All items with an asterisk (*) are required for submission.
* Name:
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Other facility, if not listed above:
RESOURCES REQUIRED
Resources needed for communicating within the organization and with the community (e.g., satellite phone, walkie-talkie).
Which of the above resources, if any, necessitated additional expenditures over those currently planned for your department?
Based on your experience implementing the template, what resources should be added to the "Required Resources" section?
Which of the above resources, if any, caused you the biggest concerns or problems? (Please explain.)
What were the most significant barriers you encountered related to the "Required Resources"?
ACTION STEPS 1. Identify medical leadership within surgery and anesthesiology for disaster planning. Leadership should collaborate in the design, implementation, and refinement of an incident command system for an operating room.
* Indicate your current progress in implementing this action step
Please provide any additional comments or explanation that will help to explain your progress.
* How long did it take to implement this step? (If you have not completed this step, estimate how long it will take you to complete implementation.)
Please provide an estimate of the effort — # of people and # of actual person hours — required to complete this action step
Please provide an estimate of the cost of implementing this action step.
What types of additional resources were required to complete this action step?
What would you change about this action step?
What were the most significant barriers you encountered in implementing this action step?
2. Select individuals for incident command roles.
* Indicate your current progress in implementing this action step
Please provide any additional comments or explanation that will help to explain your progress.
* How long did it take to implement this step? (If you have not completed this step, estimate how long it will take you to complete implementation.)
Please provide an estimate of the effort — # of people and # of actual person hours — required to complete this action step
Please provide an estimate of the cost of implementing this action step.
What types of additional resources were required to complete this action step?
What would you change about this action step?
What were the most significant barriers you encountered in implementing this action step?
3. Specify the authority, processes, and responsibilities of the OR incident command and a call schedule identifying individuals available to fill their roles 24 hours a day, beginning within two hours of the event, and extending for 72 hours.
* Indicate your current progress in implementing this action step
Please provide any additional comments or explanation that will help to explain your progress.
* How long did it take to implement this step? (If you have not completed this step, estimate how long it will take you to complete implementation.)
Please provide an estimate of the effort — # of people and # of actual person hours — required to complete this action step
Please provide an estimate of the cost of implementing this action step.
What types of additional resources were required to complete this action step?
What would you change about this action step?
What were the most significant barriers you encountered in implementing this action step?
4. Identification of one person with final decision-making authority—an "Operating Room Czar." The OR Czar would have authority to cancel scheduled OR cases, rearrange OR schedules, identify patients that could be transferred, call in and deploy OR teams, and prioritize patients for beds in the OR, PACU, and ICUs.
* Indicate your current progress in implementing this action step
Please provide any additional comments or explanation that will help to explain your progress.
* How long did it take to implement this step? (If you have not completed this step, estimate how long it will take you to complete implementation.)
Please provide an estimate of the effort — # of people and # of actual person hours — required to complete this action step
Please provide an estimate of the cost of implementing this action step.
What types of additional resources were required to complete this action step?
What would you change about this action step?
What were the most significant barriers you encountered in implementing this action step?
5. The circumstances under which the OR incident command begins and ends should be specified.
* Indicate your current progress in implementing this action step
Please provide any additional comments or explanation that will help to explain your progress.
* How long did it take to implement this step? (If you have not completed this step, estimate how long it will take you to complete implementation.)
Please provide an estimate of the effort — # of people and # of actual person hours — required to complete this action step
Please provide an estimate of the cost of implementing this action step.
What types of additional resources were required to complete this action step?
What would you change about this action step?
What were the most significant barriers you encountered in implementing this action step?
6. Methods for data collection, testing, monitoring, and improving the system should be specified.
* Indicate your current progress in implementing this action step
Please provide any additional comments or explanation that will help to explain your progress.
* How long did it take to implement this step? (If you have not completed this step, estimate how long it will take you to complete implementation.)
Please provide an estimate of the effort — # of people and # of actual person hours — required to complete this action step
Please provide an estimate of the cost of implementing this action step.
What types of additional resources were required to complete this action step?
What would you change about this action step?
What were the most significant barriers you encountered in implementing this action step?
7. Assure that individuals who might assume an incident command role are knowledgeable about incident command, operations of other hospital components, and community disaster response. This step assures that eligible candidates for OR incident command receive appropriate training. Requirements and standards for such training should be specified.
* Indicate your current progress in implementing this action step
Please provide any additional comments or explanation that will help to explain your progress.
* How long did it take to implement this step? (If you have not completed this step, estimate how long it will take you to complete implementation.)
Please provide an estimate of the effort — # of people and # of actual person hours — required to complete this action step
Please provide an estimate of the cost of implementing this action step.
What types of additional resources were required to complete this action step?
What would you change about this action step?
What were the most significant barriers you encountered in implementing this action step?
How many people were (or will be when the training is completed) involved in the training?
* How long do you estimate it took (or will take) to complete this training for your staff/personnel?
* Was/Is the required training readily available?
* How did you (will you) provide this training for all of your staff/personnel?
* If commercial or publicly provided course, please identify: ** If 'Other,' please specify:
How much do you estimate you have spent (or will spend) on this training?
What types of additional resources were required to complete this training?
8. Identify lines of communication and interactions with other components of the community-wide disaster plan and regional trauma system.
* Indicate your current progress in implementing this action step
Please provide any additional comments or explanation that will help to explain your progress.
* How long did it take to implement this step? (If you have not completed this step, estimate how long it will take you to complete implementation.)
Please provide an estimate of the effort — # of people and # of actual person hours — required to complete this action step
Please provide an estimate of the cost of implementing this action step.
What types of additional resources were required to complete this action step?
What would you change about this action step?
What were the most significant barriers you encountered in implementing this action step?
