These evaluation forms are designed to help hospitals compile responses from
the modules and compare data.
|
Hospital | # |
Question |
Incident Command Center |
Decontamination |
Triage |
Treatment |
| Section |
| Observer Information |
|
Date |
|
|
|
|
| Observer name |
|
|
|
|
| Observer title |
|
|
|
|
| Time period of evaluation |
|
|
|
|
| Time Points |
BA1 |
Time zone aware that victims affected
by biological illness |
|
|
|
|
| |
Comments: |
|
|
|
|
| Information Flow |
BA2 |
Was Incident Commander informed that biological illness
present? |
Y / N / U |
|
|
|
|
| BA3 |
Method to notify incident commander |
a. FAX sent |
|
|
|
|
| b. E-mail sent |
|
|
|
|
| c. Person-to-person contact |
|
|
|
|
| d. Telephone message |
|
|
|
|
| e. Unclear |
|
|
|
|
| f. NA |
|
|
|
|
| g. Other (specify) |
|
|
|
|
| BA4 |
Time after biological illness suspected
that incident commander notified |
<30 min |
|
|
|
|
| 30-59 min |
|
|
|
|
| 1-2 hrs |
|
|
|
|
| >2 hrs |
|
|
|
|
| Unclear |
|
|
|
|
| NA |
|
|
|
|
| BA5 |
Hospital epidemiologist or designee informed that
biological illness present |
Y / N / U |
|
|
|
|
| BA6 |
Method to notify epidemiologist or designee |
a. FAX sent |
|
|
|
|
| b. E-mail sent |
|
|
|
|
| c. Person-to-person contact |
|
|
|
|
| d. Telephone message |
|
|
|
|
| e. Unclear |
|
|
|
|
| f. NA |
|
|
|
|
| g. Other (specify) |
|
|
|
|
| BA7 |
Time after biological illness suspected
that epidemiologist or designee notified |
<30 min |
|
|
|
|
| 30-59 min |
|
|
|
|
| 1-2 hrs |
|
|
|
|
| >2 hrs |
|
|
|
|
| Unclear |
|
|
|
|
| NA |
|
|
|
|
| BA8 |
Local and/or State health department informed that
biological illness present |
Y / N / U |
|
|
|
|
| BA9 |
Method to notify local and/or State health
department |
a. FAX sent |
|
|
|
|
| b. E-mail sent |
|
|
|
|
| c. Person-to-person contact |
|
|
|
|
| d. Telephone message |
|
|
|
|
| e. Unclear |
|
|
|
|
| f. NA |
|
|
|
|
| g. Other (specify) |
|
|
|
|
| BA10 |
Time after biological illness suspected
that local and/or State health department notified |
<30 min |
|
|
|
|
| 30-59 min |
|
|
|
|
| 1-2 hrs |
|
|
|
|
| >2 hrs |
|
|
|
|
| Unclear |
|
|
|
|
| NA |
|
|
|
|
| BA11 |
CDC informed that biological illness present? |
Y / N / U |
|
|
|
|
| BA12 |
Method to notify Centers for Disease Contol
and Prevention (CDC) |
a. FAX sent |
|
|
|
|
| b. E-mail sent |
|
|
|
|
| c. Person-to-person contact |
|
|
|
|
| d. Telephone message |
|
|
|
|
| e. Unclear |
|
|
|
|
| f. NA |
|
|
|
|
| g. Other (specify) |
|
|
|
|
| BA13 |
Time after biological illness suspected
that CDC notified |
<30 min |
|
|
|
|
| 30-59 min |
|
|
|
|
| 1-2 hrs |
|
|
|
|
| >2 hrs |
|
|
|
|
| Unclear |
|
|
|
|
| NA |
|
|
|
|
| BA14 |
Occupational health informed that biological illness
present? |
Y / N / U |
|
|
|
|
| BA15 |
Method to notify occupational health |
a. FAX sent |
|
|
|
|
| b. E-mail sent |
|
|
|
|
| c. Person-to-person contact |
|
|
|
|
| d. Telephone message |
|
|
|
|
| e. Unclear |
|
|
|
|
| f. NA |
|
|
|
|
| g. Other (specify) |
|
|
|
|
| BA16 |
Time after biological illness suspected
that occupational health notified |
<30 min |
|
|
|
|
| 30-59 min |
|
|
|
|
| 1-2 hrs |
|
|
|
|
| >2 hrs |
|
|
|
|
| Unclear |
|
|
|
|
| NA |
|
|
|
|
| |
Comments: |
|
|
|
|
| Materials and Supplies |
BA17 |
Needed vaccines available within hospital? |
Y / N / U / NA |
|
|
|
|
| BA18 |
Vaccines requested from outside source? |
Y / N / U / NA |
|
|
|
|
| BA19 |
Did vaccines arrive? |
Y / N / U / NA |
|
|
|
|
| BA20 |
Approximate time between request and delivery
of vaccines from outside agency |
<2 hrs |
|
|
|
|
| 2-6 hrs |
|
|
|
|
| 7-12 hrs |
|
|
|
|
| 13-24 hrs |
|
|
|
|
| >24 hrs |
|
|
|
|
| Did not arrive |
|
|
|
|
| NA |
|
|
|
|
| |
Comments: |
|
|
|
|
| Victim Diagnosis |
BA21 |
Cause of suspected biological illness known prior
to arrival of affected victims in this zone? |
Y / N / U |
|
|
|
|
| BA22 |
How long after arrival of first victim
was cause known |
<1 hr |
|
|
|
|
| 1-4 hrs |
|
|
|
|
| 5-8 hrs |
|
|
|
|
| >8 hrs |
|
|
|
|
| Never identified |
|
|
|
|
| NA |
|
|
|
|
| BA23 |
Cause of illness |
a. Anthrax |
|
|
|
|
| b. Botulism |
|
|
|
|
| c. Plague |
|
|
|
|
| d. Severe Acute Respiratory Syndrome (SARS) |
|
|
|
|
| e. Smallpox |
|
|
|
|
| f. Tularemia |
|
|
|
|
| g. Viral hemorrhagic fever |
|
|
|
|
| h. Unknown |
|
|
|
|
| i. Other (specify) |
|
|
|
|
| BA24 |
Resources used to make diagnosis |
a. Consultation with in-hospital expert |
|
|
|
|
| b. Consultation with expert from another
hospital |
|
|
|
|
| c. Consultation with expert from local
health department |
|
|
|
|
| d. Consultation with expert from State health department |
|
|
|
|
| e. Consultation with CDC |
|
|
|
|
| f. History and physical exam by treating
physician |
|
|
|
|
| g. Microbiological data |
|
|
|
|
| h. Radiologic data |
|
|
|
|
| i. NA |
|
|
|
|
| j. Other (specify) |
|
|
|
|
| BA25 |
Cameras used to document cases? |
Y / N / U / NA |
|
|
|
|
| |
Comments: |
|
|
|
|
| Safety: Isolation Precautions |
BA26 |
Isolation required for suspected biological illness
involved? |
Y / N / U |
|
|
|
|
| BA27 |
Victims transported to isolation room? |
Y / N / U / NA |
|
|
|
|
| BA28 |
Receiving room under negative pressure? |
Y / N / U / NA |
|
|
|
|
| BA29 |
Enough isolation rooms? |
Y / N / U |
|
|
|
|
| BA30 |
How victims isolated |
a. Conversion of other rooms/area (specify) |
|
|
|
|
| b. Existing isolation room in other area
(specify) |
|
|
|
|
| c. Overflow victims not isolated |
|
|
|
|
| d. Victims with same suspected biologic
illness placed in same isolation room |
|
|
|
|
| e. NA |
|
|
|
|
| f. Other (specify) |
|
|
|
|
| BA31 |
Signs on victims' doors describing type of isolation
required? |
Y / N / U |
|
|
|
|
| BA32 |
Sign-in sheet placed at each isolation room door? |
Y / N / U |
|
|
|
|
| BA33 |
Health care workers sign in and out? |
Y / N / U / NA |
|
|
|
|
| BA34 |
Breaches in isolation precautions identified? (explain
in comment box) |
Y / N / U |
|
|
|
|
| BA35 |
Victims with similar symptoms grouped together in
the zone? |
Y / N / U / NA |
|
|
|
|
| BA36 |
Unaffected patients removed from areas with affected
victims? |
Y / N / U / NA |
|
|
|
|
| BA37 |
Precautions taken when handling materials or equipment
that came in contact with potentially infected victims? |
Y / N / U |
|
|
|
|
| BA38 |
Masks supplied to unaffected victims in zone? |
Y / N / U / NA |
|
|
|
|
| BA39 |
Lists of exposed and non-exposed victims generated? |
Y / N / U |
|
|
|
|
| BA40 |
Representatives from infection control arrive to
assess appropriateness of isolation precautions? |
Y / N / U |
|
|
|
|
| |
Comments: |
|
|
|
|
| Safety: Personal Protective
Equipment |
BA41 |
PPE needed to protect health care workers? |
Y / N / U |
|
|
|
|
| |
Safety measures available |
|
|
|
|
| BA42 |
Passive (negative pressure) filtration |
Available |
|
|
|
|
| Used by staff |
|
|
|
|
| Adequate supply |
|
|
|
|
| BA43 |
Powered (positive pressure) filtration |
Available |
|
|
|
|
| Used by staff |
|
|
|
|
| Adequate supply |
|
|
|
|
| BA44 |
Self-contained breathing apparatus |
Available |
|
|
|
|
| Used by staff |
|
|
|
|
| Adequate supply |
|
|
|
|
| BA45 |
Level B or higher suits |
Available |
|
|
|
|
| Used by staff |
|
|
|
|
| Adequate supply |
|
|
|
|
| BA46 |
Other (specify) |
Available |
|
|
|
|
| Used by staff |
|
|
|
|
| Adequate supply |
|
|
|
|
| BA47 |
Other (specify) |
Available |
|
|
|
|
| Used by staff |
|
|
|
|
| Adequate supply |
|
|
|
|
| BA48 |
Other (specify) |
Available |
|
|
|
|
| Used by staff |
|
|
|
|
| Adequate supply |
|
|
|
|
| BA49 |
Any observed staff without PPE interacting with contaminated
victims? |
Y / N / U / NA |
|
|
|
|
| BA50 |
Types of staff w/o PPE interacting with
contaminated victims |
a. Ancillary staff |
|
|
|
|
| b. Nurses |
|
|
|
|
| c. Physicians |
|
|
|
|
| d. Did not observe |
|
|
|
|
| NA |
|
|
|
|
| Other (specify) |
|
|
|
|
| |
Comments: |
|
|
|
|
| Screening and Prophylaxis |
BA51 |
Prophylactic medications available for health care workers exposed to plague or anthrax? |
Y / N / U / NA |
|
|
|
|
| BA52 |
Prophylactic medications available for victims exposed
to plague or anthrax? |
Y / N / U / NA |
|
|
|
|
| BA53 |
Vaccinations available for health care workers exposed
to smallpox? |
Y / N / U / NA |
|
|
|
|
| BA54 |
Vaccinations available for victims exposed to smallpox? |
Y / N / U / NA |
|
|
|
|
| BA55 |
Method
to manage victims needing screening for exposure and / or prophylaxis | a. Emergency department |
|
|
|
|
| b. Referred to health department clinic |
|
|
|
|
| c. Referred to hospital clinic |
|
|
|
|
| d. Triage |
|
|
|
|
| e. Other (specific) |
|
|
|
|
| |
Comments: |
|
|
|
|
| Laboratory Specimens |
BA56 |
Means to transport specimens to lab |
a. Hand carried |
|
|
|
|
| b. Packaged for sending to outside labs |
|
|
|
|
| c. Other (specify) |
|
|
|
|
| BA57 |
Guidelines available for packaging and transport
of microbiological specimens? |
Y / N / U |
|
|
|
|
| BA58 |
"Chain of custody" implemented? |
Y / N / U |
|
|
|
|
| |
Comments: |
|
|
|
|
|
540 Gaither Road Rockville, MD 20850