UTMB RESPIRATORY CARE SERVICES
PROCEDURE - Respiratory Care Services Emergency
Preparedness
Policy 5.1.1
Page 1 of 5
Respiratory Care Services Emergency Preparedness
Effective:
Revised:
Formulated: 05/78
06/01/97
05/31/05
Respiratory Care Services Emergency Preparedness Plan
Purpose
The purpose of the Respiratory Care Service (RCS) Disaster Plan is to
insure that the life supportive services provided to patients by RCS are not
interrupted due to the additional manpower and equipment demands
required during times of disaster whether from severe weather, internal, or
external causes, and that RCS employees are informed as to the extent and
severity of the disaster and that their personal needs are provided for when
necessary in the performance of their duty for the patient and the University
of Texas Medical Branch at Galveston.
Audience
This plan applies to all of the Respiratory Care Services staff.
Scope
 Respiratory Care Services implements departmental disaster
preparedness plans in conjunction with UTMB disaster preparedness
plans to assure appropriate staffing during time of emergency.
 Respiratory Care Services will follow the Hospital Plan as outlined in
the Hospital Plant Technology and Safety Manual (see attached).
 Copies of this manual are located in the directors' office, the
coordinators' office, and in the department.
Procedures
Weather Disaster
The Respiratory Care Services administrator on call, in-house administrator
or medical director can initiate Respiratory Care Service implementation of
the Disaster Plan. The medical director or his designee and the Manager or
designee will determine the extent of Respiratory Care Service
requirements.
Stores of Liquid O2 and O2 and Air Tanks:
 Call General Stores and ask that all O2 and Air cylinders on loading
dock be filled.
 Check with the Physical Plant to affirm full O2 Liquid Oxygen
Reservoir Cryostat tanks.


Call in of Essential Personnel:
Before implementation of disaster plan, the Supervisor will call all
essential personnel and remind them to be on call for duty within two
hours of implementation of disaster plan.
Evacuation
Follow the evacuation routes as established on the Respiratory Care
Services Evacuation Plan. Everyone leaves the area and meets outside in
front of Waverly Smith Pavilion (University Blvd.). Each Supervisor is
responsible for accounting of each employee in his or her section.
Continued next page
UTMB RESPIRATORY CARE SERVICES
PROCEDURE - Respiratory Care Services Emergency
Preparedness
Policy 5.1.1
Page 2 of 5
Respiratory Care Services Emergency Preparedness
Effective:
Revised:
Formulated: 05/78
Procedures
Continued
06/01/97
05/31/05
Return to work when the all clear has been given by the fire marshal
(depending on the situation).
Evacuation
 Follow the evacuation routes as established on the Respiratory Care
Services Evacuation Plan. Everyone leaves the area and meets outside in
front of Waverly Smith Pavilion (University Blvd.). Each Supervisor is
responsible for accounting of each employee in his or her section. The
Program Manager will be responsible for reporting any missing
employees. Return to work when the all clear has been given by the fire
marshal (depending on the situation).
Alternate Evacuation Route
If the regular evacuation route plan cannot be followed because of the
location of the fire, go to the nearest exit and meet the staff at the assembly
point (University Blvd. Entrance to the Waverly Smith Pavilion).
Other Actions in Case of Fire
 Close off oxygen shut-off valves located in the equipment processing
area (middle room), and outside the dispatch office in the main hallway.
 Close all doors; do not lock any doors.
 Turn off electrical equipment such as computers.
 Attempt to extinguish the fire with the fire extinguishers.
If time permits, remove employee files, computer disks, or other valuable
items to a safe area.
Accountability
The RCS Department is divided into 4 areas: Equipment Processing,
Classrooms, Commissary, and Administrative offices. The employee in
charge of each area makes a quick check of the staff present at the time the
alarm sounds in order to account for everyone at the assembly point later.
The Program Manager designates someone to check all occupied space in
his or her assigned areas to verify that everyone is evacuating (this includes
bathrooms, etc.). Any physically challenged individuals will have an
assigned aid to assist them by their respective Supervisor. These individuals
need to be identified at the time of emergency. The Program Manager of
RCS is responsible for accounting for all staff at the assembly point.
Staff/Classroom Area
The appointed Supervisor or the Program Manager must make sure that no
one remains, that the doors are closed, and that the O2 shut off valves are
closed to that area, and directs everyone to the evacuation routes.
Continued next page
UTMB RESPIRATORY CARE SERVICES
PROCEDURE - Respiratory Care Services Emergency
Preparedness
Policy 5.1.1
Page 3 of 5
Respiratory Care Services Emergency Preparedness
Effective:
Revised:
Formulated: 05/78
Accountability
Continued

06/01/97
05/31/05
Personnel not in the area at the time of the fire should be contacted by
beeper if possible, if not a messenger may be sent after everyone has
been accounted for.
When the fire Marshall has given the all clear, it is safe to return to the
area.
Fire Drills
At least once per quarter per shift all personnel must participate in a fire
drill. This does not have to interrupt essential services. All employees of
RCS must be trained in Fire safety. Staff is tested to determine their
knowledge of fire safety. Anyone who does not pass will require retraining.
Fire exit drills are conducted at least once per year to test evacuation
procedures by familiarizing personnel with exits, emergency exits not
normally used, and location of fire fighting equipment
Fire Protection Equipment
Only personnel trained in the use of a portable fire extinguisher should try
to extinguish a fire. Portable fire extinguishers are located throughout RCS.
CO2 fire extinguishers are located in:
 Administrative offices in the copy area.
 The commissary inside the entrance along the west wall.
 Inside the OVP area of the equipment processing areas just inside the
entrance of the 1.200 W. along the east wall.
 Inside the processing room (1.102) along the northeast wall.
Class A and Class B water hose is located along the east wall of the main
hallway between equipment processing area and the nutrition station.
Water hose Location:
 Near the back fore exit door in 1.200.
 Therapist report area: 1.200D alongside the west wall under the bulletin
board.
Fire Alarm Location:
In the main hallway (1.200) along the north wall near the fire exit stairwell.
Oxygen
If the loss affects an entire area, call Physical Plant work control Center at
extension 21568 to activate the emergency Oxygen back-up Manifold
system.
Respiratory Care Services will provide extra Oxygen cylinders to replenish
the back-up system.
Continued next page
UTMB RESPIRATORY CARE SERVICES
PROCEDURE - Respiratory Care Services Emergency
Preparedness
Policy 5.1.1
Page 4 of 5
Respiratory Care Services Emergency Preparedness
Effective:
Revised:
Formulated: 05/78
Procedures
Continued
06/01/97
05/31/05
If Physical Plant is unable to immediately activate, the Supervisor or
designee will dispatch the placement of Oxygen and/or Air Cylinders to the
affected areas. Therapists will set up, connect, and monitor cylinder Gas
Sources in the affected areas.
If Medical Air Vacuum Systems fail:
Contact Physical Plant work control center at 21586 to activate the
Emergency Supply Source. Electrically powered portable suction units may
be obtained through the transportation department for patients in the
affected areas.
Loss of Electrical Power:
Therapists will make sure that all ventilators and other critical devices are
plugged into the red Electrical outlets. These outlets supply Electricity
during general power outages.
Within the RCS department Red Emergency switch plates provide
Emergency lighting.
Telephones Paging Systems
In the event of an impending Emergency, the department will obtain an
appropriate number of communication radios. Supply distribution
technicians and other designees will act as runners.
Computer Down Time
 Electronic Time Capture – Staff will sign in and out using the honor
system. A Supervisor will be present at shift change to verify time
entries.
 Patient Orders will be tracked using the dispatcher log. Calls will be
dispatched by phone. When the computer system recovers, the
information will be transferred to the computerized patient list.
Bomb Threats
Refer to the IHOP Manual for Bomb Threat Procedure and proceed with
evacuation procedures if requested by Hospital authorities.
Hostage Situations
Refer to IHOP Manual for Procedures on Hostage Situations and proceed
with Evacuation procedures if requested by Hospital authorities.
Continued next page
UTMB RESPIRATORY CARE SERVICES
PROCEDURE - Respiratory Care Services Emergency
Preparedness
Policy 5.1.1
Page 5 of 5
Respiratory Care Services Emergency Preparedness
Effective:
Revised:
Formulated: 05/78
References
06/01/97
05/31/05
Institutional Emergency Operations Plan at UTMB
http://www.utmb.edu/emergency_plan/
Institutional Emergency Operations Plan at UTMB
Payroll Business Recovery and Continuity Plan
http://www.utmb.edu/finance/payrollservices/emergencypreparedness/Busin
essContinuityPlan.pdf
Attachments University of Texas Medical Branch Employee Acknowledgement Form