Public Health Emergency Preparedness
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.
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Treatment Zone Module
This module was developed by the Johns Hopkins Evidence-based
Practice Center under Contract No. 290-02-0018 from the Agency for Healthcare
Research and Quality, Rockville, MD. The content of this module is intended
to provide guidance for hospital disaster drill evaluation and should not be
construed as representing standards of care or recommendations on how to respond
to specific types of disasters. No statement in this module should be construed
as an official position of the Agency for Healthcare Research and Quality or
of the U.S. Department of Health and Human Services.
Instructions: This form can be used in the Emergency Department, and in medical and surgical care areas.
Note: Circle or check (_) as indicated. Y = Yes; N = No; U = Unclear; NA = Not applicable
Observer: ______________________________________________________________ Date: ____/____/____
Observer title: ___________________________________________________________
Hospital: _______________________________________________________________
Period of time of evaluation: _____________ AM / PM (Circle one)
to _____________ AM / PM (Circle one)
|
Time Points
| Event |
Time |
| C1. Time the drill began: (Circle one) |
_____________ AM / PM / U |
| C2. Time the hospital disaster plan was initiated in this zone: (Circle one) |
_____________ AM / PM / U / Not initiated |
| C3. Time this zone was ready to accept victims: (Circle one) |
_____________ AM / PM / U |
| C4. Time when this zone was notified that incident command was operational: (Circle one) |
_____________ AM / PM / U / Not initiated |
| C5. Time the drill ended in this zone: (Circle one) |
_____________ AM / PM / U |
| TX1. Time first victim arrived in the treatment zone: (Circle one) |
_____________ AM / PM / U |
Comments (if comment refers to a specific item, give the item number):
|
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Zone Description:
|
C6. Draw a picture of the zone setup.
|
| Question |
Response |
C7. Where was this zone located?
(Check all that apply) |
a. [ ] Ambulance ramp
b. [ ] Inside the hospital
c. [ ] Parking lot
d. [ ] Street/road
e. [ ] Other (specify):
________________________________ |
C8. Was the boundary for this zone defined? |
Y / N / U |
| C9. If this zone had a defined
boundary, how was it defined? (Check all that apply) |
a. [ ] Barricade(s)
b. [ ] Security personnel
c. [ ] Sign(s)
d. [ ] Tape
e. [ ] Vehicle(s)
f. [ ] Wall(s), permanent
g. [ ] Wall(s), temporary
h. [ ] No boundary
i. [ ] Other (specify):
________________________________ |
C10. Were providers able to move easily
through this zone? |
Y / N / U |
TX2. What type of unit is
this zone during regular hospital functioning? (Check all that apply) |
a. [ ] Emergency Department (ED
b. [ ] Intensive Care (ICU)
c. [ ] Medical Inpatient
d. [ ] Medical Outpatient
e. [ ] Surgical Inpatient
f. [ ] Surgical Outpatient
g. [ ] Other (specify):
_________________________________ |
| TX3. Location of unit (e.g., floor): |
_________________________________ |
| TX4. Did actual patients remain in the
drill treatment area (along with mock victims)? |
Y / N / U |
Comments (if comment refers to a specific item, give the item number):
|
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Personnel
| Question |
Response |
C11. Did someone take charge of this zone? |
Y / N / U |
| C12. If someone took charge
of this zone, how many minutes after the drill activities in this zone began
did this person take charge? (Check one) |
O < 10 min |
| O 10-29 min |
| O 30-59 min |
| O 1-2 hrs |
| O > 2 hrs |
| O NA |
C13. If someone took charge of this zone,
was it the officially designated person? |
Y / N / U / NA |
C14. How was the person in
charge of the zone identified? (Check all that apply) |
a. [ ] Arm band
b. [ ] Hat
c. [ ] Name tag
d. [ ] Verbal statement
e. [ ] Vest
f. [ ] Not identified
g. [ ] Other physical identification (specify): ______________________________________ |
C15. Were the following drill
participants identifiable? |
a. Drill evaluators |
Y / N / U / NA |
| b. Drill organizers |
Y / N / U / NA |
| c. Media |
Y / N / U / NA |
| d. Medical personnel |
Y / N / U / NA |
| e. Mock victims |
Y / N / U / NA |
| f. Observers |
Y / N / U / NA |
| g. Security |
Y / N / U / NA |
C16-18. How many hospital drill participants
were initially assigned to this zone? (Give approximate numbers) |
C16. Physicians: | __________________ |
| C17. Nurses: |
__________________ |
| C18. Ancillary personnel (registrars,
security, cleaning staff, etc.): |
__________________ |
| C19. Were additional drill participants added during the drill? |
Y / N / U |
C20-22. If additional zone staff were added during the drill, what
were their approximate numbers? (Leave blank if
not applicable) |
C20. Physicians: | __________________ |
| C21. Nurses: |
__________________ |
| C22. Ancillary personnel (registrars,
security, cleaning staff, etc.): |
__________________ |
Comments (if comment refers to a specific item, give the item number):
|
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Zone Operations
| Question |
Response |
C23. When was the location
of this zone determined? (Check one) |
O Determined before the drill |
| O Determined during the drill |
C24. Was the hospital disaster plan available? |
Y / N / U |
C25. If the hospital disaster plan was available, what was its format? (Check all that apply) |
a. [ ] Complete manual
b. [ ] Flow diagram
c. [ ] Job action sheets
d. [ ] No disaster plan
e. [ ] Other (specify):
________________________________ |
C26. If the hospital disaster plan was available, how was it accessed? (Check all that apply) |
a. [ ] Computer/Internet
b. [ ] Paper
c. [ ] Personal data assistant (PDA)
d. [ ] Not accessed
e. [ ] Other (specify):
________________________________ |
C27. Was there a biological incident component to the hospital disaster plan? |
Y / N / U |
| C28. Was there a radiation incident component to the hospital disaster plan? |
Y / N / U |
C29. Was the space allocated for the zone adequate? |
Y / N / U |
C30. If not enough space for the zone, where did zone activities overflow to? (Check all that apply) |
a. [ ] Adequate space allotted
b. [ ] Conference room
c. [ ] Hallways
d. [ ] Outside hospital
e. [ ] Treatment/victim care areas
f. [ ] Waiting rooms
g. [ ] No overflow
h. [ ] NA
i. [ ] Other (specify):
________________________________ |
C31. Was this zone used for the same functions
during non-drill operations? |
Y / N / U |
C32. If this zone was not
used for the same functions in non-drill operations, what was it usually
used for? (Check all that apply) |
a. [ ] Ambulance ramp
b. [ ] Conference room
c. [ ] Hallway
d. [ ] Lobby
e. [ ] Treatment, emergency
f. [ ] Treatment, non-emergency
g. [ ] Triage
h. [ ] Unused
i. [ ] Waiting room
j. [ ] Other (specify):
________________________________ |
C33. Did clinical staff interact directly
with families of victims? |
Y / N / U / NA |
| C34. Were families of victims referred
to specially designated staff? |
Y / N / U / NA |
C35. How was victims' privacy
ensured? (Check all that apply) |
a. [ ] Curtains
b. [ ] Individual areas
c. [ ] Privacy screens
d. [ ] Not ensured
e. [ ] Other (specify):
________________________________ |
Comments (if comment refers to a specific item, give the item number):
|
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Communications
If device not present, circle "N"
in column "a" and go to the next line.
| Communication Device(s) |
a. Was device present? |
b. If present, # available |
c. If present, was it used in drill? |
d. Comments (note problems) |
| Phone |
| C36. 2-way radio/phone(s) |
Y / N / U |
|
Y / N / U |
|
| C37. Direct line(s) |
Y / N / U |
|
Y / N / U |
|
| C38. Landline phone(s) |
Y / N / U |
|
Y / N / U |
|
| C39. Wireless/cell phone(s) |
Y / N / U |
|
Y / N / U |
|
| Radio and Television |
| C40. AM/FM radio(s) |
Y / N / U |
|
Y / N / U |
|
| C41. Television(s) |
Y / N / U |
|
Y / N / U |
|
| Pager |
| C42. Numeric paging |
Y / N / U |
|
Y / N / U |
|
| C43. Overhead paging |
Y / N / U |
|
Y / N / U |
|
| C44. Text paging |
Y / N / U |
|
Y / N / U |
|
| Other Electronic Device |
| C45. E-mail & Internet
access |
Y / N / U |
|
Y / N / U |
|
| C46. FAX machine(s) |
Y / N / U |
|
Y / N / U |
|
| Voice or Physical Communication Device |
| C47. Intercom |
Y / N / U |
|
Y / N / U |
|
| C48. Megaphone(s) |
Y / N / U |
|
Y / N / U |
|
| C49. Runner(s) |
Y / N / U |
|
Y / N / U |
|
| Other (Specify) |
| C50. ______________________ |
Y / N / U |
|
Y / N / U |
|
| C51. ______________________ |
Y / N / U |
|
Y / N / U |
|
| C52. ______________________ |
Y / N / U |
|
Y / N / U |
|
| Question |
Response |
| C53. How was incoming information
to the zone recorded? (Check all that apply) |
a. [ ] Computer (other electronic device)
b. [ ] Notepaper
c. [ ] Posted paper
d. [ ] White board/chalk board
e. [ ] Not recorded
f. [ ] Other (specify):
________________________________ |
Comments (if comment refers to a specific item, give the item number):
|
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Information Flow
| Question |
Response |
C54. How was this zone notified
of the event? (Check all that apply) |
a. [ ] FAX
b. [ ] Runner
c. [ ] Telephone
d. [ ] Not notified
e. [ ] Other (specify):
________________________________ |
C55. Who notified this zone
of the event? (Check all that apply) |
a. [ ] Drill organizer
b. [ ] Incident command center
c. [ ] Media
d. [ ] Other hospital staff
e. [ ] Outside source
f. [ ] Victims arriving
g. [ ] Not notified
h. [ ] Other (specify):
________________________________
|
C56. Did your zone receive updates regarding
the situation outside the hospital
(e.g., status of disaster events, number
of victims arriving, acuity of victims)? |
Y / N / U |
C57. If your zone received
regular updates, who sent them? (Check all that apply) |
a. [ ] City/State health department
b. [ ] Emergency Medical System
c. [ ] Incident command center
d. [ ] Media
e. [ ] State disaster agency
f. [ ] Did not receive
g. [ ] Other (specify):
________________________________ |
C58. How was this zone kept
aware of the ongoing general situation within the hospital? (Check all that apply) |
a. [ ] Call(s) from incident command
b. [ ] FAX from incident command
c. [ ] Other contact from incident command
d. [ ] Runner(s) from incident command
e. [ ] Contact from other internal sources (specify): ________________________________ |
C59. Were problems created by delays in
receiving information?
(If problems were created by delays in information, specify
in comment box at end of this section.) |
Y / N / U |
Comments (if comment refers to a specific item, give the item number):
|
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Security
| Question |
Response |
C60. Were security personnel present in
this zone? |
Y / N / U |
| C61. If security were needed but not present,
how were they contacted? (Check all that apply) |
a. [ ] 2-way radio/phone
b. [ ] Overhead pager
c. [ ] No security present
d. [ ] Other (specify):
________________________________ |
C62. If security personnel
were present, what type of security? (Check all
that apply and provide approximate numbers) |
a. [ ] FBI: ________________ |
| b. [ ] Hospital security: ___________ |
| c. [ ] Local police: __________ |
| d. [ ] State police: _______________ |
| e. [ ] NA |
f. [ ] Other (specify):
________________________________
|
C63. Did all security staff present have
a portable means of communication? |
Y / N / U / NA |
| C64. Were entrances and exits
strictly controlled in this area? |
Y / N / U / NA |
Did any of the following security issues arise in this zone?
If the security issue did not arise, circle "N"
in column "a" and go to the next row.
| Security Issue |
a. Arose? |
b. If yes, did security respond? |
c. If yes, was order maintained? |
d. Description of issue and measures taken |
| C65. Access in and out |
Y / N / U |
Y / N / U |
Y / N / U |
|
| C66. Assistance for family
members |
Y / N / U |
Y / N / U |
Y / N / U |
|
| C67. Assistance lifting supplies
or victims |
Y / N / U |
Y / N / U |
Y / N / U |
|
| C68. Crowd control |
Y / N / U |
Y / N / U |
Y / N / U |
|
| C69. Media control |
Y / N / U |
Y / N / U |
Y / N / U |
|
| C70. Transportation/ traffic
control |
Y / N / U |
Y / N / U |
Y / N / U |
|
| C71. Unruly victims |
Y / N / U |
Y / N / U |
Y / N / U |
|
C72. Other (specify):
________________________________ |
Y / N / U |
Y / N / U |
Y / N / U |
|
C73. Other (specify):
________________________________ |
Y / N / U |
Y / N / U |
Y / N / U |
|
Comments (if comment refers to a specific item, give the item number):
|
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Victim Documentation and Tracking
| Question |
Response |
C74. Were all incoming victims
registered and given a unique identification or medical record number? (Check one) |
O Yes, before entering this zone |
| O Yes, on entering this zone |
| O No, not while in this zone |
| O Unclear |
C75. What was the method of
documenting the victim record in this zone? (Check all that apply) |
a. [ ] Computer entry
b. [ ] Data card(s) attached to victims
c. [ ] Dictation system
d. [ ] Personal data assistant (PDA)
e. [ ] Scanner
f. [ ] Separate victim paper chart
g. [ ] No documentation
h. [ ] Other (specify):
________________________________ |
C76. Was a central list of victims generated
for this zone? |
Y / N / U |
| C77. Were the triage markers on the victims
clearly visible? |
Y / N / U |
C78. Did the triage markers stay affixed
to the victims while in this zone? |
Y / N / U / NA |
| C79. Was clinical information about victims
accessible to caregivers? |
Y / N / U / NA |
C80. What proportion of victims
arriving in this zone were labeled with a triage level? (Check one) |
O None |
| O Less than half |
| O At least half (but not all) |
| O All |
| O NA |
Comments (if comment refers to a specific item, give the item number):
|
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Victim Flow
| Question |
Response |
C81. Did a bottleneck develop in this
zone? (If a bottleneck did develop, describe in the comment box at
the end of this section.) |
Y / N / U |
C82. What was the maximum
number of victims observed waiting at the bottleneck at any time? (Check one) |
O 0 |
| O 1-10 |
| O 11-25 |
| O 26-50 |
| O 51-100 |
| O > 100 |
| O Unclear |
C83. Was the bottleneck resolved? (If the bottleneck was resolved, describe in the comment box
at the end of this section.) |
Y / N / U / NA |
C84. Were the paths leading to the next
zone marked? |
Y / N / U |
| C85. If the paths were not marked, were
verbal directions given by zone staff? |
Y / N / U / NA |
C86. Were the lowest acuity victims directed
by staff to an area separate from higher acuity victims? |
Y / N / U |
C87. What proportion of victims
had treatment delayed because of zone staffing shortage? (Check one) |
O None |
| O Less than half |
| O At least half (but not all) |
| O All |
| O NA |
C88. Were expiring victims placed in a
quiet and separate place? |
Y / N / U / NA |
| C89. Were deceased victims rapidly removed
from this zone? |
Y / N / U / NA |
C90. How many victims passed
through this zone? (Check one) |
O 0 |
| O 1-10 |
| O 11-25 |
| O 26-50 |
| O 51-100 |
| O > 100 |
| O Unclear |
TX5. What proportion of victims
was reassessed in the treatment zone? (Check one) |
O None |
| O Less than half |
| O At least half (but not all) |
| O All |
| O NA |
TX6. How were victims managed
who were NOT previously triaged? (Check one) |
O Sent back to triage zone |
| O Sent to another area (specify): ___________________ |
| O Triaged in this zone |
| O Not triaged |
TX7. What proportion of victim
treatments was delayed because of radiology service? (Check one) |
O None |
| O Less than half |
| O At least half (but not all) |
| O All |
| O NA |
| O Unclear |
TX8. What proportion of victim
treatments was delayed because of laboratory service? (Check one) |
O None |
| O Less than half |
| O At least half (but not all) |
| O All |
| O NA |
| O Unclear |
TX9. What proportion of victim
treatments was delayed because of pharmacy service? (Check one) |
O None |
| O Less than half |
| O At least half (but not all) |
| O All |
| O NA |
| O Unclear |
TX10. What proportion of victim
treatments was delayed because of transport service? (Check one) |
O None |
| O Less than half |
| O At least half (but not all) |
| O All |
| O NA |
| O Unclear |
TX11. What proportion of victim
treatments was delayed because of a problem with supplies? (Check one) |
O None |
| O Less than half |
| O At least half (but not all) |
| O All |
| O NA |
| O Unclear |
TX12. What proportion of victims
had disposition decisions made at drill termination? (Check one) |
O None |
| O Less than half |
| O At least half (but not all) |
| O All |
| O NA |
| O Unclear |
TX13. Did this zone have an assigned transport
staff? |
Y / N / U |
| TX14. Did any contaminated victims enter
this zone? |
Y / N / U / NA |
Comments (if comment refers to a specific item, give the item number):
|
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Personal Protective Equipment (PPE) and Safety
If needed, were these items for standard precautions available for the
health care workers?
If safety materials were not available, circle "N"
in column "a" and go to the next row.
| Safety Materials |
a. Available? |
b. Used by staff? |
c. Adequate Supply? |
| C91. Eye protection |
Y / N / U |
Y / N / U |
Y / N / U |
| C92. Waterproof gowns |
Y / N / U |
Y / N / U |
Y / N / U |
| C93. Isolation gowns |
Y / N / U |
Y / N / U |
Y / N / U |
| C94. Gloves |
Y / N / U |
Y / N / U |
Y / N / U |
| C95. Other (specify): _______________ |
Y / N / U |
Y / N / U |
Y / N / U |
| C96. Other (specify): _______________ |
Y / N / U |
Y / N / U |
Y / N / U |
| C97. Other (specify): _______________ |
Y / N / U |
Y / N / U |
Y / N / U |
Comments (if comment refers to a specific item, give the item number):
|
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Equipment and Supplies
| Question |
Response |
| TX15. Were medications needed for the
treatment of victims available within the hospital? |
Y / N / U / NA |
TX16. Were medications requested from
an outside source? |
Y / N / U |
| TX17. If medications were requested from
an outside source, did they arrive? |
Y / N / U / NA |
| TX18. What was the approximate time between request and delivery of medication from the outside agency?
(Check one) | O < 2 hours |
| O 2-6 hours |
| O 7-12 hours |
| O 13-24 hours |
| O > 24 hours |
| O Did not arrive |
| O NA |
Were needed medical supplies available?
If the medical supplies were not available, circle
"N" in column "a" and go to the next row.
| Medical Supplies |
a. Available |
b. Issues |
| TX19. Bandages |
Y / N / U/ NA |
|
| TX20. Basic airway equipment |
Y / N / U/ NA |
|
| TX21. Blood drawing supplies |
Y / N / U/ NA |
|
| TX22. Blood pressure equipment |
Y / N / U/ NA |
|
| TX23. Burn packs
| Y / N / U/ NA |
|
| TX24. Cleaning supplies for
contaminated equipment
| Y / N / U/ NA |
|
| TX25. Crash carts
| Y / N / U/ NA |
|
| TX26. Intravenous fluids
| Y / N / U/ NA |
|
| TX27. Intubation equipment
| Y / N / U/ NA |
|
| TX28. Medications
| Y / N / U/ NA |
|
| TX29. Monitors
| Y / N / U/ NA |
|
| TX30. Oxygen masks
| Y / N / U/ NA |
|
| TX31. Oxygen tanks
| Y / N / U/ NA |
|
| TX32. Splints
| Y / N / U/ NA |
|
| TX33. Stethoscopes
| Y / N / U/ NA |
|
| TX34. Stretchers
| Y / N / U/ NA |
|
| TX35. Suction equipment
| Y / N / U/ NA |
|
| TX36. Surgical masks
| Y / N / U/ NA |
|
| TX37. Vascular access supplies
(catheters, fluids, etc)
| Y / N / U/ NA |
|
| TX38. Ventilators
| Y / N / U/ NA |
|
| TX39. Wheelchairs
| Y / N / U/ NA |
|
TX40. Other (specify):
________________________________ |
Y / N / U/ NA |
|
TX41. Other (specify):
________________________________ |
Y / N / U/ NA |
|
TX42. Other (specify):
________________________________ |
Y / N / U/ NA |
|
Comments (if comment refers to a specific item, give the item number):
|
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Rotation of Staff
| Question |
Response |
C98. Was there a staff rotation/shift
change? |
Y / N / U |
| C99. If there was a staff rotation, did
the officially designated person in charge of the zone change? |
Y / N / U / NA |
C100. If there was a staff rotation, did
problems arise? (If problems arose, explain in comments box at the end of this
section.) |
Y / N / U / NA |
C101. What method of shift
changing was used? (Check one) |
O Group shift change |
| O Staggered shift change |
| O NA |
O Other (specify):
________________________________ |
C102. How were incoming staff
updated? (Check all that apply) |
a. [ ] Group briefing
b. [ ] Individual briefing
c. [ ] Written notes
d. [ ] Not updated
e. [ ] NA
f. [ ] Other (specify):
________________________________ |
Comments (if comment refers to a specific item, give the item number):
|
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Zone Disruption
| Question |
Response |
C103. Was there a plan in place to relocate
this zone if necessary? |
Y / N / U |
| C104. Did this zone close at any time
during the drill? If no, disregard the remainder of this
section. STOP. This zone module is complete. |
Y / N / U |
C105. If the zone closed during
the drill, what was the reason for closing? (Check all that apply) |
a. [ ] Contamination
b. [ ] Other safety concerns
c. [ ] Space
d. [ ] Other (specify):
________________________________ |
C106. If the zone closed during the drill,
was the incident command center notified? |
Y / N / U |
| C107. If the zone closed during the drill,
were other zones notified? |
Y / N / U |
C108. If the zone closed during the drill,
did it reopen in the same location? |
Y / N / U |
| If the zone did reopen in the same location: |
C109. Were operations interrupted until this zone reopened? |
Y / N / U / NA |
| C110. Was the incident command center
notified when this zone reopened? |
Y / N / U / NA |
C111. Were other zones notified when this
zone reopened? |
Y / N / U / NA |
| C112. Were any critical issues observed
with reopening this zone? (If critical issues were observed, explain in the comments
box at the end of this section.) |
Y / N / U / NA |
| C113. If the zone did NOT reopen in the
same location, was an alternate site opened? |
Y / N / U / NA |
If the zone reopened in an alternate site: |
| C114. Where did the zone reopen?
(specify): ____________________________________________________________ |
| C115. Did the initial zone close before
the new zone opened? |
Y / N / U / NA |
| C116. Were operations interrupted until
this zone reopened? |
Y / N / U / NA |
| C117. Was the incident command center
notified of this zone's relocation? |
Y / N / U / NA |
| C118. Were other zones notified of this
zone's relocation? |
Y / N / U / NA |
| C119. Were portable means of communication
used while relocating this zone? |
Y / N / U / NA |
| C120. Were any critical issues observed
with this relocation? (If critical issues were observed, explain in the comments
box at the end of this section.) |
Y / N / U / NA |
Comments (if comment refers to a specific item, give the item number):
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