Emergency Operations Plan  – Joint Commission Standards & Elements of Performance

The entire Emergency Operations Plan can be viewed/downloaded HERE as a PDF file.

EM Standards 9 - 11 and 13 - 17 can be found on the Emergency Management Program webpage.


This page is currently under construction. Anticipated completion date is: July 1, 2022.

EM.12.01.01 – The hospital develops an emergency operations plan based on an all-hazards approach.

EM.12.01.01 - Planning

  • EP 1 - Emergency Operations Plan (EOP) Includes the Following:

    The hospital has a written all-hazards emergency operations plan (EOP) with supporting policies and procedures that provides guidance to staff, volunteers, physicians, and other licensed practitioners on actions to take during emergency or disaster incidents. The EOP and policies and procedures include, but are not limited to, the following:

    • Mobilizing incident command – (See EP3 below and ICT Website)
    • Communications plan – (Emergency Communications Plan - authorized personnel only)
    • Maintaining, expanding, curtailing, or closing operations – (See EP5 of EM.12.01.01; and EM.13.01.01)
    • Protecting critical systems and infrastructure – (See EM.12.02.11)
    • Conserving and/or supplementing resources – (See EM.12.02.09)
    • Surge plans - such as flue or pandemic plans – (Incident-Specific Plans - authorized personnel only)
    • Identifying alternate treatment areas or locations – (See EP1 of EM.12.02.05)
    • Sheltering in place – (See EP4 of EM.12.02.05)
    • Evacuating (partial or complete) or relocating services – (See EP3 & EP5 of EM.12.02.05)
    • Safety and security – (See EM.12.02.07)
    • Securing information and records – (See EP1 of EM.12.02.05)

    UTMB does all of these things, and its Institutional Command Team makes decisions regarding many of the above points. An example of these activities can be seen in an overview of our emergency weather preparations.

  • EP 2 - EOP Identifies Patient Populations and Services in an Emergency

    The hospital’s emergency operations plan identifies the patient population(s) that it will serve, including at-risk populations, and the types of services it would have the ability to provide in an emergency or disaster event.

    Note: At-risk populations such as the elderly, dialysis patients, or persons with physical or mental disabilities may have additional needs to be addressed during an emergency or disaster incident, such as medical care, communication, transportation, supervision, and maintaining independence.

    UTMB intends to serve all populations that seek healthcare during emergencies including at-risk populations. UTMB may be forced to curtail or consolidate services offered depending on damage to facilities. Services may be transferred to undamaged campus hospitals. At-risk populations include the elderly, dialysis patients, or persons with physical or mental disabilities may have additional needs to be addressed during an emergency or disaster incident, such as medical care, communication, transportation, supervision, and maintaining independence.

    UTMB also has specific plans for pediatric patients (UTMB personnel only).

    More information on UTMB's Health Service Lines is located at https://www.utmbhealth.com/servicelines.

    As needed based on the situation, UTMB would coordinate with the jurisdiction to request resources from the regional, state, Emergency Management Assistance Compact, or federal assets to augment/increase care available. See EP4 in this section (EM.12.01.01) for information on the integration of Federal Medical Assistance Teams, the Texas Emergency Medical Task force, Texas A&M Task Force 1, and the Texas Task Force 2.

  • EP 3 - Shelter-in-Place and Evacuate

    The hospital’s emergency operations plan includes written procedures for when and how it will shelter in place or evacuate (partial or complete) its staff, patients, and volunteers.

    Note 1: Shelter-in-place plans may vary by department and facility and may vary based on the type of emergency or situation.

    Note 2: Safe evacuation from the hospital includes consideration of care, treatment, and service needs of evacuees, staff responsibilities, and transportation.

    SHELTER IN PLACE

    There has been an increasing prevalence of compound incidents (simultaneous, cascading, or regional incidents). Furthermore, recent research points to more rapid intensification of major storms in the Atlantic basin (Trends in Global Tropical Cyclone Activity: 1990–2021, Philip J. Klotzbach et al.) – providing less time for evacuation planning and decision making. Consequently, options to evacuate patients are decreasing. UTMB is therefore developing strategies to improve options for sheltering in place with patients.

    Toward this end, UTMB has invested considerable resources and effort in developing staff shelters at each campus. The Staff Shelter Plan is managed by the Support Division within the Logistics Section of the UTMB Institutional Command Team.

    The total number of patients sheltering will be used to calculate the number of healthcare and support staff (typically between 800-1000) that will staff the ride out. Cots and linens are on hand to use in staff shelters. Generally two shifts will be used so that around the clock care will be available. Generally, four food servings will be offered using a fixed menu (so that each shift has the opportunity to have three meals).

    Ride out staff will be identified on an HICS Organizational Assignment Form (or comparable document or information system). If at all possible the Ride out Team will be released from work prior to landfall in order to prepare their families/homes for the hurricane – and they will be given a time and date to report for their Ride out assignment. The Relief/Damage Assessment/Recovery Team will be released prior to landfall and provided a communications plan to initiate their return to campus post-storm.

    UTMB has a plan to close down non-mission essential buildings during the storm (see campus emergency planning maps). The Health System Shelter Team will remain in the healthcare core buildings. Other teams will be assigned based on critical mission such as animal care, utilities, facilities, et cetera.

    Force Account Labor tracking should include the location and assignment of all staff members during working hours. Off duty shifts will check into and out of staff shelters in order to maintain accountability. Managers must maintain staff accountability during the rideout – meaning that the location of every staff member is known and tracked through the entire ride out until demobilization and arrival of the Relief Team.

    EVACUATION

    The Health System CEO or their designee will serve as the Health System Operations Chief when the Institutional Command Team is activated – or as the Incident Commander of the Health System Incident Command. This position is responsible for Patient Management and Evacuation. Planned evacuation will be coordinated with the Institutional Command Team Incident Commander. 

    UTMB has four hospital campuses and a large number of clinic locations. Alternate care sites are primarily in these UTMB controlled spaces. Evacuation/Relocation to these sites benefits from continuity of care, communications, and services provided. The first choice will be to shift patients, medications, supplies, equipment, and staff to another facility within our organization.

    • Communications: Existing phone and network communications will be used. Handheld radios are available if needed. For mass vaccination clinics at facilities owned by partnering agencies, UTMB Information Services will be part of the planning committee and will develop a communications plan that could include secure remote network access for e.g. electronic medical records and state registries.

    UTMB has established a Shelter in Place and Evacuation Plan for evacuation of UTMB hospitals or unit within a hospital.  In the event the hospital or a unit is deemed unsuitable for continued occupancy or cannot support adequate patient care, the Evacuation Plan will be initiated. Staff members are trained on evacuating both horizontally and vertically. Staff are also trained to request assistance in evacuating non-ambulatory patients and may also use the evacuation sleds and pediatric evacuation vests or carriers if necessary.

    The UTMB Fire Plan dictates that, in the event of a fire emergency, the initial preferred evacuation method will be horizontal evacuation to an area of safe refuge / an adjoining smoke compartment. If evacuation from the facility becomes necessary due to a disaster situation where defending in place is not feasible and when the facility cannot continue to support care, treatment and services, the Incident Commander and the jurisdiction fire department may initiate and authorize a vertical evacuation of the facility. If vertical evacuation becomes necessary, the following protocol will be followed:

    Vertical Evacuations

    1. If a vertical evacuation is required, the patients should be moved vertically down and horizontally away from the affected area(s).
    2. Once evacuation priorities have been established, the safest route to vertically evacuate patients should be chosen and communicated by the on-scene incident commander. It may be necessary to move patients vertically up and horizontally across then vertically down depending on the location of the affected areas.
    3. Holding areas for the patients shall be identified by the on-scene incident commander. These areas should be chosen to keep all the patients from a specific unit together. Units can be mixed but units should not be split between areas if at all possible.
    4. UTMB staff from evacuated units should stay with the patients from their respective floor/unit. Once all patients have been evacuated to the holding area, staff shall complete a patient count and check armbands against the census for their unit to account for all patients who have been evacuated.

    Facility Evacuation once the notification by the on-scene incident commander is made to evacuate:

    1. Visitors - Because the facility does not have a way to track visitors coming and going from the facility there is not a mechanism in place to account for all visitors. Voice annunciators should be used to announce that all visitors should leave the facility immediately. If a destination for the patients has been identified, the location may also be paged overhead or otherwise communicated to the visitors.
    2. Ambulatory Patients - Ambulatory patients and their medication, equipment, and pertinent information, including essential clinical and medication-related information shall be moved as directed above to staging area as coordinated by the on-scene incident commander.
    3. Admitting staff shall track each patient as they leave the facility based on the current computer census.  Patient disposition shall be determined based on the destination.
    4. The (HICS) Patient Evacuation Tracking Form shall be utilized for patient tracking.  When more than two patients are being evacuated, the Master Patient Evacuation Tracking Form shall be completed to gain a master copy of all patients that were evacuated.
    5. A designated point of contact for the hospital will establish communications with the Fire Department/EMS On-scene Incident Command Post and provide information on the number of people remaining in the building.
    6. The Health System Incident Command should notify the Southeast Texas Regional Trauma Advisory Council (SETRAC) Duty Officer (281-822-4444) or the Catastrophic Medical Operations Center (if activated) (713-426-9508) that UTMB is conducting a hospital evacuation. SETRAC in turn, can:
      1. Issue an EMResource request to regional hospitals on bed availability in case additional receiving hospitals are needed.
      2. Mobilize regional ambulances or ambuses to assist with patient transport from initial staging areas to regional receiving hospitals
      3. Obtain needed resources such as pediatric bassinets for evacuation transport

    Non-Ambulatory Patients and their medication, equipment, and pertinent information, including essential clinical and medication-related information shall be transported by ambulance or another vehicle designed for patient transport as coordinated by the UTMB on-scene incident commander.

    UTMB Healthcare Staff may be needed to staff an alternate care site or to assist with the transfer of patients from UTMB to another UTMB facility or outside hospital. UTMB staff members should be tracked by the Health System Incident Command through the Planning Section with assistance from Human Resources. 

    More information on tracking is found in EM.12.02.07 (EP2). More information on transporting is found in EM.12.02.05 (EP1).

    Additional Resource: Texas State Guard can be called in to help evacuate an area.

  • EP 4 - Provide Essential Needs for Staff and Patients

    The emergency operations plan includes written procedures for how the hospital will provide essential needs for its staff and patients, whether they shelter in place or evacuate, that includes, but is not limited to, the following:

    • Food and other nutritional supplies
    • Medications and related supplies
    • Medical/surgical supplies
    • Medical oxygen and supplies
    • Potable or bottled water

    Vulnerable Populations: Clinical activities for vulnerable patient populations including pediatric, geriatric, disabled, or have serious chronic conditions (example: dialysis patients, respiratory patients, transplant unit patient, et c.) will be provided in the customary way but additional emphasis will be placed on security, safety, mobility in terms of evacuation should it become necessary during an emergency. UTMB plans for the possibility of a surge in patients and regularly updates its inventory of alternate care space on campuses. UTMB is part of the University of Texas System and has a shared services agreement in place with other UT institutions and healthcare institutions. Requests for staffing support is possible under the agreement.

    Transportation of patients and supplies will be handled by several means, including but not limited to: UTMB vehicles, local and county EMS, UTMB Police Department (e.g. high-water vehicle in case of flooding), mobile medical unit buses (MMU) controlled by the Regional Advisory Council (RAC), and other contracted EMS like air support.

    Food and Other Nutritional Supplies: The Logistics Section will ensure that supplies in-stock, on campus are sufficient. The Logistics Section must establish an alternate  location  to  preclude  the possibility of supplies being ruined by rising water. Optional location(s) should be included in the departmental emergency  weather plan. Food  service vendors will  be  notified of  the number of  staff  remaining on campus, and vendors will notify the ICP of the number of staff that they will have on campus. For Notice incidents such as hurricanes, the Logistics Section Chief will assure that all UTMB campuses have sufficient supplies on hand. The Food Services department handles food and water acquisition and delivery.

    Medications and Related Supplies: Pharmacy handles both the acquisition and delivery of supplies. Pharmacy also has a strategic national stockpile Chempack, which contains counter measures for organic phosphates, nerve agents, and pesticides. This is important given the proximity of several industrial facilities to UTMB campuses.

    Medical/Surgical Supplies (including PPE): Supply Chain handles the acquisition of supplies through its vendors and transport via its delivery personnel.

    Medical Oxygen and Supplies: 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.

    Potable or Bottled Water: The Food Services department handles food and water acquisition and delivery. UTMB Utilities Services department maintains regular communications with 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.

    More information on Resources and Assets is found in EM.12.02.09, as well as EM.12.02.11 (EP3).

    Personal Hygiene and Sanitary Needs of patients during emergencies will be provided. Availability of water supply used for personal hygiene and sanitary water pumps / lift stations at the hospital are connected to emergency power sources. In addition, when water intended for hand washing is not available, the hospital utilizes waterless alcohol-based hand rub, which is maintained in ample supply at the hospital.

    The alternative means to personal hygiene can be baby wipes, personal wipes, or alcohol-based rubs. The alternative means to sanitation, if toilets are inoperable, is kitty litter, red bags in toilets, or positioning of water barrels and waste collection barrels. Main campus has a campus swimming pool that can be used to obtain water for non-potable use. Limit changes of bed linen to those patients who have gross soiling from draining wounds, catheters, etc. Environmental Services use of water will be curtailed to the extent of one change of water per day for mopping except in surgery, delivery rooms, and isolation areas. 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.

    Supply Chain also handles non-medical supplies like bedding and fuel.

    Mental or Psychological Health Needs: During an emergency, UTMB will arrange for mental health services to patients. Staff may use patient registration and triage information, and medical records to determine this population and the appropriate services required. Pastoral Care and Social Workers should be made available to attend to the emotional needs of patients. If necessary, psychiatric consultation should occur, and – if necessary – patients should be transferred to a behavioral health setting. If transfer of patients is not possible, then staff should be assigned to monitor patients accordingly. As a contingency, UTMB could request support from the Gulf Coast Center (located in Galveston County); or other UT Health Institutions under the UT Disaster – Joint Services Agreement.

  • EP 5 - Incident Command Structure

    The hospital’s incident command structure describes the overall incident command operations, including a list of staff who are assigned specific incident command roles and responsibilities. The incident command structure is flexible and scalable to respond to varying types and degrees of emergencies or disaster incidents.

    Note: The incident command structure may include facilities, equipment, staff, procedures, and communications within a defined organizational structure.

    UTMB's incident command structure describes the overall incident command operations, including a list of staff who are assigned specific incident command roles and responsibilities (Organizational Chart). The incident command structure is flexible and scalable to respond to varying types and degrees of emergencies or disaster incidents. UTMB used the National Incident Management System/Incident Command System and the Hospital Incident Command System to guide the organization and implementation of incident command operations. The UTMB Incident Commander’s Command Staff includes the Institutional Emergency Preparedness Officer and technical/medical specialists that are required based on the incident. Operations Sections include:

    • Health System Operations
    • Academic Operations
    • Research Operations
    • Support Operations

    A standard agenda is used to organize deliberations. The Incident Commander convenes the meeting and a situation update is provided. The Incident Commander sets objectives for the Command Team to use to develop plans. Standing Objectives include:

    • Protect Human and Animal Life
    • Protect the Facilities, Critical Utilities, and Network Infrastructure
    • Continue Critical Missions

    Operations Sections complete a task analysis to determine the tasks and resources needed to meet each objective. A single objective will often require completing many individual tasks. They will determine what resources (people, supplies, equipment) are needed and whether the resources are on hand or need to be ordered. The Logistics Section will assist in procuring resources as needed and the Finance Section will track costs (typically through assigned disaster account numbers). The Finance Section will also do disaster claims accounting and prepared to file claims for reimbursement of costs. The Operations Sections will complete the tasks identified and report status at the next Command Team meeting. Meeting summaries will be kept and distributed. Documentation must attach every cost to a specific objective identified by the Incident Commander.

    The incident command structure may include facilities, equipment, staff, procedures, and communications within the defined organizational structure.

    The UTMB President, advised by the Health System Command Team and/or Institutional Command Team, will make decisions during an emergency on whether to maintain, expand, curtail, or close operations.

  • EP 6 - EOP Addresses Collaboration with External Entities

    The hospital’s emergency operations plan includes a process for cooperating and collaborating with other health care facilities; health care coalitions; and local, tribal, regional, state, and federal emergency preparedness officials' efforts to leverage support and resources and to provide an integrated response during an emergency or disaster incident.

    UTMB's emergency operations plan includes a process for cooperating and collaborating with other health care facilities; health care coalitions; and local, tribal, regional, state, and federal emergency preparedness officials' efforts to leverage support and resources and to provide an integrated response during an emergency or disaster incident. An example of which external entities to work with in certain types of incidents is located HERE.

    UTMB’s process for cooperating and collaborating with other healthcare facilities, healthcare coalitions, and local and regional preparedness officials uses the following processes:

    1. UTMB is part of a Healthcare Coalition that is managed by the Southeast Texas Regional Trauma Advisory Council and includes coordination through the Houston Catastrophic Medical Operations Center
    2. UTMB uses standard web-based communications tools:
      • WebEOC
      • EMResource
      • EMTrack

    Integration of Federal Medical Assistance Team - Request Process for National Disaster Medical System Support

    • Any request for Federal Support would first have to be approved by the Health System Operations Chief and by the UTMB Incident Commander.
    • A State of Texas Assistance Request (STAR) will be submitted to the Catastrophic Medical Operations Center via WebEOC (CMOC 713-426-9508) (SETRAC Duty Officer if CMOC is not yet activated 281-822-4444).
    • Galveston County Office of Emergency Management, Galveston County Health Department, and Texas Division of Emergency Management will be notified that the STAR has been submitted..
    • CMOC will forward the request for approval at the state level to the State Medical Operations Center, or to the Department of State Health Services (DSHS) if the SMOC is not yet activated.
    • Once approved at the state level, a request for federal support will be forwarded to the Federal Coordination Center (Michael E. Debakey VA Medical Center, Houston; and to HHS Region 6).
    • Requests for Trauma and Critical Care Teams would generally be used in UTMB space or Alternate Care Sites managed by UTMB.
    • Disaster Medical Assistance Teams, Disaster Mortuary Operations Response Teams, Victim Information Center Teams, and National Veterinary Response Teams (for zoonotic disease outbreaks) would be primarily controlled by the jurisdiction, but UTMB would coordinate through a Unified Command Structure under Emergency Support Function 8 (Public Health and Medical Service - National Response Framework).
    • Any requests involving the UTMB Biocontainment Care Unit would be initiated by the BCU Medical Director and could include further coordination through the National Emerging Special Pathogens Training and Education Center (NETEC); Centers for Disease Control and Prevention (CDC); the Assistant Secretary for Preparedness and Response (ASPR); and US Department of State (for air transport of patients).

    Texas Emergency Medical Task Force

    • Requests would be initiated with a STAR request to Southeast Texas Regional Advisory Council (SETRAC) / CMOC.
    • If resources were unavailable within the SETRAC area, the request would be forwarded to the state level for support from other EMTF Regions within the state.
    • Resources available within the EMTF system include:
      • Ambulance Staging Management Teams
      • Ambulance Strike Teams
      • Air Medical Strike Teams
      • Ambulance Buses (AmBus)
      • Infectious Disease Response Unit
      • Medical Incident Support Teams
      • Mobile Medical Unit
      • Registered Nurse Strike Team
      • Tactical Medi Unit Support
      • Texas Mass Fatality Operations Response Team
      • Wildland Fire Medical Support Team

    Texas A&M Task Force 1

    • Texas A&M Task Force 1 (TX-TF1) functions as one of the 28 federal teams under the Federal Emergency Management Agency (FEMA)’s National Urban Search and Rescue (US&R) System and as a statewide urban search and rescue team under direction of the Texas Division of Emergency Management (TDEM). TX-TF1 also coordinates the state’s swiftwater rescue program and the helicopter search and rescue team which works in conjunction with Texas Military Department.
    • Jurisdictions would have the primary responsibility to request TTF1 support. UTMB would coordinate with the ESF8 function through the Unified Command as needed.

    Texas Task Force 2

    • TX-TF2 serves as one of two state Urban Search & Rescue (US&R) teams in the State of Texas which provides a coordinated effort as well as the necessary personnel and equipment to locate, extricate, rescue, and provide immediate medical treatment to victims trapped as a result of a natural or man-made disaster.
    • Jurisdictions would have the primary responsibility to request TTF1 support. UTMB would coordinate with the ESF8 function through the Unified Command as needed.
  • EP 7 - Individual(s) with Authority to Activate EOP / Incident Command

    The hospital identifies the individual(s) who has the authority to activate the hospital’s emergency operations plan and/or the hospital’s incident command.

    For No Notice Incidents: Following NIMS/ICS, the first person that is aware of an incident is the incident commander. If not able to resolve the incident, that person should escalate and communicate – notifying the relevant on-call officials for the Health System, Facilities, or if appropriate UT Police (911). The response can be escalated to include formal incident management teams up to and including the UTMB Institutional Command Team if necessary.

    For Notice Incidents such as hurricanes, the UTMB President is the Incident Commander, unless the President delegates authority to another official. In the President’s absence, any executive officer or Vice President can convene the Command Team. The Associate Vice President for Institutional Preparedness and the Institutional Emergency Preparedness Officer can convene the Command Team as well.

    UTMB campuses have delegated authority to convene a command team when time is of the essence. They should notify the President’s Office as soon as is practical. 

  • EP 8 - Primary and Alternate Sites for Continuing Incident Command Operations

    The hospital identifies its primary and alternate sites for incident command operations and determines how it will maintain and support operations at these sites.

    Note 1: Alternate command center sites may include the use of virtual command centers.

    Note 2: Maintaining and supporting operations at alternate sites include having appropriate supplies, resources, communications, and information technology capabilities.

    UTMB’s Primary Command Center is Admin Building, Second Floor

    The Health System Primary Command Center and the Institutional Command Team Backup Site is Jennie Sealy Hospital 2.216Z. Each mainland hospital executive conference room will serve as a campus command center. If the Main Campus on Galveston Island suffers extensive damage, a mainland campus command center can serve as a backup

    Alternate command center sites may include the use of virtual command centers.

    Maintaining and supporting operations at alternate sites include having appropriate supplies, resources, communications, and information technology capabilities. Emergency radios, phones, and computer equipment is stored on the Second Floor of the Admin Building. Carts are available to move these supplies to other centers if needed. A limited number of 800 MHz radios are pre-deployed to mainland campuses.

  • EP 9 - Procedures for 1135 Waivers

    The hospital must develop and implement emergency preparedness policies and procedures that address the role of the hospital under a waiver declared by the Secretary, in accordance with section 1135 of the Social Security Act, in the provision of care and treatment at an alternate care site identified by emergency management officials.

    Note 1: This element of performance is applicable only to hospitals that receive Medicare, Medicaid, or Children’s Health Insurance Program reimbursement.

    Note 2: For more information on 1135 waivers, visit https://www.cms.gov/About-CMS/Agency-Information/Emergency/EPRO/Resources/Waivers-and-flexibilities and https://www.cms.gov/about-cms/agency-information/emergency/downloads/consolidated_medicare_ffs_emergency_qsas.pdf.

    In most cases, UTMB would initiate a request for a waiver through the Catastrophic Medical Operations Center in Houston, or through the Texas Department of State Health Services who would then forward the request to the federal level.

    Definition of an 1135 Waiver  When the President declares a disaster or emergency under the Stafford Act or National Emergencies Act and the HHS Secretary declares a public health emergency under Section 319 of the Public Health Service Act, the Secretary is authorized to take certain actions in addition to her regular authorities. For  example, under  section 1135 of  the  Social Security Act, she may temporarily waive or modify certain Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) requirements to ensure that sufficient health  care  items  and services are available to meet the needs of  individuals enrolled in Social Security Act programs in the emergency area and time periods and that providers  who  provide  such services in good faith can be reimbursed and exempted from sanctions (absent any determination of fraud or abuse). Examples of these 1135 waivers or modifications include:

    • Conditions of participation or other certification requirements
    • Program participation and similar requirements
    • Preapproval requirements
    • Requirements that physicians and other health care professionals be licensed in the State in which they are providing services, so long as they have equivalent licensing in another State (this waiver is for purposes of Medicare, Medicaid, and CHIP reimbursement only – state law governs whether a non-Federal provider is authorized to provide services in the state without state licensure)
    • Emergency Medical Treatment and Labor Act (EMTALA) sanctions for direction or relocation or of an individual to receive a medical screening examination in an alternative location pursuant to an appropriate state emergency preparedness plan  (or in the case of a public health emergency involving pandemic infectious disease, a state pandemic preparedness plan) or transfer of an individual who has not been stabilized if the transfer is necessitated by the circumstances of the declared emergency. A waiver of EMTALA requirements is effective only if actions under the waiver do not discriminate on the basis of a patient’s source of payment or ability to pay.
    • Stark self-referral sanctions
    • Performance deadlines and timetables may be adjusted (but not waived).
    • Limitations on payment for health care items and services furnished to Medicare Advantage enrollees by non-network providers

    These waivers under section 1135 of the Social Security Act typically end no later than the termination of the emergency period, or 60 days from the date the waiver or modification is first published unless the Secretary of HHS extends the waiver by notice for additional periods of up to 60 days, up to the end of the emergency period. Waivers

    Revised: November 4, 2009, for EMTALA (for public health emergencies that do not involve a pandemic disease) and HIPAA requirements are limited to a 72-hour period beginning upon implementation of a hospital disaster protocol. Waiver of EMTALA requirements for emergencies that involve a pandemic disease last until the termination of the pandemic-related public health emergency. The 1135 waiver authority applies only to Federal requirements and does not apply to State requirements for licensure or conditions of participation.

    1135 Waiver Tracking (Spreadsheet) for authorized personnel only.

    Other Flexibilities  In addition to the 1135 waiver authority, Section 1812(f) of the Social Security Act (the Act) authorizes the Secretary to provide for skilled nursing facility (SNF) coverage in the absence of a qualifying hospital stay, as long as this action does not increase overall program payments and does not alter the SNF benefit’s “acute care nature” (that is, its orientation toward relatively short-term and intensive care).

    Determining if Waivers Are Necessary  In determining whether to invoke an 1135 waiver (once the conditions precedent to the authority’s exercise have been met), the Assistant Secretary for Preparedness and Response (ASPR) with input from relevant OPDIVS determine the need and scope for such modifications. Information considered includes requests from Governor’s offices, feedback from individual healthcare providers and associations, and requests to regional or field offices for assistance.

    How States or Individual Healthcare Providers Can Ask for Assistance or a Waiver  Once an 1135 Waiver is authorized, health care providers can submit requests to operate under that authority or for other relief that may be possible outside the authority to the CMS Regional Office with a copy to the State Survey Agency. Request can be made by sending an email to the CMS Regional Office in their service area. Email addresses are listed below. Information on your facility and justification for requesting the waiver will be required.

    Review of 1135 Waiver requests  CMS will review and validate the 1135 waiver requests utilizing a cross-regional Waiver Validation Team. The cross-regional Waiver Validation Team will review waiver requests to ensure they are justified and supportable.

    Implementation of 1135 Waiver Authority  Providers must resume compliance with normal rules and regulations as soon as they are able to do so, and in any event the waivers or modifications a provider was operating under are no longer available after the termination of the emergency period.

    • Federally certified/approved providers must operate under normal  rules  and regulations, unless they have sought and have been granted modifications under the waiver authority from specific requirements.

    UTMB role in providing care, treatment, and services at alternate care sites identified by emergency management officials:  UTMB will coordinate with local and state officials regarding the establishment of alternate care sites such as vaccination sites. In general, such sites will be managed by the County Government who will organize and manage volunteers to staff the site so that good Samaritan protection is available to the volunteers.

EM.12.02.01 – The hospital has an emergency response communications plan that addresses how it will initiate and maintain communications during an emergency.

EM.12.02.01 - Communications

  • EP 1 - Emergency Response Contact List

    The hospital maintains a contact list of individuals and entities that are to be notified in response to an emergency. The list of contacts includes the following:

    • Staff
    • Physicians and other licensed practitioners
    • Volunteers
    • Other health care organizations
    • Entities providing services under arrangement, including suppliers of essential services, equipment, and supplies
    • Relevant community partners (such as, fire, police, local incident command, public health departments)
    • Relevant authorities (federal, state, tribal, regional, and local emergency preparedness staff)
    • Other sources of assistance (such as health care coalitions)

    Note: The type of emergency will determine what organizations/individuals need to be contacted to assist with the emergency or disaster incident.

    UTMB maintains contact information of individuals/entities to be notified of an emergency in its Staff Directory (viewable by UTMB personnel only), a backup copy of the staff directory in the event systems are compromised, key internal and external contacts listed in business continuity plans, and a very detailed Emergency Communications Plan (restricted access to key personnel). 

    Supply Chain maintains contact lists for critical suppliers. Utilities and Facilities Units within the Operations Section maintain contacts with key utilities and service providers. UTMB also has disaster response contractors. As backup, requests can be forwarded through the SETRAC Duty Officer or the Catastrophic Medical Operations Center.

  • EP 2 - Establish and Maintain Communications During an Emergency

    The hospital's communications plan describes how it will establish and maintain communications in order to deliver coordinated messages and information during an emergency or disaster incident to the following individuals:

    • Staff, licensed practitioners, and volunteers (including individuals providing care at alternate sites)
    • Patients and family members, including people with disabilities and other access and functional needs
    • Community partners (such as, fire department, emergency medical services, police, public health department)
    • Relevant authorities (federal, state, tribal, regional, and local emergency preparedness staff)
    • Media and other stakeholders

    Note: Means of communication to consider include text messaging, phone system alerts, email, social media, and augmentative and alternative communication (AAC) for those with difficulties communicating using speech.

    Communication with Staff, Licensed Practitioners, and Volunteers: UTMB has implemented communication procedures for emergency planning and response in coordination with its integrated emergency preparedness program. The UTMB Command Team will issue notifications or alerts concerning the convening of the command team for incidents response. There is a command team notification list within Everbridge, our mass notification alert system. The Command Team will integrate participants from each campus making use of network/telecommunications applications (e.g. MS Teams).

    Mechanisms of contact include text message, pager, telephone, electronic mail, public address and campus television system announcements, web and social media, and any other means available as appropriate. UTMB officials will make every effort to communicate information to employees via all possible technologies. Employees should stay tuned to radio and television stations to receive news concerning the latest conditions in Galveston. If there is a question about whether or not employees should return to work, they should call their supervisor check UTMB’s web site/social media channels, or call the UTMB information hotline at (409) 77-ALERT.

    The ISS Emergency Communications Sub-committee overseas this aspect of planning and has for instance a testing and improvement plan for use of UTMB Alerts, the SafeApp, and other social media technologies. Fire Safety is represented on the sub-committee so that fire alarm systems are part of an integrated warning system.

    Staff and Physician contact information is maintained in the UTMB Directory and is exported to UTMB implementation of Everbridge for mass notifications.

    Communications with Patients and Families: UTMB will make use of its call centers to relay patient specific information. UTMB will use its Office of Communications and Marketing for general information to the public and patients. Communications for evacuations will use a combination of patient-specific information via the call centers, and mass media for general information. 

    Communications with the Community and Media: The Public Information Officer (PIO) function will make recommendations on the best strategies to use for community communications, including the Marketing and Communications Media Relations Function. UTMB will participate in any virtual Joint Information Centers that are set up by area public health and/or emergency management agencies.

    Communications with Healthcare Organizations: UTMB distributes its key command center phone numbers to area hospitals, public health, and emergency management. Essential elements of the command centers response are communicated through SETRAC tools via WebEOC, EMResource, EMTrack. Backup communications is available through the Healthcare Coalition South Corridor Coordinator.

    UTMB has four hospital campuses and a large number of clinic locations. Alternate care sites are primarily in these UTMB controlled spaces. Existing phone and network communications will be used. Handheld radios are available if needed. For mass vaccination clinics at facilities owned by partnering agencies, UTMB Information Services will be part of the planning committee and will develop a communications plan that could include secure remote network access for e.g. electronic medical records and state registries.

    Communications to relevant authorities is addressed in EP3 of this standard (EM.12.02.01).

  • EP 3 - Provide Information to Authorities on Needs/Status

    The hospital’s communication plan describes how the hospital will communicate and provide information to relevant authorities about its organizational needs, available occupancy, and ability to provide assistance.

    Note: Examples of hospital needs include shortages in personal protective equipment, staffing shortages, evacuation or transfer of patients, and temporary loss of part or all organization function.

    UTMB will use the liaison function in ICS/HICS and existing web-based applications such as WebEOC, EMResource, EMTrack to notify and communicate with external officials. If regular communication methods are not available, UTMB would use 800mhz radios and request support from Galveston County Emergency Operations Center for HAM radio support through RACES/ARES. More detail provided in UTMB’s Emergency Communications Plan (authorized personnel only).

    UTMB has in the past and will as needed in the future, participate in a Unified Command with officials to assure an integrated response. UTMB will also participate in a virtual Joint Information Center that may be set up by officials. As a state agency, UTMB has in the past, and will as needed, serve in an advisory role to state officials for health-related incidents. This has in past incidents related to both testing and vaccination. UTMB is part of the National Special Pathogens System and as such integrated planning and response with e.g. HHS Region Six federal and state officials. In a past Ebola incident, UTMB collaborated with the state and another hospital in the Dallas area on the transport and destruction of medical waste in the UTMB medical waste incinerator.

    With regards to the integrated preparedness program, UTMB as an institution is the legal entity that can enter into formal agreements with other entities. The UTMB institutional command team should manage all communications with state and federal partners unless disaster conditions make it impossible. That said, each UTMB campus has delegated authority to communicate and work with local partners as needed. All UTMB campuses participate in County and CMOC radio checks.

  • EP 4 - Emergency Notifications and Alerts

    The emergency response communications plan identifies the hospital’s warning and notification alerts specific to emergency and disaster events and the procedures to follow when an emergency or disaster incident occurs.

    The Public Information Officer will provide recommendations to the Incident Commander on the best mechanisms to use to notify staff members and licensed independent practitioners of an emergency situation – and to provide instructions. In general, this will make use of UTMB Alerts and may include Everbridge mass notifications, global email messages, web-based updates, or chain of command notifications. The Emergency Communications Sub-committee to the Institutional Safety and Security Committee will develop overlapping digital communication strategies to make information on emergency preparedness available to staff and students.

  • EP 5 - Releasing Location & Medical Information

    In the event of an emergency or evacuation, the emergency response communications plan includes a method for sharing and/or releasing location information and medical documentation for patients under the hospital’s care to the following individuals or entities, in accordance with law and regulation:

    • Patient’s family, representative, or others involved in the care of the patient
    • Disaster relief organizations and relevant authorities
    • Other health care providers

    Note: Sharing and releasing of patient information is consistent with 45 CFR 164.510(b)(1)(ii) and (b)(4).

    In accordance with the law, UTMB would communicate to disaster relief organizations through city and county emergency management agencies. For hurricane scenarios, local officials’ preference is not to set up shelters or mass care centers as this would be a disincentive for people to follow mandatory evacuation orders. Post landfall, if local jurisdictions were to set up mass care shelters, UTMB’s primary communications would be through the local public health and EMS regarding the need to transport patients to the hospital for care, or to discharge patients to a shelter.

    For evacuations, UTMB would use its own call center capabilities to communicate information to patients and family members et c. General information would be released by the PIO with the approval of the Incident Commander and the advice of General Counsel (Command Staff member). Pertinent medical information is transported with each patient as a hard-copy HICS 260 form. Additional information about the patient can be pulled from EMTrack by the sending hospital, receiving hospital, and EMS/transport. UTMB has agreements in place with alternate care sites that will sign non-disclosure agreements to view the patient data (window into our electronic medical records).

    • Patient identification information can also be entered into the Texas Emergency Tracking Network (TxETN) system in accordance with the State Medical Special Needs Evacuation Plan so that patient location can be tracked to the destination alternative care site by RFID device and GPS. 

    Patient information may be transmitted to appropriate third parties in accordance with laws protecting patient information confidentiality. During infectious disease outbreaks UTMB will release information to official public health authorities in accordance with law. 

    In all cases the release of protected health information would be in accordance with law and regulations.

  • EP 6 - Providing & Testing Backup Communications

    The hospital’s communications plan identifies its primary and alternate means for communicating with staff and relevant authorities (such as federal, state, tribal, regional, and local emergency preparedness staff). The plan includes procedures for the following:

    • How and when alternate/backup communication methods are used
    • Verifying that its communications systems are compatible with those of community partners and relevant authorities the hospital plans to communicate with
    • Testing the functionality of the hospital’s alternate/backup communication systems or equipment

    Note: Examples of alternate/back-up communication systems include amateur radios, portable radios, text-based notifications, cell and satellite phones, reverse 911 notification systems.

    UTMB Information Services develops and maintains backup voice and data communications systems. This includes VOIP, POTS, and satellite telephony, redundant network connectivity to state backbones and internet service providers. A cell tower on a Main Campus building has been connected to emergency power in cooperation with the telephone company. UTMB uses the Government Emergency Telephone System (GETS) and Wireless Priority Service (WPS). Campus Police and Environmental Health & Services have FirstNet satellite access.

    Advanced Preparation for emergency communications occurs at UTMB through various activities, including frequent exercises and real incidents that ensure plans are adequate, regular maintenance of communication equipment, practice with alternate communications during exercises, and an annual review of plans by the ISS Executive Committee. UTMB participates in a Healthcare Coalition radio check on a monthly basis (800 MHz Zone 78 Channel CMOC-3); as well as a monthly radio check with the County Office of Emergency Management (800 MHz GCOEM 1).

    For example, in the event of an internal (telephone) hospital communication failure, either total or partial, strategically placed emergency telephones should be used.  Should they fail or not be available, portable two-way radios will provide an effective internal communication system.  Distribution of these radios will be made by the Incident Commander or designee. In the event of an unexpected telephone failure affecting parts or all of the hospitals between the hours of 5 pm and 8 am, or on weekends and holidays, the Clinical Operations Administrator may gain access to the emergency radio units by contacting the Institutional Preparedness department.

EM.12.02.03 – The hospital has an emergency response staffing plan for managing all staff and volunteers.

EM.12.02.03 - Staffing

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

    The hospital develops an emergency response 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, physicians, and other licensed practitioners
    • Acquiring staff, physicians, and other licensed practitioners from its other health care facilities
    • Use of staffing agencies, volunteer staffing, or 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 emergency response 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

    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.12.02.05 – The hospital has an emergency response plan for patient care and clinical support.

EM.12.02.05 - Patient Clinical & Support Activities

  • EP 1 - Transferring Patients and Sharing their Information

    The hospital’s plan for providing patient care and clinical support includes written procedures and arrangements with other hospitals and providers for how it will share patient care information and medical documentation and how it will transfer patients to other health care facilities to maintain continuity of care.

    Formal agreements and arrangements are in place with several receiving hospitals in the event UTMB must evacuate most/all of our facilities, which is unlikely given the number of campuses and buildings we have spread across a large area. The first choice will be to shift patients, medications, supplies, equipment, and staff to another facility within our organization. This can be achieved using internal resources.

    Scope of Responsibilities for Evacuated Patients

    For Notice Incidents such as a hurricane, the Command Team will activate at the direction of the UTMB Incident Commander. The Health System Evacuation Team will begin to populate the Patient Evacuation Planning Form. This information will be shared with evacuation partners to include the Catastrophic Medical Operations Center (CMOC); Texas Division of Emergency Management (TDEM); Galveston County Ambulance Authority; and planned receiving hospitals:

    • Seton
    • UT Tyler Health
    • UTSW Medical Center
    • Parkland

    Once a decision is made to evacuate by the IC, the Evacuation Team will complete the Patient Roster/Emergency Memorandum of Transfer Form in partnership with receiving hospitals. Staff at receiving hospitals (that have signed NDAs) will be given access to the EPIC patient record. The roster will include the specific receiving hospital and receiving physician.

    Once the receiving hospital is identified, the Evacuation Team will begin to populate EMTrack to create missions (through the CMOC) to transport individual patients to their receiving hospital. As needed, local and contract ambulances will be used to transport patients:

    • Between UTMB campuses
    • To Scholes Field for fixed wing air transport

    Patients will retain their UTMB wristband, but also be provided a Texas Emergency Tracking Network Wristband (administered by the Texas Division of Emergency Management; TDEM), and they will be enrolled in that statewide evacuee tracking system. Any associated equipment will be tagged and associated with the patient in the state database. The state ambulance (ground or air) will have a barcode that will also be scanned when the patient is loaded and associated with the patient in the database. When the patient arrives at the receiving hospital they will be scanned in and associated with that hospital for tracing purposes.

    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.

    Non-Ambulatory Patients and their medication, equipment, and pertinent information, including essential clinical and medication-related information shall be transported by ambulance or another vehicle designed for patient transport as coordinated by the UTMB on-scene incident commander. UTMB Healthcare Staff may be needed to staff an alternate care site or to assist with the transfer of patients from UTMB to another UTMB facility or outside hospital. UTMB staff members should be tracked by the Health System Incident Command through the Planning Section with assistance from Human Resources.

    More information on tracking is found in EM.12.02.07 (EP2).

    Securing Information and Records: UTMB has policies, procedures, and systems to maintain all vital records in accordance with State of Texas requirements. All Protected Health Information is maintained in accordance with HIPAA and other confidentiality requirements. UTMB trains all staff on information security. Proper procedures (including encryption) and contracts/agreements are used when sharing information, both internally and externally. Plans for vital records are part of business continuity planning. UTMB strives to keep paper records above flood zones, but if vital records are water damaged, UTMB has contract support to provide freeze-drying and restoration services.

  • EP 2 - Managing Individuals During a Disaster Who Do Not Need Medical Care

    The hospital’s emergency response plan for patient care and clinical support includes written procedures for managing individuals that may present during a disaster or emergency that are not in need of medical care (such as visitors).

    When necessary during a disaster, UTMB will establish a Family Reception Center (FRC) to collect and provide up-to-date and accurate information to individuals (generally family members and visitors). Personnel typically involved in the FRC include:  UTMB Staff, Medical Services, Red Cross, Pastoral Care, Social Workers, Interpreters, Gulf Coast, Employee Assistance, Student Services, Student Life, UTMB Police or a designated security branch, et cetera. No media will be allowed, but UTMB's Public Information Officer (PIO) may be on hand to provide incident information to families. 

    • Note that UTMB's Family Reception Center is more inclusive than the jurisdiction's Family Assistance Center.
    • More information on UTMB's Family Reception Center.

    As a general strategy for disaster care, UTMB will attempt to keep families in close proximity to the extent possible. Medical necessity will be the ultimate determinant. Information about current and future operations will be provided.

    UTMB not directly affected by damage from the incident:  UTMB has plans to establish a Family Reception Center (FRC) for each campus appropriately distanced from the Emergency Department. For example, the Galveston Main Campus would use the Trauma Building, Old Red Basement, and/or Levin Hall depending on the scale of the incident. In a large mass casualty/fatality incident, UTMB would expect to receive up to 10 family members per victim at the hospital. UTMB would also work in collaboration with the Family Assistance Centers established by the jurisdiction or industry.

    UTMB expected to receive effects or damage from the incident: During a hurricane ride out, the UTMB President is the only official that can authorize an external person to be on campus. UTMB does have approved mutual aid agreements with local first responders to house them in major storms.  In accordance with City, County, and State Officials, all potential ‘visitors’ to campus should obey mandatory evacuation orders. If needed, resources are available to assist them in transport and shelter for the evacuation.

    Additional location requirements for the FRC in this scenario are: 1) Secure, 2) Wireless Connectivity, 3) Does not overlook the disaster site.

    Shelter or Refuge of Last Resort: City, County, and State officials discourage the public announcement of plans for a shelter of last resort as this could provide a disincentive to obey mandatory evacuation orders. In case where residents disregard mandatory evacuation orders and then become overwhelmed by floods, extreme winds, or complete destruction of their homes, they might seek to use UTMB as a shelter of last resort. In this case, UTMB would be prepared to work with City and County officials to transfer these people to established mass care shelters as expeditiously as possible. Shelter, food, and potable water would be provided until transport could be arranged. The Logistics Section would manage this operation. UTMB would plan to provide Texas Emergency Tracking Network wristbands for each person and enroll them in the state system so that their whereabouts is known and can be tracked to shelters.

  • EP 3 - Medical Examiner & Mass Fatality Plan

    The hospital coordinates with the local medical examiner’s office, local mortuary services, and other local, regional, or state services when there is a surge of unidentified or deceased patients.

    • The Galveston County Medical Examiner is a UTMB Faculty member (who is also the Medical Examiner for the multi-county Region).
    • UTMB collaborates with the County and Medical Examiner in planning for Mass Casualty/Fatality Incidents.
    • UTMB resources could be used to augment County Resources in a major mass fatality incident.
    • Resource requests to support a Mass Fatality incident would be submitted via WebEOC to the County, and/or to the Catastrophic Medical Operations Center.
    • Resource requests could be for e.g. refrigerated trucks / semi-tractor trailers.
    • UTMB has a plan to establish a Family Reception Center on campus (insert link) when it becomes aware of a major Mass Casualty/Fatality incident in the region, regardless of whether live patients are transported to UTMB.
    • We anticipate that up to 10 family members per victim of the incident could arrive at UTMB (e.g. to accompany a living patient – or to try to ascertain if their family member is a patient).
    • The Family Reception Center will coordinate with any jurisdictional Family Assistance Centers, Family Resilience Centers, or Family Reunifications centers that the jurisdictions or industry may set up.
    • The Family Reception Center does not include a medico-legal role.
    • As the jurisdictions or industry ramp up their operations, UTMB will begin to ramp down the Family Reception Center. We would work with the jurisdictions to provide transportation to a Family Assistance Center if needed.
    • If a mass fatality incident were to occur on a UTMB campus, we would offer a campus location to the jurisdiction to set up an Family Assistance Center.
    • If local and regional Emergency Medical Services make use of EMTrack to help manage the incident, UTMB is prepared to use EMTrack as well.
    • If needed, the Medical Examiner could work through the County to request state TMORT team or federal DMORT team, or federal Victim Information Center Teams.
    • The Biocontainment Unit had developed an agreement with local mortuary services for the disposition of patient remains.

    If assistance from the Texas Mass Fatality Operations Response Team (TMORT) is needed, they can provide operational assistance to medicolegal authorities with incident site, deployable morgue, victim identification center, and victim information center operations following a mass fatality incident that overwhelms the local jurisdiction.

    Additional assistance may be requested from the Texas funeral Directors Association (TFDA) Disaster Team.

    If assistance from the National Disaster Medical System (NDMS) is needed, specifically a Disaster Mortuary Assistance Team (DMORT), 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.

EM.12.02.07 – The hospital has an emergency response plan for safety and security.

EM.12.02.07 - Safety & Security

  • EP 1 - Roles of Community Security Agencies

    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.

    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.12.02.09 – The hospital has an emergency response plan for resources and assets.

EM.12.02.09 - Resources & Assets

  • EP 1 - Document, Track, Monitor and Locate Resources/Assets

    The hospital’s plan for managing its resources and assets describes in writing how it will document, track, monitor, and locate the following resources (on-site and off-site inventories) and assets during and after an emergency or disaster incident:

    • Medications and related supplies
    • Medical/surgical supplies
    • Medical gases including oxygen and supplies
    • Potable or bottled water and nutrition
    • Non-potable water
    • Laboratory equipment and supplies
    • Personal protective equipment
    • Fuel for operations
    • Equipment and nonmedical supplies to sustain operations

    Note: The hospital should be aware of what resources and assets it has readily available and what resources and assets may be quickly depleted depending on the type of emergency or disaster incident.

    Supply Chain, Pharmacy, Food Services and similar departments set par values for supplies, ordering more when levels fall too low. During an emergency, remaining inventory is measured against the consumption rate to determine future needs. Most departments have tools to help manage resources and assets, like Pharmacy’s Pyxis machines which are automated medication dispensing systems that support decentralized medication management.

    Advanced preparation for resource and assets occurs at UTMB through various activities, including frequent exercises and real incidents that ensure plans are adequate. Plans pertaining to resources and assets 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 resources and assets.

    Additional information on this topic (e.g. locating resources) is found in EP2 of this standard (EM.12.02.09).

    The hospital conducts an annual review of its inventory: The findings of the review are documented: UTMB began a review of its emergency inventory in April 2021. The review addresses emergency supplies; fuel, medications, food, and water. The review will be presented to the ISS at the June 2021 meeting.

    UTMB participates in the national Joint Supply Chain Resilience Working Group (SCC/GCC) in order to monitor medical supply chain issues and share information on constraints 

  • EP 2 - Obtain, Allocate, Mobilize, Replenish and Conserve Resources/Assets

    The hospital’s plan for managing its resources and assets describes in writing how it will obtain, allocate, mobilize, replenish, and conserve its resources and assets during and after an emergency or disaster incident, including the following:

    • If part of a health care system, coordinating within the system to request resources
    • Coordinating with local supply chains or vendors
    • Coordinating with local, state, or federal agencies for additional resources
    • Coordinating with regional health care coalitions for additional resources
    • Managing donations (such as food, water, equipment, materials)

    Note: High priority should be given to resources that are known to deplete quickly and are extremely competitive to receive and replenish (such as fuel, oxygen, personal protective equipment, ventilators, intravenous fluids, antiviral and antibiotic medications).

    UTMB maintains most supplies onsite at each of its four campuses, with the Galveston Main Campus (GMC) housing the majority and clinics storing smaller volumes. The aforementioned supplies are reviewed annually and throughout the duration of a major incident; Pharmacy and Supply Chain are active members of the Institutional Command Team.

    The process for obtaining and replenishing supplies that fall below par are the use of vendors and contractors, even during an emergency. As was the case for Covid-19, strategic sourcing of new vendors occurred to meet demand. In an emergency, EMResource and SETRAC will aid in locating and obtaining supplies.

    The Logistics Section Chief is responsible for planning for the replenishment of critical supplies, including both medical and non-medical supplies. Distribution is coordinated by the Staging Manager upon activation of the EOP and is handled by Supply Chain in most cases. As an Academic Medical Center, Supply Chain is centrally managed. With enough advanced warning, caches containing predetermined supplies will be delivered to designated staging areas.

    With regards to medications and related supplies, Pharmacy handles both the acquisition and delivery of supplies. Pharmacy also has a strategic national stockpile Chempack, which contains counter measures for organic phosphates, nerve agents, and pesticides. This is important given the proximity of several industrial facilities to UTMB campuses.

    With regards to medical supplies, including personal protective equipment (PPE), Supply Chain handles the acquisition of supplies through its vendors and delivery via its delivery personnel.

    With regards to non-medical supplies, including food and bedding, Supply Chain handles non-medical supplies, bedding, and fuel while Food Services handles food and water.

    Share resources with healthcare organizations within and outside the community . The Regional Healthcare Preparedness Coalition (RHPC) organized by SETRAC provides collaborative planning and response (including resource and asset sharing) to preserve the medical infrastructure of our region. If the emergency impacted our entire region, DSHS could reach out to other RACs on our behalf. The EMResource tool is used to manage the interchange of supplies between hospitals.

    Transportation of patients and supplies will be handled by several means, including but not limited to: UTMB vehicles, local and county EMS, UTMB Police Department (e.g. high-water vehicle in case of flooding), mobile medical unit buses (MMU) controlled by the Regional Advisory Council (RAC), and other contracted EMS like air support.

    • Patients are transported along with their medications, supplies, and equipment (when able).
    • Equipment is tracked using UTMB equipment tags, as well as tags we can associate with the patient in the Texas Emergency Tracking Network.
  • EP 3 - Resource Sustainability for 96 Hours

    The hospital’s plan for managing its resources and assets describes in writing the actions the hospital will take to sustain the needs of the hospital for up to 96 hours based on calculations of current resource consumptions.

    Note 1: Hospitals are not required to remain fully functional for 96 hours nor required to stockpile 96 hours’ worth of supplies.

    Note 2: The 96-hour time frame provides a framework for hospitals to evaluate their abilities to be self-sufficient for at least 96 hours. For example, if a hospital loses electricity and has back-up generators, the emergency response plan for resources and assets establishes how much fuel is on hand and how long those generators can be operated before determining next steps. The plan may also address conservation of resources and assets such as rationing existing resources, canceling noncritical procedures, or redirecting resources.

    UTMB has a 144-hour analysis for each of its main campuses that uses a simple green, yellow, and red color scheme. Input and review from area experts at each campus is done annually. Final review is done by Institutional Preparedness and the Incident Command Team. The sample below is for the Galveston Main Campus:

EM.12.02.11 – The hospital has an emergency response plan for utilities management.

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.

EM.12.03.01 – The hospital has a crisis standards of care plan.

EM.12.03.01 - Crisis Standards of Care

  • EP 1 - Clinical Strategies for Scarce Resource Situations [This EM/EP was removed]

    The hospital has a crisis standards of care (CSC) plan that includes clinical strategies for scarce resource situations. The hospital’s leadership, medical staff, ethics, and legal counsel determine when and how it will implement CSC.

    UTMB determines when and how it will implement CSC. Since Texas law does not codify the use of crisis standards of care, UTMB may participate in the development of crisis standard of care guidance as a member of the Texas Medical Center and in consultation with organization such as the Texas Hospital Association, Texas Medical Association, the North Texas Mass Critical Care Guideline Task Force, the Southwest Texas Regional Trauma Advisory Council, US Health and Human Services Office of Civil Rights, and disability rights organizations such as Disability Rights Texas, the Center for Public Representation, The Arc of the United States, and Justice in Aging.

    Any decisions regarding use of the crisis standards of care guidance would be made by the UTMB Incident Command Team while the UTMB Emergency Operations Plan is activated. Hospital leaders, medical staff to include a bioethicist, and legal counsel are members of the Incident Command Team. Decisions made by the Incident Command Team are recorded in a meeting summary.

Additional Resources

FEMA Comprehensive Preparedness Guide - "Developing and Maintaining Emergency Operations Plans"