State Territory preparedness staff training

Attachment 1 -- Data Elements for HAvBED System

Form Approved

OMB No. 0990-XXXX

Exp. Date 02/29/2010

Available Beds

• Intensive Care Unit;

• Medical and Surgical (Med/Surge);

• Burn Care;

• Pediatric ICU;

• Pediatrics;

• Psychiatric;

• Emergency Department;

• Negative Pressure Isolation; and

• Operating Rooms;

Emergency Department Diversion Status;

Decontamination Facility Availability

Ventilators:

• Total number of ventilators in each facility (collected only once)

• Number of staffed ventilators available for use

  • Number of available ventilators that are NOT pediatric capable

• Number of patients that could be managed with rescue therapies e.g. ECMO, High Frequency Oscillation, etc.

  • Number that are pediatric capable

• Number of patients related to the event who are currently being managed on rescue therapies

  • # Adults

  • # Children < 18 years

• Does the facility have adequate ancillary ventilator supplies for the next 72 hours?

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-XXXX. The time required to complete this information collection is estimated to vary between 1 to 3 hours which averages to approximately 2 hours per response, including the time to review instructions, search existing data resources, gather the data needed and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:  U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 537-H, Washington, D.C. 20201 Attention: PRA Reports Clearance Officer.

Facility Stress:

• Total number of beds in each facility emergency department (collected only once)

• Occupancy of each hospital emergency department as of 7PM yesterday?

• Number of patients who left the ED without being seen

• Number of patients who left the ED without being seen

• Has the facility activated its incident command structure e.g. HICS? YES/ NO

• Has the facility implemented surge strategies? YES/NO

  • If yes, select all those that apply

<surge in place strategies e.g. early discharge, cancel elective surgeries, etc.>

<augmented personnel e.g. extra shifts, volunteers, etc.>

<established alternate care sites or activated mobile units>

<requested mutual aid>

• Are staffing shortages affecting your ability to provide services? YES/NO

• Does your facility have enough general medical supplies for the next 72 hours? YES/NO

• Does your facility have enough pharmaceuticals for the next 72 hours? YES/NO

• Does your facility have enough personal protective equipment for the next 72 hours? YES/NO

• Does the facility have sufficient supplies of potable water for the next 72 hours?

Facility Infrastructure (linked with CMS EPRI):

• Operational Status. Select one.

<Fully operational>

<Limited operation> <Explain>

<Closed> <Explain>

• Evacuation Status. Select one.

<No evacuation>

<Evacuation in process>

<Evacuation pending>

<Evacuation partial> <Explain>

<Evacuation completed> <Explain>

• Is the facility on back up power? YES/NO

  • If yes, is there sufficient fuel for 96 hours? YES/NO