EM.12.02.03 - Staffing

• EP 1 - Bringing In Staff & Volunteers to Meet Patient Care Needs

  The hospital develops a staffing plan for managing all staff and volunteers to meet patient care needs during the duration of an emergency or disaster incident or during a patient surge. The plan includes the following:

  • Methods for contacting off-duty staff
  • Acquiring staff from its other health care facilities
  • Use of volunteer staffing, such as staffing agencies, health care coalition support, and those deployed as part of the disaster medical assistance teams

  Note: If the hospital determines that it will never use volunteers during disasters, this is documented in its plan.

  As of September 1, 2022, UTMB will implement a formal labor pool as part of the Incident Command Response. Certain staff members will have been assigned specific emergency roles and they will receive training for those roles. When activated by the Incident Command, the emergency role will become the primary full-time role for activated staff members. 

  Off-duty staff, physicians, and other licensed practitioners will be contacted via departmental call trees, email notification, or mass notification systems.

  If necessary and appropriate, staff may be temporarily reassigned to another campus or location. furthermore, staff may be needed to accompany evacuating patients.

  UTMB will normally seek staffing assistance from other state agencies and other University of Texas medical institutions. In the case that UTMB does have the need for volunteers, UTMB would only grant privileges to volunteer licensed practitioners when the Emergency Operations Plan has been activated in response to a disaster and the hospital is unable to meet immediate patient needs. Plans to accept volunteers include Texas Emergency Medical Task Force Members and federal Disaster Medical Assistance Teams (see NDMS below).
  

  UTMB may use temporary staffing services or travelers to address staffing needs, as well as the local Medical Reserve Corps. If assistance from the National Disaster Medical System (NDMS) is needed, UTMB's request would be forwarded through the County and through the Catastrophic Medical Operations Center (CMOC) to the State. If approved by the State, the request would be forwarded to the Federal Coordination Center in Houston. UTMB would plan to expect support within 72hrs. UTMB would collaborate with the jurisdiction (e.g. Galveston County) in setting up a location for the disaster assistance team and establish a unified command in order to coordinate actions.

  • Trauma and Critical Care Team (TCCT)
  • Disaster Medical Assistance Team (DMAT)
  • Disaster Mortuary Assistance Team (DMORT), Victim Information Center Team (VICT), National Veterinary Response Team (NVRT).
    
• EP 2 - Managing Staff/Volunteers During an Emergency

  The hospital's staffing plan addresses the management of all staff and volunteers as follows:

  • Reporting processes
  • Roles and responsibilities for essential functions
  • Integrating staffing agencies, volunteer staffing, or deployed medical assistance teams into assigned roles and responsibilities

  
  

  Reporting Process:

  For notice incidents (e.g. hurricanes), if at all possible we will try to release the recovery team at a certain hour before landfall and provide a time by which the rideout team needs to be in place. For no-notice incidents, we would use either Everbridge or departmental call lists to call people in to report to their assigned place of reporting. 

  UTMB uses the Incident Command System/National Incident Management System and Hospital Incident Command System to manage staff during an emergency. For notice events such as hurricanes and floods, the Institutional Command Team will activate and formal roles will be assigned. UTMB assigns disaster responsibilities to staff and volunteer (non-LIPs) only when the Emergency Operations Plan has been activated in response to a disaster and the hospital is unable to meet immediate patient needs. These disaster responsibilities are assigned by the Incident Commander, their designee, or the Chief Medical Officer. 

  More information on the Chain of Command and Succession Planning is found in EM.13.01.01 EP3.

  The Process for Assigning Staff to All Essential Staff Functions: 

  • Pre-incident: UTMB uses an ‘Annual Acknowledgement Process’ where staff and managers are required to review the staff member’s emergency role and to whom they would report in an emergency. Both the manager and employee record the acknowledgment on a UTMB web application.
  • Response Phase: The Incident Action Plan includes an Organizational Assignment to Command Team functions. The assignment is based on the expertise required to complete the assigned role and availability. If a formal Incident Action Plan is published, it may include an Organizational Assignment List. 

  For those assigned a formal role in the Command Team, each staff member will report to their respective campus Incident Commander. When the Institutional Command Team is activated, each campus will report to the Institutional Incident Commander (generally the UTMB President or their designee).

  UTMB will oversee the performance of staff and volunteers through direct observation, mentoring, and medical record review. Direct supervision will be one by UTMB personnel (e.g. nurse manager).

  Integrating External Staffing:

  Human Resources (HR) would manage external staff that come from staffing agencies, volunteer staff, or deployed medical assistance teams. HR would manage the identity and licensure verification processes. External staff would be provided with onboard training and a familiarization process before integrating them into our operations. If needed, they would be given a username and password to use information systems they require, as well as badges with access to appropriate areas. A UTMB employee would be assigned to supervise their work. Most recently, this process was used during the Covid-19 pandemic.

  • For volunteers, our primary strategy is to coordinate volunteers through the County to maximize their Good Samaritan protections.
  • Medical assistance teams can be lumped with staffing agencies because they would be run the same way. If there is a state of federal declaration it is possible for those volunteers to be compensated for their work (done during Covid-19 to great effect).
• EP 3 - Relocation of Staff and Volunteers [This EP was Removed]

  If on-duty staff and volunteers are relocated during an emergency or disaster incident, the hospital documents the name and location of the receiving facility or other location.

  Staff and student volunteers could be assigned to accompany patients to planned evacuation receiving hospitals. In general, staff would go to hospitals and students would go to shelters. For example, during hurricane Ike, several nurses were evacuated alongside pediatric patients to accompany them to the receiving hospital.

  UTMB would use our evacuation planning tools in order to record each facility where a staff or volunteer member is sent. Human resources will manage the deployment of staff. Once staff arrive at the receiving hospital, they will be given an assignment.

  More information on evacuations can be found in EM.12.01.01 (EP3).

• EP 4 - Managing & Verifying Volunteer Licensed Independent Practitioners (LIPS)

  The hospital's staffing plan describes in writing how it will manage volunteer licensed practitioners when the Emergency Operations Plan has been activated and the hospital is unable to meet its patient needs. The hospital does the following:

  • Verifies and documents the identity of all volunteer licensed practitioners
  • Completes primary source verification of licensure as soon as the immediate situation is under control or within 72 hours from the time the volunteer licensed practitioner presents to the organization
  • Provides oversight of the care, treatment, and services provided by volunteer licensed practitioners

  Note: If primary source verification of licensure cannot be completed within 72 hours, the hospital documents the reason(s) it could not be performed.

  UTMB grants disaster privileges to volunteer licensed independent practitioners (LIPS) only when the Emergency Operations Plan is activated in response to a disaster and the hospital is unable to meet immediate patient needs. The Incident Commander (IC), their designee, or the Chief Medical Officer is responsible for assigning disaster responsibilities. 

  The IC or designee will verify licensure, certification, or registration if held, or other validation of their identity and competency before any work assignment is made. Primary source verification of licensure occurs as soon as the disaster is under control or within 72 hours from the time the volunteer licensed independent practitioner presents him-or herself to the hospital, whichever comes first. If primary source verification of a volunteer licensed independent practitioner’s licensure cannot be completed within 72 hours of the practitioner’s arrival due to extraordinary circumstances, UTMB documents the reason, evidence the LIP's demonstrated ability, and evidence of UTMB's attempt to perform primary source verification (all of this is done as soon as possible).

  UTMB would use the Emergency System for Advanced Registration of Volunteer Health Professionals (ESAR-VIP) to verify credentials.

  

  UTMB Identification Cards issued through the Badge Officer will be used for identification of all UTMB-affiliated persons. UTMB will distinguish volunteer licensed independent practitioners from other licensed independent practitioners through the use of badges or vests.

  The Incident Commander and Incident Command Team will provide guidance, direction and supervision to volunteers. The primary method of oversight for volunteer performance will be direct observation by UTMB personnel (e.g. nurse manager). As part of the annual acknowledgement process, campus leaders will provide written communication to License Independent Practitioners about their emergency role and to whom they will report. In most cases, these practitioners would report to their normal supervisors.

  Recent mass vaccination efforts (Covid-19) have greatly expanded UTMB’s use of volunteers. Registration of the volunteers is accomplished through the County Office of Emergency Management and the Health Department so that volunteers have liability protection. 

• EP 5 - Granting Disaster Privileges to Volunteer Physicians and Other Licensed Practitioners

  The hospital identifies the individual(s) responsible for granting disaster privileges to volunteer physicians and other licensed practitioners (such APRNs and PAs) and has a process for granting these privileges. This is documented in the medical staff bylaws, rules and regulations, or policies and procedures.

  UTMB grants disaster privileges to volunteer physicians and other licensed practitioners only when the Emergency Operations Plan is activated in response to a disaster and the hospital is unable to meet immediate patient needs. The Incident Commander (IC) or their designee, or the Chief Medical Officer is responsible for assigning disaster responsibilities to volunteer practitioners. The IC will assign volunteers to members of the Incident Command Team (who are directly involved in patient care operations) for guidance, direction and supervision. 

• EP 6 - Employee Assistance and Support

  The emergency response staffing plan describes how it will provide employee assistance and support, which includes the following:

  • Staff support needs (for example, housing or transportation)
  • Family support needs of staff (for example, childcare, elder care)
  • Mental health and wellness needs
  
  

  The Support Division within the Logistics Section of the Incident Command Team has delegated authority from the Incident Commander (IC) to oversee any staff shelter, feeding, daycare needs. Transportation needs may be included as required by the incident and approved by the Institutional IC. Portfolio Management will assist in planning for staff shelter related to the use of space. The Logistics Section will provide cots and linens; scrubs from the "Auto Valet System" to specific departments only. Food Service will assist in arranging meals for staff (e.g. in a hurricane ride out).  Employee Health, faculty with mental health expertise and pastoral care staff are available to provide counseling and stress debriefing. Additional resources are available from Gulf Coast Center if required.

  Mutual Aid Agreements have been executed between UTMB and various local agencies, which may provide shelter for personnel and vehicle parking during an emergency. A written acknowledgement of the agreement shall exist, and the agency will indemnify and hold harmless UTMB for any physical or personal injuries that may occur while its personnel or equipment is on UTMB property.

  In general, the Logistics Section, Support Division will monitor family support and communications needs. In extraordinary circumstances such as the early phase of the Covid-19 response in 2020, daycare may be arranged. That said, staff are expected to make family emergency plans, and for instance, family members (with pets) are expected to follow all evacuation orders during hurricanes or other similar large-scale incidents. The safest place for family members and pets is in the evacuation zone and not in e.g. a hurricane or flood zone.

  Additional assistance is covered in EP1 of standard EM.12.02.05. Most patient support items are also available to employees.

  Accommodations for Dependent Family Members: Authorization for housing of employees’ family members must be secured from the President in advance. A written request must be made, by the academic or clinical department chairman, or the appropriate university department head or dean of the department. Exceptions allowing dependent housing will be provided  during emergency weather conditions only if one of the following categories applies.

  1. An Essential employee is a single parent responsible for a child or adolescent, and is unable to make other arrangements for housing.
  2. Two Essential employees are responsible for a child or adolescent, and are unable to make alternate arrangements for housing.
  3. An Essential employee is responsible for a frail or elderly family member, and is unable to make alternate arrangements for housing.

  Dependents are expected to be self-sufficient and bring all required food, water, medications, bedding and personal convenience items. Housing for dependents will be determined at the time of the emergency plan activation and employees will be told where to bring the dependent. All dependent needs are the responsibility of the employee.

  Not Allowed - Appliances or Pets: Under no circumstances may any electrical appliances or combustible fuel- powered appliances, e.g., propane camp stoves or lanterns, candles or similar items, be brought into the hospitals or other university building. Hospital or academic space may not be used for housing pets.

EM.12.02.07 - Safety & Security

• EP 1 - Safety & Security Plan

  The hospital has a plan for safety and security measures. The plan describes the roles that community security agencies (for example, police, sheriff, National Guard) will have in the event of an emergency and how the hospital will coordinate security activities with these agencies.

  The UTMB Chief of Police is primarily responsible for security during emergencies. The UTMB Police Force is part of the Incident Command structure and response. UTMB maintains its own Police Department, which is approved by the Texas Commission on Law Enforcement and accredited by the Commission on Accreditation for Law Enforcement Agencies.  UTMB Police and Security Officers are posted 24/7 at each of UTMB’s four primary campuses, including Galveston, Clear Lake, League City, and Angleton.  The UTMB Police Department will provide internal and external security at each of these campus locations during emergencies. UTMB offsite clinic locations and satellite offices are generally closed during emergency periods and would rely primarily on local area law enforcement response should the need arise.  UTMB Police also maintain a 24/7 911 Emergency call and dispatch center which is registered with the State of Texas and the Federal Communications Commission as a Public Safety Answering Point (PSAP).

  Arrangements for internal security and safety are provided by UTMB’s own police department (PD). Furthermore, UTMB has an Institutional Safety & Security Executive Committee – along with subcommittees – that prioritize risks and approve programs to address those risks. UTMB also has its own Environmental Health and Safety department and Institutional Safety Officer (ISO) to ensure internal security and safety.

  • Control entrances and exits: The UTMB Police department maintains the mechanical and electronic access control systems for all campus facilities, including door locks and badge readers. UTMB Police Officers and/or guards are also posted at certain security checkpoints, including the Galveston National Laboratory and Emergency Departments. Most entrances and exits are monitored by one of two camera systems (Lenel & Genetec), which include video analytic capabilities. If necessary, at the time the EOP is activated, police officers will stand guard at high profile areas, such as mother-baby units and irradiator facilities. Furthermore, UTMB employees and students are required to always wear ID badges when inside of campus facilities.
  • Control movement within the facility: Movement throughout UTMB facilities is controlled by the previously mentioned key/lock systems, as well as signage, staff, and/or police directing the flow of patients and employees during an emergency. When able, communications will be sent to staff providing more information (e.g. location of their assigned shelter-in-place area).
  • Control vehicles: Vehicles that access our facilities during an emergency will be controlled through a collaborative effort by auxiliary services, parking, and campus police. Signage will be posted if time allows, along with communications to vehicle operators (or their agencies) providing more information. Essential UTMB employees with credentials will be allowed to pass through roadblocks and provided access to appropriate UTMB facilities. Escorts from the Department of Public Safety are available. Parking will be in designated lots / garages. The Public Information Officer will provide public announcements providing information on vehicle access to the campus. 

  Coordination with community security agencies: UTMB Police and Emergency Management collaborate with local jurisdictions, and can request mutual assistance as required. As a state agency, UTMB can request state assets to augment police and security if needed. If additional police/security resources are requested, UTMB will establish a unified command to coordinate activities. UTMB collaborates in emergency planning with city, county, and state officials to include development of the regional re-entry plan..

  Advanced preparation for security and safety occurs at UTMB through various activities, including frequent exercises and real incidents that ensure plans are adequate. Plans pertaining to security and safety are updated frequently and reviewed annually, which includes approval by the ISS Executive Committee. The Incident Command Team meets regularly during times of emergency (e.g. Covid-19) where reports are provided by departments who manage security and safety.

• EP 2 - Tracking Name and Location of Everyone

  The hospital’s plan for safety and security measures includes a system to track the location of its on-duty staff and patients when sheltered in place, relocated, or evacuated. If on-duty staff and patients are relocated during an emergency, the hospital documents the specific name and location of the receiving facility or evacuation location. Note: Examples of systems used for tracking purposes include the use of established technology or tracking systems or taking head counts at defined intervals.

  Staff Tracking

  UTMB uses the Incident Command System/National Incident Management System and the Hospital Incident Command System in emergency response. The Management chain of command as well as Incident Command System Resource Management principles will be used to track the location of on-duty staff. 

  Tracking movement through our facilities is done through a combination of badge readers, check points, sign-in sheets, status boards, locked doors, signage, staff and/or police directing the flow of people, et cetera. Restriction of non-critical movement during an emergency may occur. When able, communications will be sent to staff providing more information (e.g. location of their assigned shelter-in-place area).

  During Shelter-In-Place operations, staff will be tracked in and out of the shelter. Employee badges will be used to monitor entry and exiting buildings. For on-duty personnel, force account labor accounting will be used to track the location of the staff members while working. ICT will assign demobilization plan to assure all staff are accounted for once the disaster ends and normal operations resume.

  During hurricane ride out operations, Police will secure buildings in accordance with the hurricane plan. Access will only be granted to buildings that are required for critical operations. The Logistics Section, Support Division will sign in people to off-duty/sleeping areas, and then sign them back out when they report back to duty. Staff may not enter secured locations until those locations have been inspected by EH&S and Police. EH&S may establish a check-in/check-out system for certain buildings until such point that the building is fully opened. Staff will use their assigned badges to check in and out of designated parking garages and buildings.

  Tracking evacuated staff can be done through regular communication with their supervisor, a HICS Organizational Assignment Form (or comparable document or information system), and slight modifications to several of the tracking mechanisms used for patients (who staff may accompany during an evacuation).

  Patient Tracking
  

  UTMB tracks the locations of patients sheltered on site during an emergency using wristbands, bed assignments, electronic management systems, and nurse check-ins. Furthermore, badge access and key entry doors limit movement throughout our facilities.

  The system also includes documentation of the name and location of the receiving facility or alternate site in the event a patient is relocated during the emergency. The name and location of receiving facilities or alternate sites may be defined in the emergency management plan, formal transfer agreement, or other accessible documents. UTMB is prepared to use manual downtime procedures to record patient information during an emergency. UTMB uses a set of planning documents to support patient evacuation and tracking. In preparation for evacuation to planned receiving hospitals, UTMB uses a spreadsheet form that lists the patient name, demographic information, and abbreviated medical information, and physician contact information. This form is posted to a secure SharePoint site that receiving hospitals can access. The receiving hospital system then enters the specific hospital, address, and physician for each patient. This information is then used to request ambulance transport through EMTRack from the Southeast Texas Regional Advisory Council (SETRAC). When the patient arrives at the receiving hospital, UTMB is provided notice.

  • Patient Evacuation Planning Form
  • Patient Roster / Emergency Memorandum of Transfer

  As a backup, each patient will be provided with a hardcopy HICS 260 Patient Evacuation Tracking Form. A HICS 255 Master Patient Tracking Form will be used as a backup to assure that all patients arrive at their receiving hospitals. The ambulance service and receiving hospitals will assume responsibility for the patient when the patient is in their care. UTMB will be prepared to support family members in obtaining information about the condition/location of the patient until contact is made.

  If the state of Texas deploys its Texas Emergency Tracking Network system, a bar code tag is attached to the patient and any accompanying equipment. The bar code, name of person, and driver’s license number are enrolled into the system and stored on a server at the University of Texas at Austin. Transport (ground ambulance, ambus, and aircraft) are also bar coded when the person is loaded so that the person is associated with the transport in the database. Conversely the person is disassociated when they are unloaded. If the receiving facility has access to the TETN, they can enter the person and their location into the system. Texas also has the ability to use GPS tracking when buses are used.

  If UTMB becomes aware that a patient is missing, UTMB will contact CMOC to request assistance in tracking the patient. If necessary the request will be escalated to the Department of State Health Services and the Texas Division of Emergency Management/Department of Public Safety (who administers the Texas Emergency Tracking Network mentioned above).

  Information related to transferring and tracking personnel is found in EP1 of EM.12.02.05.

• EP 3 - Hazardous Materials Incidents [This EP was removed]

  The hospital’s emergency response plan for safety and security describes in writing the process for how it will manage and respond to internal and external hazardous materials incidents. The plan includes the following:

  • Process to identify hazardous materials such as chemical, biological, radiological, nuclear, or high-yield explosives (CBRNE)
  • Who will be notified in the event of a hazardous materials incident
  • Who responds to a hazardous materials incident
  • Who has access and authority for initiating shutdown procedures (such as medical gases, ventilation)
  • Triage procedures for potentially exposed patients
  • Decontamination procedures and equipment maintenance

  
  

  Management of Hazardous Materials: Environmental Protection Management (EPM) under the Environmental Health and Services department (EHS) is responsible for providing hazardous material and waste disposal services for all UTMB properties (campuses and off-site clinics alike). Activities and services include consultation, training, interface with facilities for new and renovated spaces, compliance audits and risk assessments for handling hazardous materials.  EPM services include the following programs:

  • Emergency response to spill of hazardous materials and environmental hazards.
  • Laboratory waste pick up of hazardous chemicals and radioactive waste.
  • Provide assistance to personnel working with processes that generate hazardous chemicals or wastes in applying source reduction and waste minimization practices.
  • Facility and laboratory audits.
  • University wide environmental policy and program development, permit reporting and documentation.
  • Municipal solid waste permit (includes medical waste operations) and reporting requirements.
  • Consulting on facility operations to ensure regulatory compliance with UTMB’s Title V Operating Permit with reporting on annual air emission and mass cap and trade.
  • Oversee and coordinate environmental protection programs such as pharmaceutical and medical waste management with the associated committees.
  • Collect and analyze compliance related data for monthly performance indicators, identify and coordinate performance improvement initiatives for hazardous materials and wastes.
  • Serve committees to ensure compliance with the Joint Commission standards and elements of performance for hazardous materials and waste management.

  EPM ensures the Hazardous Materials and Waste Management plan is up to date, including review and approval by a subcommittee with the same name. This plan and others like it can be found at www.utmb.edu/eoc.

  Radioactive, biological, and chemical isolation/decontamination: Due to the potential for UTMB to serve as a medical treatment/triage facility in the event of a regional Chemical / Biological / Radioactive / Nuclear / Explosive (CBRNE) event, several steps have been made to prepare the institution for isolation and decontamination of received patients and the worried-well:

  • UTMB Health Trauma Centers/EDs have decontamination-trained staff with access to required Personal Protective Equipment to ensure safety. Furthermore, decontamination facilities are located adjacent to the Emergency Departments. Gross decontamination should be accomplished in the field by EMS or Fire personnel prior to transportation of the patient(s) to UTMB, where secondary decontamination will occur. Note: secondary decon conducted before entry into the cold zone (Emergency Room) is a more thorough and comprehensive than decon conducted in the field.
  • UTMB Campus Police will provide crowd control, ensuring access to UTMB Health facilities is limited only to screened/decontaminated patients. In the event of suspected contamination in the Emergency Department, UTMB Police will secure the building and no patient, visitor or staff traffic shall be permitted into the main hospital and clinic complex until cleared by the Institutional Safety Officer or their designee. 
  • UTMB has an emergency equipment stockpile containing equipment capable of detecting and identifying ionizing radiation that might be present on people, equipment, and vehicles.
  • Our Environmental Health & Safety Department is staffed with 24/40-hour HAZWOPER trained professionals who provide on-site support for patient screening and decontamination efforts in the event of a mass casualty incident.
  • UTMB is one of ten hospitals designated by the U.S. Department of Health and Human Services to serve as a Regional Ebola and Special Pathogen Treatment Network and is home to the Biocontainment Critical Care Unit.  UTMB Health staff in this facility are trained and equipped with state-of-the art technology to safety treat patients infected with highly infectious, life-threatening diseases.

EM.12.02.11 - Utilities

• EP 1 - Essential Utility Systems

  The hospital’s plan for managing utilities describes in writing the utility systems that it considers as essential or critical to provide care, treatment, and services.

  Note: Essential or critical utilities to consider may include systems for electrical distribution; emergency power; vertical and horizontal transport; heating, ventilating, and air conditioning; plumbing, steam boilers; medical gas; medical/surgical vacuum; and network or communication systems.

  Critical System are listed in the UTMB  Facilities/Missions Readiness Report (Spreadsheet). The Readiness Report evaluates the design and maintenance level of the building system against UTMB Priority Risks. For instance, the elevation of the lowest point of vulnerability to hurricane flooding for each system is listed. Information from the Readiness Report is used to help prioritize major mitigation and maintenance programs in order to continuously improve UTMB resilience to incidents. Additional information: March 2022 Readiness Report (Presentation) given annually at the ISS executive committee (UTMB personnel only).

  See the Emergency Module in Archibus for more information on modeling and disaster recovery related to essential utility systems.

  

  Higher quality images are available:  Galveston Main Campus and  Angleton Danbury, Clear Lake, and League City Campuses (UTMB personnel only).

• EP 2 - Maintaining Essential Utility Systems if One or More is Impacted

  The hospital’s plan for managing utilities describes in writing how it will continue to maintain essential or critical utility systems if one or more are impacted during an emergency or disaster incident. 

  See EP3 below in this standard (EM.12.02.11).

  The Vice President for Business Operations and Facilities oversees both Utilities and Facilities within the Operations Section (of the Incident Command Team) and is responsible for the continued delivery of utility services and the availability of backup systems. The Utilities and Facilities Unit will coordinate with any outside utility service providers, vendors, and disaster response contractors to assure continued service as possible.

  The HVA lists utilities outages as a significant hazard. When the Command Center is activated, Business Operations and Facilities (BOF) will fall under the Support Operations Section. BOF maintains contingency plans and standard operating procedures to address the alternative means of providing:

  • Electricity (backup generators, portable generators, fuel storage, fuel supply, disaster response contractors)
  • Water needed for consumption and essential care
  • Water needed for equipment and sanitary purposes
  • Fuel required for building operations or essential transport (fuel storage tanks, contingency contracts, disaster response contractors, contingency plans with the State Government for emergency transportation)
  • Medical gas and vacuum systems
  • Utility systems defined as essential to UTMB: Vertical and horizontal transport, Cooling and heating, Steam for sterilization.
    

  For offsite clinic locations, BOF will assist clinic management in working with leasers and local utility companies to maintain and restore service.
  

  In addition to the main campus BOF will support continuity of service for other UTMB campuses.

• EP 3 - Alternative Means to Provide Essential Utilities

  The hospital’s plan for managing utilities describes in writing alternative means for providing essential or critical utilities, such as water supply, emergency power supply systems, fuel storage tanks, and emergency generators.

  Alternative Means of Providing Water: Water needed for consumption and essential care activities: UTMB Business Operations and Facilities – Utilities Services maintains regular communications with UTMB campus utility providers and the Brazos River Water Authority in regard to water supply and quality. UTMB developed a Mutual Aid Agreement with the City of Galveston that would allow UTMB to use the 1-million-gallon water tank in proximity of campus in the event of a water pressure issue or water outage. UTMB Food Services maintains an inventory of bottled water at each campus for emergency use. UTMB has at least two disaster response companies that can provide potable water. UTMB has used a water barge to provide potable water; and can request state support for potable water as needed.

  Alternative Means for Non-Potable Water and Sanitation: The two thermal energy storage tanks can be utilized to provide process water at the utility plants   Also, UTMB has made use of the campus swimming pool to provide water barrels for sanitary needs such as flushing of toilets.

  Alternative Means of Providing Electricity and Lighting: All campuses maintain emergency power supply systems in accordance with applicable NFPA Codes and CMS regulations.

  Note: UTMB Main Campus has a co-generation facility that has a dedicated high pressure natural gas line that can be isolated from city users. The power generated at the co-generation plants can only be used on thermal utility production equipment in the plants. The bypass was successfully tested in 2020.

  Backup fuel required for building operation, generators, and essential transport services that the hospital would typically provide is stored on campus. UTMB Main Campus has two 50,000-gallon diesel tanks on campus. The tanks are filled prior to each hurricane season. Main campus is also fed by a dedicated high pressure fuel line. Other campuses have on-site emergency fuel storage. Additional supplies can be provided by existing job order contractors, disaster response contractors, or by a State of Texas Resource Request.

  • ADC has 3,000 gallons of fuel for its generators (M700).
  • CLC has 12,500 gallons of fuel for its generators (M230).
  • GMC has 100,000+ gallons of fuel for its generators (2x 50,000 diesel tanks).
  • LCC has 10,900 gallons of fuel for its generators (M80).
    

  Alternative means of providing medical gas / vacuum systems: UTMB can provide bottles gases supplied by normal vendors or disaster response contractors, or by a state resource request. Vacuum systems are interconnected between buildings and are connected via rollover valve assemblies with automatically open or close dependent on demand. In complete loss, portable battery powered vacuum systems can be deployed to areas as needed.

  Alternative means of providing essential utility systems: are managed by the AVP of Utility Services. UTMB’s Archibus system shows elevation level for all floors in all buildings that can allow for flood planning to determine which utility systems would be impacted. All minimum points of vulnerability are addressed in the readiness plan.  UTMB has two 50,000-gallon diesel tanks and backup generators for all healthcare related buildings. UTMB has a dedicated high-pressure gas line that is separate from the City line that feeds UTMB’s co-generation facility. UTMB has a mutual aid agreement with the City of Galveston for use of water in the City elevated tower that holds one million gallons.

  UTMB implements components of its plan that require advance preparation to provide utilities during an emergency: Business Operations and Facilities conducts an annual preparedness program in advance of hurricane season. A multi-year exercise program addresses various aspects of a resilient infrastructure for all campuses. Prior to hurricane season, BOF presents a Readiness Report to the ISS Executive Committee that addresses the ability to provide continuous utility services as well as opportunities for continuous improvement and further mitigation of risk.

  Generators must be located so as to provide backup power in scenarios anticipated by the risk assessment – allowing healthcare to continue through foreseeable emergency conditions. All emergency generator locations meet the environmental requirements of NFPA 110 7.1 UTMB has completed a detailed risk analysis that includes the elevation above sea level of all critical building systems including generators – and those systems’ lowest point of vulnerability. The most critical building systems were elevated or protected in the post-Hurricane Ike recovery. UTMB continues to conduct annual risk assessments and will mitigate, operationally manage (so as to prevent catastrophic failures), and develop backup systems as is economically feasible. UTMB has established building standards related to hurricane flood (highest priority risk) where new construction is required to fully function at an inundation level of 25’ msl, and renovations are required to function at 20’msl. The UTMB standard exceeds FEMA requirements

• EP 4 - Alternative Sources for Maintaining Energy

  The hospital’s plan for managing utilities includes alternate sources for maintaining energy to the following:

  • Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions
  • Emergency lighting
  • Fire detection, extinguishing, and alarm systems
  • Sewage and waste disposal

  Note: It is important for hospitals to consider alternative means for maintaining temperatures at a level that protects the health and safety of all persons within the facility. For example, when safe temperature levels cannot be maintained, the hospital considers partial or full evacuation or closure.

  All campuses maintain emergency power supply systems in accordance with applicable NFPA Codes and CMS regulations (which includes emergency lighting).

  A co-generation facility on the Main Campus has a dedicated high pressure natural gas line that can be isolated from city users. The power generated at the co-generation plants can only be used on thermal utility production equipment in the plants. The bypass was successfully tested in 2020. 

  UTMB uses Combined Heat & Power (CHP), which is a highly efficient process that captures and utilizes the heat that is a by-product of electricity generation. This captured heat can be applied to facility loads in the form of process heating, steam, hot water, or even chilled water. This is important for HVAC, temperature, and humidity control in many of our facilities.

  Backup fuel required for building operation, generators, and essential transport services that the hospital would typically provide is stored on campus. UTMB Main Campus has two 50,000-gallon diesel tanks on campus. The tanks are filled prior to each hurricane season. Main campus is also fed by a dedicated high pressure fuel line. Other campuses have on-site emergency fuel storage. Additional supplies can be provided by existing job order contractors, disaster response contractors, or by a State of Texas Resource Request.

  • ADC has 3,000 gallons of fuel for its generators (M700).
  • CLC has 12,500 gallons of fuel for its generators (M230).
  • GMC has 100,000+ gallons of fuel for its generators (2x 50,000 diesel tanks).
  • LCC has 10,900 gallons of fuel for its generators (M80).

  Fire alarm panels are code compliant by having their own battery powered supplies that last 24 hours, plus the duration of an alarm event. Additionally, all fire alarm components are installed to be powered off of the Life Safety branch of electrical systems so that during the course of an extended outage the system will be powered up as if normally.

  UTMB collaborates with cities on continuity of sewage and waste disposal services/systems. Galveston Island is the most vulnerable to flood damage, however, after Hurricane Ike, the City mitigated the risk to lift stations and sewerage treatment plants. UTMB has disaster response contracts in place that would include delivery of portable toilets. In emergencies, waste would be collected in barrels.