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Disaster Alternate Care Facility Selection Tool

Public Health Emergency Preparedness

This resource was part of AHRQ's Public Health Emergency Preparedness program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.

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Appendix C: Alternate Care Facility Questionnaire (continued)

V. ACF Operations

A. General

1. In retrospect, would you have preferred your ACF to have been administered by a different agency?
      ___  Yes   ___  No
      1a. If yes, why?: _________________________________________________________________
     ______________________________________________________________________________
     ______________________________________________________________________________

2. Was your ACF part of a shelter for otherwise healthy evacuees or was it purely a medical treatment facility?
     ____  Shelter care  ____  Medical treatment facility

3. Was your goal to serve as a place for hospitals to send their patients in order to "decompress" or were you a primary receiving      facility?
     ____  Hospital decompression   ____  Primary receiving facility

4. How did you provide for the daycare needs of workers with young children? ____________________________
      ______________________________________________________________________________________
     ______________________________________________________________________________________
     ______________________________________________________________________________________

5. Did you provide child care for children of patients when there were no family members available?
      ____  Yes     ____  No

6. Did you have any patients being cared for at the intensive care unit level?
      ____  Yes     ____  No

7. Do you think it is reasonable for an ACF to be expected to do so?
     ____  Yes     ____  No

8. If you provided inpatient care, did you have a formal rounds system?
     ____  Yes     ____  No

9. Did you place a limit on the number of visitors/family members?
      ____  Yes     ____  No

10. If you had an inpatient component, did you take for feed and shelter the family/visitors of patients?
      ____  Yes     ____  No

11. Did you integrate any outside State or Federal teams such as Disaster Medical Assistance Teams into your operations?
      ____  Yes     ____  No

12. Were there any lessons learned with regards to doing so?
      ___  Yes   ___  No
     12a. If yes, please elaborate:  _______________________________________________________
      ______________________________________________________________________________

13. Did you allow pets in your facility?
     ____  Yes     ____  No

14. Did you identify any issues with your facility that impaired operations (e.g. inability to control lighting, presence of noise, etc.)?
      ____  Yes     ____  No
      14a.     If yes, please elaborate:  __________________________________________________________
      ___________________________________________________________________________________
     ___________________________________________________________________________________
     ___________________________________________________________________________________

15. Are there any other issues with regards to operations which you would like to share: __________________
     ____________________________________________________________________________________
     ____________________________________________________________________________________
     ____________________________________________________________________________________

B. Patient Care

1. Did patients self-present to your ACF?
      ____  Yes     ____  No

2. In your opinion, should ambulances bring patients directly to the ACF or should they go to the hospital (if available) first?
      ____  Directly to ACF    ____  Hospital first

3. Did you have mental health professionals at your facility?
      ____  Yes     ____  No

4. Did your definition of futility of care change during your operations?
      ___  Yes   ___  No
     4a. If so, what guidelines did you use? ________________________________________________________
      ______________________________________________________________________________________
     ______________________________________________________________________________________

5. Which of the following did you have available to provide care for children?
      ____  Emergency nurses?
      ____  Emergency physicians?
      ____  Family physicians?
      ____  Pediatric emergency physicians?
      ____  Pediatric midlevel practitioners?
      ____  Pediatric nurses?
      ____  Pediatricians?
      ____  Other?
                  Please specify: ___________________________________________________________________

6. Did you provide immunizations at your ACF?
      ____  Yes     ____  No

7. Did you conduct infectious disease surveillance at your ACF?
      ___  Yes   ___  No
     7a. If so, how? ___________________________________________________________________________
      ______________________________________________________________________________________
     _______________________________________________________________________________________

8. Did you have a system for transferring patients who were beyond the capabilities of your ACF to a hospital?
      ____  Yes     ____  No

9. Please indicate any of the following that were utilized in those hospitals to make room for patients transferred from the ACF:
      ____  Early discharge home
     ____  Transfer of hospital patients to the ACF
     ____  Transfer of ICU patients to the ward
     ____  Transfer of hospital patients to another hospital
     9a. What criteria were used in selecting these patients, if known? _____________________________________
     ________________________________________________________________________________________
     ________________________________________________________________________________________

10. Did your ACF specifically take care of populations with special medical needs?
      ___  Yes   ___  No
     10a. If yes, please indicate those populations:
          ____  Dialysis patients
          ____  Mental health patients
          ____  Ventilator patients
          ____  Other (please specify): ________________________________________________________________

11. Are there any groups of patients who should have their own ACF set up in order to concentrate resources and/or expertise?
       ___  Yes   ___  No
       11a. If yes, please specify: ___________________________________________________________________
       ________________________________________________________________________________________
       ________________________________________________________________________________________

12. Given your experience is it reasonable to expect an ACF to care for multiple ventilator-dependent patients?
    ____  Yes     ____  No

13. Are there any other issues with regards to special medical needs populations or patient care in general that you would like to        share? __________________________________________________________________________________
      _________________________________________________________________________________________
      _________________________________________________________________________________________
      _________________________________________________________________________________________

C. Patient Tracking

1. How did you know which patients were currently at your facility? _______________________________________
     ________________________________________________________________________________________
     _________________________________________________________________________________________

2. How did you know where in the facility they were located? ____________________________________________
    _________________________________________________________________________________________
     _________________________________________________________________________________________

3. How did you track the disposition of patients (discharge or transfer)? ___________________________________
    _________________________________________________________________________________________
     _________________________________________________________________________________________
     _________________________________________________________________________________________

4. Had you developed a disaster patient tracking system prior to the event?
     ____  Yes     ____  No

5. How did you keep medical records? ____________________________________________________________
    _________________________________________________________________________________________
    _________________________________________________________________________________________
    _________________________________________________________________________________________

6. Who became the custodian of those records after the event? __________________________________________
     _________________________________________________________________________________________
     _________________________________________________________________________________________
      _________________________________________________________________________________________

7. Did you keep families together or were adult and pediatric patients separated?
      ____  Families kept together  ____  Adult/peds separated

8. Did you separate spouses in order to maintain separation of the sexes?
      ____  Yes     ____  No

9. In your opinion, is it better to keep families together throughout the care process?
      ___  Yes   ___  No
     9a. If yes, how do you maintain patient privacy? ____________________________________________________
     _________________________________________________________________________________________
     _________________________________________________________________________________________
     _________________________________________________________________________________________

VI. ACF Finance

1.  Did you have an active finance section?
     ____  Yes     ____  No

2. What percentage of the operating costs were born by each of the following? (total should equal 100%):
      ____%  Volunteer
      ____%  Charitable donations
      ____%  Institution/Health care system
      ____%  Private corporations
      ____%  Local/Municipal/County
      ____%  State
      ____%  Federal
      ____%  Other (please specify): ________________________________________________________________

3. Did you submit an invoice to the Federal Government in order to be reimbursed for expenses which you accrued during the      operation of your ACF?
      ___  Yes   ___  No
      3a. If so, have you received any reimbursement from them yet?
              ____  Yes     ____  No

4. Are there any "secrets" which you discovered to increase your chances of being reimbursed by the Federal Government:      _________________________________________________________________________________________
     _________________________________________________________________________________________
     _________________________________________________________________________________________
     _________________________________________________________________________________________

5. Did you have any issues of health care workers becoming ill or injured while working at the ACF?
     ____  Yes     ____  No

6. Were there any accompanying workmen's compensation issues that accompanied this?
      ___  Yes   ___  No
     6a. If so, what were they and how did you handle them? _______________________________________________
     _________________________________________________________________________________________
     _________________________________________________________________________________________
     _________________________________________________________________________________________

7. Are there any other issues with regards to finance which you would like to share? __________________________
     _________________________________________________________________________________________
     _________________________________________________________________________________________
     _________________________________________________________________________________________
     _________________________________________________________________________________________
     _________________________________________________________________________________________

Any other comments that would benefit communities that would be setting up an Alternative Care Facility would be very much appreciated: _____________________________________________________________________________________
  ______________________________________________________________________________________________
  _____________________________________________________________________________________________
  _____________________________________________________________________________________________
  _____________________________________________________________________________________________
  _____________________________________________________________________________________________
  ______________________________________________________________________________________________
  _____________________________________________________________________________________________
  _____________________________________________________________________________________________
  _____________________________________________________________________________________________
  ______________________________________________________________________________________________
  _____________________________________________________________________________________________
  _____________________________________________________________________________________________
  _____________________________________________________________________________________________
  ______________________________________________________________________________________________
  _____________________________________________________________________________________________
  _____________________________________________________________________________________________
  _____________________________________________________________________________________________
   ______________________________________________________________________________________________
  _____________________________________________________________________________________________
  _____________________________________________________________________________________________
  _____________________________________________________________________________________________

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Part 2: Comments on the Alternate Care Facility Selection Tool

In the table below, you will find the complete list of the various factors that were originally selected for inclusion in the Alternate Care Facility (ACF) Selection Tool.

  • The first column lists the specific factors as found in the tool.
  • The second column provides an explanation of the intent/definition for that factor.
  • In the third column we are asking that you please rate the importance of that factor in making a decision regarding the selection of a site for one of two types of ACF, the first being for providing "clinic" type ambulatory medical care at a shelter housing displaced persons and the second being at an ACF providing in-patient level care (as well as ambulatory care), using the following rating system:
3 – this factor is an essential component for selecting a site for an ACF
2 – this factor is of moderate importance for selecting a site for an ACF
1 – this factor is of minor importance for selecting a site for an ACF
0 – this factor is unnecessary for selection of a site for an ACF
ACF Selection Tool Factor Explanation/Definition Rating
(please circle)
Infrastructure   Shelter Care ACF
In-Patient
and
Ambulatory
Care
Doors/corridors adequate size for gurneys This factor evaluates the width of the doorways to allow for passage of gurneys and stretchers. 3    2    1    0 3    2    1    0
Floors This factor evaluates the nature of the floor in the proposed site and whether or not it is acceptable for use for gurneys and stretchers. 3    2    1    0 3    2   1    0
Loading dock This factor evaluates whether or not there is a loading dock available for use to deliver supplies, equipment and patients as well as pickup patients needing transfer away from the ACF. 3    2    1    0 3    2    1    0
Parking for staff and visitors This factor evaluates whether or not there is adequate parking for staff personnel and visitors. 3    2    1    0 3    2    1    0
Roof This factor evaluates whether or not there is a roof on the proposed ACF site and its’ integrity to protect the housed staff and patients. 3    2    1    0 3    2    1    0
Toilet facilities/showers (#) This factor evaluates if there is adequate toilet and shower capability and capacity. 3    2    1    0 3    2    1    0
Ventilation This factor evaluates if there is adequate ventilation in the proposed ACF site. 3    2    1    0 3    2    1    0
Walls This factor evaluates if there are adequate side walls for the protection of staff and patients. 3    2    1    0 3    2    1    0
Additional Infrastructure Factors:      
    3    2    1    0 3    2    1    0
    3    2    1    0 3    2    1    0
    3    2    1    0 3    2    1    0
Total Space and Layout      
Auxiliary spaces (Rx, counselors, chapel) This factor evaluates if there is adequate space in the proposed site to permit designated area for patient treatment and procedures, counseling and chapel. 3    2    1    0 3    2    1    0
Equipment/supply storage area This factor evaluates if there is adequate space in the proposed site for equipment/supply cache and storage. 3    2    1    0 3    2    1    0
Family area This factor evaluates if there is adequate space for relatives/family/friends to gather. 3    2    1    0 3    2    1    0
Food supply and prep area This factor evaluates if the proposed site has adequate food preparation capability and supply. 3    2    1    0 3    2    1    0
Lab specimen handling area This factor evaluates if the proposed site has adequate space to provide a lab specimen handling area. 3    2    1    0 3    2    1    0
Mortuary holding area This factor evaluates if the proposed site has an area that can be used as a mortuary holding area. 3    2    1    0 3    2    1    0
Patient decontamination areas This factor evaluates if the proposed site has facilities that could be used for patient/victim decontamination. 3    2    1    0 3    2    1    0
Pharmacy area This factor evaluates if there is adequate space that could be used as a pharmacy area. 3    2    1    0 3    2    1    0
Staff areas This factor evaluates if there is adequate space that could be used for staff rest and rehab. 3    2    1    0 3    2    1    0
Additional Space/Layout Factors:      
    3    2    1    0 3    2    1    0
    3    2    1    0 3    2    1    0
    3    2    1    0 3    2    1    0
Utilities      
Air conditioning This factor evaluates if the proposed ACF site has air conditioning capability (if needed). 3    2    1    0 3    2    1    0
Electrical power (backup?) This factor evaluates if the proposed site has adequate electrical power as well as a backup electrical power source. 3    2    1    0 3    2    1    0
Heating This factor evaluates if the proposed site has adequate heating capability (if needed). 3    2    1    0 3    2    1    0
Lighting This factor evaluates if the proposed site has adequate lighting to provide for patient care needs and treatment. 3    2    1    0 3    2    1    0
Refrigeration This factor evaluates if there is adequate refrigeration capability, both for food as well as lab specimen storage. 3    2    1    0 3    2    1    0
Water (hot?) This factor evaluates if there is adequate water supply (in general) as well as hot water. 3    2    1    0 3    2    1    0
Additional Utility Factors:      
    3    2    1    0 3    2    1    0
    3    2    1    0 3    2    1    0
    3    2    1    0 3    2    1    0
Communication      
Communication(# phones, local/long distance, intercom) This factor evaluates if there is adequate telephone communications capability (in terms of numbers of phones, phone lines, and both local and long distance) as well as internal site communication such as intercom capability. 3    2    1    0 3    2    1    0
Two-way radio capability to main hospital This factor evaluates if the proposed site can accommodate radio communication from the site to receiving hospitals. 3    2    1    0 3    2    1    0
Wired for IT and internet access This factor evaluates if the proposed site is wired for IT and internet access. 3    2    1    0 3    2    1    0
Additional Communication Factors:      
    3    2    1    0 3    2    1    0
    3    2    1    0 3    2    1    0
    3    2    1    0 3    2    1    0
Other Services      
Ability to lock down facility This factor evaluates the ability for the proposed ACF site to be secured and locked down (if necessary). 3    2    1    0 3    2    1    0
Accessibility/proximity to public transportation This factor evaluates the accessibility of and proximity to public transportation of the proposed ACF site. 3    2    1    0 3    2    1    0
Biohazard and other waste disposal This factor evaluates the capacity of the proposed site for appropriate management of biohazard and other medical waste disposal. 3    2    1    0 3    2    1    0
Laundry This factor evaluates the capacity and capability of the proposed site to launder dirty linens. 3    2    1    0 3    2    1    0
Ownership/other uses during disaster This factor evaluates the ownership of the proposed facility, the ease with which the facility can be obtained for use as an ACF and whether or not the site is slated for other uses in the event of a mass casualty incident. 3    2    1    0 3    2    1    0
Oxygen delivery capability This factor evaluates the capability of the proposed site to provide oxygen to patients. 3    2    1    0 3    2    1    0
Proximity to main hospital This factor evaluates the proximity of the proposed site to referral hospitals. 3    2    1    0 3    2    1    0
Additional "Other Services" Factors:      
    3    2    1    0 3    2    1    0
    3    2    1    0 3    2    1    0
    3    2    1    0 3    2    1    0

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