Updated May 26, 2011
September 2003
Department of Radiology Emergency Response Policies and Procedures
The policies within this packet have been developed for the Department of Radiology in conjunction with, and as a supplement to, Hospital-wide policies and procedures. It is the responsibility of all Department members to be familiar with the content of this
procedure and to proceed accordingly when an emergency response condition occurs. The hospital Emergency Notification System (ENS) will notify the Chairman of the Department of Radiology and the Radiology Director and of an emergency and the department phone tree and/or department ENS can be started as detailed below. Additional personnel that may need to be contacted in an emergency are:
Radiology Director: Ann Costello Radiology Chair: Nick Bryan, MD, PhD Office: 215-662-6954 Office: 215-662-3030
Cell: 215-410-0801 Cell: 215-873-9395
Home: 610-527-8872 Home: 215-925-6416
Department Fire/Safety Officer: John Detruf Radiology Vice-Chair: Michael Bleshman, MD Office: 215-662-6456 Office: 215-662-3032
Cell: 215-410-0803 Cell: 610-986-3719
Home: 856-881-4711 Home: 610-667-5857
Personal Cell: 856-889-0714
Department Nurse Manager: Sue Sweeney Vice-Chair Informatics: Curtis Langlotz, MD Office: 215-662-4034 Office: 215-662-2836
Pager: 215-487-8180 Cell: 215-266-4015
HUP Cell: 215-327-4260 Personal Cell: 610-608-1271 Home: 610-583-9462
Associate Chair, Inpatient Operations: Bill Stavropoulos, MD Office: 215-662-6839
Cell: 215-264-6461 Home: 610-527-9676
Department of Radiology Emergency Response
Policy: It is the policy of the Department of Radiology to establish and follow the specified procedures described below and to initiate and proceed accordingly during conditions of an emergency disaster. During any emergency event, all Radiology personnel must wear their HUP identification badges.
Purpose: To clearly delineate personnel responsibilities during an emergency disaster. Scope: All department members must observe the procedures identified in this policy. Procedure: Implementation of the Emergency Plan
The UPHS operator/administration will make contact with the Chairman of the Department of Radiology (Nick Bryan) and back-up (Michael Bleshman) and the
Radiology Director (Ann Costello) and back-up (John Detruf) for the emergency through the Emergency Notification System (ENS).
1. The first act will be for the Radiology Director or back-up to contact the highest ranking radiology physician in the hospital (Chair, On-call Attending or On-call Resident) to assess the situation and the resources that may be needed. Once the situation has been assessed the Radiology Director will go to the HUP Command Center which is at 106 Dulles (backup Command Center is the ED Conference room) for additional information and to obtain hand-held radio.
2. In case of large-scale emergency: Radiology Director or back-up will begin phone chain activating the Radiology group on the UPHS ENS which consists of
Radiology Modality Supervisors including the Nursing Supervisor. The IT Single Point of Contact will also be contacted.
3. Supervisors will contact attending physicians on-call for given section. 4. Supervisors will then contact appropriate technologists and/or nurses in their
modality.
5. Attending physicians who are on-call will contact Section Chiefs in their section. If Radiology services will not be immediately affected:
1. In the event that radiology services will not be affected by the emergency event, supervisors should remain available and prepared if the status changes.
2. Primary communication to the section supervisors will be the responsibility of one of the following individuals: Department Director, Department Fire/Safety Officer, and Department Nurse Manager.
If Radiology Services will be affected:
1. Depending on the disaster, a meeting may be arranged with the section
supervisors to describe the disaster and to specify the plan of action, including instructions regarding the need to discontinue normal patient exams, and to remove patients from the designated areas.
2. If/when the decision to evacuate inpatients is made; radiology clinical staff are required to transport patients to their inpatient rooms. At least one employee must be specifically designated to stay with and monitor patients still in the
Department. The department nurses are responsible for monitoring and verifying that each patient is stable, and can be moved safely. If a patient needs special attention, a physician and/or nurse must accompany the patient to the floor.
3. Each radiology nurse will report to area assigned by Director, Safety Officer, or nurse manager. Nurse will provide appropriate treatment as needed with the assistance of a department physician.
4. Outpatients will be apprised of the circumstances, and informed of their ability to leave building. These patients will also be given instructions about rescheduling their exams if necessary.
5. Employees who are working in nonclinical areas should report to clinical areas as instructed by their supervisor.
6. Clinical Radiology Information Systems downtime procedures will be implemented as needed.
Emergency Classification: Emergency events at HUP are classified as either External, Internal or Access emergencies. An External emergency is an incident outside of the hospital that causes a large influx of patients into the Emergency Room such as a mass casualty incident. An Internal emergency is an incident that occurs within the hospital, such as a water pipe break and flood, and may impact the ability to complete procedures. An Access emergency is an event that makes it difficult for staff to gain access to the hospital such as a large snowstorm.
External Emergency Response:
1. Notification of an External emergency will be announced via the overhead paging system. There may be a follow-up phone call from the hospital telephone operator or from the HUP Command Center (614-0442) to the Radiology Director. The Radiology director and Radiology Chairman are also on the Emergency Notification System list for the hospital and will receive any alerts sent via that system. The Radiology Director will notify the Department Chairman or highest-ranking Radiology physician in the Department at the time of the Emergency. The Radiology Director will begin phone chain which involves activating the Radiology group on the UPHS ENS (consisting of Radiology Modality Supervisors including the Nursing Supervisor) and will be in charge of the ALERT in the Radiology Department. The IT Single Point of Contact will also be contacted. On nights, weekends, and holidays, the highest ranking MD or resident on duty will implement and be in charge of the ALERT until the arrival of the Radiology Director.
With a large influx of casualties, a primary
consideration will be the volume of patients requiring radiology services and the demand that may be placed on the Radiology Department. The following guidelines will be followed.
2. The director/radiologist in charge will go to the HUP Emergency
Department to assess the extent of the disaster; type of x-ray examinations to be expected and the volume of patients. The decision will be made by the director/radiologist, according to volume of patients expected in
Radiology, how many people will be needed to put this Emergency Plan into action.
3. The director/radiologist will notify the receptionist and the technologists on duty to notify their supervisors. Supervisors will be contacted at home based on the volume of patients expected. They will be instructed to call in their staff and the attending physicians on-call for their modality based on need. Phone numbers for staff are in the Chest/Bone Control Room, they are updated quarterly by the Radiology Director.
4. The Supervisor of the shift will:
1. Review patients presented in the Department and examinations in progress, assess the need to cancel, reschedule or postpone
regularly scheduled appointments
2. Stop the scheduling of inpatients and outpatients
3. Assign available staff (and additional staff as they arrive) to sections where needed to handle demand
4. Have one additional portable unit brought to the Emergency Department.
Internal or Access Emergency Response: It will be necessary to determine if the event is impacting the operations of Radiology or may impact appointments, schedules or the ability of staff to complete their work schedules or get into work.
1. The Director or designee will stay in contact with the HUP Command Center (614-0442) or Administration to determine the impact of the internal or access event on the Radiology department.
2. Follow guidelines as noted above under Implementation of the Emergency Plan. Additional guidelines for:
Coordinating Patient Evacuation Information: Radiology Safety officer and Nurse Manager will circulate through the Department to provide instructions to section supervisors as needed, and to feed back information to the Chairman/Director acting as the principal department coordinator.
Evacuation of Disabled Employees: If the Internal Emergency is determined to require evacuation of employees, employees with known handicaps will be assisted to a
designated safe location by a staff member in his/her section immediately after the evacuation alert has been sounded.
Radiation Exposure: If the disaster involves concerns involving radioactive exposure, this will be handled by the radiation safety department of the University of Pennsylvania. The contact with this office will be handled by the department director or designee. Release of Radiology Personnel: During or after a declared Emergency, it may be necessary to dismiss personnel for the following reasons:
1. An employee may be concerned about his/her family and/or possessions, in the event that someone was involved with the ALERT, and desires to go home. 2. An employee may have difficulty with child/elderly care due to events related to
the ALERT in his/her environment. This may have necessitated bringing the dependents to work.
3. An employee may be emotionally upset by the event and desire to go home. The decision regarding the above circumstances will be handled by the employee's immediate supervisor. If this individual is not available, the Radiology Director will make the decision. No employee should leave the Hospital without approval.
If the RIS is unavailable:
1) Immediately call the single point of contact (SPOC) support line (215-200-4003). 2) Any orders that were completed before the system went down are likely available
in Talk, and can be reported there.
3) If SPOC is unable to bring the system back up within 30 minutes, call SPOC again to confirm that you should begin using paper/phone downtime procedures, as follows:
a) Inform callers that anyone wishing to schedule an exam must call radiology scheduling (215-662-3000).
b) Call in backup resident to answer ED reading room phone (215-662-7707) and provide preliminary readings to referring providers who call.
c) Use paper forms as a substitute “work list”, writing preliminary readings on the forms.
d) Use Talk to dictate the report. At the beginning of each report, dictate the control number from the paper form along with the patient name, MRN, DOB, date of service, exam time, exam code, and radiologist(s) names. The report will be held in Talk and will be sent to the RIS when it becomes available. e) Any verbal communication of results must be documented on the paper form
or in the dictated report.
f) File paper forms in an accordion folder in ED reading room, where they can be used to provide preliminary readings to referring providers who call.
If the GE PACS is unavailable:
1) Immediately call the single point of contact (SPOC) support line (215-200-4003). 2) If SPOC is unable to bring the system back up within 30 minutes (15 minutes for
chest/bone), call SPOC again to confirm that you should begin using Terarecon. 3) If necessary, remind technologists to send images to downtime destination.
4) Start Terarecon, which is installed on all PACS workstations in the department. In the event of a problem using Terarecon, contact the SPOC support line (215-200-4003).
5) Use the RIS work list to select cases. Launch the cases manually on Terarecon for interpretation.
6) Referring providers will need to visit the reading room if they wish to view images.
If Talk is unavailable:
1) Use GE speech recognition
If there is a data center outage or a loss of connectivity to the data center: It is likely that both RIS and PACS will be unavailable.
1) Immediately call the single point of contact (SPOC) support line (215-200-4003). 2) If SPOC is unable to bring the system back up within 30 minutes (15 minutes for
chest/bone), call SPOC again to confirm that you should begin using PACS-IW. 3) If necessary, remind technologists to send images to downtime destinations.
4) Images sent to downtime destinations can be viewed on PACS-IW, which is installed on all PACS workstations in the department. In the event of a problem using PACS-IW, contact the SPOC support line (215-200-4003).
5) For orders and reports, use the RIS downtime procedures described above.
6) Referring providers will need to visit the reading room if they wish to view images.
If there is an internal network outage:
The network may be completely unavailable or partially unavailable, and can exhibit many different failure modes, so some flexibility is required in response to network downtimes:
1) If SPOC believes that a network outage is causing the problem you are experiencing, they may ask you to describe the issue to UPHS desktop support (215-662-7474), which is responsible for maintaining the network.
2) If the RIS loses connectivity, Talk may be usable as a backup reporting system. Otherwise, institute RIS downtime plan as above.
3) If the PACS loses connectivity but Terarecon does not, institute PACS downtime plan as above.
4) If the modalities cannot send images, or if no image viewing software is functional, images must be reviewed on the modality consoles.
If there is a Complete Power Failure
If there is a hospital-wide power failure, the CT scanner in the ED is connected to the emergency power. Portable plain x-ray units can be used with the red emergency outlets. These can be brought to the ED if needed and/or can be used to take ICU images. The CT images will be read off the CT scanner by the body imaging radiologist or in-house on call radiologist if power failure occurs after hours. An Emergency Downtime report
book will be kept in the ED CT control room and paper reports will be written in this report book until power and RIS dictation system is restored.
Update Record
Date Revision Team
8-4-2009 V1.0 Stavropoulos, Langlotz, Costello, Bryan, Bleshman 1-27-2010 V1.0 Langlotz, Stavropoulos, Costello
