Introduction

OverviewPark Nicollet's Emergency Management Plan ensures we continue to provide effective patient care when an emergency affects our facilities. The goal of this course is to provide information for responding to situations that may affect the health and safety of you, your coworkers, patients, and visitors.

This course fulfills the annual Emergency Management requirement for Mandatory Education.

This course addresses corporate-wide emergency protocols. There will be additional emergency protocol responses that are specific to your department; your manager will provide this training.

Approximate length: 35 minutes

Audience The Emergency Management course is intended for all Park Nicollet team members including clinicians.

Topics

I. Safety and Security

II. Park Nicollet's Emergency Management Plan

III. Responses to specific emergency events

IV. The Hospital Incident Command System (HICS)

Need help getting started?

Click on the Presentation Tips tab in the upper right hand corner of the window.

For information on earning Continuing Medical Education credits or Contact Hours, click Attachments in the upper right-hand corner and select the relevant PDF.

Course Objectives Aligned HHT Behaviors

Identify resources that the Safety and Security Department provides to support a safe and secure environment at PNHS.

Head: Thinks Critically

Be able to access emergency preparedness resources.

Head: Thinks Critically; Sets Priorities

List the four points of the fire emergency plan and apply strategies if a fire (Code Red) occurs.

Head: Thinks Critically

Heart: Focuses on Those We Serve

Together: Maintains Composure

Describe appropriate procedures and your potential role(s) during:• Operation Orange • Severe weather• Threat Assessment and Response • Weapons incident• Active Shooter • Code Pink• Code White

Head: Thinks Critically; Sets Priorities

Heart: Focuses on Those We Serve; Self Development

Together: Promotes Teamwork; Maintains Composure; Communicates Effectively

Identify and explain the Hospital Incident Command System (HICS).

Head: Thinks Critically

Together: Promotes Teamwork;

Maintains Composure

Head + Heart, Together Behaviors

Safety and Security

Topics covered in this section include:

• Safety and Security Department

• Operations and services

• What to report

• How to report

• What to expect

• Security badge

• Protecting Park Nicollet property

Safety and Security

Security technology

PNHS team members and

community agencies

Safety and Security Department

The Safety and Security Departmentserves to support a safe and secure environment in which our team members and customers experience exceptional service. We do this by providing services and developing operational goals that support Park Nicollet strategic initiatives.

Maintaining a safe and secure environment is a partnershipSafety and Security works with PNHS team members and community agencies to achieve this goal by maintaining open communications, utilizing technology and establishing a security awareness in our facilities.

Maintaining a safe and secure environment at PNHS is a partnership of people and the utilization of security technology. This includes YOU!

Operations and Services

• Safety and Security dispatchers and officers

• You can reach Safety and Security dispatchers twenty-four hours a day, seven days a week at 952-993-5101.

• Our Safety and Security officers provide a constant security presence at Methodist Hospital, PNC-St. Louis Park, and Melrose Institute. If you need routine emergency support at any other Park Nicollet location, please call Safety and Security.

• Security systems

• Development and management of security systems including:

• Surveillance equipment

• Intercoms and emergency call boxes

• Facility lock/unlock schedules

• Corporate security badge/photo ID system in coordination with Human Resources, Marketing, and Administration

• Lock hardware and key systems

Security and access systems allow team members to move throughout facilities they work in while still maintaining a safe and secure environment.

Operations and Services

• Access assistance

• Assist our patients and visitors in entering and exiting our facilities safely and conveniently, as well as finding their way to their destination.

• Access assistance is available at both Park Nicollet Methodist Hospital and Park Nicollet Clinic St. Louis Park by calling Safety and Security dispatch at 3-5101.

• Parking

• Parking management program administrators, parking shuttle drivers, and parking attendants work together to provide convenient and close parking for patients and visitors, while maintaining adequate and safe parking for team members.

• Staff parking guidelines can be found on the Safety and Security Department page on Facets

• Parking guidelines for patients and visitors can be found at Parknicollet.com

What to report

All team members, regardless of the PNHS location at which they work, should report the following to Safety and Security for support, response and/or reporting purposes:

• Thefts or diversion of corporate or personal property

• Suspicious people or events, unusual activity

• Property damage or vandalism

• Situations that could have an impact on personal safety or security to the facility, personal belongings, and corporate resources and equipment

• Harassment

• Falls/injuries in public areas and grounds (at St Louis Park campuses)

• Vehicle accidents or abandoned vehicles

For response and support, promptly report suspicious activity to your manager, site leader, and/or Safety and Security.

If you’re not sure an incident should be reported, contact Safety and Security and they will assist you.

See something?

Say something!

How to report

During any emergency event, providing the right information promptly will assure the most effective response. To call in a report of an emergency event, please use the process below to assure an effective information exchange.

Methodist Hospital and Park Nicollet Clinic –St. Louis Park

campuses

Ambulatory clinic and office locations outside of St. Louis Park

Call 1-1-1 Call 9-1-1 (local emergency responder)

After, report event to PNHS Safety and Security at 952-993-5101

Provide the following information:• building name and address • floor • department or unit name • a brief description of the emergency event • your name and call back number

Every PNHS facility is different, whether because of size, location and/or service mix within the facility. The information reported regarding the event is one of the tools used to determine the level of security and response required at each facility.

What to expect

Safety and Security will respond to routine and emergency events while supporting team members and visitors during times of crisis. The desired outcome is to:

• Ensure the safety of all persons on PNHS property

• Preserve corporate resources

• Return the department or facility to routine operations

See something. Say something.

Security ID badge

Security ID badges are used to verify that a team member or contractor has business in a PNHS facility. These badges are your corporate name tag while working on PNHS properties.

The Human Resources Personal Appearance policy requires that all team members wear this visible identification while on duty.

Security ID badges are also used:

• by non-exempt team members to swipe in and out at TIPS stations

• to provide and control access to facilities, departments, and parking as authorized

For more information, review the Security Management Program policy.You may also refer to the Human Resources Personal Appearance policy.

Protecting Park Nicollet property

Office access

• Only request and issue keys to those team members who need them.

• Report lost or stolen keys and access cards to Safety and Security promptly.

• Leave hallway access doors unlocked only if they can be seen or monitored by team members.

• Leaving unmonitored entrances unlocked for convenience purposes gives access to unwanted persons.

• When leaving the office unoccupied, ensure all hallway access doors are closed and locked.

Office activity

Inform Safety and Security of unusual office hours or work being done. Inform them when:

• your office is open after regular business hours or on weekends

• team members are working late on a special event or project

• a change is made to your site's regular business hours

Protecting Park Nicollet property

Petty cash

• Minimize the number of team members who will be accountable for these funds

• Lock the cash in an office away from visitor and patient view.

• Make daily deposits.

• Assure that keys to petty cash and revenues are kept in a secure location.

• Arrangements for lock boxes or other secured containers are available.

• Keep a minimum amount of cash.

• Maintain a ledger that shows exactly how much cash is on hand at any given time.

• Thefts or shortages in these funds must be reported to your supervisor immediately for resolution.

Protecting Park Nicollet property

Construction• Security officers will not provide access to facilities or offices for contractors they have not

been advised about.• Security officers will request identification and work information from construction workers.• Work which generates complaints during customer hours or has a negative impact on

working conditions may be shut down until arrangements are made to evaluate and/or mitigate the disruption.

Office equipmentAll PNHS owned equipment should have the following information recorded and stored for insurance purposes: date purchasedoriginal costserial and model numbers a picture or brochure displaying the equipment

If there is a theft, this information will be required in law enforcement reporting. Park Nicollet actively reports these thefts to assure investigation support and potential return of recovered properties.

Make use of security cables or locks on all valuable equipment.

Park Nicollet's Emergency Management Plan

Topics covered in this section include:

• Where to find emergency preparedness resources

• Park Nicollet's Emergency Management Plan

• Park Nicollet Emergency Management Team

• Planning to keep Park Nicollet safe

Where to find emergency preparedness resources

The resources listed below are used throughout PHNS as emergency management guides.

Emergency Management Procedures Quick Reference Locate it: Facets>Departments>Emergency Preparedness>Quick Clicks sidebar>Emergency Management Procedures Quick Reference

Note: This can also be referenced anytime during this course by clicking the Attachments tab and then selecting “Emergency Management Procedures Quick Reference.“

Emergency Management CardLocate it: attached to your security badge

Emergency Quick Reference GuideLocate it: available in your department

Utility Systems Failure Response PlacardLocate it: Facets>Departments>Real Estate>Quick Clicks sidebar>Utility Systems Failure Response

Park Nicollet's Emergency Management Plan

The Emergency Management Plan describes how Park Nicollet will maintain communications and operations when responding to emergencies affecting PNHS facilities and the care of patients. The plan outlines methods for preparing team members and resources for multiple hazards, as well as the procedures to follow when responding to and recovering from an emergency.

The Emergency Management Plan (EMP) uses the four phases of comprehensive emergency management (described below).

You may access this plan in the future via the Emergency Preparedness department website on Facets.

Phase Severe weather example

Mitigation Identify safe shelter locations in your work area or facility

Preparedness Participate in Severe Weather Awareness Week drills

Response Assist patients and visitors to safe areas in a severe weather event

Recovery Report any damage to facilities

Emergency Management Team

The Emergency Management Team oversees the Emergency Management Plan. This committee is responsible for helping take the written Emergency Management Plan and making it an active part of Park Nicollet.

The Emergency Management Team works to:

• Assess risks for natural disasters and other emergency events.

• Develop, maintain and test system-wide preparedness in responding to internal or external disasters.

• Provide system-wide oversight for development of plans to respond to emergencies and disasters while providing patient care.

• Develop and sustain partnerships with community preparedness partners, such as police, fire, emergency medical services, emergency management, public health, and other healthcare systems.

If you would like to be part of represent your department in the Emergency Management Team, please contact your leader or the Emergency Preparedness Manager.

Responses to specific emergency events

The following sections will outline potential emergency events, examples of that emergency, your potential role(s) in a response, and available training resources.

Every Park Nicollet team member has the responsibility of being prepared for potential emergency situations.

Each team member will have a different role in any given response. Your department plan will outline your potential roles more specifically. Ask your supervisor for more information.

The Emergency Management Procedures Quick Reference summarizes these threats, you may review it at:

Facets>Departments>Emergency Preparedness>Quick Clicks sidebar>Emergency Management Procedures Quick Reference

Responses to specific threats covered:

• Fire

• Operation Orange

• Severe Weather

• Threat Assessment and Response Protocol

• Weapons

• Active Shooter

• Code Pink

• Code White

This course will NOT cover Code Blue Protocols or Downtime Protocols. You may learn more about these protocols on Facets, after this course.

Fire: Your responsibilities in your work area

You have certain responsibilities in the event of a fire, whether the fire is in your work area or in another area of the floor or building.

In the event of a fire in your work area, you should:

1. Be familiar with emergency procedures to promptly and calmly direct co-workers, patients, and visitors to your designated safe area

2. Know the location of the fire extinguishers and fire alarm boxes and exit routes

3. Understand security systems

o In compliance with regulatory requirements, and to assure patient safety, some departments/nursing units are secured or partially secured against free entry/exiting. Security systems are integrated with the fire system devices within these departments.

o Team members working in these areas are required to understand the security and fire system integration and operations to assure safe egress (exiting) in an emergency. Team members working within fully or partially secured units should assure that their departmental orientation has included operational information on these security systems

Code Red

Step 1: Move those in danger to safety

Anyone in immediate danger (including yourself) should be moved to safety before doing anything else.

Step 2: Alert others

• Activate the nearest fire alarm

• Dial the emergency phone number for your facility

• 111 for Methodist Hospital campus and Park Nicollet Clinic (St. Louis Park campus)

• 911 for Melrose Institute, ambulatory clinics and office sites

• Identify yourself and specify your department, location and type of fire. Do not hang up the phone. Contact must be maintained with the switchboard and fire dispatcher if flames or smoke are reported.

Code Red

Step 3: Contain the fire • Close all windows and doors• At Methodist Hospital, Melrose Institute, & 3900 Ambulatory Surgery:

• Move visitors into rooms & instruct them to stay with patients• At Clinics and Office Sites:

• Move visitors into the next compartment• Remain calm and reassure patients and visitors• Mark empty rooms (post-it notes or medical tape works well) to determine

checked areas• Clear hallways and entrances• Do not use elevators

Step 4: EvacuateFollow the evacuation procedure for your type of building. See the upcoming evacuation procedures page.

All PNHS Safety and Security, Engineering and Facilities staff are trained emergency responders. Other team members should focus on their own safety as well as the safety of their colleagues, patients, and visitors.

P.A.S.S.: Fire extinguisher use guideline

The fire extinguisher technique P.A.S.S. stands for "pull, aim, squeeze, and sweep." In the event of a fire, your main priority as a team member should be to ensure your own safety and the safety of others. PNHS team members are not instructed on how to use firefighting equipment; however, it is helpful to be aware of general fire extinguisher use guidelines. Click each flashing arrow in the interaction below to learn more about the P.A.S.S. steps.

Fire out

A “fire out” is any sign that a fire has occurred. Some examples include burned linens, scorched electrical plugs and, everyone's favorite, burnt popcorn.

What do I do when I encounter a “fire out”?Report the "fire out" to Safety and Security immediately so the appropriate response measures can be taken.

If a fire is out, why do I need to report it?A fire may look like it is extinguished but may continue to smolder unseen by you. If you dispose of the remains of a seemingly extinguished fire, you may introduce other combustible materials that may also ignite. Safety and Security Officers are specially trained and will be able to identify the best method to deal with a “fire out.”

Disposable cautery pens must be properly disposed of to prevent fires. This includes breaking off the cautery tip with a hemostat or similar device and recapping the cautery pen.

Evacuation procedures

In the event of a fire emergency that requires evacuation, team members need to know the correct evacuation procedure.

People should be evacuated in the following order:

1. Persons in greatest dangerThose nearest the fire or source of smoke

2. AmbulatoryThose who can walk out on their own and follow instructions

3. Semi-ambulatoryThose using walking devices, crutches, or walkers, or who need physical support and guidance

4. BedriddenThose who cannot ambulate or help themselves

Keep in mind the following:

• Depending on the type of building and location of the fire, evacuations should first take place horizontally, or on the same floor as the fire. If the fire continues to spread, evacuations should then take place vertically using stairs (not elevators), or on neighboring floors.

• Elevators are not to be used in the event of a fire.

• All team members should know their route of egress. Ambulatory clinic and office site team members must identify an external meeting location to account for the safety of team members, patients, and visitors.

These evacuation procedures are also to be used for non-fire emergencies that require evacuation.

Evacuation procedures for your building type

Methodist Hospital and 3900 Ambulatory Surgery

Locations in this category:

Heart & Vascular Center

Melrose Institute

St. Louis Park 3900 Building

TRIA

Evacuation procedures

In these buildings where there are patients who are not capable of self-evacuation, your leader will explain the best evacuation procedure.

Evacuation procedures for your building type

Sprinkled clinics and officesLocations in this categoryBloomington Park Place WestBrookdale Prairie CenterBurnsville Prior Lake Carlson Rogers Camplin Shakopee 1415Chanhassen Shakopee 1515 Creekside Shakopee 1601 Eagan ShorewoodGolden Triangle N St. Louis Park 3800 Golden Triangle S St. Louis Park 3850 Golden Valley St. Louis Park 3930 Lakeville St. Louis Park 4916 Maple Grove St. Louis Park 4951 Maple Grove Rehab St. Louis Park 5050 (Bank) Meadowbrook Struthers Parkinson's Center Minneapolis Westside Business Center Plymouth

Evacuation proceduresEvacuate your department first, and/or the building as directed by your on-site leader (incident commander).

Evacuation procedures for your building type

Non-sprinkled clinics and offices

Locations in this category:

St. Louis Park 6700 (Stilts) Building

Wayzata

Evacuation procedures

Evacuate the building. In single level facilities, this may lead staff and visitors directly outside.

Fire drills

Fire drills are code-required emergency response procedures scheduled at all PNHS sites. They are intended to be both an evaluation of team member knowledge and a test of the fire systems in place.

Who conducts the fire drill?

• PNHS Safety and Security Officers conduct fire drills at Methodist Hospital, Melrose Institute, and Park Nicollet Clinic—St. Louis Park Campus facilities.

• Managers and supervisors conduct required drills at ambulatory clinics and office sites.

Safety and Security Officers will survey numerous areas during each drill. Team members who are uncertain of procedures will be walked through the process to ensure learning is achieved. A debrief will be held at the conclusion of each drill to allow team members to ask questions and officers to clarify procedures.

Incident commander: In the event of an evacuation (or fire drill), the role of "incident commander" needs to be filled to help direct evacuation, account for all persons, and communicate with safety and security.

Who regulates requirements for conducting fire drills?

• The National Fire Protection Association (NFPA) and the Joint Commission require one drill per occupied shift per year at ambulatory clinic sites and office sites.

• NFPA and the Joint Commission require one quarterly fire drill per shift at Methodist Hospital, Melrose Institute, and 3900 Ambulatory Surgery.

Operation Orange

Operation Orange prepares Methodist Hospital to receive a large influx of patients in a small amount of time. This is sometimes called a “patient surge.” This protocol is used to prepare Methodist Hospital for an increased influx of patients resulting from an external or internal disaster.

• An external disaster is one that occurs in the community and may result in a sudden influx of patients to Methodist Hospital Emergency Center.

• An internal disaster, such as structural damage from severe weather, may result in an influx of patients into other areas of the hospital.

From the headlines

On August 16th, 2011, a large gust of wind toppled a stage structure into a crowd of concertgoers at the Indiana State Fair. Four people were killed, and over forty were sent to local hospitals via ambulance. Many others reported to local emergency departments with injuries. Because of advanced planning, emergency medical services were able to communicate the anticipated increase in patients, and hospitals were able to increase staffing to meet those needs.

You may read more about how a local hospital responded to this disaster and how their Operation Orange staffing plan supported their Emergency Center.

Operation Orange response levels

Every department in Methodist Hospital has an Operation Orange plan. Team members from nursing units and support departments will respond according to their department’s plan to provide additional staffing, services and materials to support the Emergency Center in treating patients and assisting family members.

Ask your supervisor if you would like more information about your individual department’s plan.

Department leaders are responsible for updating their plans on an annual basis.

Training resourcesMethodist Hospital departments are responsible for maintaining their individual plans and notification rosters. The Emergency Preparedness Manager is responsible for ensuring the plans are exercised annually..

Operation Orange standbyThis is announced to prompt teams to prepare for a small number of casualties or be prepared for a surge of casualties when the immediate impact of the disaster is unknown. Department leaders should place their teams on standby alert, review their department policies, and await further instructions from the Incident Commander.

Operation Orange full alert This is announced when a large number of casualties is expected and activates all needed departmental plans. The alert will be called by the Incident Commander.

For more information review the Disaster Plan “Operation Orange.” To find this policy again, go to Facets>Departments>Emergency Preparedness.

Severe weather response

In Minnesota, severe weather is a real and frequent threat. In the next few pages, you’ll review Park Nicollet’s Severe Weather Plan, which is designed to direct team members in an established severe weather response and ensure an orderly and efficient transition from routine to emergency operations.

Topics covered in this section include: • Notification process• Actions to take • Locating a safe area • Resources and training

Park Nicollet’s Severe Weather Plan may be found at: Facets>Departments>Emergency Preparedness>Quick Clicks sidebar>Severe Weather Response Plan

How will you be notified of potential severe weather?

Methodist Hospital, Melrose Institute, and Park Nicollet Clinic – St. Louis Park campuses

Ambulatory clinic and office locations outside of St. Louis Park

Weather conditions are monitored by Safety and Security and Switchboard who will notify the site administrator of any watches and warnings.

Site administrator arranges for monitoring of weather conditions and alerting team members to changing conditions. Prepare at least three people at each ambulatory and office site to be responsible for monitoring weather conditions specific to that facility.

From the headlines

On Sunday, May 22, 2011, a massive EF5 tornado struck Joplin, Missouri – with St. John’s Regional Medical Center directly in the path of this massive storm. Team members at the hospital were well trained in tornado drills and severe weather procedures. Upon direction from security, patients were evacuated to hallways, and team members and visitors were ordered to take shelter in safe areas. Though the campus was directly hit by an EF5 tornado, loss of life was greatly minimized through the strict and swift execution of the hospital severe weather protocols. Four patients and zero team members died as a result of the tornado.

Read more about how Saint John’s team members saved lives during the 2011 Joplin Tornado.

Severe weather: what do you do?

Introduction:

When severe weather occurs, follow these directions in order to maintain the safety of our patients, visitors, and staff.

Always (all weather conditions)

• Be aware of safe areas.

Severe thunderstorm watch:

• Monitor weather conditions.

Severe weather: what do you do?

Severe thunderstorm warning and/or tornado watch:• Keep calm and reassure patients and visitors• Close all patient room and hallway doors• Close window blinds and curtains• Move visitors from waiting areas with windows• Clear hallways of equipment and supplies• Refresh your memory on where safe areas are located• Pay special attention to further overhead announcements• At Ambulatory Clinic and business office locations, continue to monitor your weather

radio for warnings in your geographical area• Report any problems to your supervisor

Tornado Warning/Straight Line Wind >75MPH:• Considerations should be given to whether conditions are immediately or directly

threatening a PNHS facility before taking actions that affect patient care• Move patients and visitors away from windows • Instruct patients to cover faces with a pillow or blanket (primary care)• Limit or avoid use of elevators• Standby for further instructions or announcements

Severe weather: what do you do?

“Take cover” announcement:

• Methodist Hospital Campus and PN-St.LP Clinic Buildings - overhead page will alert this status. All other sites initiate internal overhead paging

• Instruct patients to cover their faces with a pillow or blanket

• Move visitors to safe areas within the facility

• Staff will move to safe areas within the facility

• Stand by for further instructions or announcements

“All clear” announcement:

• Ensure patient safety

• Account for all staff

• Return patients and visitors to regular locations

• Report any damage to facilities

What is a severe weather safe area?

When instructed, seek shelter in safe areas during severe weather. Safe areas are located throughout PNHS facilities and have the following characteristics:

• Interior room: a room not located along the exterior walls of the building.

• Latching door

• No windows

• Small ceiling span: a smaller room is generally better than a larger room, although there are exceptions to this rule, such as some of the meeting rooms at the Heart and Vascular Center.

This plaque can help you identify safe areas in the event of severe weather.

Resources and training

ResourcesHere are some places where you can quickly access severe weather response information:

• Emergency Management CardLocate it: attached to your security badge

• Emergency Management Procedures Quick Reference Locate it: Facets>Departments>Emergency Preparedness>Quick Clicks sidebar>Emergency Management Procedures Quick Reference

• Emergency Quick Reference GuideLocate it: available in your department

TrainingEvery spring Park Nicollet participates in Severe Weather Awareness Week. During this week, every department is expected to drill their severe weather plans.

Threat Assessment and Response Protocol

Introduction• The PHNS Threat Assessment Response Protocol provides a standardized process

for identifying, investigating and resolving threats which have the potential for harm to persons on PNHS properties and/or disruption of business operations or continuity of our systems and infrastructure.

What is a threat?A threat refers to any verbal or physical behavior, communication or device that could be interpreted as communicating or conveying any one of the following:• intent to cause emotional or physical harm or injury to persons• intent to interrupt business services or continuity• intent to cause damage to property

Examples of types of threats• Personal threat: a person threatens the safety of another person on PNHS

property.• Weapons threat: a person threatens they will use a gun on PNHS property.• Infrastructure threat: threat to take down the computer network or contaminate

the ventilation system.

Threat Assessment and Response Protocol

Who should you notify?Alert any of the following (an immediate response to the reported event will be initiated):• your supervisor or manager• Safety and Security• Human Resources• Risk Management

Additional resourcesPNHS has additional resources available that can be used to support your team during and after a crisis event.

PNHS Threat Assessment TeamUsed early on or during an event

• Safety and Security• Risk Management• Human Resources• Your leaders• Media Relations

Critical Incident Stress Debriefing Team Used soon after or during an event

• Spiritual Care• Employee Occupational Health and Safety

Weapons policy

PNHS bans weapons on all PNHS owned or leased properties, which includes inside buildings, surrounding grounds, and parking lots. The ban covers all individuals on PNHS property, but the ban does not apply to on-duty law enforcement.

Individuals finding themselves on PNHS properties with a weapon are expected to comply with this ban by one of the following means:

• Secure the weapon in a secure lockbox or trunk in their vehicle

• Leave the property

• Turn it over to Safety and Security to be stored in the departmental lockbox (Methodist, SLP Clinic & Melrose)

Weapon examples: guns, tasers, chemical sprays, and knives over three inches in length.

You encounter or become aware someone with a weapon.

What do you do?

Advise your department or site leader of your observation.

IF there is no immediate threat or danger, consider approaching the individual and advising them of the corporate ban on weapons.

IF there is a potential or immediate threat to safety, team members are expected to move anyone in danger as is reasonable, without risk of bodily harm and contact the appropriate response provider based on location.

Methodist Hospital, Melrose Institute and Park Nicollet Clinic–St. Louis Park campusesPromptly provide all pertinent information.• Call Safety and Security (3-5101) or

• Call the campus emergency number (1-1-1)

Ambulatory clinic and office locations outside of St.

Louis Park

• Call local law enforcement (9-1-1) • Call Safety and Security (3-5101) for support and

response as needed.

For more information, review the Weapons policy.To find this policy again, you may search policies on Facets.

Active Shooter Response policy

An active shooter is defined as one or more persons who participate in a random or systematic shooting spree, demonstrating intent to continuously harm others. Active shooter situations are unpredictable and evolve quickly. Typically, the immediate deployment of law enforcement is required to stop the shooting and mitigate harm to victims.

What do you do?Choose and commit to the response option that either removes you and others from danger or puts you in the least amount of danger. Provide the following safest response options (as able) to all others in the area; see options at right.

Only attempt to call 9-1-1 when you are safe. Stay on the line to provide law enforcement with needed information.

Safest response options

1. Evacuate the areaIf there is an accessible escape path, attempt to evacuate the premises.

2. Hide If evacuation is not possible, find a place to hide where the active shooter is less likely to find you.

3. Act against the shooter as a last resort Only when your life is in imminent danger, attempt to disrupt and/or incapacitate the active shooter by any means available.

Click Here for Active Shooter Video

For more information, review the Active Shooter Response policy.To find this policy again, you may search policies on Facets.

Code Pink: Enacting

Code Pink goes into effect when there is a removal or attempted removal of an infant or child from a unit or facility by a noncustodial individual. All team members participate in this process designed to locate and recover a missing infant or child.

Enacting a Code Pink: follow the steps below.

At Methodist Hospital , Melrose Institute,Park Nicollet Clinic-St. Louis Park

Ambulatory clinic and office locations outside of St. Louis Park

1. Alert your supervisor or manager.

2. Call the emergency phone number: 111

3. Advise the operator of a potential Code Pink.

• Give a summary of the situation

• Request Security STAT to your location.

4. Do not leave until Security arrives

5. Report the direction of travel and suspect description to the emergency number. Keep them in view as long as possible

6. Station team members at all exits (stairwells,elevators, etc.) No one may leave until Safety and Security calls the "all clear.“

7. Identify any potential parties that fit theannounced victim's description

1. Alert your supervisor or manager

2. Call the emergency phone number: 911

3. Advise police of a potential infant/childabduction

• Give a summary of the situation

• Give your address and request immediate police assistance

4. Do not leave until the police arrive

5. Report the direction of travel and suspect description to 911. Keep them in view as long as possible

For more information, review the Code Pink: Missing or Abducted Infant/Child policy.To find this policy again, you may search Policies on Facets.

Responding to a Code Pink

If you are not directly involved in a Code Pink event, but you hear the overhead page, you and all other team members should respondfollowing these procedures:

1. Watch for any individual moving toward facility exits with an infant or child.

2. Be especially alert for:

• Children who do not appear to want to go with this individual

• Adults with infants

• Those who are intent on leaving the department or facility immediately

3. All departments and team members should coordinate quickly to:

• Station one team member at each department doorway or nearby stairwell

• Station one or two team members at each facility exit door if in close proximity to your work area or department

• Search your department for unknown individuals

• Upon observing an individual with an infant or child, approach and ask that this individual stop and wait until the Code Pink is over. Be open about explaining what Code Pink is; those visitors who are not acting suspiciously will be willing to cooperate and wait. Report any individuals not complying with your request

• Document or share information quickly regarding any non-compliant visitors or patients

Code White

Code White is the plan that goes into effect when an adult patient has left an in-patient or out-patient care area without written discharge orders from their physician or without knowledge of patient care team members, and the patient’s location is not known. When a patient has been away from their designated location (room, treatment area) for an undue, unplanned period of time, a decision must be made based on the patient’s identified level of risk for wandering/elopement as to the course of action to be taken in instituting a search plan and/or initiating a Code White.

Code White activation promotes a coordinated team member response to ensure patient safety and security.

Park Nicollet Methodist Hospital team members will respond according to the process outlined in this policy to locate and reunite missing adult patients with caregivers as quickly and safely as possible.

The clinical population that this policy applies to are adult patients 18 years of age and older, a danger to themselves or others and/or a vulnerable adult.

*Code Pink is the appropriate response for a missing patient under age 18.

For more information on the Code White response, you may search Policies on Facets.

Code White

Enacting a Code White - team member roles 1. Upon identification that a patient is missing, the discovering team member will immediately advise the patient’s primary nurse and charge nurse, and enlist all available team members to assist in locating the missing patient.

2. Team members from the area of activation will report promptly to their unit/department to assist in the response efforts as directed by the unit charge nurse.

3. The Unit Charge nurse will request an overhead “Code White” page. This page, much like a Code Pink, will indicate the unit impacted, and a brief physical description of the missing patient.

4. All other team members in public areas, near doorways or exit areas should watch the public access points for potential individuals matching this description. If observed, please call Safety and Security (at 3-5101) and identify yourself and your specific location. Do not attempt to resolve this situation yourself. Contact Safety and Security.

5. Wait for the “Code White, All Clear” before leaving area.

Code White

Team members listed below have active roles in a Code White response and will receive additional education and training. • Patient’s RN• Unit Charge RN• Unit Nursing Assistants• Health Unit Coordinator• Administrative Nursing Supervisor (ANS)• Safety & Security Officers • EC Tech (for EC events)

ScenarioMartin Petrov is an 82-year-old patient at Methodist Hospital. Mr. Petrov's recovery from shoulder replacement surgery is going well. However, he also suffers from mild dementia.

SituationAt 3:30 pm, his wife came to visit and they went for a walk in the hospital halls. During their walk, his wife went to bathroom while her husband waited in the hall. When she came out, he was no longer in the hall.

ResponseAfter a brief search of the immediate area, team members were unable to find Mr. Petrov. A Code White was paged to initiate a search for Mr. Petrov.

The Hospital Incident Command System (HICS)

Topics covered in this section include:

• The Hospital Incident Command System (HICS)

• HICS model

The Hospital Incident Command System (HICS)

In an emergency, agencies such as hospitals, law enforcement, medical transportation, local governments, and fire departments can communicate more efficiently when all agencies follow the same command structure. This structure is called the Incident Command System (ICS). ICS customized for hospitals is called the Hospital Incident Command System (HICS).

In emergency events, PNHS may activate the Hospital Command Center (HCC), using HICS to assign roles and responsibilities. The HCC will coordinate the emergency response from a central location and will work with the community partners such as the fire department or EMS, as well as other hospitals.

For additional information, visit the Hospital Incident Command System (HICS) page on the Emergency Preparedness Department website on Facets.

Related information:

• Clinics may also activate a command center to respond to events within their clinic.

• HICS can be used to manage not only emergency events, but planned events such as migration to our new electronic medical record.

HICS model

The HICS model defines a chain of command for managing Park Nicollet's emergency response and ongoing operations.

In a disaster, the Incident Commander (IC) is the person responsible for giving overall direction for hospital or clinic operations during the emergency situation. The person assuming the role of Incident Commander will vary depending on who is on duty and the nature of the emergency. The IC is the only position that is always activated in HICS.

Other HICS positions will be assigned as necessary based on what is required to respond to the event. These positions include:

Safety Officer Public Information Officer Liaison Officer Section Chiefs for Operations, Logistics, Planning, and Finance/Administration

Each position has a job action sheet that acts as checklist of responsibilities and accountability, and to prompt specific actions for that job duty. The most qualified person will be assigned to a position, not necessarily the most senior person.

HICS model

What will be your role in an emergency?

The HICS model enables Park Nicollet to respond to all types of incidents by identifying alternate responsibilities of personnel during emergencies including whom they report to within the organization’s command structure and when they are activated.

Staff

In an emergency, you may not work in your day-to-day location or for your normal supervisor. If you are not immediately needed in your regular job, you may be asked to report to a Labor Pool to be evaluated and assigned a new job duty to support emergency response operations.

Leaders

Leaders who are on-site during an emergency situation should report to the Incident Command Center. At this time it can be discussed and determined whether they are needed and appropriate for a leader role in the HICS model.