Name of Hospital:_____________________________________________________
Hospital Address:_____________________________________________________
_____________________________________________________
Name and Title of Person(s) Completing Form:_______________________________
___________________________________________________________________
___________________________________________________________________
Contact Information:
Phone:(____)___________________________
Pager:(____)___________________________
Fax:(____)_____________________________
Email:_________________________________
Healthcare facilities play a vital role in the detection of and response to biological emergencies, including new emerging infections, influenza outbreaks, and terrorist use of biological weapons. The information and data obtained from this questionnaire will be used to help assess the preparedness and capacity of your hospital to respond to and treat victims of a biological incident. Many of the questions only require yes, no, or don't know (DK) responses. Others will require some research.
Thank you for taking the time to complete this questionnaire.
This questionnaire was developed by Booz-Allen & Hamilton under Contract No. 290-00-0019 ("Understanding Needs for Health System Preparedness and Capacity for Bioterrorist Attacks") from the Agency for Healthcare Research and Quality. This document is in the public domain and may be reproduced without permission.
1. Does your hospital conduct in-service training on biological weapons? __Yes __No __DK
If yes:
a) When was the last training provided?___________________
b) Who is being trained?
Medical Staff: __Yes __No __DK
Nursing Staff: __Yes __No __DK
Medical/Nursing Students: __Yes __No __DK
Residents: __Yes __No __DK
Administration: __Yes __No __DK
Laboratory Personnel: __Yes __No __DK
Security Personnel: __Yes __No __DK
c) Is training mandatory?
Medical Staff: __Yes __No __DK
Nursing Staff: __Yes __No __DK
Medical/Nursing Students: __Yes __No __DK
Residents: __Yes __No __DK
Administration: __Yes __No __DK
Laboratory Personnel: __Yes __No __DK
Security Personnel: __Yes __No __DK
d) How often is in-service training on biological weapons provided?
__ Quarterly
__ Biannually
__ Annually
__ Other
__ Don't Know
e) Who provides the biological weapons training to your hospital staff?
__ In-house instructor (please list)__________________________________________
__ Outside consultant (please list)__________________________________________
__ Other (please list)____________________________________________________
__ Don't Know
f) What type of training was provided (check all that apply)?
__ Classroom/seminar training
__ Home study manuals (i.e., self-study)
__ Computer based training
__ Satellite broadcast
__ Video
__ Other, please specify__________________________________________________
2. Does your hospital send staff to Bioterrorism training seminars offered outside of the hospital?
__Yes __No __DK
1. What is your average daily inpatient census (averaged over the 2000 Calendar year)?
________________________________________________________________
2. Approximately how many people work at your hospital?___________________
3. Please indicate your licensed, operational, and surge bed capacity below:
| Bed capacity in the following areas | Licensed Beds (Under Certificate of Need) | Staffed Beds (Operational Capacity) | Approximate Surge Bed Capacity* (Estimated maximum number of additional staffed beds created in 6 & 12 hours) |
|---|---|---|---|
| Adult medical & surgical | / | ||
| Pediatric medical & surgical | / | ||
| Adult ICU (all units including CCU) | / | ||
| Adult Intermediate Care Ward (Progressive Care Unit) | / | ||
| Pediatric ICU (including NICU) | / | ||
| Pediatric Intermediate Care Ward (Progressive Care Unit) | / | ||
| Emergency department beds | / | ||
| OB/GYN | / | ||
| Psychiatry | / | ||
| Substance Abuse | / | ||
| Transitional Care (e.g., short-term care facility, rehabilitation) | / | ||
| All other departments (including outpatient surgical areas) | / | ||
| Total | / |
* Surge bed capacity: In the event of an emergency, what is the maximum number of additional staffed beds that your institution can create in 6 hours and in 12 hours for the treatment of mass casualties? (e.g., beds made available by opening up closed wards/units; beds made available by canceling elective surgeries; beds obtained from associated clinics; endoscopy suites; outpatient surgical areas; etc.)
4. How many times a month does your hospital reach 100% of operational capacity
(i.e., staffed beds)?___________________________________________________
5. Has your hospital implemented the Incident Command or Management System facility-wide?
__Yes __No __DK
6. Does your hospital's emergency preparedness plan address mass casualty incidents involving biological agents (i.e., influenza epidemics, new emerging infections, or terrorist use of biological agents)? __Yes __No __DK
If yes:
a) How frequently is this facet of your plan exercised and updated? _________________________
b) What was the date of your last exercise involving biological agents? ______________________
c) How is your bio-plan initiated?
__________________________________________________________________________
d) How are hospital personnel and medical staff within the hospital notified about the plan's initiation?
__________________________________________________________________________
e) How is affiliated medical staff notified about the plan's initiation?
__________________________________________________________________________
f) How does the hospital monitor staff's knowledge of the plan? ___________________________
__________________________________________________________________________
7. Does your hospital have a coordinator designated to oversee all preparedness efforts as it relates to your hospital's bioterrorism preparedness efforts? __Yes __No __DK
8. Does your hospital have a medical director that oversees all training and preparedness efforts as it relates to your hospital's bioterrorism preparedness efforts? __Yes __No __DK
9. Does your hospital's emergency preparedness plan address expanding staff availability?
__Yes __No __DK
If yes:
a) Where would you access additional staff (please check all that apply)?
__ Local registry (agency)?
__ Change shift length from 8 to 12 hours?
__ Change nursing/patient ratios?
__ Offer services to keep staff at the hospital (e.g., babysitting, elderly care)?
__ Does your hospital's emergency preparedness plan address requesting state or federal resources for assistance? __Yes __No __DK
b) Does your hospital participate in multiple facility credentialing procedures to permit rapid recognition of credentialed staff from other facilities or hospitals? __Yes __No __DK
10. Does your hospital experience problems staffing your ED, general medical, pediatrics, and surgical floors with nurses employed by the hospital? __Yes __No __DK
If yes:
a) During calendar year 2000, how many shifts per week (on average) are you short of nurses for:
___General medical
___Pediatrics
___Surgery (post-surgical care)
___ICU
___ED
b) Does your hospital have an on-call nursing policy for the following areas (i.e., where nurses are on-call and will come in when additional staff is required)?
General medical: __Yes __No __DK
Pediatrics: __Yes __No __DK
Surgery (post-surgical care): __Yes __No __DK
ICU: __Yes __No __DK
ED: __Yes __No __DK
11. Does your hospital's emergency preparedness plan address increasing operational (staffed-bed) capacity by at least:
a) 10%: __Yes __No __DK
b) 15%: __Yes __No __DK
c) 20%: __Yes __No __DK
12. Does your hospital's emergency preparedness plan address canceling elective surgeries in order to make additional beds available for inpatient use? __Yes __No __DK
13. Does your hospital's emergency preparedness plan address early inpatient discharge protocols to create additional beds? __Yes __No __DK
If yes:
a) Who decides which patients can be discharged early? _______________________________
b) Is this a voluntary policy with your medical staff? __Yes __No __DK
c) Is there a staff member involved in early discharge planning? __Yes __No __DK
14. Are you able to utilize hallways as short-term inpatient care areas in the event of a declared disaster?
__Yes __No __DK
If yes:
a) How many additional inpatient beds can be opened using the hallways during a declared disaster?
_______________________________________________
b) Can your hospital's computer process orders for patients not residing in traditional patient care areas (i.e., residing in the hallways)? __Yes __No __DK
c) Do you have a mechanism to provide privacy to patients residing in the hallway?
__Yes __No __DK
15. Do you have other areas of the hospital designated for emergency overflow of patients (e.g., an auditorium, lobby) in the event of a declared disaster? __Yes __No __DK
a) If yes:
i. Where are these areas located?_______________________________________
ii. Do you have beds or cots available onsite for these alternative patient care areas?
__Yes __No __DK
iii. Do you have a mechanism to provide privacy to these patients? __Yes __No __DK
iv. Do these overflow patient care areas have ready access to:
Supplemental oxygen source: __Yes __No __DK
Running water: __Yes __No __DK
Pharmaceuticals: __Yes __No __DK
Bath/showers: __Yes __No __DK
Toilets: __Yes __No __DK
Suction: __Yes __No __DK
Supplies: __Yes __No __DK
Monitoring Units: __Yes __No __DK
Computer access: __Yes __No __DK
Hand washing areas: __Yes __No __DK
Food and drink: __Yes __No __DK
Telephone: __Yes __No __DK
v. In the past five years, have you ever had to expand your bed capacity beyond your licensed number of beds? __Yes __No __DK
16. Does your hospital have a memorandum of agreement (MOA) with nearby extended care facilities (ECF) or rehabilitation hospitals to accept patients during a declared disaster that can be discharged early from the affected hospital but still require nursing care? __Yes __No __DK
17. Does your hospital have a memorandum of agreement (MOA) with outlying hospitals to accept inpatients during a declared disaster? __Yes __No __DK
18. Does your hospital's emergency preparedness plan address processes to increase inpatient treatment capacity within the city? __Yes __No __DK
19. Does your hospital's emergency preparedness plan address extending outpatient clinic hours (on and off-campus) beyond normal scheduled hours? __Yes __No __DK
If yes:
a) How do you staff these extended hours?_______________________________________
b) Has there ever been a need to extend clinic hours during a disaster situation?
__Yes __No __DK
20. Does your hospital's emergency preparedness plan address processes to increase outpatient treatment capacity within the city? __Yes __No __DK
21. Does your hospital's emergency preparedness plan address the provision of the following services if staff had to return to work during a community disaster (check all that apply)?
Provided:
Day (night) care for their children? __Yes __No __DK
Day (night) care for their dependent adults? __Yes __No __DK
Day (night) care for their pets? __Yes __No __DK
Sleeping quarters? __Yes __No __DK
Nourishment? __Yes __No __DK
Distribution of medication prophylaxis? __Yes __No __DK
22. Does your hospital have policies concerning emergency department diversion?
__Yes __No __DK
If yes:
a) What are your hospital's criteria to go on diversion?____________________________
_____________________________________________________________________
b) Who is delegated within the hospital to make the decision to go on diversion?________
_____________________________________________________________________
c) List who needs to be notified about your diversion policy outside the hospital?________
_____________________________________________________________________
d) In general, how many times a year does your hospital go on diversion?_____________
_____________________________________________________________________
23. What is the approximate number of functioning on-site ventilators that belong to your institution?_____
a) How many ventilators, if any, can be mobilized from associated long-term care, rehab facilities, or other satellite clinic facilities?___________________________________
b) How many additional ventilators does your institution rent weekly (average over the past year)? __________________________________________________________________________
c) Do you have access to ventilators that can be rented on an emergency basis? __Yes __No __DK
If yes:
_____ How many can be obtained?
_____ How long does it take your hospital to obtain these additional ventilators?
d) Is there a regional plan to provide extra ventilators if needed? __Yes __No __DK
If yes:
_____ How many additional ventilators can you access within 4 hours?
_____ How many additional ventilators can you access within 8 hours?
Do other hospitals in your area access ventilators from the same vendor?
__Yes __No __DK
24. Does your hospital have an information system that provides the following:
a) Inpatient staffing? __Yes __No __DK
b) Hospital bed availability? __Yes __No __DK
c) Diversion status of other hospitals in the area or region? __Yes __No __DK
d) Bed availability of other hospitals in the area or region? __Yes __No __DK
e) Information on biological agents and the management of infectious patients? __Yes __No __DK
f) Internet access? __Yes __No __DK
25. Does your hospital's emergency preparedness plan address stockpiling antibiotics and supplies?
__Yes __No __DK
If yes:
a) Does your hospital currently maintain a separate cache of antibiotics to treat hospital staff in the event of a bioterrorist incident? __Yes __No __DK
If yes:
i. What antibiotics are cached (check all that apply)?
| Name | Unit Doses |
|---|---|
| __ Doxycycline | _____________ |
| __ Tetracycline | _____________ |
| __ Ciprofloxin | _____________ |
| __ Levaquin | _____________ |
| __ Gentamicin | _____________ |
| __ Tobramycin | _____________ |
ii. How quickly can supplies be accessed? ____________________________________
iii. Where are these supplies stored? ________________________________________
26. How many days supply of antibiotics does your pharmacy maintain (based on current average daily usage)? ______________________________________________________________
27. Does your hospital stockpile or have 12-hour access to antibiotics (Doxycycline, ciprofloxacin) in order to provide community prophylaxis? __Yes __No __DK
28. During an average 24-hour period, how many additional orders (based on standard dosing) for the following antibiotics would exhaust your current in-hospital pharmaceutical supply (inventory):
_____ Doxycycline i.v.
_____ Doxycycline p.o.
_____ Ciprofloxacin i.v.
_____ Ciprofloxacin p.o.
_____ Levofloxacin i.v.
_____ Levofloxacin p.o.
_____ Gentamycin i.v.
_____ Tobramycin i.v.
a) How long would it take you to replenish these supplies? ________________________________
b) How would you obtain these supplies? _____________________________________________
c) Do other hospitals in your area access these drugs in the same manner and from the same source?
__Yes __No __DK
29. During an average 24-hour period, how many prescriptions for the following antibiotics (based on standard dosing) would exhaust your current outpatient pharmaceutical supply (inventory):
_____ Doxycycline p.o.
_____ Tetracycline p.o.
_____ Ciprofloxacin p.o.
_____ Levofloxacin p.o.
a) How long would it take you to replenish these supplies? ________________________________
b) How would you obtain these supplies? _____________________________________________
c) Who do you obtain these supplies from? ___________________________________________
d) Do other hospitals in your area access these drugs in the same manner and from the same source?
__Yes __No __DK
30. Has your hospital ever participated in a community or regional pharmaceutical stockpile?
__Yes __No __DK
31. Is your hospital's emergency preparedness plan integrated into the city emergency preparedness plan?
__Yes __No __DK
32. Does your hospital's emergency preparedness address the following:
a) Designating mental health services (Critical Incident Stress Management - CISM) to care for emergency workers, victims and their families, and others in the community who need special assistance coping with the consequences of a disaster? __Yes __No __DK
b) Provisions to provide for the proper examination, care, and disposition of deceased?
__Yes __No __DK
c) Mass immunization/prophylaxis? __Yes __No __DK
d) Mass fatality management? __Yes __No __DK
If yes, does the plan address the following:
i. Augmenting morgue facility and staff: __Yes __No __DK
ii. Expanding morgue capacity: __Yes __No __DK
iii. Procedures for decontamination/isolation of human remains: __Yes __No __DK
iv. Backup isolation procedures when morgue capacity is exceeded: __Yes __No __DK
v. Environmental surety? __Yes __No __DK
e) Ensuring adequate bio-protection (Universal Precautions) gear for hospital/clinic personnel?
__Yes __No __DK
f) Ensuring adequate supplies (including food, linens & patient care items) are available from local or regional suppliers, or that plans are in place to obtain them in a timely manner in order to be self-sufficient for 48-hours? __Yes __No __DK
g) Access to portable cots, sheets, blankets and pillows? __Yes __No __DK
h) Triage of mass casualties? __Yes __No __DK
i) Enhancing hospital security by utilizing community law enforcement assets? __Yes __No __DK
j) Tracking expenses incurred during an emergency? __Yes __No __DK
k) Coordination with state or local public health authorities? __Yes __No __DK
l) Creating additional isolation beds? __Yes __No __DK
33. Does your hospital have an internal health surveillance system in place that tracks patients presenting problems or complaints? __Yes __No __DK
If yes:
a) Does your hospital's surveillance system track the following (please check all that apply):
__ ED visits
__ Hospital admissions (total numbers and patterns)
__ Presenting patients' complaints
__ Influenza-like illness monitoring
__ Increased antibiotic prescription rate
b) Is this information gathered automatically electronically or done manually?
c) When is this information gathered?
d) Who gathers this information?
e) Who (and how - phone, fax, etc.) does the ED notify when unusual clusters of illnesses present and can they be notified 24-hours per day (check all that apply)?
| Personnel/Department | 24-hour Notification | How Contacted |
|---|---|---|
| Hospital infection control personnel | __Yes __No __DK | _________________ |
| Other designated (resource) in-house personnel | __Yes __No __DK | _________________ |
| Local Health Department | __Yes __No __DK | _________________ |
| State Health Department | __Yes __No __DK | _________________ |
| Other, please specify _____________________ | __Yes __No __DK | _________________ |
34. Is your in-patient laboratory staffed 24 hours a day, 7 days a week? __Yes __No __DK
35. What diagnostic capability does your in-patient laboratory have? (check all that apply)
__ Minimal identification of agents
__ Identification, confirmation, and susceptibility testing
__ Advanced laboratory capacity with some molecular testing
36. What is the highest Biosafety level (BSL) capability of your in-patient lab?
__ BSL 1 (basic level of containment for minimal potential hazards)
__ BSL 2 (primary containment practices for moderate potential hazards)
__ BSL 3 (primary and secondary containment practices for potentially lethal agents)
37. What is the current volume of culture specimens that can be processed in your in-patient lab on a daily basis?
_______________ Sputum
_______________ Blood
_______________ Urine
38. What is the estimated maximum volume of culture specimens that can be processed in your in-patient lab on a daily basis?
_______________ Sputum
_______________ Blood
_______________ Urine
39. Does your hospital have protocols or procedures for the handling of laboratory specimens in the event of a biological terrorism incident? __Yes __No __DK
If yes, do these protocols or procedures address the following (please check all that apply)
__ Collection
__ Labeling
__ Chain of custody (similar to rape packages)
__ Secure storage
__ Processing
__ Transportation to secondary laboratory
__ Storage
__ Referral to Public Health Department (PHD) lab
__ Contacting the CDC
__ Contacting local law enforcement
__ Contacting the FBI
__ Decontamination of bio-hazardous waste
__ Safe disposal of waste
40. Please check the appropriate box to describe your hospital's in-patient laboratory capacity with regard to the following organisms (check all that apply):
| Organism | Culture | Rule Out | Confirm* | None** |
|---|---|---|---|---|
| Anthrax | ______ | ______ | ______ | ______ |
| Plague | ______ | ______ | ______ | ______ |
| Tularemia | ______ | ______ | ______ | ______ |
| Brucellosis | ______ | ______ | ______ | ______ |
| Q-Fever | ______ | ______ | ______ | ______ |
| Smallpox | ______ | ______ | ______ | ______ |
* If checked, please indicate how your lab confirms the organism's identification. ________________________________________________________________
** Checking none means your hospital laboratory does not have the capacity to culture, rule out, or confirm the listed organism.
41. How would you rate your laboratory's ability to identify specimens of biological terrorism?
__ Very poor
__ Poor
__ Fair
__ Good
__ Very good
42. How would you rate your hospital's ability to manage victims of biological terrorism?
__ Very poor
__ Poor
__ Fair
__ Good
__ Very good
Sources: Questions 1, 2, 3 and 23 in Section II of this questionnaire were adapted from New York City Department of Health, institutional surge capacity questions 1-6 in "Biological, Chemical, and Radiological Emergency Planning/Preparedness Capabilities" survey, dated 11/13/2000. The following documents were also consulted: Marasco Newton Group Ltd., "Hospital Weapons of Mass Destruction Needs and Resource Assessment Survey," dated 2/8/2000; Booz-Allen & Hamilton, WMD Checklist; Institute of Medicine, 2000 MMRS Evaluation Instrument in "Preparing for Terrorism: Tools for Evaluating the Metropolitan Medical Response System"; American Hospital Association, Chemical and Bioterrorism Preparedness Checklist; Disaster Preparedness International, "Hospital Capability to Respond to Pandemic Influenza, Bioterrorism, and Emerging Infectious Disease Outbreaks," dated 12/11/2001.