/policies/,/policies/clinical/,/policies/clinical/uw-health-clinical/,/policies/clinical/uw-health-clinical/emergency-response/,

/policies/clinical/uw-health-clinical/emergency-response/514.policy

20160384

page

100

UWHC,UWMF,

Policies,Clinical,UW Health Clinical,Emergency Response/Management

Evacuation of Staff and Patients from Locked Psychiatric Inpatient Unit (5.1.4)

Evacuation of Staff and Patients from Locked Psychiatric Inpatient Unit (5.1.4) - Policies, Clinical, UW Health Clinical, Emergency Response/Management

5.1.4


UW HEALTH CLINICAL POLICY 1
Policy Title: Evacuation of Staff and Patients from Locked Psychiatric Inpatient Unit
Policy Number: 5.1.4
Category: UW Health
Type: Inpatient
Effective Date: December 18, 2015

I. PURPOSE

To establish procedures to be follow ed on the Inpatient Psychiatric unit in case of the need to evacuate
patients and personnel.

II. POLICY ELEMENTS

Inpatient Psychiatric unit staff, hospital security and patients are informed by the nursing off ice coordinator
or administrator in charge of the possibility and/or need to evacuate.

III. PROCEDURE

A. Organize staff - delegate staff to evacuate all ambulatory, non-acute patients dow n appropriate stairw ells to
designated areas.
B. Care team leader/senior team member w ill identify patients needing special evacuation procedures due to
their level of acuity, such as patients w ith high elopement, aggression, or suicide risk factors.
C. In the event of sedated, combative or out of control patients w ho are a threat to the safety of others or
themselves, a minimum of four (4) staff should be available to accompany these patients. (Behavioral
Response Team, Security, Nursing Service and Hospital Administration may be notif ied to acquire additional
staff.)
D. If a patient's behavior cannot be contained by available staff, other appropriate methods of restraints should
be employed, including physical restraints w hile transporting the patient to a designated safe area. See
UWHC policy #10.27 (Restraint and Seclusion).
E. Staff w ill remain w ith patients until it is safe to return to the unit or their transfer to an appropriate facility has
been completed.

IV. COORDINATION

Author: Nurse Manager, Inpatient Psychiatry
Senior Management Sponsor: SVP, Patient Care Services and CNO
Review ers: General Counsel; Directors, Psychiatric Services
Approval committees: UW Health Clinical Policy Committee
UW Health Clinical Policy Committee Approval: November 16, 2015

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

V. APPROVAL

Jeff Grossman, MD
UW Health CEO

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VI. REFERENCES

UWHC policy #10.27, Restraint and Seclusion

VII. REVIEW DETAILS




UW HEALTH CLINICAL POLICY 2
Policy Title: Evacuation of Staff and Patients from Locked Psychiatric Inpatient Unit
Policy Number: 5.1.4

Version: Revision
Next Revision Due: December 18, 2018
Formerly Know n as: Hospital Administrative policy #10.21