Department of Neonatology
Beth Israel Deaconess Medical Center
Policy and Procedure
Title:
Emergency Preparedness Plan
Policy #:
CL-7
Purpose:
The purpose of this document is to outline the role and responsibilities of the department and its
personnel in the context of the Hospital's Emergency Management plan.
Policy Statement:
A.
The departmental Emergency Management plan and response shall be developed, maintained,
and implemented in accordance with the policies and guidelines in the BIDMC Emergency
Management Plan (Code “Triage”). The department plan shall be reviewed a minimum of every
6 months and submitted to the chair of the Emergency Management Committee.
B.
A fan out list, which includes department primary and secondary contacts as well as employees’
names and 24/7 contact information, shall be maintained and updated as needed, a minimum of
every 6 months. The revised/updated list shall be distributed to the departments designated
callers and the chair of the Emergency Management Committee. During a Code Triage event the
department’s primary and secondary contacts will be notified and requested to activate the
department plan, if necessary.
C.
The Hospital and the departmental Emergency Management Plans shall be reviewed with each
member of the staff upon hire; after any significant change in department responsibilities or
location; and on an annual basis. Documentation of this review shall be recorded for each
physician and/or in the minutes of departmental meetings.
D.
In the event of a Code Triage activation, department manager(s) shall contact, and receive
approval from, the administrator on call (AOC), or their designee, before releasing any on-duty
staff from the Hospital campus. This will ensure that an adequate number of staff are available to
assist as needed.
Guidelines for Implementation:
A.
Staff/Department Responsibilities
The neonatologist on duty in the NICU and the NICU floor marshall shall be the senior person on
duty and in charge of implementation of the emergency preparedness response for the department
of neonatology. These individuals will be responsible for assuring the provision of physician
services to newborns during the emergency response. This will include implementation of the
fan-out call list as well as consultation with the senior persons on duty for newborn nursing and
neonatal respiratory therapy in order to assure adequate staffing.
B.
Fan-Out Call List
See attached template.
C.
Notification/Recall of Employees
In the event of Code Triage activation and the need for staff notification, the following process
shall be followed:
Policy CL-7; Page 1 of 3
During regular working hours:
The neonatologist on duty will be responsible for calling the neonatology office (7-3276) to
determine the availability of the other neonatologists currently in the hospital. If the resources
available within hospital are insufficient, the neonatologist on duty will instruct the department
staff to use the fan-out call list.
During non-regular working hours:
The neonatologist on duty will instruct the NICU unit coordinator to use the fan-out call list in
order to identify the additional physician resources needed for the emergency response.
D.
Work Pool/Assignment Areas/Information Flow During Code Triage Events
Neonatal Intensive Care Unit (RS-9) and Newborn Nurseries (FD-5&6)
1. During regular and non-regular working hours:
NOTE:
a.
The Neonatologist-in-Chief and the Neonatology Administrative Director are
contacted through the Code Triage Paging system at the direction of the AOC.
They will obtain information regarding the nature of the emergency and the
level of response required from the department.
b.
The departmental fan out list shall be initiated by the department’s designated
caller (the NICU unit coordinator(s) and/or Department of Neonatology
administrative support staff) in accordance with the level of response required.
c.
Each staff member contacted shall state his/her estimated time of arrival at the
hospital.
Staff members should not report to the hospital unless specifically instructed to do so.
2. Following a Code Triage response (actual or drill), a completed response
summary/critique form, shall be completed by affected departments and forwarded to
the Environmental Health & Safety Office within twenty-four (24) hours of the disaster.
This information will be included in the summary report and associated follow up action
plan reflecting the effectiveness of the institution's overall response.
E.
Supplies: Material and Equipment
List items that are critical for maintaining department functions. Be sure to include, and
maintain hard copy forms and documents, as well as other supplies in response to electronic
down time.
1.
2.
3.
Departmental inventory: N/A
Hospital inventory: All routine M&S supplies normally delivered to the newborn
units.
Area vendors to contact (prior written agreements required) in case of a supply
shortage/emergency: N/A
Policy CL-7; Page 2 of 3
Appendices:
Hospital Emergency Preparedness Plan – EOC-08
Version:
10/10/01; revised 11/04/04; revised 3/07, revised 4/13/09
Policy CL-7; Page 3 of 3