/policies/,/policies/administrative/,/policies/administrative/uwhc/,/policies/administrative/uwhc/department-specific/,/policies/administrative/uwhc/department-specific/facilities--engineering-services/,

/policies/administrative/uwhc/department-specific/facilities--engineering-services/fe041011.policy

201509253

page

100

UWHC,UWMF,

Policies,Administrative,UWHC,Department Specific,Facilities & Engineering Services

Facilities & Engineering Biological (Pandemic) Event Procedure (F&E.04.10.11)

Facilities & Engineering Biological (Pandemic) Event Procedure (F&E.04.10.11) - Policies, Administrative, UWHC, Department Specific, Facilities & Engineering Services

F&E.04.10.11

FACILITIES & ENGINEERING SERVICES DEPARTMENT
POLICY & PROCEDURE




Effective Date:
July 2015
X Administrative Manual
Computer Room Manual

Policy #:
F&E.04.10.11


Original
X Revision
Page 1
of 6
Title: Facilities & Engineering
Biological (Pandemic) Event
Procedure


PE.04.10.11 PE Biological Event Procedure
I. Purpose:
To establish the Facilities & Engineering Services departmental procedures that insure a planned
and organized response to a Biological Event at the University of Wisconsin Hospital and Clinics
(UWHC) in accordance with the UWHC Emergency Operations Plan. This departmental plan
covers both the short term creation of special clinical environments and the long term effects of
staff illness or quarantine. When a Biological Event occurs, department personnel who are on
duty or called in to assist will respond in an organized and professional manner that maintains
patient and staff safety at all times.

II. Policy:
UWHC is a special environment in which the normal patient population is dependent upon the
continuous maintenance of appropriate environments. The organization’s Emergency
Operations Plan requires Facilities & Engineering Services to create, test, and maintain both
existing and expanded special areas set aside for the treatment of affected patients.

In addition, Facilities & Engineering Services employees must change their daily habits to insure
that they protect others and themselves from the pathogen. Knowledge of and adherence to the
current recommended infection control procedures and practices are required to reduce the
pathogen spread throughout the institution, staff and their families.

During a declared biological (pandemic) event, Facilities & Engineering Services staff may
become affected by the pathogen. Facilities & Engineering Services managers should be
creative and flexible when scheduling operational activities and building staffing plans while
always insuring that patient and staff safety and comfort are not compromised during the event.

SEE ALSO: UWHC Emergency Operations Plan

III. Forms Used: Biological Event Checklist (attached)

IV. Event Activation Immediate Procedure:

A. Isolation Unit Activation
i. The notice to activate the biological event environment will be given by the Facility
Unit Leader from the Healthcare Command Center (HCC).

ii. The Control room Operator will print out the attached ‘Sequence of Events
Checklist’. Beginning with step 1, as each item is completed, record the time and
your initials. Proceed through the entire checklist until complete. Upon completion,
deliver the checklist to the Maintenance and Operations Manager.


iii. Following the attached checklist, the Control room operator will:
Notify the Maintenance and Operations Manager - cell 235-4216
or Manager On-call (during off hours)
Notify the Building Trades Supervisor - cell 444-7461
Notify the Clinical Engr Runner or On-call technician (during off
hours)- cell 516-1897
Notify the Customer Service Manager - cell 235-7908

FACILITIES & ENGINEERING SERVICES DEPARTMENT
POLICY & PROCEDURE




Effective Date:
July 2015
X Administrative Manual
Computer Room Manual

Policy #:
F&E.04.10.11


Original
X Revision
Page 2
of 6
Title: Facilities & Engineering
Biological (Pandemic) Event
Procedure


PE.04.10.11 PE Biological Event Procedure

iv. Activate the Metasys “Isolation” mode using Metasys object F6/5 AHU-13\Isolation-
MODE

v. Dispatch runner to patient unit F6/5 along with the magnetic ‘stop signs’ from D4/163
storage.
Runner will verify:
a. All Isotek monitors on all F6/5 East Hallway
rooms
b. Verify that the Isotek monitor indicators across
from the F6/5 nurses station are indicating
green
c. Report results to Control room
d. Post special ventilation stop signs on all F6/5
unit entrance doors

vi. Control room operator goes to the WAM maintenance module >Benchmark work
orders. Search for B110422. When found, use Actions>Create work order from
benchmark. Use the number generated as a task list and assignment for all other
Facilities & Engineering Services sections. Be prepared to supply the Biological
Event work order number to other sections as they call in to report their activities.

vii. Control room will activate the PE Leadership Team List Page to notify them of
Biological Event activation.

viii. Control room will contact the Facility Unit Leader and report completion of the
following tasks:
1. A negative air balance for unit F6/5 has been achieved
and confirmed
2. Carpenters installation of doors in F6/5 hall completed
3. Carpenters removal of lockers from F8/502 and
relocation of same to temporary storage.
4. Laborer delivery of folding table and chairs
5. Clinical Engineering installation of patient monitors in all
required patient rooms and central station in room
F8/572.

ix. If the Biological Event requires additional negative pressure treatment rooms, a
Facilities & Engineering Services manager will contact the Building trades
supervisor or the sheet metal shop and begin planning for using the four in-house
HEPA fan units to create additional negative units.


FACILITIES & ENGINEERING SERVICES DEPARTMENT
POLICY & PROCEDURE




Effective Date:
July 2015
X Administrative Manual
Computer Room Manual

Policy #:
F&E.04.10.11


Original
X Revision
Page 3
of 6
Title: Facilities & Engineering
Biological (Pandemic) Event
Procedure


PE.04.10.11 PE Biological Event Procedure
1. Unit planned to be changed to negative pressure will be
discussed and identified by the Incident command
center
2. Requests for negative pressurization will be received by
the Facilities & Engineering Services Department
3. The sheet metal and, if necessary, carpenter shops will
select an appropriate empty room in the unit, set up the
in-house HEPA fan and exhaust it through a window.
Door hold open magnets on the unit doors will be
deactivated. Upon completion, the unit will be smoke
tested to insure that it is negative at all entrances from
the adjacent space.

B. Clinical Engineering Activities
i. Clinical Engineering technician acknowledges Biological Event activation by
contacting Control Room at 263-5205.

ii. Clinical Engineering technician proceeds to room B5/B05 and inventories the
number of patient monitoring units available.

iii. Notify Healthcare Command Center of number of patient monitoring units available
by radio or at (262-6208)

iv. Notify Control Room of the number of patient monitoring units available by radio or
at (263-5205)

v. Proceed to patient unit F6/5 and begin the installation of the central station and
portable monitors. Call in additional Clinical Engineering technicians if required.

vi. Clinical Engineering technician acknowledges completion of patient monitor install
and activation by contacting the Healthcare Command Center by radio or at (262-
6208)

vii. Notify Control Room that patient monitoring installation for F6/5 is complete by
radio or at (263-5205)

viii. It is estimated that the patient monitoring installation will be complete in app. 1 hour
from notification of the event.

ix. If the event occurs during off hours, add app. 1 hour to each of the completions times
to allow for calling in of staff.

C. Building Trades Activities
i. Upon notification of the Biological Event activation, the responding
Carpenters will notify the Facilities & Engineering Services Control Room
Operator that they are en route to the Unit.

ii. Carpenters responding to the notification are to perform the following:

FACILITIES & ENGINEERING SERVICES DEPARTMENT
POLICY & PROCEDURE




Effective Date:
July 2015
X Administrative Manual
Computer Room Manual

Policy #:
F&E.04.10.11


Original
X Revision
Page 4
of 6
Title: Facilities & Engineering
Biological (Pandemic) Event
Procedure


PE.04.10.11 PE Biological Event Procedure

iii. Install double egress doors in frame located in the East wing of F6/5 Nursing Unit
(closer arm also needs to be attached). Doors are located/stored in the E5/ part
of the basement tunnel where we store the new doors & frames.

iv. Notify Facilities & Engineering Services Control Room operator when the doors
have been installed.

v. Remove the lockers from F8/502 and store in the adjacent air handler room.

vi. Notify Facilities & Engineering Services Control Room operator when the
lockers have been removed.

vii. It is estimated that the doors installation will be complete in app. 1 hour from
notification of the event. The locker relocation will be complete in app. 1 ½ hours
following the doors installation.

viii. If the event occurs during normal working hours, 2 crews may be sent, one crew
to complete the doors, and one crew to complete the lockers.

ix. If the event occurs during off hours, add app. 1 hour to each of the completions
times to allow for calling in of staff.

x. Please note that there will be a lot of activity in that wing of the F6/5 Nursing Unit
as everyone is working to complete their assignments for the event.

D. Customer Service Manager
i. The Customer Service Manager contacts to the HCC Logistics Chief within 15
minutes to (262-6208) and to obtain situation update.

ii. After being notified of completion of F6/5 double door installation and locker
removal by UWHC carpenters, the Customer Service Manager arranges for the
delivery and install of one portable table and four (4) chairs to the physician
charting room F8/502 within 60 minutes.

iii. Transportation staff reports the delivery of the table and chairs to the Customer
Service Manager in the HCC (262-6208)

iv. Customer Service Manager notifies Control Room operator of the completion of
the delivery of the table and chairs to room F8/502.

II. Event Activation Long Term Procedure:
A. Critical Function Priorities
i. It is anticipated that a pandemic will increase Facilities & Engineering Services
staff absenteeism due to illness of staff and their immediate family members.
This absenteeism is anticipated to force the department to operate at near 65%
staffing levels.



FACILITIES & ENGINEERING SERVICES DEPARTMENT
POLICY & PROCEDURE




Effective Date:
July 2015
X Administrative Manual
Computer Room Manual

Policy #:
F&E.04.10.11


Original
X Revision
Page 5
of 6
Title: Facilities & Engineering
Biological (Pandemic) Event
Procedure


PE.04.10.11 PE Biological Event Procedure
ii. With reduced staff the daily functions maintained by the department must be
prioritized and reduced. The continuing critical functions by priority are:
a. Maintain operations at all UWHC locations open to the public to
include temperature, air pressurization, and utilities
b. Provide transportation for laboratory specimens, medical
records, and supplies. The event may increase the volume and
schedule of these items
c. Maintain code compliance testing in the facilities mentioned in
item a.

B. Maintain Facility Operation
i. To gather a list of available employees in the department, PE managers will log
into Report Express, select Distributions from the left-hand toolbar and select
the report titled “Available Employees in Plant Engineering”.

ii. PE managers will also maintain a shared departmental ‘Pandemic’ calendar
showing the roster of departmental employees ill or quarantined and their
expected date of return.

iii. Minimum specialized personnel will need to be maintained during an extended
event. The levels during regular work hours (7:00am – 3:30 PM) are:
1. F&E Managers - 2
2. F&E Supervisor - 1
3. Maintenance/Zone mechanic - 5
4. Electrician - 3
5. Carpenter - 3
6. Painter - 2
7. Plumber - 4
8. Steamfitter- 4
9. Sheetmetal - 2
10. Driver - 12

iv. Night staffing levels are set to minimal weekend staff of two mechanics and call
in staff.

v. Before staffing approaches the levels noted above, Facilities & Engineering
Services management staff will begin using a staffing pool concept system
whereby other Facilities & Engineering Services staff is used to augment the
remaining staff where possible. If the shortages occur in the craft specialties,
contact should be made with state contracted local contractors to obtain
similarly skilled craft workers as a substitute.


vi. F&E managers should maintain close communication with service vendors,
supply vendors, to determine when these organizations will not be able to
supply services. Alternate sources can be determined by contacting the
manager who typically works with the vendor. First response will be to use the

FACILITIES & ENGINEERING SERVICES DEPARTMENT
POLICY & PROCEDURE




Effective Date:
July 2015
X Administrative Manual
Computer Room Manual

Policy #:
F&E.04.10.11


Original
X Revision
Page 6
of 6
Title: Facilities & Engineering
Biological (Pandemic) Event
Procedure


PE.04.10.11 PE Biological Event Procedure
vendor list created for these events using the contact information provided by
the agreement letters that have been distributed by UWHC purchasing.

C. Transportation Operations
i. PE managers should maintain close communication with UWHC clinic, medical
records, and central services department to insure that the current
transportation routes are adequate to maintain patient and staff safety.

ii. If it becomes necessary to increase the volume or frequency of transportation
routes or driver staffing approaches the level noted above, Facilities &
Engineering Services managers will locate additional UWHC qualified staff to
train/orient on the routes.

iii. If it appears that supplies critical to operation are going to be delayed due to the
staffing of the vendor or their trucking companies, alternative like pickup by
UWHC transportation will be researched and implemented if required.

iv. F&E managers will insure adequate staffing is provided to the bed moving and
hallway cleaning functions during the incident.

III. Coordination:
Continual Readiness Committee





Wayne Abbott
Director, Facilities & Engineering Services