NORTHEAST HOSPITAL CORPORATION

NORTHEAST HOSPITAL CORPORATION Title: Emergency Management Plan Date Effective: Historical Date Revised: 5/97, 12/97, 3/98, 5/98, 2/99, 11/99, 11/00, 7/01, 9/01, 11/01, 11/02, 11/03, 1/05, 12/06, 11/07, 3/08, 11/08, 11/10, 03/22/12 Date Reviewed: 03/22/12 Joint Commission Chapter: Emergency Management (EM) I. Purpose or Intent A. To assure an organized and coordinated response to an external or internal emergency. B. To assure an organized and coordinated response to emergencies requiring partial or full evacuation. C. To maximize availability of resources for the continuity of care during an emergency. D. To facilitate integration with external resources at the time of an emergency. E. To follow the National Incident Management System Guidelines, including the use of the Incident Command System (ICS) to manage emergency situations. II. III. Use of the Emergency Management Plan A. This all hazards plan/policy is designed to integrate an all hazards approach to emergency management. B. This policy is divided into sections: 1. Section 1 - The Emergency Management Plan is the main portion, which outlines the Emergency Management Program. Included is the Activation of all disaster type emergencies. 2. The other sections are specific to the type of disaster involved. C. For ease of use of the multiple page document, please see table of contents below. D. Activation procedures for all emergencies/disasters can be found on pages 5 & 6 dependent upon the type of emergency/disaster. Table of Contents Pages Section 1: Emergency Management Plan 2-18 Section 2: Plan D (Mass Casualty) External Disaster 19-23 Section 3: Plan E (Evacuation) Internal Disaster 24-28 Section 4: Surge Capacity Plan 29-34 Section 5: Severe Weather 35-39 Section 6: Earthquake Response 40-43 Section 7: Mass Fatality 44-47 Section 8: Bioterrorism Response Plan 48-56 Page 1 of 56

Section 1: Emergency Management Plan Table of Contents Page I. Purpose or Intent 2 II. Policy or General Principles 3 III. Definition 3 IV. Applies To 3 V. Used in Conjunction With 3 VI. Procedure 3 a. Phases of Emergency Management 3 b. Hazard Vulnerability Analysis 4 c. Emergency Operations Plan d. Response i. Activation 4 5 iii. ii. Incident Command System 6 Assigned Locations 7 e. Alternate Care Sites See Section 3 7 f. Communications During Emergencies See Appendix B g. Managing Resources and Assets See Appendix B h. Safety and Security During Emergencies i. Staff Roles and Responsibilities During Emergencies j. Utilities Management See Appendix C k. Patient and Clinical Support During Emergencies VII. Documentation 9 VIII. Orientation/Training 9 IX. Monitoring 9 X. References 9 Appendices: A. Communication Strategies During Emergencies 10 B. Managing Resources and Assets During Emergencies 12 C. Utility Management During Emergencies 13 D. Recovery 14 E. Monitoring and Performance 15 F. Managing the Vulnerable Patient 17 G. Hygiene During a Plan W 18 8 8 I. Purpose or Intent A. To assure an organized and coordinated response to an external or internal emergency B. To assure an organized and coordinated response to emergencies requiring partial or full evacuation C. To maximize availability of resources for the continuity of care during an emergency D. To facilitate integration with external resources at the time of an emergency E. To follow the National Incident Management System Guidelines, including the use of the Incident Command System (ICS) to manage emergency situations Page 2 of 56

II. III. IV. Policy or General Principles A. The Governing Body, CEO, COO and Medical Staff receive regular reports of the activities of the Emergency Management Program from the Emergency Management Committee Minutes, as well as annually as part of the Annual Emergency Management Report. They review the reports, and as appropriate, communicate concerns. B. The Emergency Management/EMS Coordinator is the Chair of the Emergency Management Committee. The Emergency Management/EMS Coordinator, in conjunction with members of the Emergency Management Committee is responsible for maintaining the Emergency Management Program. C. Department Directors, Managers, Supervisors and Team Leaders are responsible for implementing the Emergency Management Plan in their departments. They develop and maintain department specific plans, train employees regarding their roles and responsibilities, and to the details of the plan. D. Employees are responsible for complying with their department specific plan and understanding the hospital plan Definition AGH = Addison Gilbert Hospital BH = Beverly Hospital BHD = Beverly Hospital at Danvers BRH = BayRidge Hospital Applies to Northeast Hospital Corporation V. This policy and procedure is to be used in conjunction with all other safety management, department-specific and site-specific policy and procedure VI. Procedure A. Phases of Emergency Management 1. Mitigation refers to actions taken to eliminate or reduce the risk of an occurrence or its affects. Northeast Hospital Corporation implements numerous mitigation initiatives to: a. Reduce or eliminate the effects of hazards. b. Identify hazard, through hazard vulnerability analysis, that may affect the facility. 2. Preparedness is proactive anticipation and determination of the most appropriate planned response mechanisms to be used in an emergency. This includes establishing processes to effectively assess a situation and rapidly mobilize necessary resources in a controlled manner. 3. Response is the ability to implement and execute pre-determined plans effectively and efficiently is essential. Staff knowledge with regard to their roles is a critical element of an effective response. 4. Recovery is the final phase of the emergency response cycle. Residual and indirect effect of the response must be managed. Considerations include but are not limited to the impact of the event on staff, facility, supply inventory, service recovery and environmental conditions. B. Hazard Vulnerability Analysis (HVA) 1. A Hazard Vulnerability Analysis is developed and maintained by the Emergency Page 3 of 56

Management Committee to determine what conditions/events are likely to have a significant adverse impact on patients, staff, the community, and the hospital. 2. A matrix of probability, risk, and level of NHC preparedness is used to set planning priorities for a variety of emergencies (natural and human, and technological). Emergency Response Plans are developed and maintained in the Emergency Management Manual for emergencies identified as priorities in the HVA. 3. The HVA s are reviewed by local Public Safety Organizations, such Police, Fire, EMS, and local Emergency Management. 4. The HVAs are shared with other local hospitals that part of the DPH Regions III Hospital Emergency Preparedness Committee. 5. HVAs are maintained for all localities/communities where NHC has an accredited facility and are evaluated annually. 6. NHC utilizes the Kaiser Permanente HVA Program for all NHC property in which are accredited. 7. The HVA risk threshold that requires pre-planning is equal to, or greater than 35%. Whereas, Risk=Probability*Severity 8. HVAs are maintained with the Emergency Management/EMS Coordinator C. Emergency Operations Plan 1. A successful response relies upon planning around the management of six critical areas: communications, resources and assets; safety and security, staffing, utilities, and clinical activities 2. The NHC Emergency Management Committee uses an "all-hazard" approach in combination with the HVA to anticipate resources needed and to develop selected plans 3. NHC has adopted the National Incident Management System (NIMS) at the organizational level by incorporating each of the elements of NIMS 4. NHC manages all internal and external emergency incidents and exercises in accordance with Incident Command system, which is coordinated with the communities that we serve. Task lists are available for each Command Center position as well as key deptspecific roles within each plan. 5. Emergency Preparedness is part of general orientation and includes (activation, role and function of Command Center, and location and use of one-page department plans for PLAN D/E). Department managers train employees in their specific role and responsibility during individual disasters - including which Command Center position they most frequently report to. One-page PLAN D and PLAN E response plans are posted in each department and include department/role-specific assignments. 6. All managers and supervisors who may be asked to serve as an Incident Commander, PIO, Liaison Officer, or Operations Chief (a minimum of two persons are to be trained for each of the specified roles) will be trained in IS 700, IS 100, and IS 200. DPH/DHS has identified that two individuals within the organization must have the IS- 800 completion certificate. The Emergency Management/EMS Coordinator will maintain documentation of compliance. 7. Additional training in disaster response is obtained through outside seminars as available (i.e., Region III EMS, MEMA/FEMA) 8. An inventory of routine, critical, specialty supplies, meds, food/water, fuel, linen is maintained. A combination of local, regional, and national vendor contracts are also maintained. D. Response 1. Activation Page 4 of 56

a. The audible paging system is used to announce most emergencies. b. All Command Center staff, as well as key personnel/managers are notified utilizing the AMCOM e-notify system by the Switchboard. c. All disasters activations are communicated to all NHC facilities to facilitate timely preparation. d. Activation of the Emergency Management Plan is accomplished by following the instructions below: i. Plan D (Mass Casualty) External Disaster activated by the ED MD, ED Charge Nurse, AOC, Emergency Manager in conjunction with pre-hospital personnel. If the AOC or Emergency Manager is not consulted prior to activation, contact must be made ASAP. PLAN D (mass casualty) is activated when every-day resources must be increased to accommodate a sudden influx of patients a. Contact the switchboard via 3333 (BH), 333 (AGH) requesting a Plan D Activation with a stage level (see below): i. Stage I - less than fifteen (15) casualties BH, less than ten (10) AGH ii. Stage II - greater than fifteen (15) casualties BH, greater than ten (10) AGH b. Switchboard audibly pages "PLAN D In Effect, Location and Stage (if known)", and makes notification utilizing the e-notify system. ii. iii. iv. Plan E (Evacuation) - activated by the affected Department Manager/Director (or designee), AOC, or Emergency Manager. If the AOC or Emergency Manager is not consulted prior to activation, contact must be made ASAP. PLAN E is activated when the internal environment cannot support adequate patient care (evacuation). PLAN E is linked to other EOC plans with attention to fire, armed intruder, bomb threat, HAZMAT spill/leak. NHC maintains a 96 hour plan to assist in identifying trigger points for evacuation. a. Contact the switchboard via 3333 (BH), 333 (AGH)) requesting a Plan E Activation with the location of the emergency. b. Switchboard audibly pages "PLAN E In Effect, and Location, and makes notification utilizing the e-notify system. c. BHD and BRH will call 9-1-1 first, and the switchboard second. Surge Capacity Plan activated when activities are unsuccessful in mitigating the High Census Alert and/or ED Capacity exceeds licensed capacity, the Surge Capacity Plan is activated by the Director of Emergency and Critical Care Services or designee. a. Contact the switchboard via 3333 (BH), 333 (AGH)) requesting a Surge Capacity Activation with the facility location. b. Switchboard audibly pages "SURGE CAPACITY PLAN In Effect, and Location, and makes notification utilizing the e-notify system. Severe Weather/Earthquake Response activated by the AOC, Director of Support Services or Emergency Manager. Page 5 of 56

a. Contact the switchboard via 3333 (BH), 333 (AGH)) requesting a Severe Weather Activation with the location of the emergency. b. Switchboard audibly pages "Severe Weather Plan In Effect, and Location, and makes notification utilizing the e-notify system. v. Utility Disruption activated when the disruption is verified by Plan Operations or IS Leadership. Collaboration with the AOC and Emergency Manager is recommended. a. Contact the switchboard via 3333 (BH), 333 (AGH)) requesting a Utility Disruption Activation with the type and location of the emergency. b. Switchboard audibly pages "Utility Disruption in Effect, and Location, and makes notification utilizing the e-notify system. 2. Incident Command System (ICS) a. For every incident, an Incident Action Plan (IAP) will be developed (verbal or written) to provide incident supervisory personnel with direction for actions to be implemented b. The IAP will be in effect for the duration of the incident, or operational period c. The hospital will utilize a single command where the Incident Commander has complete responsibility for management of the incident i. A representative(s) from the hospital may be sent to a Community Emergency Operation Center to be part of a Unified Command or Multiagency Coordination System d. A Command Center is activated for all emergencies, regardless of the size or type until a full needs assessment has been completed by the Hospital Incident Commander i. There will be only one Incident Commander at a time for the duration of the incident, however, transfer of command may be necessary due to the length of an incident or because a more knowledgeable or experienced person arrived e. The Command Center will be positioned outside of the hazardous zone. It may be utilized to manage internal Code Red, Dr Strong, Code Rascal, Plan S, Code Yellow, Plan D, Plan E, Code Green, Plan P, Plan W, Status II, electrical failures or other internal emergencies requiring planning and operations, whether planned or unplanned f. There will be an Incident Commander for all incidents i. The Incident Commander assigns designation of the Command Staff and General Staff Chiefs. Command Staff and General Staff positions may be grouped together and covered by one individual, or may not be necessary for certain incidents. g. In emergencies which require assistance from local, state or government agencies, a Unified Command will occur 3. Assignment Locations Beverly Hospital: NHC Emergency Operation Center/Incident Command Center (2232) Addison Gilbert Hospital Command Post (x122) BayRidge Hospital Command Post (781-599-9200 x6950) Page 6 of 56

Beverly Hospital at Danvers Command Post (x8006). 4. Credentialing a. Medical Staff By-Laws reflect the steps to be taken to ensure only qualified individuals are given temporary credentials for physicians that volunteer their services during a disaster b. Another method of recruiting volunteers during a disaster is through the state run MSAR (Massachusetts System for Advanced Registration of Healthcare Professionals) Program 5. Decontamination (refer to Chemical Decontamination Policy for additional details) Chemical/Radiation Decon team, facilities, equipment/supplies are available at AGH and BH (Level C PPE) a. Decon requiring SCBA is performed by local fire personnel (Level B) or regional HAZMAT team (Level A) 6. Non-Medical Volunteers: Currently, NHC does not have a mechanism to authenticate non-medical volunteers, and will not use these individuals during an identified Disaster E. Alternate Care Sites 1. Identified Alternate Care Sites can be found in Section 3, Plan E (Evacuation Protocol) Internal Disaster. F. Communication Strategies During Emergencies 1. Communication Strategies during Emergencies can be found in Section 1, Appendix A of this policy. G. Managing Resources and Assets During Emergencies 1. Managing Resources and Assets during Emergencies can be found in Section 1, Appendix B of this policy. H. Safety and Security During Emergencies 1. NHC implements internal safety and security operations during emergencies a. Additional Safety and Security Plans are located in the Safety Manual to be used in conjunction with this Plan. b. Other Plans include civil/political disturbances, bomb threats, infant abductions, armed intruders, hazmat spill, chemical or radiological decontamination, mass casualty, evacuation, weather, fire and utility disruptions. 2. When selected emergencies are announced, Security personnel affect a facility lockdown (refer to Lockdown Policy found under Environment of Care/Security) to assure centralized access control and prevent potential building contamination if a hazardous/contagious substance may be involved. 3. At times, movement throughout the facility may need to be limited, traffic may need to be restricted, persons may need to be removed from unauthorized areas, strict parking policies may need to be implemented and the ED/helipad may require open access a. Hospital Security will be responsible for coordinating these events through the ICS system. This may require additional hospital or external agency support. 4. Assignments locations for the Command Center, media, families, staff break area, employee childcare, and alternate treatment areas are posted to facilitate traffic Page 7 of 56

control, supply distribution, and staffing. I. Staff Roles and Responsibilities During Emergencies 1. Routine training in emergency procedures, including drills, facilitates appropriate use of each facility and prepares staff care to for patients in selected emergencies. 2. Department specific one-page check sheets are available for each unit, identifying the roles and responsibilities of staff in those areas. 3. During emergencies, NHC staff is required to wear hospital identification. Command Center personnel wear identifying vests. J. Utilities Management During Emergencies 1. Segregation, multiple redundancies and alternatives are built into the utility systems (i.e., electrical power feed, HVAC, medical gas, phone systems) to minimize the impact of utility disruption. 2. Alternate Sources of utilities can be found in Section 1, Appendix C of this policy. K. Patient and Clinical Support During Emergencies 1. As an integrated healthcare system, NHC can provide care at multiple sites and/or move providers across campuses to maximize triage capabilities and prevent a single facility from being overwhelmed. 2. For mass casualty incidents (Plan D) Triage is performed in the ED. Patients presently in the ED are triaged by the ED Physician and discharged, admitted, or get transferred to Fast Track for completion of care. 3. Clinical and Non-Clinical Resource Assessments are completed during all emergencies, regardless of size or length. a. The Clinical Resource Assessment identifies the total number of patients on the unit, patients who can be discharged or transferred, patients with special or critical needs, and number of staff on unit. b. The Non-Clinical Resource Assessment identifies number of staff on unit, length of time operations can be sustained with current supply inventory, and other special considerations. 4. The medical record is transferred with the patient and under the patients legs. 5. Meds and equipment are transferred with the patient as safe to do so (Medication Administration Record [MAR] is always taken). 6. Local pharmacy and local hospital inventory may be needed. 7. Patient tracking is maintained by Access Services utilizing Meditech, as well as the Emergency Operations Center utilizing HICS Forms. 8. NHC staff is sent with evacuated patients depending on EMS triage/acuity. 9. Patient families are notified of evacuation/transfer by NHC personnel from the alternate care site. 10. Behavioral health staff at BH and AGH, as well as BayRidge Hospital can support the mental or behavioral health issues during an emergency, and can be augmented by Care Coordinators and Pastoral Care Services. 11. Additional resources, internal to NHS and external, could be obtained through the Mental Health Unit of the Incident Command System. L. Recovery 1. The recovery process can be found in Section 1, Appendix D of this policy. Page 8 of 56

VII. VIII. IX. Documentation As described in Section 1, Appendix E, Monitoring & Performance. Orientation/Training Hospital and unit-based orientation upon hire and policy change. Monitoring Emergency Management Committee X. References Page 9 of 56

Section 1, Appendix A Communication Strategies During Emergencies A. Employee & MD Response Employee & MD callback is initiated at the discretion of the NHC Incident Commander in collaboration with the Operations Section Chief, and will be accomplished through individual Department Managers. A pyramid format is utilized to assure timely/uninterrupted response. Accuracy & completeness of callback lists are maintained by the Department Managers. Note: an alternate area of reporting may be necessary & is communicated at the time of the callback. The Meditech sign-on screen, GroupWise/MOX emails and/or rounding will be used to augment communication to in-house staff. B. Supplies, Service and Equipment Following the Incident Command System, NHC Logistics Chief, will maintain a level of supplies (medication, equipment & non-medical) adequate for continuity of operations. If at any time during the emergency there is a predicted diminish in supply quantities, Branch Directors and Service Leaders will work with appropriate vendors and/or other hospitals to increase supply quantities. C. External Authorities The Emergency Operations Center will notify external agencies, as appropriate, when emergency response measures are initiated. A centralized phone listing of all local/state agencies, utility vendors, emergency responders and area healthcare facilities is maintained in the Command Center and Switchboard. A member of the Command Staff (typically the Liaison Officer) collaborates with the On-Scene Incident Commander, or designee, early in the emergency to identify the need for an Administrative or Clinical presence at the scene - to maximize the use of NHC resources/facilities. Two-way radio communication (through Security/Disaster radios with PD or FD) or cell phone is used. Northeast Hospitals is part of Region III EMS & actively participates in city-wide (LEPC, EMP Committees), regional, & state planning activities. In addition, NHC personnel attend MEMA, MDPH, Mass State Police, Mass Department of Fire Services, & Mass Homeland Security training & planning sessions. The Mass Hospital Association is instrumental in augmenting communication & collaboration with state agencies. NHC maintains Mutual-Aid Agreements with the Beverly Fire Department to assist NHC with mass decontamination of patients at Beverly Hospital, and Gloucester Fire Department to assist NHC with mass decontamination of patients at Addison Gilbert Hospital. D. Community Integration Northeast Hospitals functions as a full service community hospital capable of treating many levels of injury. 1. AGH & BH: Receives priority I, II, III (red, yellow, green) casualties. 2. BayRidge: Not routinely included in MCI response. BayRidge Hospital may be considered to receive selected non-medical psychiatric patients depending on emergency. Regional bed availability is conducted through the Massachusetts Department of Public Health Hospital Capacity Website (https://mdph.webeocasp.com/mdph/). Page 10 of 56

C-MED may be useful in identifying Hospitals that are affected by widespread disasters, which is part of the MCI Incident Command model & National Disaster Medical System (NDMS). AGH & BH are registered with NDMS. Multiple alarm and/or mutual aid fire response is activated by the Fire Department Incident Commander based on community resource & PLAN E level of evacuation. Specialty resources (i.e., Mass State Police Bomb Squad, regional HAZMAT Team, NIAT Team, NCMEC) are included in individual response plans, are included in the centralized resource phone list, & are utilized as necessary at the request of the Public Safety jurisdiction of record. During emergencies, communication will be in plain English, using common text and terminology, especially when communicating to external resources and agencies, to eliminate confusion. E. Other Healthcare Organizations Northeast Hospitals will communicate to other regional and state hospitals in a variety of methods to share pertinent information, such as, command structure & phone numbers (Region III), resources and assets that could be shared, and names of patients and deceased individuals, as appropriate. Methods of communicating include: 1. Direct phone contact 2. Unified or Multi-Agency Command 3. Region III DPH 4. Massachusetts Health & Homeland Alert Network (HHAN) 5. Web EOC F. Back-up Communication Systems NHC has a variety of back-up communication systems in place (refer to Plan P Policy for additional details regarding phone outages). Two way Security and Disaster radios are available for select communications. BH is equipped with an emergency back-up phone system installed throughout the hospitals clinical and support areas. The backup system allows internal departmental calls, operator assistance as well as outbound calls and inbound calls. Hospital cell phones and/or personal cell phones may be used. BH & AGH have been issued Government Emergency Telecommunications Service (GETS) cards to be used when unable to complete emergency calls through normal or alternate telecommunications means. AGH, BH, BHD and BRH have HAM Radios installed for redundant external communication. Page 11 of 56

Section1, Appendix B Managing Resources and Assets During Emergencies A. Obtaining Supplies Following the Incident Command System, NHC Logistics Chief, will maintain a level of supplies (medication, equipment & non-medical) adequate for continuity of operations. If at any time during the emergency there is a predicted diminish in supply quantities, Branch Directors and Service Leaders will work with appropriate vendors and/or other hospitals to increase supply quantities. Directors and Leaders will work with the Finance Section regarding reimbursement. B. Staff Support Activities Staff accommodations may be made on-site for selected emergencies (i.e., severe weather), as determined by Senior Leadership. Hospital provided transportation may be provided in certain circumstances. A list of local hotels is also maintained by Logistics Chief for staff/family accommodations. Staff/family is also included community EMP shelter plans. The staff Child Development Center at BH may be used to augment staff childcare needs during a disaster. Staff are encouraged to pre-identify plans for family care, including elderly, children and pet care utilizing the Caring is Preparing All Hazards Employee Preparedness Guidelines located on Northeast Internet Community (NIC). C. Sharing Resources During emergencies, NHC may request additional resources from other local hospitals, vendors, DPH, local EOC's, MEMA, etc. The request for supplies will be on an as identified need, and will be made to agencies by locale, depending on the location, severity and projected length of the incident. Page 12 of 56

Section1, Appendix C Utilities Management During Emergencies A. Utilities Management During Emergencies Segregation, multiple redundancies & alternatives are built into the utility systems (i.e., electrical power feed, HVAC, medical gas, phone systems) to minimize the impact of utility disruption. Alternate Sources of utilities include: Utility Electricity Medical Gas Telecommunications Water HVAC Computer Nurse Call Sewer/Waste Elevators Alternate Sources Generator (red-outlets) Batteryoperated equipment Manual processes (i.e. ambu-bags, handregulated IV drip chambers) Portable O2, suction, air Back-up cylinders of nitrous, nitrogen, CO2 Emergency by-pass (switchboard) Pay phones, cell phones Portable radios Runners Portable bottled water Non-portable: AGH,BH wells, contracted source (tanker truck) Blankets, fans, windows Manual requisitions, forms Hand Bells Sewer disposal companies Stairs Page 13 of 56

Section1, Appendix D Recovery A. Recovery The recovery process is coordinated through ICS & includes the following considerations: 1. Use of alternate care sites until return to full building use (may involve structural integrity - earthquake). 2. Use of temporary utility & central services until full service can be restored. 3. Management of post-incident publicity. 4. Management of patient/family satisfaction concerns. 5. Provision for critical incident stress debriefing (CISD) to employees, emergency responders, casualties, families, community. 6. Capture of employee hours worked - assure accurate/complete payroll 7. Completion of data entry for all patient care activity. 8. Capture of post-incident charges, assuring equipment/supplies are accounted for, replenishing inventory. 9. Return of physical plant to pre-emergency status (trash, ESD services, etc). 10. Finalization of reports to external agencies (insurance company, MDPH, etc). 11. Completion of post-incident critique. Page 14 of 56

Section 1, Appendix E Monitoring and Performance A. Monitoring and Performance The Emergency Operations Plan is tested twice a year, either through drills or in response to an actual event. At least one activation includes an influx of actual or simulated patients. All departments & all sites participate in disaster drills. The facilities that are required to have two exercises/event annually are: Addison Gilbert Hospital BayRidge Hospital Beverly Hospital Facilities designed as Business Occupancy per Life Safety Code are required to have at least one exercise/event annually are: Beverly Hospital at Danvers BH-Cable Center BH Radiology at Liberty Tree BH Radiology at Manchester Hunt Center Wound & Hyperbaric Center Community & EMS agency drill participation is encouraged. At least one exercise a year involves community participation. To the extent possible, common equipment will be purchased and utilized in disaster planning. Drill objectives are identified & approved by the Emergency Management Committee. Objectives may include appropriate activation, timeliness/coordination of response, resource availability, and/or employee knowledge of role. Drills will follow the utilization of ICS. Planned exercises are realistic and related to priority emergencies identified on the HVA for that facility. During planned exercises the following are monitored: 1. Communication within the hospital as well as with response entities outside of the hospital. 2. Resource mobilization and allocation including responders, equipment, supplies, personal protective equipment, and transportation. 3. Safety and security. 4. Staff roles and responsibilities. 5. Utility systems. 6. Patient clinical and support care activities. Critiques are completed for all exercises by a multidisciplinary team, including qualified observers to identify deficiencies and opportunities of improvement. NOTE: external agencies are also included in critique. Results & trends are used to revise the plan as needed. During planned exercises, an individual whose sole responsibility is to monitor performance and who is knowledgeable in the goals of the exercise documents opportunities for improvement. The Emergency Operations Plan is revised in response to critique results. Page 15 of 56

NIMS organizational adoption, command and management, preparedness planning, training, exercises, resource management, and communication and information management activities will be tracked from year to year with a goal of improving overall emergency management capability. An Emergency Management-related PI indicator is identified annually by the Emergency Management Committee. Performance measures are developed through the Emergency Management Committee on an annual basis: 1. Unscheduled activations: incidence & critique results 2. Drills: critique results 3. Verification of community response expectations The Emergency Preparedness (Disaster) Management Plan is evaluated annually by the Emergency Management Committee in terms of its objectives, scope, performance, and effectiveness. The Emergency Manager is responsible for the evaluation in collaborations with the Emergency Management Committee & community emergency personnel. The review is completed at the end of the fiscal year (9/30). Criteria for annual review include: 1. HVA appropriateness 2. Drill frequency 3. Command Center functionality 4. Integration of emergency response across all EOC plans Documentation of Exercises, Pre-planned Events, and Incidents are completed utilizing the Homeland Security Exercise and Evaluation Program (HSEEP). The Six Critical Functions of Emergency Management are monitored and recorded on the Initial Action Plan (HICS Form 201), and as and appendix to the HSSEP document. Page 16 of 56

Section 1, Appendix F Managing the Vulnerable Patient A. Managing the Special Care Patient a. Following a bioterrorism or mass casualty event, anxiety and alarm can be expected from victims with special needs, for example foreign language, geriatrics, obstetrics, pediatric/infants and disabled (deaf, blind, paralysis), and from their families. b. Response plans include health workers (physicians, nurse practitioners, nurses, interpreters, psychologists, social workers and clergy) to address these special needs when developing facilityspecific response plans. c. The following are some points to consider when caring for the victim with special needs. i. Communicate clear, concise information about infections or agents how and if it is transmitted or contagious; what treatment and preventive options currently are available; when prophylactic antibiotics, antitoxin serum or vaccines will be available; and how prophylaxis or vaccines will be distributed, in a format and method a victim with special needs will understand. ii. Provide age appropriate counseling and possible anxiety-reducing medications to victims with special needs and their family members taking into consideration the special care requirements they may need. iii. Provide educational materials in a format they comprehend. iv. Provide home care instructions in a format they comprehend. v. Provide information on quarantine and isolation in a format they comprehend. Information released to the public should be coordinated with local and state health officials taking into consideration the special legal protection afforded victims with special needs. Page 17 of 56

Section 1, Appendix G Hygiene During a Plan W A. Hygiene for Patients a. Drinking water i. A minimum of 2 liters/day per person of potable water is the recommendation. b. Hand Hygiene i. Methods of hand washing that involve standing water are not acceptable. ii. An alcohol gel rinse or foam can provide an effective alternative. c. Bathing i. An alternate to bathing a patient with potable water is bath-in-a-bag. B. Hygiene for Staff a. Drinking water i. A minimum of 2 liters/day per person of potable water is the recommendation. b. Hand Hygiene i. Methods of hand washing that involve standing water are not acceptable. ii. An effective alternative is at the recommendation of the Infection Prevention Department. C. Toilet use during a Plan W a. Toilet use during a Plan W is limited to staff and patients. b. Toilets will need to flushed manually, with a minimum of 2 gallons to ensure enough pressure to flush. Reference: Association or Progressions in Infection Control and Epidemiology, 2005, Chapter 119 Disaster Management Page 18 of 56

Section 2: Plan D (Mass Casualty) External Disaster Table of Contents Page I. Applies To 19 II. Procedures A. Indications 19 B. Activation 19 C. Response 19 D. Roles and Responsibilities 20 E. Triage and Treatment 20 F. Communications 20 G. Supplies and Equipment 20 III. Documentation 21 IV. Orientation/Training 21 V. Monitoring 21 VI. References 21 Appendix A: Clinical Resource Form 22 Appendix B: Non-Clinical Resource Form 23 I. Applies to Addison Gilbert Hospital and Beverly Hospital II. Procedure A. Indications 1. PLAN D is activated when every-day resources must be increased to accommodate a sudden influx of patients 2. Staging a. Stage I less than fifteen (15) casualties BH; less than ten (10) casualties AGH b. Stage II more than fifteen (15) casualties BH; more than ten (10) casualties AGH 3. Casualty Placement a. AGH and BH: Receives Priority I, II, III (red, yellow, green) casualties b. BayRidge: Not routinely included in PLAN D response. BayRidge Hospital may be considered to receive selected non-medical psychiatric patient (s) depending on MCI. c. Beverly Hospital at Danvers: No casualties received. d. Satellites: No casualties received 4. Examples: CBRNE (chemical, biological/infectious, radiological, nuclear, explosive) incidents, fire, plane crash, boat/water incident, earthquake, major trauma B. Activation please see page 5 of this document. C. Response 1. PLAN D response is a process to maximize employee preparedness a. Review PLAN D b. Contact first person on call-back list. c. Create a list of potential discharges, complete the Clinical Resource Assessment Form (attached) and communicate to the Emergency Operations Center d. Review schedule and prepare to cancel elective tests/procedures Page 19 of 56

e. Complete task(s) in process and prepare to fully activate department plan f. Fully activate department plan and callbacks (per stage) g. Prepare patients for discharge h. Work with the Command Center to cancel electives (per stage) i. Non-clinical departments will complete the Non-Clinical Resource Assessment Form (attached) and communicate to the Emergency Operations Center 2. Department managers are responsible to maintain current/accurate callback lists for their departments 3. The Switchboard initiates callback lists for Command Center members and key departments without 24-hour coverage 4. Employee Callback Protocol a. Let phone ring four (4) times b. Go to next call if no answer or if goes to voice mail c. Announce to first person contacted "PLAN D in Effect, Location and stage (if known) d. Keep list of those not contacted D. Roles and Responsibilities 1. A one-page, PLAN D response plan is posted in each department and includes department/job-specific assignments 2. The one-page plan includes assignment locations and phone numbers for key areas needing to be accessed in an MCI 3. Space is assigned for families, patients awaiting discharge, and media by the Operations Section Chief in collaboration with the Facilities Department. E. Triage and Treatment 1. Triage is performed in the ED 2. Patients presently in the ED are triaged by the ED Physician and discharged, admitted, or get transferred to Fast Track for completion of care 3. Non-disaster patients who arrive during PLAN D are triaged using normal operating procedures 4. Treatment areas a. AGH ED and Rehab Department (non-critical) b. BH ED and Fast Track i. Initially, the Red, Yellow and Green Zones will be used for Status I (red), Status II (Yellow), and Status III (Green) patients ii. Other areas may be identified and areas expanded as necessary based upon the event/incident. F. Communication 1. Refer to the Communications Section 1, Appendix B of this policy. G. Supplies and Equipment 1. Lists are maintained by Materials Management, Pharmacy, and Food Service supplies including alternate sources as needed (includes customary distributors, local healthcare facilities, and/or local businesses. III. Documentation A. All casualties are tagged using the SMART tag system B. There are no changes in paperwork during a disaster. A system for rapid-registration is Page 20 of 56

implemented in the Access Services Department. C. Critical Incident Stress Debriefing (CISD) is conducted following PLAN D activations as necessary D. A critique is completed for all PLAN D drills and activations. External agencies are included in the critique. Critiques are reviewed at the Emergency Management and Safety Committees. IV. Orientation/Training Hospital and unit-based orientation upon hire and policy change. V. Monitoring Emergency Management Committee VI. References References Page 21 of 56

Clinical Resource Assessment Form Hospital: Beverly Addison Gilbert BayRidge Other: Department: Person Completing Form: Phone Ext: Date: Time: I. PATIENTS a. How many patients in your department at this time: b. How many patients on your unit could be discharged/transferred: c. Patients on your unit with special/critical resource needs be specific: Patient Name Critical Need or Resource i. ii. iii. II. STAFF a. Number of staff on your unit at this time (by job title): b. Is your Director/Manager on-site or responding to callback: c. Number of staff on your unit/department that can be sent to the Personnel Pool for re-assignment if requested (by job title): d. Internal PLAN E only: List any compromised utility systems (be specific): III. ADDITIONAL IMMEDIATE NEEDS (please list any additional needs of the unit: Please fax to BH Emergency Operations Center at: 978-816-2735 Page 22 of 56

Non-Clinical Resource Assessment Form Hospital: Beverly Addison Gilbert BayRidge Other: Department: Person Completing Form: Phone Ext: Date: Time: IV. STAFF a. Number of staff on your unit at this time (by job title): b. Is your Director/Manager on-site or responding to callback: c. Number of staff on your unit/department that can be sent to the Personnel Pool for re-assignment if requested (by job title): V. RESOURCES: a. How long can you sustain operations with current supplies (continuing at the same rate): b. Special department considerations, conditions, needs: c. Internal Plan E only: List any compromised utility systems (be specific): VI. ADDITIONAL IMMEDIATE NEEDS (Please list any additional needs of the department: Please fax to BH Emergency Operations Center at: 978-816-2735 Page 23 of 56

Section 3: Plan E (Evacuation) Internal Disaster Table of Contents: Page I. Purpose or Intent 24 II. Policy or General Principles 24 III. Definitions 25 IV. Applies To 25 V. In Conjunction with 25 VI. Procedures A. Shelter in Place vs. Evacuation 25 B. Authority to Activate 25 C. Activation 26 D. Response 26 E. Lockdown 26 F. Evacuation Priority 27 G. Evacuation Confirmation 27 H. Patient Evacuation Destination 27 I. Tracking Patients 27 J. Family Notification 28 K. Community Notification and Response 28 L. Alternate Site and Facilities 28 VII. Documentation 28 VIII. Orientation/Training 28 IX. Monitoring 28 X. References 28 I. Purpose or Intent The purpose of this plan is to assure an organized and coordinated response to partial of full evacuation necessitated by either internal disasters or external emergencies. Depending on the severity of the incident, evacuation of patients, visitors and staff might require immediate relocation until a new location/facility is identified or until hospital operations are restored. II. Policy or General Principles A. Potential reasons for/examples of evacuations 1. The need to evacuate can be a result of internal or external incidents or situations 2. Internal incidents may include, but are not limited to: fire, hazardous materials spills, flooding, or utility impairments a. Examples of utility impairments include: electrical distribution failures, generator failures, medical gas disruptions greater than (>) 8 hours, seasonal loss of heat/ac greater than (>) 8 hours, and loss of potable water greater than (>) 24 hours 3. External incidents may include, but are not limited to: earthquakes, flooding, hurricanes, natural disasters, act of terrorism, hazardous material or radiation incidents, loss of public utility systems Page 24 of 56

III. IV. Definitions Complete Evacuation: evacuation of the entire facility resulting in the relocation of all patients, visitors and employees Fire Doors: solid core rated fire doors are located throughout the hospital that are designed to be part of the smoke and fire barrier system. Fire/Smoke Barrier Walls: a continuous barrier, either vertical or horizontal, such as a wall or floor assembly that is designed and constructed with a specified fire rated material to limit the spread of smoke and/or fire. The facility is compartmentalized with rated smoke and fire barriers. Horizontal Evacuation: an evacuation from one smoke compartment to another. Fire doors are the separation points of between compartments and exit ways to the public way. Means of Egress: a continuous and unobstructed way of exit travel from any point in a building or structure to a public way, consisting of three separate and distinct parts: 1. the way of exit access, 2. the exit, and 3. the way of exit discharge. MCI: mass casualty incident Partial Evacuation: an evacuation of certain groups of patients or of certain areas within the facility, resulting in the relocation of patients, visitors and employees from a hospital building/unit or part of a building/unit Self-Closing Fire Door: doors that are equipped with an approved device that will ensure closure after having been opened. Some of the fire doors may be held open magnetically and will automatically shut with the activation of the fire alarm system. During fire alarm activation they must remain closed. Blocking these doors open (or shut) circumvents the system and limits their effectiveness. Shelter in Place: a protective strategy used to maintain patient care by limiting the movement of patients, visitors and employees to protect people and property Vertical Evacuation: an evacuation from one floor/level to another floor/level Applies to all NHC facilities A. BayRidge, Beverly Hospital at Danvers and satellite locations: direct contact with local police/fire is necessary. These locations should contact Hospital AOC as soon as is safe to do so. V. This policy and procedure is to be used in conjunction with all other safety management, department-specific, and site-specific policy and procedure. VI. Procedure A. Shelter In Place VS. Evacuation (Horizontal, Vertical or Complete) 1. During emergencies, the decision to evacuate versus shelter in place must be made. 2. Sheltering in place is the preferred option, unless conditions are such that it is deemed unsafe to have patients, visitors and employees in the area. 3. The decision to evacuate part of the facility, but to also shelter in place in another part of the facility may be made by the NHC Emergency Operations Center in collaboration with the Fire Department Incident Commander. B. Authority to Activate 1. The Emergency Operations Center (EOC) will be activated for emergencies involving the potential need to, or the need to evacuate 2. The EOC will be activated under the direction of the Administrator-on-Call (AOC) and/or Nursing Supervisor, and the decision to evacuate and the level of evacuation will be made by the Incident Commander Page 25 of 56

3. For situations (internal and external) in which evacuation may be/is necessary, and the hospital has forewarning/time, the EOC will be activated to monitor events, determine the extent and timing of evacuation, secure personnel and resources, and initiate a Plan E 4. In situations where there is an immediate threat to life or safety the affected department manager/designee may activate a Plan E. The EOC will then be activated C. Activation 1. Please see page 5 of this policy for activation. D. Response 1. PLAN E response is divided into (3) separate roles as safe to do so: departments with patients, departments who respond to the scene to assist with evacuation and traffic control/entrance restriction 2. A one-page PLAN E response plan is posted in each department and includes department/job-specific assignments. The Department Manager should contact the Nursing Supervisor/Emergency Operations Center for additional resources needed to safely move patients. 3. Initiate "horizontal" evacuation first. 4. Use "vertical" evacuation routes occurs when there are no other options. 5. Stair chairs are utilized to move patients vertically, when elevators are not available and/or at the direction of fire personnel. 6. Clinical staff prioritizes use of portable O2, monitors, and suction as well as preservation of IV lines/medications 7. Be prepared to identify employees and visitors requiring assistance as well as patients 8. A tracking system is established to account for all patients, visitors, and employees. Full Medical Records (as available), Kardexes (if Medical Record is not immediately available) and appointment logs are evacuated with patients. 9. Clinical personnel accompany and stay with their patients until ALL CLEAR is announced. E. Lockdown 1. Once an evacuation has been implemented, the hospital will implement the Lockdown Policy. 2. The Incident Commander, with the assistance of the Operations Section Chief and Medical Care Branch Director will determine the need for and level of divert. 3. The Operations Section Chief or Security Branch Director will contact the local Police Department to assist in Security and traffic control to and from the facility. F. Evacuation Priority 1. The level of evacuation and the order in which units will be evacuated is the decision of the Operations/Planning Section Chief and/or the Incident Commander 2. During an emergency, initial evacuation of persons in immediate danger must take precedence over all other actions 3. Evacuate patients in immediate danger first, followed by ambulatory patients. Appoint a helper to go with them and lead them to the safest part of the same floor. G. Evacuation Confirmation 1. Once a room has been evacuated, medical tape should be used to place a large X on the closed room door 2. Once an entire unit/department has been verified as being fully evacuated, medical tape should be used to place a large X on the closed door(s) to the unit/department Page 26 of 56

3. When units/departments are fully evacuated, the Medical Gas Zone Valves are shut-off by the Charge Nurse, or their designee. H. Patient Evacuation Destination 1. Patients, visitors and employees may be evacuated from their unit/department to an area of refuge (staging area) as a temporary means while the situation is being assessed and appropriate decisions can be made. The Planning Section Chief will track those evacuated to an area of refuge. 2. Areas of refuge (patient staging areas) are pre-designated for complete hospital evacuation. Dependent on the situation at hand, the Logistics Section Chief may have to identify alternate areas of refuge. These are the same areas that patient evacuation would occur during a complete facility evacuation. Addison Gilbert Hospital ambulatory patients can be staged in the Longan and Women s Health Conference Rooms by the Washington Street Entrance, non-ambulatory patients can be staged in the main lobby of the hospital and cafeteria, and emergent/critical patients can be staged in the Emergency Department. BayRidge Hospital all patients are ambulatory and should assemble in the next available smoke/fire compartment or a safe distance from the facility. The outside fenced/gated yard may NOT be used as an area of refuge. Beverly Hospital ambulatory patients can be staged in the hallway and cafeteria near the Cafeteria Parking Lot, non-ambulatory patients can be staged in the main lobby of the hospital, and emergent/critical patients can be staged in the Emergency Department. Beverly Hospital @ Danvers ambulatory patients can be staged in the main waiting area, non-ambulatory patients (surgical patients) should be transferred to Beverly Hospital. 3. The Operations Section Chief would decide where patients would be evacuated internally during a partial evacuation I. Tracking Patients 1. The Planning Section Chief will facilitate patient movement and tracking 2. HICS Forms 254 (Disaster Victim/Patient Tracking Form) and 255 (Master Patient Evacuation Tracking Form) should be used by the Planning Section Chief to track patient movement J. Family Notification 1. Family notification will be made by Access Services staff K. Community Notification and Response 1. Contact and requests to the community for resources is done by the Liaison Officer 2. Multiple alarm and/or mutual aid fire response is activated based on community resource and PLAN E level of evacuation, in collaboration with the Fire Department Incident Commander. 3. Specialty resources such as bomb experts, HAZ MAT teams, etc. are contacted as needed by the on-scene Fire Commander. 4. PLAN E evacuation initiates automatic response by EMS personnel with additional resources and equipment. 5. C-Med coordinates regional bed availability per Massachusetts MCI Incident Command model. L. Alternate Site and Facilities Page 27 of 56