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<p><strong>You Are Here:</strong> <span class="crumb_link"><a href="/" class="crumb_link">AHRQ Archive Home</a> > <a href="/prep/" class="crumb_link">Public Health Preparedness Archive</a> > <a href="." class="crumb_link">Tool for Evaluating Core Elements of Hospital Disaster Drills</a> > Modules and Addenda (continued)</span></p>
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<tr>
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<td height="30px"><span class="title"><a name="h1" id="h1"></a>Tool for Evaluating Core Elements of Hospital Disaster Drills</span></td>
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</tr>
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<tr>
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<td><div id="centerContent"><p><strong>Public Health Emergency Preparedness</strong></p> <div class="headnote">
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<p>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.</p>
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<!-- <p>Now this resource is supported by the <a href="http://emergency.cdc.gov/">Centers for Disease Control and Prevention</a> (CDC).</p> -->
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<p>This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: <a href="https://info.ahrq.gov/">https://info.ahrq.gov</a>. Let us know the nature of the problem, the Web address of what you want, and your contact information. </p>
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<p>Please go to <a href="https://www.ahrq.gov/">www.ahrq.gov</a> for current information.</p></div>
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<a name="triage" id="triage"></a>
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<h3>Triage Zone Module</h3>
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<p><strong>Note</strong>: Circle or check as indicated. Y=Yes; N=No; U=Unclear; NA=Not applicable</p>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td><p>Observer: _________________________________________ Date: ____/____/_______</p>
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<p>Observer title: ____________________________________________________________</p>
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<p>Hospital: ________________________________________________________________</p>
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<p>Period of time of evaluation: ______ AM/PM (<strong>Circle one</strong>.) to _____ AM/PM (<strong>Circle one.</strong>)</p></td>
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</tr>
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</table>
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<p><strong>1. Time Points</strong></p>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td><p><strong>1a. Did the drill start on time?</strong> Y / N / U</p>
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<p>Comments:</p></td>
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</tr></table>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td>1b. Time the drill began: <strong>(Circle one.)</strong> ______ AM / PM / U</td>
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</tr></table>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td>1c. Time this zone was ready to accept victims: <strong>(Circle one.)</strong> ______ AM / PM / U</td>
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</tr>
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</table>
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<p><strong>Zone Description</strong></p>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td><p><strong>2a. Were the zone boundaries clearly defined?</strong> Y / N / U</p>
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<p>Comments:</p></td>
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</tr></table>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td><p>2b. How was the boundary for this zone defined? <strong>(Check all that apply.)</strong></p>
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<p>a. ___ Barricade(s) b. ___ Sign(s) c. ___ Tape</p>
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<p>d. ___ Wall(s) e. ___ No boundary f. ___ Other (specify): _________________</p></td>
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</tr>
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</table>
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<p><strong>3. Personnel</strong></p>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td><p><strong>3a. Did someone assume command of this zone?</strong> Y / N / U</p>
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<p>Comments:</p></td></tr>
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</table>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td><p>3b. Was staffing for the triage zone adequate? Y / N / U</p>
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<p>Comments:</p></td></tr>
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</table>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td><p>3c. How many minutes after the drill activities in this zone commenced did the incident commander assume command of the zone? (<strong>Check one</strong>.)</p>
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<p>___ <10 min ___ 10 - 29 min ___ 30 - 59 min</p>
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<p>___ 1 - 2 hrs ___ >2 hrs ___ NA</p>
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<p>___ No one took charge. </p></td>
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</tr>
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</table>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td><p>3d. Were the following drill participants identifiable?</p>
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<p>a. Person in charge Y / N / U / NA b. Drill evaluators Y / N / U / NA</p>
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<p>c. Drill organizers Y / N / U / NA d. Media Y / N / U / NA</p>
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<p>e. Medical personnel Y / N / U / NA f. Mock victims Y / N / U / NA</p>
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<p>g. Observers Y / N / U / NA h. Security Y / N / U / NA</p>
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</td>
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</tr>
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</table>
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<p><strong>4. Zone Operations</strong></p>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td><p><strong>4a. Did the triage area function efficiently? </strong>Y / N / U</p>
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<p>Comments:</p></td>
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</tr>
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</table>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td>4b. Was the hospital disaster plan followed? Y / N / U / Partially / No plan</td>
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</tr>
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</table>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td><p>4c. If not followed, what were the reason(s)? (<strong>Check all that apply.</strong>)</p>
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<p>a. ___ Not available b. ___ Too complex</p>
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<p>c. ___ Not relevant to drill d. ___ Participants unfamiliar with plan</p>
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<p>e. ___ Too hard to access f. ___ Other (specify): ___________________________________</p></td>
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</tr>
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</table>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td><p>4d. If the hospital disaster plan was available, what was its format? (<strong>Check all that apply.</strong>)</p>
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<p>a. ___ Complete manual b. ___ Flow diagram c. ___ Job action sheets</p>
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<p>d. ___ No disaster plan e. ___ Other (specify): __________________________________</p></td>
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</tr>
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</table>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td><p>4e. Was the space allocated for the zone adequate? Y / N / U</p></td>
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</tr>
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</table>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td> <p>4f. If victims were screened for biological, chemical, or radiological exposure, how were they screened? (<strong>Check all that apply</strong>.)</p>
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<p>a. ___ Personal interview b. ___ Physical examination c. ___ Screening device (e.g., radiation or chemical detector)</p>
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<p>d. ___ Not screened e. ___ NA f. ___ Other (specify): ______________</p></td>
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</tr>
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</table>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td><p>4g. Did a bottleneck develop in this zone? Y / N / U</p>
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<p><strong>If a bottleneck did develop, describe in the comment box at the end of this module.</strong></p></td>
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</tr>
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</table>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td>4h. If triage occurs after decontamination, did any contaminated victims enter this zone? Y / N / U / NA</td>
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</tr>
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</table>
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<p><strong>5. Victim Documentation and Tracking:</strong></p>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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</table>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td><p><strong>5a. Were all incoming victims registered and given a unique identification or medical record number?</strong> Y / N / U</p>
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<p>Comments:</p>
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<p> </p><p> </p></td>
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</tr>
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</table>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td><p>5b. When were incoming victims registered and given a unique identification or medical record number? (<strong>Check one.</strong>)</p>
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<p>___ Before entering this zone ___ On entering this zone</p>
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<p>___ Not while in this zone ___ Unclear</p></td>
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</tr>
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</table>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td><p>5c. What was the method of documenting the victim record in this zone? (<strong>Check all that apply.</strong>)</p>
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<p>a. ___ Computer entry b. ___ Data card(s) attached to victims</p>
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<p>c. ___ Scanner d. ___ Separate victim paper chart</p>
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<p>e. ___ No documentation f. ___ Other (specify): ________________________________</p>
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</td>
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</tr>
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</table>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td>5d. Were clearly visible triage levels identified for each patient prior to leaving the triage area? Y / N / U / NA</td>
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</tr>
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</table>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td>5e. Was information about victims' prior field interventions accessible to caregivers? Y / N / U / NA</td>
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</tr>
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</table>
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<p><strong>6. Communications</strong></p>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td><p><strong>6a. Were communications effective?</strong> Y / N / U</p>
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<p>Comments:</p></td>
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</tr>
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</table>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
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<tr>
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<td>Were the following communications devices used in the drill for internal or external communications? (<strong>Check all that apply.</strong>)</td>
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</tr>
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<tr><td>
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<table cellspacing="0" cellpadding="8" border="1" width="99%">
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<tr><th scope="col">Communications Device</th>
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<th scope="col">A. Used</th>
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<th scope="col">B. Comments (Note strengths and weaknesses.)</th>
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</tr>
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<tr>
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<td scope="row">6b. 2-way radio/phone(s)</td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td scope="row">6c. Landline phone(s) </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td scope="row">6d. Cell phone(s) </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td scope="row">6e. Personal data assistant(s) (PDA) </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td scope="row">6f. Numeric paging </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td scope="row">6g. Overhead paging</td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td scope="row">6h. Text paging</td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td scope="row">6i. E-mail/Internet/network </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td scope="row">6j. Fax machine(s) </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td scope="row">6k. Intercom </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td scope="row">6l. Megaphone(s) </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td scope="row">6m. Runner(s) </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td scope="row">6n. Satellite phone(s)</td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td scope="row">6o. Emergency radio </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td scope="row">6p. Ham radio </td>
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<td> </td>
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<td> </td>
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</tr>
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<tr>
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<td scope="row"><p>6q. Other (specify): _________________ </p></td>
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<td> </td>
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<td> </td>
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</tr>
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</table></td>
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</tr>
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</table>
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<p>7<strong>. Information Flow</strong></p>
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<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p><strong>7a. Was necessary information received?</strong> Y / N / U</p>
|
|
|
|
<p>Comments:</p></td>
|
|
</tr>
|
|
<tr></tr></table><table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td> 7b. Did your zone receive updates regarding the situation outside the hospital (e.g. status of disaster events, number of victims arriving, acuity of victims)? Y / N / U</td>
|
|
</tr>
|
|
</table><table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>7c. How was this zone kept aware of the ongoing general situation within the hospital? (<strong>Check all that apply.</strong>)</p>
|
|
|
|
<p>___ Call from incident command ___ Fax from incident command</p>
|
|
<p>___ Other contact from incident command ___ Runner(s) from incident command </p>
|
|
<p>___ Contact from other internal sources (specify): ________________________________ </p></td>
|
|
</tr>
|
|
</table>
|
|
|
|
<p><strong>8. Security</strong></p>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p><strong>8a. Were entrances and exits strictly controlled in this area?</strong> Y / N / U</p>
|
|
|
|
<p>Comments:</p><p> </p><p> </p></td>
|
|
</tr>
|
|
</table><table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>8b. Did any of the following security issues arise in this zone? (<strong>Check all that apply</strong>)</p>
|
|
|
|
<p>a. ___ Crowd control b. ___ Media control</p>
|
|
|
|
<p>c. ___ Unruly victims d. ___ Other (specify): _________________________________</p>
|
|
</td>
|
|
</tr>
|
|
</table><table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td>8c. Were security personnel present in this zone? Y / N / U</td>
|
|
</tr>
|
|
</table>
|
|
|
|
<p><strong>9. Personal Protective Equipment (PPE) and Safety:</strong></p>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p><strong>9a. Was an appropriate supply of PPE available?</strong> Y / N / U</p>
|
|
|
|
<p>Comments:</p><p> </p><p> </p></td>
|
|
</tr>
|
|
</table><table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>9b. Was the PPE applied correctly? Y / N / U</p>
|
|
|
|
<p>Comments:</p><p> </p><p> </p></td>
|
|
</tr>
|
|
</table><table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr><td><p>If needed, were these items for standard precautions available for the healthcare workers?</p>
|
|
<p><strong>If safety materials were not available, circle "N" in column "A" and go to the next row.</strong></p></td>
|
|
</tr> <tr><td><table cellspacing="0" cellpadding="8" border="1" width="99%">
|
|
<tr>
|
|
</tr><tr align="left">
|
|
<th scope="col">Safety material</th>
|
|
<th scope="col">A. Available?</th>
|
|
<th scope="col">B. Used by staff?</th>
|
|
<th scope="col">C. Adequate supply?</th>
|
|
<th scope="col">D. Problems with use? (e.g., donning)</th>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">9c. Face shields/masks </td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">9d. Waterproof gowns </td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">9e. Isolation gowns </td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">9f. Gloves </td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">9g. Passive (negative pressure) filtration (e.g., N95 or N99 masks) </td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">9h. Respirators (e.g., powered air purifying respirator) </td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">9i. Other (specify): _______________ </td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
</tr></table></td>
|
|
</tr>
|
|
</table></div></td>
|
|
</tr>
|
|
</table><table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr><td>9j. Were instructions available regarding appropriate donning and removal of PPE? Y / N / U</td>
|
|
</tr>
|
|
</table><table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr><td><p>9k. If available, in what format were they? (<strong>Check all that apply</strong>).</p>
|
|
|
|
<p>a. ___ Verbal instructions by staff b. ___ Poster(s) c. ___ Written instruction(s)</p>
|
|
|
|
<p>d. ___ Video e. ___ Other (specify): ___________________________</p></td>
|
|
</tr>
|
|
</table>
|
|
|
|
<p><strong>10. Equipment and Supplies</strong></p>
|
|
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p><strong>10a. Were there appropriate quantities of medical supplies?</strong> Y / N / U</p>
|
|
|
|
<p>Comments:</p><p> </p><p> </p></td>
|
|
</tr>
|
|
</table><table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr><td><p>Were these medical supplies available?</p>
|
|
<p><strong>If the medical supplies were not available, circle "N" in column "A" and go to the next row.</strong></p></td>
|
|
</tr><tr><td> <table cellspacing="0" cellpadding="8" border="1" width="99%">
|
|
<tr align="left">
|
|
<th scope="col" width="40%">Medical Supply</th>
|
|
<th scope="col">A. Available</th>
|
|
<th scope="col">B. Issues</th>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">10b. Alcohol-based hand cleaner</td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">10c. Bandages</td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">10d. Basic airway equipment</td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">10e. Blood pressure equipment </td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">10f. Oxygen masks</td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">10g. Oxygen tanks</td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">10h. Stethoscopes</td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td>10i. Stretchers</td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td>10j. Suction equipment</td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td>10k. Vascular access supplies (catheters, fluids, etc)</td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td>10l. Wheelchairs</td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td>10m. Other (specify): _______________</td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
</table>
|
|
</td>
|
|
</tr>
|
|
</table>
|
|
<p> </p>
|
|
|
|
<table width="95%" cellspacing="0" cellpadding="8" border="1">
|
|
<tr valign="top">
|
|
<td height="100"><strong>Comments (If referring to a specific item, give the item number.)</strong>
|
|
<p> </p><p> </p></td>
|
|
</tr>
|
|
</table>
|
|
|
|
<p class="size2"><a href="index.html#contents">Return to Contents</a></p>
|
|
|
|
<a name="treat" id="treat"></a>
|
|
<h3>Treatment Zone Module</h3>
|
|
<p><strong>Instructions:</strong> This form can be used in the Emergency Department, and in medical and surgical care areas.<br />
|
|
<strong>Note</strong>: Circle or check as indicated. Y=Yes; N=No; U=Unclear; NA=Not applicable</p>
|
|
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>Observer: _________________________________________ Date: ____/____/_______</p>
|
|
|
|
<p>Observer title: ______________________________________________________________________</p>
|
|
|
|
<p>Hospital: __________________________________________________________________________</p>
|
|
|
|
<p>Period of time of evaluation: ______ AM/PM (<strong>Circle one</strong>.) to _____ AM/PM (<strong>Circle one.</strong>)</p></td>
|
|
</tr>
|
|
</table>
|
|
|
|
<p><strong>1. Time Points</strong></p>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p><strong>1a. Did the drill start on time?</strong> Y / N / U</p>
|
|
<p>Comments:</p><p> </p><p> </p></td>
|
|
</tr></table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td>1b. Time the drill began: (<strong>Circle one.</strong>) ______ AM / PM / U</td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td>1c. Time this zone was ready to accept victims: <strong>(Circle one.)</strong> ______ AM / PM / U</td>
|
|
</tr>
|
|
</table>
|
|
|
|
<p><strong>Zone Description</strong></p>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p><strong>2a. Were the zone boundaries clearly defined?</strong> Y / N / U</p>
|
|
<p>Comments:</p><p> </p><p> </p></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>2b. What type of unit is this zone during regular hospital functioning? <strong>(Check all that apply.)</strong></p>
|
|
|
|
<p>a. ___ Emergency Department (ED) b. ___ Intensive Care (ICU)</p>
|
|
<p>c. ___ Medical Inpatient d. ___ Medical Outpatient</p>
|
|
<p>e. ___ Surgical Inpatient f. ___ Surgical Outpatient</p>
|
|
<p>g. ___ Other (specify): _______________________________________________________</p></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td>2c. Were actual patients treated in the drill treatment area (along with mock victims)? Y / N / U</td>
|
|
</tr>
|
|
</table>
|
|
|
|
<p><strong>3. Personnel</strong></p>
|
|
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p><strong>3a. Did someone assume command of this zone?</strong> Y / N / U</p>
|
|
<p>Comments:</p><p> </p><p> </p></td></tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>3b. Was staffing of the treatment zone adequate? Y / N / U</p>
|
|
<p>Comments:</p><p> </p><p> </p></td></tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>3c. How many minutes after the drill activities in this zone commenced did someone assume command of the zone? (<strong>Check one</strong>.)</p>
|
|
|
|
<p>___ <10 min __ 10 - 29 min ___ 30 - 59 min ___ 1 - 2 hrs ___>2 hrs ___ NA</p>
|
|
|
|
<p>___ No one took charge.</p></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>3d. Were the following drill participants identifiable?</p>
|
|
|
|
<p>a. Drill evaluators Y / N / U / NA b. Drill organizers Y / N / U / NA</p>
|
|
<p>c. Media Y / N / U / NA d. Medical personnel Y / N / U / NA</p>
|
|
|
|
<p>e. Mock victims Y / N / U / NA f. Observers Y / N / U / NA</p>
|
|
|
|
<p>g. Security Y / N / U / NA</p>
|
|
</td>
|
|
</tr>
|
|
</table>
|
|
|
|
<p><strong>4. Zone Operations</strong></p>
|
|
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p><strong>4a. Did the treatment area function efficiently? </strong>Y / N / U</p>
|
|
|
|
<p>Comments:</p><p> </p><p> </p></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td>4b. Was the hospital disaster plan followed? Y / N / U / Partially / No plan</td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>4c. If not followed, what were the reason(s)? (<strong>Check all that apply.</strong>)</p>
|
|
|
|
<p>a. ___ Not available b. ___ Too complex</p>
|
|
|
|
<p>c. ___ Not relevant to drill d. ___ Participants unfamiliar with plan</p>
|
|
|
|
<p>e. ___ Too hard to access f. ___ Other (specify): ___________________________________</p></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>4d. If the hospital disaster plan was available, what was its format? (<strong>Check all that apply.</strong>)</p>
|
|
|
|
<p>a. ___ Complete manual b. ___ Flow diagram c. ___ Job action sheets</p>
|
|
|
|
<p>d. ___ No disaster plan e. ___ Other (specify): ____________________________________</p></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>4e. Was the space allocated for the zone adequate? Y / N / U</p>
|
|
<p><strong>If space allocated was not adequate, specify in comment box at end of this module.</strong></p></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>4f. Did a bottleneck develop in this zone? Y / N / U</p>
|
|
<p><strong>If a bottleneck did develop, describe in the comment box at the end of this module.</strong></p></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>4g. How were victims managed who were not previously triaged? (<strong>Check one.</strong>)</p>
|
|
|
|
<p> ___ Sent back to triage zone ___ Sent to another area (specify): ________________________</p>
|
|
|
|
<p>___ Triaged in this zone ___ Treated without being triaged</p></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td>4h. Did all victims have disposition decisions made at drill termination? Y / N / U / NA</td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td>4i. Did any contaminated victims enter this zone? Y / N / U / NA</td>
|
|
</tr>
|
|
</table>
|
|
|
|
<p><strong>5. Victim Documentation and Tracking</strong></p>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p><strong>5a. Were all incoming victims registered and given a unique identification or medical record number?</strong> Y / N / U</p>
|
|
|
|
<p>Comments:</p><p> </p><p> </p></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>5b. When were all incoming victims registered and given a unique identification or medical record number? (<strong>Check one.</strong>)</p>
|
|
|
|
<p>___ Before entering this zone ___ On entering this zone</p>
|
|
|
|
<p>___ Not while in this zone ___ Unclear</p></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>5c. What was the method of documenting the victim record in this zone? (<strong>Check all that apply.</strong>)</p>
|
|
|
|
<p>a. ___ Computer entry b. ___ Data card(s) attached to victims</p>
|
|
|
|
<p>c. ___ Dictation system d. ___ Personal data assistant (PDA)</p>
|
|
|
|
<p>e. ___ Scanner f. ___ Separate victim paper chart</p>
|
|
|
|
<p>g. ___ No documentation h. ___ Expedited registration</p>
|
|
|
|
<p>i. ___ Other (specify): ________________________________</p>
|
|
</td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td>5d. Were triage designations for each patient clearly visible upon entry into the treatment area? Y / N / U / NA</td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td>5e. Was information about victims' prior field interventions accessible to caregivers? Y / N / U / NA</td>
|
|
</tr>
|
|
</table>
|
|
|
|
|
|
<p><strong>6. Communications</strong></p>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p><strong>6a. Were communications effective?</strong> Y / N / U</p>
|
|
<p>Comments:</p></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td>Were the following communications devices used in the drill for internal or external communications? (<strong>Check all that apply.</strong>)</td>
|
|
</tr>
|
|
<tr><td>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="99%">
|
|
<tr><th scope="col">Communications Device</th>
|
|
<th scope="col">A. Used</th>
|
|
<th scope="col">B. Comments (Note strengths and weaknesses.)</th>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">6b. 2-way radio/phone(s)</td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">6c. Landline phone(s) </td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">6d. Cell phone(s) </td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">6e. Personal data assistant(s) (PDA) </td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">6f. Numeric paging </td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">6g. Overhead paging</td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">6h. Text paging</td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">6i. E-mail/Internet/network </td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">6j. Fax machine(s) </td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">6k. Intercom </td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">6l. Megaphone(s) </td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">6m. Runner(s) </td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">6n. Emergency radio </td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">6o. Ham radio </td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">6p. Satellite phones </td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row"><p>6q. Other (specify): _________________ </p></td>
|
|
<td> </td>
|
|
<td> </td>
|
|
</tr>
|
|
</table></td>
|
|
</tr>
|
|
</table>
|
|
|
|
<p>7<strong>. Information Flow</strong></p>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td scope="row"><p><strong>7a. Was necessary information received?</strong> Y / N / U</p>
|
|
|
|
<p>Comments:</p><p> </p><p> </p></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td>7b. Did your zone receive updates regarding the situation outside the hospital (e.g. status of disaster events, number of victims arriving, acuity of victims)?<br /> Y / N / U</td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>7c. How was this zone kept aware of the ongoing general situation within the hospital? (<strong>Check all that apply.</strong>)</p>
|
|
|
|
<p>a. ___ Call from incident command b. ___ Fax from incident command</p>
|
|
<p>c. ___ Other contact from incident command d. ___ Runner(s) from incident command </p>
|
|
<p>e. ___ Contact from other internal sources (specify): _________________________________________ </p></td>
|
|
</tr>
|
|
</table>
|
|
|
|
<p><strong>8. Security</strong></p>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p><strong>8a. Were entrances and exits strictly controlled in this area?</strong> Y / N / U</p>
|
|
|
|
<p>Comments:</p><p> </p><p> </p></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>8b. Did any of the following security issues arise in this zone? (<strong>Check all that apply</strong>)</p>
|
|
|
|
<p>a. ___ Crowd control b. ___ Media control</p>
|
|
|
|
<p>c. ___ Unruly victims d. ___ Other (specify): _________________________________</p>
|
|
</td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td>8c. Were security personnel present in this zone? Y / N / U</td>
|
|
</tr>
|
|
</table>
|
|
|
|
<p><strong>9. Personal Protective Equipment (PPE) and Safety:</strong></p>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p><strong>9a. Was an appropriate supply of PPE available?</strong> Y / N / U</p>
|
|
|
|
<p>Comments:</p></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>9b. Was the PPE applied correctly? Y / N / U</p>
|
|
|
|
<p>Comments:</p><p> </p><p> </p></td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td>If needed, were these items for standard precautions available for the healthcare workers?
|
|
<p><strong>If safety materials were not available, circle "N" in column "A" and go to the next row.</strong></p></td></tr><tr><td>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="99%">
|
|
<tr align="left">
|
|
<th scope="col">Safety material</th>
|
|
<th scope="col">A. Available?</th>
|
|
<th scope="col">B. Used by staff?</th>
|
|
<th scope="col">C. Adequate supply?</th>
|
|
<th scope="col">D. Problems with use? (e.g., donning)</th>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">9c. Face shields/masks </td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">9d. Waterproof gowns </td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">9e. Isolation gowns </td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">9f. Gloves </td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">9g. Passive (negative pressure) filtration (e.g., N95 or N99 masks) </td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">9h. Respirators (e.g., powered air purifying respirator) </td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">9i. Other (specify): _______________ </td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
<td>Y / N / U</td>
|
|
</tr>
|
|
|
|
</table></td>
|
|
</tr>
|
|
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td>9j. Were instructions available regarding appropriate donning and removal of PPE? Y / N / U</td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>9k. If available, in what format were they? (<strong>Check all that apply</strong>).</p>
|
|
|
|
<p>a. ___ Verbal instructions by staff b. ___ Poster(s) c. ___ Written instruction(s)</p>
|
|
|
|
<p>d. ___ Video e. ___ Other (specify): ____________________________</p></td>
|
|
</tr>
|
|
</table>
|
|
|
|
<p><strong>10. Equipment and Supplies</strong></p>
|
|
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p><strong>10a. Were there appropriate quantities of medical supplies?</strong> Y / N / U</p>
|
|
|
|
<p>Comments:</p><p> </p><p> </p></td>
|
|
</tr>
|
|
</table></td></tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td>10b. Were medications needed for treatment of victims available in the hospital? Y / N / U / NA</td>
|
|
</tr>
|
|
</table>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr>
|
|
<td><p>Were needed medical supplies available?</p>
|
|
<p><strong>If medical supplies were not available, circle "N" in column "A" and go to the next row.</strong></p></td>
|
|
</tr> <tr>
|
|
<td>
|
|
<table cellspacing="0" cellpadding="8" border="1" width="99%">
|
|
|
|
<tr align="left">
|
|
<th scope="col">Medical Supply</th>
|
|
<th scope="col">A. Available</th>
|
|
<th scope="col">B. Issues</th>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">10c. Alcohol-based hand sanitizer</td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">10d. Bandages</td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">10e. Basic airway equipment</td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">10f. Blood drawing supplies </td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">10g.Blood pressure equipment </td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">10h. Burn packs</td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td scope="row">10i. Cleaning supplies for contaminated equipment</td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td>10j. Crash carts </td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td>10k. Intravenous fluids </td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td>10l. Intubation equipment </td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td>10m. Medications </td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td>10n. Monitors </td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td>10o. Oxygen masks </td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td>10p. Oxygen tanks </td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td>10q. Splints </td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td>10r. Stethoscopes </td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td>10s. Stretchers </td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td>10t. Suction equipment </td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td>10u. Surgical masks </td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td>10v. Vascular access supplies (catheters, fluids,etc.)</td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td>10w. Ventilators </td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td>10x. Wheelchairs </td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
<tr>
|
|
<td>10y. Other (specify): _____________________________ </td>
|
|
<td>Y / N / U / NA</td>
|
|
<td> </td>
|
|
</tr>
|
|
</table>
|
|
</td>
|
|
</tr>
|
|
</table>
|
|
<p> </p>
|
|
|
|
<table cellspacing="0" cellpadding="8" border="1" width="95%">
|
|
<tr valign="top">
|
|
<td height="300"><strong>Comments (If comment refers to a specific item, give the item number.):</strong></td>
|
|
</tr>
|
|
</table>
|
|
|
|
<p class="size2"><a href="index.html#contents">Return to Contents</a><br />
|
|
<a href="drillelementsmod3.htm">Proceed to Next Section</a></p>
|
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<p> </p>
|
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<div class="footnote">
|
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<p> The information on this page is archived and provided for reference purposes only.</p></div>
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