Appx 5 Hospital Survey SAMPLE

Appendix 5: Hospital Survey

Form Approved

OMB No. 0923-XXXX

Exp. Date XX/XX/20XX

Hospital Survey Part A: Surge

[Introductory statement that includes description of the incident.]

1. How many beds are in your hospital? ____

2. How many beds are in your ED? ____

3. What is the average number of patients seen in your ED daily? ____

I’m going to ask you some questions about patients that presented to your ED because of the incident. I will ask you about the number of patients within 24 hours of the incident and the total number of patients since the incident occurred up to today. Fill out the table provided below. Insert part a into the [timeframe] and write down the respondent’s answer. Then repeat the question, inserting part b into the [timeframe]. For example, for A4, you will first ask “How many patients presented to your ED within 24 hours after the incident?” for part a. You would then ask “How many patients presented to your ED total, since the incident?” for part b before continuing to A5.

	Timeframe
	within 24 hours after the incident?	total, since the incident? This will be the total number from when the incident occurred to the present.
How many patients presented to your ED [timeframe]
How many asymptomatic patients requested evaluation [timeframe]
How many patients were admitted to the hospital from the ED [timeframe]
How many patients left the ED without being seen [timeframe]

8. Are you still seeing patients because of this incident?

Yes

No  Go to next part

9. Are you still admitting patients?

Yes

Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS E-11 Atlanta, Georgia 30333; ATTN: PRA (0923-XXXX)

No

Hospital Survey Part B: Response

1. How did your hospital first learn about the [description of emergency chemical release] on [date of release]?

media

on-scene commander or first responders on scene

911 call center

ambulance en route to hospital with patient(s)

patient self-presenting at hospital

first arriving ambulance/casualty

other (Please specify):

2. Approximately how much warning were you given before patients began arriving? If a warning was given, check whether the time is in minutes or hours. If no warning was given, check the box marked no warning given. _____ minutes hours no warning was given

3. How did patients arrive? Approximately how many or what percentage arrived by each means of transport? Check whether the number provided is a count or a percentage.

EMS count percentage

POV count percentage

Walk in count percentage

4. Did your hospital activate any sort of disaster response?

Yes

No  Go to Question B6

5. What did you do to activate disaster response?

Go to Question B7

6. Why did you not activate disaster response?

7. Did your hospital call in or reallocate staff because of the incident?

Yes

No  Go to Question B9

8. Why did you need to call in or reallocate staff?

9. Did your hospital require any additional resources or supplies because of the incident?

Yes

No  Go to Question B11

10. What additional resources or supplies did your hospital require because of the incident?

11. Did your hospital need to set up communications to connect patients with family members?

Yes

No  Go to Question B13

12. Please explain what was done to set up communications to connect patients with family members.

13. If patients self-transported from the scene, was there a need to decontaminate vehicles parked in your facility’s parking lot?

Yes

No  Go to next part

14. Please explain what was done to decontaminate vehicles parked in your facility’s parking lot.

Hospital Survey Part C: Decontamination

1. How did you make a decision on whether or not patients needed to be decontaminated?

2. Did any patients arrive at your hospital without appropriate decontamination?

Yes

No

3. Did any staff members experience signs and symptoms possibly attributable to secondary contamination because of treating patients contaminated by the [description of emergency chemical release]?

Yes

No

4. Did your hospital decontaminate any patients or staff members related to incident?

Yes

No  Go to next part

5. Approximately how many patients did your hospital decontaminate? ____

6. Did any patients experience adverse consequences from decontamination such as hypothermia?

Yes

No  Go to Question C9

7. Approximately how patients experienced adverse consequences as result of being decontaminated? ____

8. Please describe the adverse consequences they experienced.

9. Approximately how many staff members did your hospital decontaminate? ____

10. Did any staff members experience adverse consequences from decontamination such as heat exhaustion or extreme anxiety, as result of performing decontamination?

Yes

No  Go to Question C13

11. Approximately how many staff members experienced adverse consequences as result of performing decontamination? ____

12. Please describe the adverse consequences they experienced.

13. What type of facilities did your hospital use for decontaminating patients, or staff members? Read choices to respondent.

Indoor, fixed  Go to Question C15

Outdoor, fixed  Go to Question C15

Outdoor, mobile or temporary

14. Who supplied the mobile/temporary outdoor decontamination facility?

hospital

firefighters

HazMat unit

other (Please specify):

15. What decontamination agent or process did your hospital use? Check all that apply.

clothing removal

water alone

soap and water

other (Please specify):

16. From when your hospital first became aware that patients were potentially contaminated, approximately how long did it take for your hospital decontamination facility to get ready to receive patients? Check whether the time is in minutes or hours.

_____ minutes hours

17. How long did it take to prepare the facility/set up the decontamination unit? Check whether the time is in minutes or hours.

_____ minutes hours

Hospital Survey Part D: Lessons Learned

1. Did you receive sufficient information from the scene or Emergency Operations Center?

Yes  Go to Question D3

No

2. What types of information would you have liked to receive from the Emergency Operations Center?

3. Can you provide anything additional that your hospital learned during your response to this emergency chemical release that may assist public health officials or other hospitals in preparing for a similar emergency?

Closing Statement:

That completes the survey. I would like to sincerely thank you for your time. Your contributions will help us in our efforts to better assist and respond to future chemical releases with significant community exposure. Be sure to record the end time on the first page of this survey.

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