This resource was part of AHRQ's Public Health Emergency Preparedness program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.
This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://info.ahrq.gov. Let us know the nature of the problem, the Web address of what you want, and your contact information.
Please go to www.ahrq.gov for current information.
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 Control
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: |
|
|
|
|
|
5600 Fishers Lane Rockville, MD 20857