. If unit evacuated outside hospital, ensure Command centers evacuates OB near PICN or NICU

9 OB Tech / Nursing Assistant Mission: Ensure that safe patient care continues in the event of the disaster. Date: _ Start: _ End: _ Your name: Report to Asst. Unit Leader (Name): Position Reports to: Asst. Unit Leader **Equipment needed: ID Badge, Stethoscope, Pen, Flashlight *** Immediate (Operational Period 0-2 Hours) Getting started: 1. Get the disaster box from the supply room and bring to Unit Leader 2. Pull out the Department Damage Map. 3. Check your assigned rooms for damage/patient/family members and note this on map and report to Assistant Unit leader 4. Identify and communicate any immediate patient needs to Asst. Unit Leader. 5. Be sure to check stairwells/bathrooms/sleeping rooms for injured 6. Write on door: OK to enter or Damage Do not enter with Sharpie 7. Assist AUL in filling out the Department Status Report, using information from your map 1. Locate and distribute flashlights/headlamps if needed. 2. Be prepared to act as a runner if needed 8. Continue use of personal protective equipment Done?

10 OB Bedside Nurse Mission: Ensure that safe patient care continues in the event of the disaster. Date: Start: End: Nurse: Patient assignment: Position Reports to: OB Unit Leader **Equipment needed: ID Badge, Stethoscope, Pen, Flashlight *** Immediate (Operational Period 0-2 Hours) Getting Started 1. Assess assigned patients and identify immediate needs based on disaster impact (PP: Assess Mother / Baby location and status). 2. Ensure that all life sustaining equipment is plugged into a RED EMERGENCY PLUG if on Emergency Power. 3. Report room status/pt condition and # of family members to the OB tech completing the department damage map 4. Reassure the patient and visitors that an emergency plan is in place and that for their safety they should not leave the premises until instructed to do so. 5. Utilize personal protective equipment as needed. 6. Complete patient acuity assessment for possible Rapid Discharge Planning / TRAIN. 7. Fill out patient form for possible transfer. 8. Be prepared to evacuate patients. Do not evacuate unless directed by Nursing Supervisor/Hospital Command Center unless immediate danger is present. 9. Request additional resources needed such as supplies/equipment/staff/medication Done?

11 OB Assistant Unit Leaders: 1 OB MD and 1 RN L&D: Stanford Resident on call and L&D Nursing TL F2: Stanford Resident on call and F2 Nursing TL F1: Stanford Resident on call and F1 Nursing TL Date: Start: End: Position Assigned to: Initial: Position Reports to: Unit Leader: Signature: **Equipment needed: ID Badge, Stethoscope, Pen, Flashlight *** Immediate (Operational Period 0-2 Hours) Getting Started 1. Report any urgent patient or room needs to the Unit Leader. 2. Fill out Department Status Report based on Damage Map form Ob techs and give to Unit Leader 3. Assess needs of the unit and assign runners for Pharmacy, Supplies and Equipment as needed 4. Turn off gas valves if instructed to by the command center 5. Meet with Unit Leader as instructed (i.e. q 30 min). 6. Complete patient acuity assessment for possible Rapid Discharge Planning / TRAIN. 7. Continue to round on unit to ensure patient care, staff and family needs are met. 8. Prepare for potential emergent admissions of overflow Emergency Department patients. 9. Begin rapid discharge assessment as directed by Command center and distribute paper copies of order sets/transfer notes. 10. Identify and send one RN to ED Support Pool with Vacant Bed/Bed Availability List if requested. Done?

12 OB Unit Clerk Mission: Assist Nursing staff in the provision of safe care during a disaster. Date: _ Start: _ End: _ Your name: Report to Asst. Unit Leader (Name): **Equipment needed: ID Badge, Pen, Flashlight *** Immediate/Intermediate Response to Disaster Getting Started 1. Determine if computers and phone lines are functional and update Unit Leader with status. 2. Distribute the Job Action Sheets with lanyards to all unit personnel. 3. Complete census list using the Department damage map completed by the tech. Account for all patients and family members on the census list and give to Asst. Unit Leader. 4. Print patient records and face sheets for each patient in case of transfer/power outage. 5. Keep track of all patients entering or exiting the unit.(use the Evacuation Triage TRAIN Log in the Department Disaster Plan to log where patients are being sent out) 6. Pull Rapid Discharge Packets from Forms Cabinet on each unit when asked by Unit leader. 7. Maintain manual Admission/Transfer/Discharge forms (A/T/D Board). 8. Monitor unit entrance activities for security concerns. Done?

13 OB TRAIN for AP & LD Transport CAR (Discharge) BLS ALS SPC SHELTER IN PLACE Labor Status Mobility Epidural Status None Early Active Ambulatory* None Ambulatory or Non-ambulatory Non-ambulatory Placement > 1 hour** Placement < 1 hour** At risk for En route delivery Nonambulatory N/A If delivery is imminent, Shelter in Place and TRAIN after delivery Maternal or Fetal Risk Low Low/Moderate Moderate/High High (SPC) Specialized = must be accompanied by MD or Transport RN * Modified Bromage Score 6 = PaIent is able to perform a parial knee bend from standing ** Epidural catheter capped off

14 OB TRAIN for postpartum Transport Car (Discharge) BLS ALS SPC Delivery VD > 6 hours or CD > 48 hours VD < 6 hours or CD < 48 hours Complicated VD or CD Medically complicated Mobility Ambulatory* Ambulatory or Non-ambulatory Ambulatory or Nonambulatory Non-ambulatory Post Op > 2 hours from non-cd surgery** > 2 hours from CD < 2 hours from non-cd surgery < 2 hours from CD Medically complicated Maternal Risk Low Low/Moderate Moderate/High High (S) Specialized = must be accompanied by MD or Transport RN * Modified Bromage Score 6 = PaFent is able to perform a parfal knee bend from standing ** If adult supervision is available for 24 hours

15 Grab and GO Off Site Delivery Kit ITEM: LOCATION: DETAILS: Sterile single gloves Delivery Cart Drawer gloves Exam gel Delivery Cart Drawer packets Bulb Syringe Delivery Cart Drawer 3 x1 Umbilical cord clamp Delivery Cart Drawer 3 x3 Sutures Delivery Cart Drawer 3 Monocryl 2-0 x1 Monocryl 3-0 x1 Vicryl 3-0 x1 Sterile gloves Delivery Cart Drawer 4 Size 6.5 x2, Size 8 x1 L&D Instrument Set Delivery Cart Drawer 5 Mayo Scissors Mayo Clamp Needle Driver Delivery Pack Delivery Cart Drawer 5 Underbuttocks drape Sterile gown Sterile towel Needle count box Table cover 4x4 Sponges 2 packs Cord clamp x 2 Red bag Delivery Cart Drawer 5 x2 Peripad Delivery Cart Drawer 6 x2 Large non-sterile gloves Wall above sink One box (50 gloves) Hand Sanitizer LDR room Chux LDR Closet One chux Ambu-bag self-inflating (neonatal) PANDA Neonatal stethoscope PANDA Baby blanket Warmer x3 Baby hat Warmer x1 Fetal Doppler Disaster Box or lock drawer by clerk Space Blanket Disaster Box x 1 Paper & Pen Front Desk Oxytocin 20U IM + needle/syringe Pyxis Methergine 0.2mg IM + needle/syringe Pyxis Misoprostol 1000mcg Pyxis Lidocaine 1% 30ml + needle/syringe Pyxis Sharps box Disaster Box Labor Module Delivery Module Medication Module Neonatal/Postpartum Module

16 Checklist for Well Baby Discharge by OB in a Disaster All answers should be YES If any answers are NO or DON'T KNOW, refer to peds for disposition. YES NO DON T KNOW Baby > 24 hrs old? Is Mom going home? Baby 38 weeks gestation? Has the baby had a normal MD exam? Is the baby feeding well without any issues? Has the baby lost < 10% of its birth weight? Does the baby have normal vital signs? HR = bpm RR = /min Temp = C Is the bilirubin level: < 6.0 at 24 hrs or < 9.0 at 36 hrs or < 11.0 at 72+ hrs Have ALL (3) the following screening tests been done? Cardiac Screening (O2 sat) Newborn Screen If indicated, baby has blood glucose 45 x3? Car seat available? Newborn screen done (can be done if >12 hours ) NBS# here All answers should be NO If any answers are YES or DON T KNOW, refer to peds for disposition. YES NO DON T KNOW Does that baby have any risk factors for infection? Maternal chorioamnionitis or endometritis, or risk factors for chorio: o ROM 18 hrs o PROM o GBS positive (+) with < 4hrs of antibiotics Maternal history of syphilis/genital herpes/hep B during this pregnancy Is a car seat challenge needed? Is CPS involved?