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Revisions Approved by DBOH 02/23/12, Effective 07/01/12 MULTI-CASUALTY INCIDENT PLAN MUTUAL AID EVACUATION ANNEX Approved Washoe County Health District 06/28/2000 Revisions Approved by DBOH 07/26/07, Effective 12/01/07 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 Page 1 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 TABLE OF CONTENTS 1.0 INTRODUCTION…………………………………………………………………………….. 4 4 2.0 ANNEX OVERVIEW………………………………………………………………………… 4 2.1 Annex Objective……………………………………………………………………………. 4 2.2 Annex Scope………………………………………………………………………………... 4 2.3 Assumptions………………………………………………………………………………... 5 3.0 RESPONSIBILITIES………………………………………………………………………... 5 3.1 All Annex Members………………………………………………………………………... 5 3.2 Evacuating Hospital……………………………………………………………………….. 6 3.2.1 General Responsibilities…………………………………………………………………. 6 3.2.2 Hospital Planning Technical Specialist………………………………………………... 7 3.3 Receiving Hospitals……………………………………………………………………….. 7 3.4 Washoe County Health District………………………………………………………….. 8 3.5 REMSA……………………………………………………………………………………….. 8 3.6 HAvBED 8 4.0 IMMEDIATE VS. URGENT EVACUATION (LEVEL 1 VS LEVEL 2)…………………. 9 4.1 Definitions…………………………………………………………………………………… 9 4.2 Annex Activation for Level 1 (Immediate) Partial or Full Evacuation…………….. 10 4.3 Annex Activation for Level 2 (Urgent) Partial or Full Evacuation…………………. 10 5.0 PATIENT EVACUATION AND DISTRIBUATION OVERVIEW……………………….. 12 6.0 TRANSPORTATION OF PATIENTS……………………………………………………… 12 6.1 Emergency Medical Services Coordination with Evacuating Hospital…………... 12 6.2 Transportation Staging Area…………………………………………………………….. 13 6.3 Out of State (California) Hospitals……………………………………………………… 14 7.0 COMMUNICATIONS………………………………………………………………………... 14 7.1 Required Notifications……………………………………………………………………. 14 7.2 Patient/Resident Transfer Communications………………………………………….. 15 7.3 Administrative Hospital-To-Hospital Communications…………………………….. 15 7.4 Additional Required Notifications By Evacuating and Receiving Hospitals……. 15 7.5 Regional Call Center………………………………………………………………………. 16 7.6 Facsimile (Fax) Systems………………………………………………………………….. 16 7.7 Telephone Contacts……………………………………………………………………….. 16 7.8 Two-Way Radio System………………………………………………………………… 16 7.9 Alternate Communications………………………………………………………………. 16 8.0 LIMITED LIABILITY AND DISASTER DECLARATION PROCESS………………….. 17 9.0 COLLATERAL CONSIDERATIONS……………………………………………………… 17 9.1 Skilled Nursing Facilities…………………………………………………………………. 17 9.2 Public Information…………………………………………………………………………. 17 9.3 Admitting and Billing……………………………………………………………………… 18 9.4 Use of Evacuating Hospital Staff……………………………………………………….. 18 9.5 Out of State Staff and Physicians………………………………………………………. 18 9.6 Medical Records…………………………………………………………………………… 18 9.7 Biomedical Equipment……………………………………………………………………. 19 9.8 Pharmaceuticals……………………………………………………………………………. 19 Page 2 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 10.0 ANNEX DEVELOPMENT AND MAINTENANCE……………………………………….. 19 APPENDIX A DEFINITIONS…………………………………………………………………….. 20 APPENDIX B OPERATIONAL CONCEPTS………………………………………………….. 23 APPENDIX C EVACUATION ALGORITHM…………………………………………………... 24 APPENDIX D INITIAL PATIENT EVACUATION AND ACCEPTANCE OVERVIEW…….. 25 APPENDIX E MEMBERS, CONTACT PERSONS, AND EXTERNAL HOLDING AREAS 29 APPENDIX F INDIVIDUAL HOSPITAL COMMUNICATION INFORMATION……………. 33 APPENDIX G HOSPITAL EVACUATION MILEAGE CHART………………………………. 37 FORMS Hospital Evacuation Planning Worksheet…………………………………. 38 Field Evacuation Planning Worksheet……………………………………… 39 Patient Evacuation Tracking Form………………………………………….. 40 Page 3 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 1.0 INTRODUCTION Our region is at risk for many natural and technological disasters, and it is not unthinkable that at least one hospital might have to be evacuated in a disaster. In order to ensure compliance for patient safety and business continuity concepts, as well as acknowledging the need to comply with standards and requirements for evacuation planning for healthcare facilities, the following Annex has been developed. Best practices and nationally recognized standards include AHRQ's Hospital Evacuation Decision Guide (May 2010), California Hospital Association's Sample Hospital Evacuation Plan Checklist, June 2008, AHRQ's Hospital Assessment and Recovery Guide (May 2010) and the HICS Hospital Evacuation Incident Planning Guide. This Annex aims to optimize the medical care and safety of patients who have been evacuated from a hospital with minimal disruption to the community's acute care system. The goal is to integrate this Annex into the current medical disaster planning efforts and the Washoe County Health District's Multi-Casualty Incident (MCI) Plan, as well as the Washoe County Emergency Operations Plans. It is also intended to be coordinated with other applicable city and county emergency procedures. 2.0 ANNEX OVERVIEW 2.1 Annex Objective To coordinate transportation and care of patients who are being evacuated from one member hospital to another in a disaster, with minimal disruption to the provision of acute emergency care to the community. This annex is designed for natural and technological types of disasters. It is not designed as part of a contingency plan for patient evacuation due to employee work stoppage or financial closure of a hospital (unless agreed upon by individual members at the time of the occurrence). Examples of natural and technological disasters are: earthquake, fire/explosion, floods, hazardous material incidents, extended utility outage, structural failure, or acts of terrorism. 2.2 Annex Scope The scope of this plan is intended to include all facilities in the Northern Nevada and California area that belong to the Interhospital Coordinating Council (IHCC) and have developed collaborative agreements to assist each other in the event of a full or partial evacuation of one of the hospitals. This includes healthcare facilities in the State of Nevada and bordering counties of California, and as such, takes into consideration issues related to transferring patients across state lines and reciprocal credentialing of medical licensures. The Annex constitutes a Memorandum of Understanding between all parties to make their "best effort" to accommodate the minimum number of patients agreed upon in this document. Page 4 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 2.3 Assumptions In order to develop this annex, certain assumptions had to be made: • Only one hospital requires evacuation. • This plan is based on the short term transfer of patients and not a long term relocation. It is not designed to accommodate provisions if the evacuating hospital will potentially be unable to operate for an extended period of time. • Emergency Departments at receiving hospitals will NOT to be used as receiving sites for these patient transfers. They will continue to focus on the emergency healthcare needs of the community. • Members agree to make their "best effort" to accommodate the minimum number of patients agreed upon in this document. • Whenever possible, patients will be transferred to a hospital that provides similar services at the same or increased level of care. • Whenever possible, patients will be kept in the community, close to friends and family. • Non-ambulance transport methods for non-critical patients may be used if needed. It is assumed that the primary modes of non-ambulance transportation will come from vendors that have been pre-identified and listed as resource assets with the jurisdictional emergency management system. • Once the evacuating hospital has resumed normal operations, the receiving hospitals agree to return any patients and equipment from the evacuating hospital as soon as feasible. • Whenever possible, critical care patients (a generalized term to include intensive care, cardiac care, cardiac surgery, pediatric intensive care, and neonate intensive care) will be sent directly to receiving hospitals rather than external holding areas. • The Regional Emergency Operations Center will be activated and will utilize the hospital representative position to act as a liaison between hospitals and to coordinate patient tracking information in a central location. • Unless there is a federal declaration, there is no deviation from EMTALA compliance. Transfer and tracking of patients will be in accordance with HIPAA regulations. • That prior to the transfer of patients, the evacuating facility has utilized its Alternate Care Facility plan in an attempt to keep patients with in its healthcare system and to minimize disruption of patient care and business continuity. 3. 0 RESPONSIBILITIES 3.1 All Annex Members • It is the responsibility of each member hospital to maintain an internal plan to protect life and property during a disaster. Maintenance of such plans is the responsibility of each institution. • Each facility will conduct required and best practice mitigation efforts to reduce hazards potentially associated with an evacuation (i.e. Conducting Hazard Vulnerability Analysis, developing structural and nonstructural mitigation plans). • All members agree to participate in collaborative efforts with community partners to optimize resources and response utilization. Page 5 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 • Past exercises have shown that planning for the evacuation of outpatient clinic and professional services patients also needs to be considered in hospital internal plans. Each hospital is responsible for making its own plans for these types of patients. • Hospitals agree to use the Hospital Incident Command System (HICS). (See Appendix B) • Members agree to participate in training and drills related to hospital evacuations and the Annex plan. • If a member hospital has permanent changes in its ability to receive the agreed upon number of patients, identification of contact personnel, or external holding areas, it will notify the Washoe County Health District of any changes so those changes can made to the Annex. • Members will use the annex's patient evacuation tracking sheet and may also enter information in the patient tracking section of WebEOC. • Members will identify external holding areas close to their location to provide temporary shelter if an immediate evacuation is required, and internal staging areas for patients for an urgent evacuation. • Members will develop and maintain internal plans for receiving the influx of patients dispersed under this plan. • All members will maintain adequate business interruption insurance. • Public information and community confidence are important considerations during an evacuation. The hospitals agree to participate in a joint information center to include the Field ICS Public Information Officer to provide information to the public and the media. • All facilities will have in place emergency credentialing plans that will permit credentialing of personnel who may wish to volunteer their professional's services during an emergency. 3.2 Evacuating Hospital 3.2.1 General Responsibilities • The evacuating hospital's administration or other authority having jurisdiction (AHJ) declares the hospital unsafe and unstable; requiring a full or partial evacuation. Hospital decision to evacuate should be determined based on pre-developed evacuation criteria. • The evacuating hospital carries out measures to decrease patient census (as time allows) including: review all elective surgical procedures, early discharges and discharge of appropriate patients to home, or transfer to a Skilled Nursing Facility (SNF). • Evacuating hospital will activate its Alternate Care Facility Plan to relocate patients to an alternative location within its healthcare system, if possible. • Documents patient tracking (patient evacuation tracking sheet and WebEOC if time allows) and during an urgent evacuation is responsible for notification of each patient's physician and family of pending relocation, if time allows. • Responsible for sending current medical records with patients whenever possible. If time does not allow for pulling medical records, at a minimum, the evacuating hospital will ensure that the MAR (Medication Administration Record) accompany the patient. Page 6 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 • Whenever possible sends appropriate nursing or physician personnel to accompany patients to the receiving hospital. • Send one administrator or nursing supervisor to coordinate with the receiving hospital administration. Send one pharmacist to assist with patient medication orders, and resolve any formulary changes to patient medication orders. • The medical staff/patient ratio during transport will be determined as reasonably safe for care by the Hospital Medical Officer and the Field Transportation Supervisor • Maintains responsibility for patients until accepted by a receiving hospital. • Ensure that the vacated premises are secure and that no one is left behind after the evacuation. • As time allows, evacuating hospital will notify the State Health Division Bureau of Licensure and Certification about their change in bed status. 3.2.2 Hospital Planning Technical Specialist The evacuating hospital will assign one personnel to participate in the field ICS, a Hospital Planning Technical Specialist. This annex includes the Checklist for this ICS position in Appendix H. The evacuating hospital will work to ensure their patients are prepared for evacuation to a hospital that will provide the same or higher level of care, depending on the state of community resources. The hospital staff most familiar with the medical needs of the patients will work with the Field Incident Command System (ICS) Medical Branch to determine the most appropriate destination, staff, equipment, and method of transport. Thus, the Field Medical Branch personnel must rely upon the medical triage completed by the hospital and utilize hospital personnel to coordinate appropriate treatment personnel, equipment and methods of transport. This is the rationale for the Hospital Planning Technical Specialist. 3.3 Receiving Hospitals • Carries out measures to decrease patient census including: review all elective surgical procedures, early discharge and discharge of appropriate patients to home, or transfer to a Skilled Nursing Facility (SNF). • Determine ability to accommodate influx of patients. If changes to plan numbers need to be made, contact REMSA to notify. • Makes preparations for receiving patients, including calling in additional staff and implementing their emergency credentialing policy. • Obtains additional equipment and supplies needed to provide care. • Maintains communications with the evacuating hospital if feasible. See Communications Plan (Section 7) • Continues patient tracking within its hospital when patients are received. When the patients have been received, the receiving hospital will assign an individual the responsibility for faxing the Patient Tracking Form to the Hospital Representative at the Regional EOC. • Upon receipt of patients from the evacuating hospital, notifies: Families/responsible party Attending physician • Is responsible for the safety of staff from the evacuating hospital working within its building, and for the safekeeping and continuing operability of medical equipment that is sent from the evacuating hospital. Page 7 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 • Assumes responsibility of evacuated patients when received. • Ensure that the completed top form of the Patient Tracking Form is sent back to the evacuating hospital after it is completed. This form will be used to let the evacuating facility know where to send the patient records and to document the patient tracking process. • As time allows receiving hospital will notify State Health Division Bureau of Licensure and Certification about their change in status or if they have exceeded licensed bed capacities. • Upon notification that the evacuating hospital is able to be reoccupied, returns all patients and equipment to the hospital of origin unless other arrangements have been made. 3.4 Washoe County Health District • Washoe County Health District will be contacted by REMSA Medical Dispatch and will assist in the assessment of public health impacts. • Washoe County Health District is responsible for maintenance and update of Mutual Aid Evacuation Annex. • Because of the extensive public health liaison required with government and private agencies in such a declared disaster, the District Health Officer or designee takes an active role in the ICS Unified Command structure in the jurisdictional Emergency Operations Center to coordinate public health issues. • The Multi Causality Incident Plan requires that the Health District staff arrange a debriefing for multi casualty incidents that exceed 10 patients. The Field Incident Commander and Hospital Agency Representative will assist the Health District in gathering documentation regarding the evacuation process and participate in debriefings as requested. 3.5 REMSA • In a multi casualty incident REMSA medical dispatch determines the destination of patients based on information from area hospitals. In this annex, the plan members have agreed upon a pre-planned patient distribution scheme. • In a Level 1 or Level 2 evacuation, REMSA Medical Dispatch will notify the plan members regarding the evacuation. REMSA Medical Dispatch will contact receiving facilities as patients are transported from the evacuating hospital to let them know what type of patient they will be receiving (Type refers to patient category – critical care, non-ambulatory, ambulatory, etc.) 3.6 HAvBED • The Nevada State Health Division (NSHD), Public Health Preparedness Program • (PHP) has a statewide, bed tracking, availability, and alerting/information system in place throughout Nevada's system, entitled "HAvBED." HAvBED is a robust and reliable system used to track bed availability, hospital capacity/status, along with tracking hospital, Coroner, Mortuary, and healthcare facility storage of decedents. The system is dual-redundant with east and west coast backup servers. Nevada's HAvBED system is a vital component of the Nevada Health alert Network (NVHAN), for immediate transmission of critical health information during a catastrophic event in our state and the western region of the United States (Nevada Border States). All hospitals throughout the state are on the system and update regularly. Page 8 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 • During a hospital evacuation, HAvBED would be an essential Username/Password controlled-system to enable hospitals to communicate with each other regarding patient transfers on one shared platform. All data entered into HAvBED is transmitted and monitored by State and Federal authorities to plan logistics during an emergent event and respond timely and appropriately. • While the Evacuation Annex plan provides overall estimates for types and numbers of patients that can be accepted into receiving facilities for pre-event planning, HAvBED compliments the Evacuation plan by providing up to date patient census numbers at the time of the evacuation event. 4.0 IMMEDIATE VS. URGENT EVACUATIONS 4.1 Definitions Level 1 - Immediate evacuation requires the immediate, prompt departure of patients from a hospital due to life-threatening conditions. Such an evacuation may require the evacuating hospital to move patients to an external holding area in the parking lot or other outside sheltered location(s) before being moved to a receiving hospital. Critical Care patients should be evacuated directly to a receiving hospital without going to an external holding area. In an immediate evacuation, it may not be practical to pull medical records to go with the patients. Medical records may have to follow the patients after the evacuation occurs. Level 2 - An Urgent evacuation allows for a quick, but orderly hospital departure. Such an evacuation allows time for patient dispersion from the evacuating hospital directly to the receiving hospitals. It may result from non-life threatening environmental conditions, which along with internal horizontal evacuation strategies, allows for orderly gathering of transportation and staffing resources before patients are moved out of the evacuating hospital. Patients will be moved to pre-designated internal staging areas before departing the facility. The hospital, depending on the number of patients and its resources, may wish to designate more than one internal staging area for patients (ambulatory versus wheelchair versus gurney patients). This allows appropriate transport resources to externally stage at different locations to expedite patient movement and egress. In a Level 2 evacuation, there should be time to ensure that the patient's records are sent with the patient. The critical consideration that Level 1 (Immediate) vs. Level 2 (Urgent) evacuations affects is the decision regarding which patients to evacuate first. Patients with critical care needs require more time and resources to evacuate. Their place in the evacuation process may change depending on whether the evacuation is immediate or urgent. In an immediate evacuation, the priority will be to get as many patients out as possible, so the first priority might be the easiest to evacuate – ambulatory patients, those with the least equipment and who need the least amount of assistance from staff. In this scenario, patients with special needs would be the last to be evacuated. In an urgent evacuation when there is time to move patients, the critical care patient would be the first to move as there is time to accommodate equipment and patient care considerations. Page 9 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 4.2 Annex Activation for Level 1 (Immediate) Partial or Full Evacuation The evacuating Hospital notifies 911 to report a Level 1 (Immediate) hospital evacuation. The 911 Center will notify REMSA Medical Dispatch, who will contact other agencies using the usual MCI plan procedure, which includes the District Health Officer's designee and the Washoe County Emergency Manager. The hospital may already be in the process of moving patients to a designated external holding area during an immediate evacuation. Upon arrival, outside agencies will set up a field Incident Command Post appropriately linked to the internal Hospital ICS structure. Certain Hospital ICS and field ICS positions must interface in order to share information. The hospital will send a Hospital Planning Technical Specialist to work with the Patient Transportation Group Supervisor. If needed, the District Health Officer's designee will assess the public health impacts of an evacuation. The Washoe County Emergency Manager is responsible for contacting the City's Emergency Manager. It is the responsibility of the field Incident Commander from the authority having jurisdiction to request a Disaster Declaration from the appropriate political subdivision in association with the jurisdiction's Emergency Manager. The decision to open the EOC rests with the Crisis Action Team (CAT) which is led by the County Manager and will authorize activation of the EOC. REMSA Medical Dispatch is responsible for notification of all receiving hospitals that an evacuation is underway. Upon this notification, receiving hospitals will implement their internal plans to receive patients. Initial field transportation of patients will follow the baseline acceptance numbers in the plan for the receiving hospitals. HAvBED will also be utilized when considering bed availability. Receiving hospitals may be contacted later by REMSA Medical Dispatch for additional capacities. The Medical Branch Patient Transportation Group Supervisor, in coordination with the Hospital Planning Technical Specialist sent to the field by the evacuating facility, will coordinate communications and movement of patients to appropriate destinations along with appropriate staff and equipment (if available). 4.3 Annex Activation for Level 2 (Urgent) Partial or Full Evacuation If a disaster situation requires a hospital to partially or fully evacuate, but there is no immediate life threat to the building occupants, the evacuating hospital notifies 911 and reports that a Level 2 (urgent) hospital evacuation may be necessary. The 911 Center will notify REMSA Medical Dispatch, who will contact other agencies using the usual MCI plan procedure, to include the District Health Officer's designee and the Washoe County Emergency Manager. If needed on scene, the District Health Officer's designee will assess the public health impacts of an evacuation. Page 10 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 The Washoe County Emergency Manager is responsible for contacting the City's Emergency Manager. It is the responsibility of the Field Incident Commander from the authority having jurisdiction to request a Disaster Declaration from the appropriate political subdivision in association with the jurisdiction's Emergency Manager. The decision to open the REOC rests with the Crisis Action Team (CAT) which is led by the County Manager and will authorize activation of the REOC. REMSA Medical Dispatch is responsible for notifications to all receiving hospitals that an evacuation may become necessary, and when the evacuation is initiated. Upon this notification, receiving hospitals will implement their internal plans to receive patients. Initial field transportation of patients will follow the baseline acceptance numbers in the plan for the receiving hospitals. HavBed will also be utilized when considering bed availability. Receiving hospitals may be contacted later by REMSA Medical Dispatch for additional capacities. Because time limitations may not be as critical as with a Level 1 immediate evacuation, in a Level 2 urgent evacuation the evacuating hospital may be able to initiate notification of physicians and patient family members that an evacuation will be taking place. Upon arrival outside agencies will set up a field Incident Command Post, in appropriate proximity to the hospital. Certain Hospital ICS and field ICS positions must interface to share information. The hospital will send a Hospital Planning Technical Specialist to coordinate with the Field Patient Transportation Group Supervisor. The Hospital ICS Planning and Hospital ICS Operations Chief will reduce the hospital census by a review of possible discharges to home, cancellation of elective procedures, etc. and recommend the appropriate patient care destinations for each type of patient to be moved. This information will be communicated to the Field Hospital Planning Technical Specialist and Field ICS Patient Transportation Group Supervisor who will direct the patient distribution process The Hospital Operations Chief will direct the packaging of all patients so that appropriate medical records, medications, and vital support equipment can be moved at the same time the patients may be moved to an internal hospital staging area(s). Location(s) should be convenient for pickup by ambulances or other transportation resources. The field ICS Patient Transportation Group Supervisor and Hospital ICS Planning Technical Specialist will coordinate communications and movement of Critical Care Unit and Non-Critical Care Unit patients to appropriate destinations along with appropriate staff and equipment (if available). NOTE: See Algorithm for Level 1 (Immediate) and Level 2 evacuation (Urgent) in Appendix C. Page 11 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 5.0 PATIENT EVACUATION AND DISTRIBUTION OVERVIEW The Patient Evacuation and the Patient Acceptance Overview (Appendix D) are based on data submitted by the participating facilities. The figures used in this document are known to be highly variable. In some cases, they may not be accurate to describe a hospital's patient population at a particular time. In view of the inherent nature of disasters, flexibility of design and flow are necessary for a successful evacuation. Each facility has taken their average high census for the previous two years to determine the numbers in the overview. Each hospital is responsible for providing updated capacity information during the evacuation process to REMSA Medical Dispatch. These tables show that it is possible to evacuate all but the largest hospital in the community, even though some hospitals will be severely taxed. Should the towers at Renown Regional Medical Center have to be fully evacuated patient dispersal may have to be coordinated with other hospitals outside the region. This would be done through existing mutual aid agreements or in coordination with the State EOC Emergency Support Function #8 (Health and Medical). The internal logistics of evacuating patients from operating rooms to internal staging areas is the responsibility of each participating hospital. Although the Emergency Departments of receiving hospitals will remain available for community emergency care, the patients being evacuated will not be routed through the Emergency Departments of receiving hospitals. A mileage chart depicting the distance between member hospitals is located in Appendix G. 6.0 TRANSPORTATION OF PATIENTS Patients may be transported from the evacuating hospital to an external holding area in a Level 1 (Immediate) evacuation or, in the case of a Level 2 (Urgent) evacuation, directly to a receiving hospital. Subsequent transportation could also occur from an external holding area to receiving hospitals. In either case, critical care patients will be sent directly to hospitals without going to external holding areas. Cost of transportation of patients shall be the responsibility of the evacuating hospital. 6.1 Emergency Medical Services Coordination with Evacuating Hospital Upon a decision that patients will be evacuated from a hospital, the field ICS staffed ICS interface will be instituted. The Field ICS Patient Transportation Group Supervisor under the Field ICS Medical Branch will implement field transportation staging operations and establish coordination with the Hospital Planning Technical Specialist (see position Action Sheet Appendix H) and the field ICS Medical Branch Director regarding patient destination(s). Ideally the external patient holding area(s) for an immediate evacuation will be pre-designated by each hospital in their internal plans, prior to the incident. However, if the pre-designated patient external holding area cannot be utilized, the Hospital Planning Technical Specialist along with the Field ICS Medical Page 12 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 Branch Director may determine the safest place to establish a patient external holding area if not already determined by the hospital. The medical authority for identifying the method of transfer of the patients from the hospital to another hospital should be a collaborative process between the Hospital Planning Technical Specialist and the ICS Medical Branch Director. The receiving hospital destination and transportation resources to be used will be decided upon jointly by the Patient Transportation Group Supervisor and Hospital Planning Technical Specialist working with the Medical Branch. More than one staging area for ambulances, non-ambulances or equipment may be established at the evacuating facility. Traditional field triage tags will generally not be used. The Patient Transportation Group Supervisor will track patients using the name and hospital number from the patient's existing armband and write this information on the patient tracking form. Triage tags will only be used if individuals must be evacuated who do not have such an identifying armband. 6.2 Transportation Staging Areas Field ICS transport vehicle staging area(s) will be established in close proximity to the internal staging areas or external patient holding areas. Ambulances will park and be dispatched in order as directed by the Field ICS Patient Transportation Group Supervisor. The Hospital Planning Technical Specialist will receive information about the appropriate medical care and needs of each patient from the Hospital ICS Planning and Operations Chiefs. Information on the transport needs and requirements for specialized equipment or staffing will be shared between the Hospital Planning Technical Specialist and the Field ICS Medical Branch Patient Transportation Group Supervisor. The hospital external patient holding area(s) will be used by the hospitals to re-evaluate patients just prior to transfer, if needed. The field ICS Patient Transportation Group Supervisor, in consult with the Hospital Planning Technical Specialist, will direct ambulance and non-ambulance resources to the appropriate receiving hospital that has the ability to care for the patient's medical needs. REMSA Medical Dispatch will notify the receiving hospital's contact person that the patient is en route, the ETA, and type of patient. Identifying patient information such as names will be transmitted via landline (due to HIPAA issues) if time allows. Because of the limited ambulance resources that may be available, there will not be room for family members to be transported with the patient; unless there are child supervision issues involved (all pediatric patients will be accompanied by a staff nurse or a parent). Additional transport vehicles may be required to move non-acute patients to other receiving hospitals. For the most part, these additional vehicles will be from the Regional Transportation Commission, Washoe County School District, Citilift buses, or other resources provided by non-ambulance providers. These authorized transportation services are specified in the County EOC resource list. Staging of these non-ambulance vehicles will be in close proximity to the ambulance staging area(s). The Field ICS Staging Officer will make contact with Page 13 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 supervisory personnel of the non-ambulance provider to receive help in dispatching those vehicles to the evacuating hospital staging area(s). In addition the Field ICS Staging Officer may work with the Field ICS Medical Communications Coordinator to place an Amateur Ham Radio Operator (ARES) on each vehicle to insure communications during transport (see Communications Plan Section 7). 6.3 Out of State (California) Hospitals • Should Barton Memorial Hospital need to evacuate their facility, they will contact the California Tahoe Emergency Services Operations Authority (City of South Lake Fire Department and Lake Valley Fire Protection District) via South Lake Tahoe 911 Dispatch. The California Tahoe Emergency Services Operations Authority will be responsible for the transportation of patients from Barton Memorial Hospital to facilities in Nevada. Decision as to where patients will be transported will be coordinated through California Tahoe Emergency Services Operations Authority and REMSA. In the event there are not sufficient ambulances to transport patients, additional ambulances can be requested through the Lake Tahoe Regional Fire Chief's mutual aid plan by the South Tahoe Joint Powers Authority. The Barton Memorial Hospital representative working with the South Tahoe Joint Powers Authority will be responsible for ensuring that REMSA is contacted for the patient placement efforts. • Should Tahoe Forest Hospital need to evacuate their facility, they will contact Truckee Fire via the Grass Valley 911 Dispatch. Truckee Fire will be responsible for the coordination of transportation of patients from Tahoe Forest Hospital to facilities in Nevada. The TFH Agency Representative will work through/with REMSA dispatch to identify hospital bed availability and patient destinations in Nevada. Decisions as to where patients will be transported will be coordinated through REMSA and the TFH Agency Representative. Truckee Fire, through Grass Valley Dispatch, will use the mutual aid system to ensure that a sufficient number of ambulances are notified and responding to transport patients in the timeliest manner possible. 7.0 COMMUNICATIONS 7.1 Required Notifications Certain notifications will be required for Level 1 (Immediate) or Level 2 (Urgent) evacuations • 911: The hospital will contact and report either a Level 1 (Immediate) or Level 2 (Urgent) Hospital Evacuation. • The 911 Public Safety Answering Point (PSAP) will transfer the hospital caller to REMSA Medical Dispatch so that REMSA can activate an MCI. The PSAP will notify the Fire Department and appropriate mutual aid agencies per its protocols. The MCI notifications by REMSA Medical Dispatch include the District Health Officer's designee and the Washoe County Emergency Manager. Page 14 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 • REMSA Medical Dispatch shall notify appropriate healthcare facilities of the disaster incident. The individual in the receiving healthcare facility or hospital shall take note of the information given, and shall acknowledge as directed. REMSA Medical Dispatch will request that each receiving hospital provide a name and contact number for the person in the receiving hospital who will be receiving in bound patient information as patients are transported to its facility 7.2 Patient/Resident Transfer Communications Ambulances involved in the transportation of patients from the evacuating hospital to receiving hospitals shall communicate on Medical Channel frequencies assigned by the field IC or by other communications frequencies (e.g. ARES/RACES) as may be feasible. The hospitals and REMSA have 800 MHz radios to augment back-up communications between the hospitals, REMSA and the Washoe County Health District should landlines and cell phones fail. A Health District 800 MHz talk group has been programmed onto the radios for this purpose. Communications regarding identifying patient information should be made via landline due to HIPAA issues. Other modes of transportation being utilized for the transfer of patients to receiving hospitals, or other designated areas or facilities, may not be equipped with Med Channel Radios. Prior to departure, appropriate scene personnel will notify receiving hospitals through REMSA Medical Dispatch of the ETA of units transporting patients. ARES/RACES operators or others with portable communications devices may be used as an alternate means of communications for vehicles not having radio communications with REMSA Medical Dispatch. 7.3 Administrative Hospital-To-Hospital Communications Communications between hospitals shall be by regular telephone or cellular telephone whenever possible. Appendix F lists telephone numbers for a variety of departments in each hospital, including the designated telephone numbers for hospital command posts (if assigned). Such communications should be limited during the incident as to avoid lines being tied up. Calls between hospitals may be patient information related, requests for supplies, equipment or manpower, etc. As hospital Command Centers activate, specific phone numbers for the various hospital ICS positions may be assigned by each Hospital Command Center. 7.4 Additional Required Notifications by Evacuating and Receiving Hospitals • The Washoe County Emergency Manager will be responsible for notifying the Emergency Manager for the appropriate jurisdiction. Emergency managers may activate the resources of the Amateur Radio Emergency Services (ARES) or Radio Amateur Civil Emergency Services (RACES), which may be used to augment communications at the incident scene, communications with non-emergency transport vehicles, the receiving hospitals, and the evacuating hospital's internal staging area or external holding area. • State of Nevada Bureau of Health Facilities, Licensure and Certification if the facility needs to exceed its licensed bed numbers Page 15 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 • Family and Physicians of evacuated patients – it is the responsibility of the evacuating hospital to notify family and physicians of the evacuated patients of the movement of these individuals to the receiving hospital (as time allows). 7.5 Regional Call Center In the event of overwhelming calls for information regarding the location of evacuated patients that exceed the evacuating facility ability to answer, or if the evacuating hospital is unable to make the necessary contacts due to the urgency of the situation, the REOC can set up a regional call center to assist with the dissemination of information. The call center would operate under HIPAA guidelines as they relate to patient information. 7.6 Facsimile (Fax) Systems Facsimile numbers are listed for each hospital in the Communication Annex. These systems may be utilized to transmit written information such as patient records, hospital maps, or other forms of documentation. The fax number for the REOC is also listed for transmittal of Patient Tracking Forms. 7.7 Telephone Contacts The Appendix F shows the telephone numbers for critical areas in each hospital such as the Emergency Departments, Admitting, Security, Main Switchboards and lines dedicated to the Hospital Command Center. 7.8 Two-Way Radio Systems In the event of land line and cell phone failures, the 800 MHz radios and the med channel radios base radios at most of the facilities, offer a redundant communication method during an emergency. These radios allow hospitals, REMSA and the Health District to communicate on the 800 MHz talk group dedicated for such purposes by the Washoe County Health District. 7.9 Alternate Communications Washoe County, City of Reno, City of Sparks, Airport Authority of Washoe County, Washoe County Sheriff's Office, City of Reno Police and Fire Departments, City of Sparks Police and Fire Departments, and each jurisdiction's Emergency Management may be called upon to provide additional communications resources, command posts, and to activate amateur (ARES) radio resources. Contact Information for all facilities and agency is located in Appendix E (Contact Information) and Appendix F (Hospital Phone Numbers). Page 16 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 8.0 LIMITED LIABILITY AND DISASTER DECLARATION PROCESS All hospitals participating in the Mutual Aid Evacuation Annex are advised to consult private legal counsel to evaluate their hospital's potential exposure to liability. While the event of a facility evacuation represents a potential deviation from care, hospital personnel are held to the same standard of care in an evacuation as in any other activity of patient care. It is recognized that the evacuation process may entail unavoidable interruption of some aspect of patient care (ex. giving medication on schedule) that are beyond the control of the hospital staff. The expectation is that hospital personnel will use such reasonably prudent practices as any professional person in their place might be expected to use. The Hospital Incident Commander of the evacuating hospital should already be in contact with the Field Incident Commander when a hospital evacuation decision is made. Once the decision to evacuate has been made, the Incident Commander from the Authority Having Jurisdiction shall initiate the jurisdiction's process for a Disaster Declaration. It is the Incident Commander's responsibility to include this strategy in the Incident Action Plan in a timely fashion. 9.0 COLLATERAL CONSIDERATIONS 9.1 Skilled Nursing Facilities A Skilled Nursing Facility (SNF) may be contracted by an evacuating hospital as part of their internal controlled discharge plan or policy. The SNF (if not compromised by the qualified disaster) may potentially be put on notice by both the evacuating hospital and a receiving hospital (as part of each hospital's internal controlled discharge policy). The contracted SNFs and non-contract SNFs who are contacted may receive patients of appropriate acuity from evacuating and/or receiving hospitals. If an alternate facility such as a SNF is included in the receiving process, it is expected that the SNF will understand and be familiar with the MAEA and that they are able to meet the same expectations outlined in the Annex as the receiving facility. 9.2 Public Information All media releases distributed by the evacuating hospital will be coordinated through Unified Command. (It is suggested that the first message should instruct the public not to come to the scene, but inform them that information will be made available.) A joint information Center (JIC) may be developed as part of the Unified Command structure. . Page 17 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 9.3 Admitting and Billing • Patients will be discharged from the evacuating hospital and admitted to the receiving hospital. • Patients sent by the evacuating hospital will maintain the current attending physician whenever possible. If the current physician does not have privileges at the receiving hospital, the receiving hospital will initiate their emergency credentialing process. • The evacuating hospital will be responsible for patient billing for the portion of the patient's stay at the evacuating hospital and will be billed in compliance with State and Federal reimbursement guidelines for transferred patients. • The receiving hospital will be responsible for patient billing for the portion of the patient's stay at the receiving hospital and will be billed in compliance with State and Federal reimbursement guidelines for transferred patients. • Receiving hospital will admit all patients transferred from the evacuating hospital and be responsible for the patient billing of the patient's stay at the receiving hospital and will be billed in compliance with State and Federal reimbursement guidelines for transferred patients 9.4 Use of Evacuating Hospital Staff • The evacuating hospital will bill the receiving hospital for all staff supplied to the receiving hospital at the actual employee payroll costs plus an additional 35% to cover the cost of fringe benefits. Any supply items forwarded to the receiving hospital from the evacuating hospital will be billed by the evacuating hospital at the actual cost. Equipment transferred to the receiving hospital by the evacuating hospital will be billed to the receiving hospital at the current fair market rental value for such equipment. • Evacuating hospital will be responsible for supplying the receiving hospital a schedule that includes all the employees sent to assist the receiving hospital, including available information regarding appropriate professional licensure. . • Receiving hospital will be responsible for the validation of all professional licensure information for all employees transferred from the evacuating hospital to the receiving hospital in a timely fashion. 9.5 Out of State Staff and Physicians • In order to allow staff from another state to practice in Nevada, it would require that the Governor has to declare a state of emergency before the nurses or physicians from other states could provide assistance/be recognized as licensed. 9.6 Medical Records • If time and evacuation conditions permit, pertinent medical records and information will accompany each patient to the receiving hospital. At a minimum, the Medication Administration Record will accompany the patient when transferred. Page 18 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 • Upon transfer back to the original hospital, a copy of pertinent medical record information will accompany each patient or be made available to the attending physician. 9.7 Biomedical Equipment • Only such equipment as is medically necessary to accompany the patient during transfer will be sent with the patient. Biomedical Equipment distributed from the evacuating hospital will be initially accepted by all receiving hospitals. • All equipment sent with patient will be documented on the Patient Tracking Form. • The receiving hospital may catalogue and carry out safety checks of the equipment as time and patient condition permits. • Equipment will be returned to the evacuating hospital upon return of the patient, unless arrangements have been made otherwise. 9.8 Pharmaceuticals • Only those medications that are medically necessary will be transported with the patient. . • Prescribed pharmaceutical products that arrive with the patient will be subject to review by the receiving hospital's pharmacy. • Any additional medications that the evacuating or receiving facility may need will be requested through the resource request process of Incident Command of the EOC and hospital liaison. 10.0 ANNEX DEVELOPMENT AND MAINTENANCE Each hospital is responsible for maintaining accuracy of the information regarding its medical facility. Since this is an annex to the Washoe County District Board of Health Multi-Casualty Incident Plan, the Health District will coordinate a periodic meeting for updates. Washoe County Health District will be responsible for annually updating the Annex to ensure the most current information. The updates should include: • Evacuating dispersal and receiving hospital acceptance numbers. • Phone numbers of Annex members, contact persons and external holding areas. • Hospital communication information. Page 19 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 APPENDIX A - DEFINITIONS Alternate Care Facility A predetermined, designated location within a healthcare's system or vicinity that patients can be safely relocated to in a disaster to allow them to remain within the existing healthcare system. Authority Having Jurisdiction (AHJ) The government agency responsible for public safety or code enforcement within any given geographical area. Care Capacity The number of beds for which the hospital is able to staff to provide care. Declared Disaster Executive order from the authority having jurisdiction (i.e. governor or president) declaring a state of emergency which activates disaster response and recovery aspects of the state, local, interjurisdictional or federal emergency plans. Emergency Operations Center (EOC) A secured site where public officials exercise support, direction and control of an emergency in concert with public and private agencies. Environment of Care A term used to describe the building, equipment and people that provide services that allows patient care to take place. External Holding Area A sheltered location close to the evacuating hospital where patients can be temporarily held for safety purposes and during which an assessment of the hospital may take place. From there, the patients are either returned to the original hospital, or dispersed to other members. External holding areas are primarily used during an immediate evacuation. Page 20 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 Field Command Post The designated location where primary command functions are executed. Field Incident Commander (IC) The person from the Authority Having Jurisdiction who responds to the emergency and who is responsible for all decisions relating to the incident and management of incident operations (i.e. fire or law enforcement). HICS An Incident Command System designed specifically for use in the medical environment. Hospital Command Center A location where primary hospital emergency response functions are carried out to manage a healthcare disaster or emergency. Hospital IC The hospital Incident Commander leading a healthcare's disaster response efforts. Incident Command System (ICS) An operational command and control organizational system to manage resources based on the principle functions performed in any disaster. These are: Command, Operations, Finance, Logistics, and Planning. Internal Staging Areas Pre-designated areas within a hospital where patients are collected prior to being transported outside of the facility. Hospitals may designate staging areas for various types of patients, i.e. ambulatory, non-ambulatory, etc. Multi-Casualty Incident Plan (MCIP) Guidelines maintained by the Washoe County Health District for the Reno, Sparks, and Washoe County area to effectively, efficiently and safely organize multi-casualty incidents utilizing ICS as the management tool. Page 21 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 Patient Overflow Area An alternative care location identified by each hospital where basic patient care can take place. Such locations may be auditoriums, cafeterias, hallways, or lobbies, and are used by receiving hospitals when it needs to surge its capacity to receive evacuated patients. Political subdivision Under Nevada Revised Statutes 414.038, political subdivision means a city or a county. Skilled Nursing Facility (SNF) A facility that provides sub-acute nursing and/or rehabilitation services. Critical Care Unit A generalized term to include Intensive Care, Cardiac Care, Cardiac Surgery, Pediatric Intensive Care, Neonatal Intensive Care Units, patients undergoing surgical procedures, and patients that are in Post Anesthesia Recovery (PACU). Unified Command A method for all agencies who have jurisdictional or functional responsibility to contribute to incident planning and strategies. Page 22 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 APPENDIX B - OPERATIONAL CONCEPTS 1.1 Incident Command System—Linkage to Hospital ICS System The Washoe County District Health Board and the annex participating facilities follow the principles of the Incident Command System (ICS). Healthcare facilities also use the Hospital Incident Command System (HICS), an internal ICS management model developed to address hospital management functions The chart below shows the relationship of the major Field ICS and hospital staffed ICS positions. The hospital position that need to be filled in the field ICS System is the Hospital Planning Technical Specialist. The hospital position that needs to be filled in the EOC is the Hospital Representative. Based on ICS unified command concepts, it is critical that the evacuating facility, through its hospital representatives, participate in unified command in the field command post. Linkage of Hospital ICS Positions and Field ICS / Multi-Casualty Branch Positions HOSPITAL AGENCY FIELD INCIDENT REPRESENTATIVE IN COMMANDER UNIFIED COMMAND** FIELD FIELD OPERATIONS PLANNING CHIEF CHIEF FIELD MEDICAL BRANCH DIRECTOR FIELD MEDICAL HOSPITAL FIELD PATIENT GROUP PLANNING TRANSPORTATION SUPERVISOR TECHNICAL GROUP SUPERVISOR SPECIALIST** FIELD MEDICAL COMMUNICATIONS COORDINATOR FIELD ICS Organization Lines of Authority POSITON NOTE: ** STARRED POSITIONS ARE THOSE HOSPITAL REPRESENTATIVES TO BE POSITION FILLED PRESENT IN THE FIELD BY HOSPITAL INCIDENT COMMAND REPRESENTATIVE STRUCTURE AS THE MOST CRITICAL LINKS Page 23 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 APPENDIX C - Evacuation Algorithm Evacuation Decided. Hospital Calls 911Hospital Calls 911L 911 notifies fire and transfers call to REMSA REMSA notifies Washoe dispatch to activate MCI plan County Emergency Manager, District Health Officer and hospitals of Hospital evacuation Field Incident Command set up at hospital. Field determines Patient Transportation Supervisor (PTGS) and patient numbers, Hospital Planning Technical Specialist (HPTS) meet to CAT determines if equipment needs coordinate patient transport REOC is to be opened. and recommends type of transport Hospital representative is assigned to REOC Level I –Immediate Hospital will prioritize moving as many patients Level 2 - Urgent out of the facility as possible. Least critical Hospital moves non critical patients to external patients will be evacuated first. Staff begins holding areas (if needed) and evacuates critical filling out Patient Tracking Forms patients first. Hospital staff begins filling out Patient Tracking forms PTGS and HPTS coordinate patient transportation needs based on typing of patients and determine what equipment will go with patients Transports are sent based on typing determined. REMSA notifies Patient tracking forms are filled out by transport receiving hospitals personnel and sent with patients of type and number of patients being transported Receiving hospital accepts patients at designated receiving areas and completes Patient Tracking Receiving hospital faxes Form copy of patient tracking form to hospital When time allows receiving hospital will ensure representative at REOC return of patient tracking form to evacuating Page 24 hospital Revisions Approved by DBOH 02/23/12, Effective 07/01/12 APPENDIX D - Initial Patient Evacuation Overview (after census reduction) Type of patient that Renown Incline VA Northern St Mary's Reg Renown Renown So. Barton Tahoe Carson Carson can be accepted: Regional Village Medical Nevada Med Ctr & Rehab Meadows & Memorial Forest Valley Tahoe Med Ctr Comm. Center (B) Medical Tahoe Pacific Hospital Tahoe Pacific Hospital Hospital Medical Regional Hospital Center West So. Meadows Center Medical Center ICU (Med/Surg) 27 0 8 6 0 / 4 0 4 / 3 4 2 2 10 Cardiac Care Unit 23 0 0 0 16 / 1 0 0 / 2 0 0 0 2 Cardiac Surgery 6 0 0 0 2 / 0 0 0 / 0 0 0 0 0 Telemetry/SD/Cardiac 52 0 0 0 16 / 1 0 0 / 0 0 0 0 0 Critical Care Subtotal 108 0 8 6 34 / 6 0 4 / 5 4 2 2 12 Telemetry/SD/Med-Surg 35 0 2 10 0 / 4 0 0 / 5 8 1 2 23 Surgical 90 2 8 10 31 / 2 0 11 / 0 12 2 1 27 (Ortho/Neuro/GSU) Oncology 18 0 0 0 15 / 0 0 0 / 0 0 0 0 6 Medical/General 31 2 17 15 30 / 3 0 11 / 4 16 3 7 38 Med-Surg/Tele 174 4 27 35 76 / 16 0 22 / 9 36 6 10 94 Subtotal IC Nursery 24 0 0 0 13 / 0 0 0 / 0 0 0 0 0 Page 25 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 APPENDIX D - Initial Patient Evacuation Overview (after census reduction) Pediatric ICU 7 0 0 0 0 / 0 0 0 / 0 0 0 0 0 Pediatrics 18 0 0 0 3 / 0 0 0 / 0 4 1 0 3 Laboring/Antepartum 20 0 0 0 5/ 0 0 0 / 0 4 1 0 3 Postpartum 17 0 0 0 11 / 0 0 0 / 0 4 0 0 3 MCH Subtotal 86 0 0 0 32 / 0 0 0 / 0 12 2 0 9 Surgery (Intra-Op) 15 1 3 4 10 / 0 0 1 / 0 4 1 1 0 PACU & Preop 15 1 3 3 10 / 0 0 2 / 0 4 1 0 6 Day Surgery 20 1 0 0 10 / 0 0 8 / 0 2 1 0 4 Peri Operative 50 3 6 7 30 / 0 0 11 / 0 10 3 1 10 Subtotal Psych (c) 0 0 8 14 0 / 0 0 0 / 0 0 0 0 30 Skilled/Rehab 0 0 52 6 0 / 0 20 32 / 0 40 25 0 2 Other Subtotal 0 0 60 20 0/ 0 0 32 / 0 40 25 0 32 TOTAL (A) 418 7 101 68 172/ 13 20 69 / 14 102 38 13 157 Emergency 20 1 3 2 8 / 0 0 3 / 0 6 3 5 0 (a) Skilled/Rehab includes Long Term Care and Assisted Living (b) Tahoe Pacific West is located inside St. Mary's and Tahoe Pacific South Meadows is inside Renown South Meadows Medical Center Page 26 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 APPENDIX D - Initial Patient Acceptance Overview (after census reduction) Type of patient that can be Renown Incline VA Northern Saint Mary's Renown Renown Barton Tahoe Carson Carson accepted: Regional Village Medical Nevada Reg Med Ctr Rehab So. Memorial Forest Valley Tahoe Med Ctr Comm. Center Medical & Tahoe Hospital Meadows Hospital Hospital Medical Regional Hospital Center Pacific West & Tahoe Center Medical Pacific So. Center Meadows ICU (Med/Surg) 25 0 2 4 11 / 2 0 6 / 3 2 1 2 4 Cardiac Care Unit 19 0 0 0 0 / 1 0 0 / 2 0 0 0 4 Cardiac Surgery 4 0 0 0 2 / 0 0 0 / 0 0 0 0 0 Telemetry/SD/Cardiac 12 0 0 6 14 / 1 0 15 / 1 0 0 0 0 Critical Care Subtotal 60 0 2 10 27 / 4 0 21 / 6 2 1 2 8 Telemetry/SD/Med-Surg 18 0 0 8 0/ 2 0 0 / 2 2 1 2 3 Surgical (Ortho/Neuro/GSU) 46 1 3 15 45 / 1 25 0 / 2 2 0 1 4 Oncology 10 0 0 0 7 / 0 0 0 / 0 0 0 0 2 Medical/General 22 1 2 4 22 / 2 25 15 / 2 4 3 3 6 Med-Surg/Tele Subtotal 96 2 5 27 74 / 5 50 15 / 6 8 4 6 14 IC Nursery 20 0 0 0 16 / 0 0 0 / 0 0 0 0 0 Pediatric ICU 3 0 0 0 0 / 0 0 0 / 0 0 0 0 0 Pediatrics (D) 4 0 0 0 12 / 0 0 0 / 0 2 0 0 3 Page 27 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 APPENDIX D - Initial Patient Acceptance Overview (after census reduction) Laboring/Antepartum 22 0 0 0 8 / 0 0 0 / 0 2 1 0 4 Postpartum 40 0 0 0 8 / 0 0 0 / 0 2 1 0 4 MCH Subtotal 89 0 0 0 44 / 0 0 0 / 0 6 2 0 11 Surgery (Intra-Op) 14 0 2 4 7/ 0 0 1 / 0 2 0 1 0 PACU & Preop 13 0 4 4 7 / 0 0 10 / 0 1 1 1 8 Day Surgery 10 0 0 4 10 / 0 0 0 / 0 0 1 0 2 Peri Operative Subtotal 37 0 6 12 24 / 0 0 11 / 0 3 2 2 10 Psych (C) 0 0 12 8 0 / 0 0 0 / 0 0 0 0 4 Skilled/Rehab 87 0 9 2 0/ 0 20 0 / 0 0 1 0 4 Other Subtotal 87 0 21 10 0 / 0 20 0 / 0 0 1 0 8 TOTAL (A) 369 2 34 59 169 / 9 70 47 / 12 19 10 10 51 Emergency 19 3 2 8 30 / 0 0 6 / 0 3 4 4 Page 28 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 APPENDIX E Members, Contact Persons and External Holding Areas AGENCY NAME EXTERNAL HOLDING AREA ADDRESS ADDRESS PHONE PHONE CONTACT PERSON Renown Regional Medical Center 1. Center for Advanced Medicine 1155 Mill Street 75 Pringle Street 982-4100 Reno, NV 89502 Reno, NV 89502 24 hour Emergency Contact Title: 2. Renown Rehabilitation Hospital Nursing Coordinator 1495 Mill Street 982-3500 Number: 982-3310 Reno, NV 89502 Annex Issues Contact Person: Michael Munda, Safety Officer, 982-4232, 221-1190 Renown South Meadows Medical Center 10101 Double R Blvd. Reno, NV 89521 24 hour Emergency Contact Title: Hospital Operator 982-7000 Nursing Coordinator, 982-7020 Annex Issues Contact Person: Quality Improvement Coordinator, 982-7062 Saint Mary's Regional Medical Center Saint Mary's Center for Health 235 West Sixth Street 645 N. Arlington Avenue Reno, NV 89503 Reno, NV 89503 24 Hour Emergency Contact Title: Administrator on Duty or Nursing Supervisor Number: 770-3000 Annex Issues Contact Person: Debra Barone, Director, Environment of Care and Emergency Preparedness, 232-4540 Northern Nevada Medical Center Vista Medical Building 356-9393 2375 E. Prater Way 2345 E. Prater Way Sparks, NV 89434 24 Hour Emergency Contact Title: Medical Office Building 356-9393 Administrator on Duty or Patient Care 2385 E. Prater Way Coordinator 24 Hour Number: 331-7000 Annex issues Contact Person: Director of Emergency Services 356-4917 Page 29 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 AGENCY NAME EXTERNAL HOLDING AREA ADDRESS ADDRESS PHONE PHONE CONTACT PERSON Tahoe Pacific Hospital West Saint Mary's Center for Health (Inside St. Mary's Regional Medical Center) 645 N. Arlington Ave. 235 W. Sixth Street Reno, NV 89503 Reno., Nevada 89520 24 Hour Emergency Contact Title: Charge Nurse 24 Hour Number: 770-7988 Annex Issues Contact Person: Director of Quality Management 355-5970 Tahoe Pacific Hospital South Meadows Not yet designated (inside RENOWN South Meadows) 10101 Double R. Blvd Reno, Nevada 89521 24 Hour Emergency Contact Title: Charge Nurse 24 Hour Number: 326-6148 Annex Issues Contact Person: Director of Quality Management 355-5970 Veterans Administration Veteran's Memorial School 333-5090 Sierra Nevada Health Care System 1200 Locust St 975 Kirman Avenue Reno, NV 89520 Reno, NV 89502 24 Hour Emergency Contact Title: Wooster High School 333-5100 Administrative Officer of the Day 1331 East Plumb Lane 24 Hour Number: 328-1414 Reno, NV 89502 Annex Issues Contact Person: Rob McLaughlin, Emergency Manager Cell 622-2139 Office 328-1757 Incline Village Community Hospital Incline High School 832-4260 880 Alder Street 499 Village Blvd., Incline Village Incline Village, NV 89451 24 Hour Emergency Contact Title: Incline Middle School 832-4220 Emergency Department Nurse 931 Southwood Blvd., Incline Village 24 Hour Number: 833-4100, ext. 212 Annex Issues Contact Person: Incline Elementary School 832-4205 Judy Newland, Director 771 Southwood Blvd., Incline Village 833-4100, ext. 220 IVGID Recreation Center 832-1300 980 Incline Way, Incline Village Page 30 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 AGENCY NAME EXTERNAL HOLDING AREA ADDRESS ADDRESS PHONE PHONE CONTACT PERSON Renown Rehabilitation Hospital 1495 Mill Street Reno, NV 89503 24 Hour Emergency Contact Title: Administrator on Call 24 Hour Number: 982-3500 Annex Issues Contact Person: Director of Nursing 982-3531 Barton Memorial Hospital Lake Tahoe Community College – 2170 South Avenue Gymnasium South Lake Tahoe, CA 96150 1 College Drive 24 Hour Emergency Contact Title: South Lake Tahoe, CA 96150 (530) 541-4660 Nursing Supervisor 530-543-5736 South Lake Tahoe Airport - Heated Hangar Annex Issues Contact Person: 1901 Airport Rd. South Lake Tahoe, CA 96150 (530) 542-6180 Rodney Wright 530-543-5707 Carson Tahoe Regional Medical Center 1600 Medical Parkway NV 79702-2168 24 Hour Nursing admin: 775-315-7125 Annex Issues Contact person: Henry Lucas 775-445-8023 775-291-1201 Carson Valley Medical Center Jobs Peak Internal Medicine & Family Practice 1107 Hwy 395 1516 Virginia Ranch Road, Gardnerville Gardnerville, NV 89410 775-783-3081 24 Hour Emergency Contact Title: ER Department 24 Hour Number: 782-1600 Annex Issues Contact Person: Christine O'Farrell: 775-721-6680 Director of Clinical Services/Risk Tahoe Forest Hospital System Truckee Community Arts Center 10121 Pine Ave. 10046 Church Street Truckee, CA 96161 Truckee, CA 96161 24 Hour Emergency Contact Title: Truckee Veteran's Hall AOD/House Supervisor 10214 High Street Truckee, CA 96160 Page 31 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 530-587-6011 ext. 0 (ask for AOD or supervisor) Annex Issues Contact Person: Sierra Mountain Middle School Tami Prior, House Supervisor, EMC Chair 11603 Donner Pass Rd. Truckee, CA 96161 530-582-6662 EOC FAX Number: 775-337-5894 EOC Hospital Representative Number: (775) 337-5833 HAV-BED John Flamm 775-230-9576 Washoe County District Health Primary Contact: Stacey Akurosawa (775) 328-2420 (775) 762-0934 Page 32 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 APPENDIX F - Individual Hospital Communications Information SAINT MARY'S REGIONAL MEDICAL CENTER RENOWN REGIONAL MEDICAL CENTER ACCESS: PHONE/FAX PHONE FAX ACCESS: PHONE/FAX PHONE FAX Switchboard/PBX 775-770-3000 N/A Switchboard/PBX 775-982-4100 Nursing Administration 775-770-3012 775-770-3671 Nursing Administration 775-982-4629 775-982-4628 Security Department 775-770-3135 775-324-7809 Security Department 775-982-7998 775-982-6660 Safety Department 775-770-6220 775-324-3680 Safety Department 775-982-4173 775-982-4337 Admitting 775-770-6559 775-770-6171 Admitting 775-982-4140 775-982-2185 Emergency Department 775-770-3188 775-770-3490 Emergency Department 775-982-4144 775-722-5555 Operations Center 775-770-3761 775-770-3737 Operations Center 775-982-6891 775-982-6890 INCLINE VILLAGE COMMUNITY HOSPITAL RENOWN REHAB HOSPITAL ACCESS: PHONE/FAX PHONE FAX ACCESS: PHONE/FAX PHONE FAX Switchboard/PBX 775-833-4100 or Switchboard/PBX 775-982-3500 775-722-3665 832-3810 and 3530 775-831-2790 Nursing Administration 775-833-4100 Ext 214 775-832-3800 Nursing Administration 775-982-3512 775-329-3667 Page 33 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 Security Department 775-833-4100 Security Department 775-982-7998 775-982-6660 Safety Department 775-833-4100 Safety Department 775-982-4173 Admitting 775-833-4100 Ext 213 775-831-2790 Admitting 775-982-3510 Emergency Department 775-833-4100 Ext. 775-831-2790 Emergency Department N/A 212 Operations Center 775-833-4100 Operations Center 775-982-3505 775-348-4696 VA MEDICAL CENTER RENOWN SOUTH MEADOWS ACCESS: PHONE/FAX PHONE FAX ACCESS: PHONE/FAX PHONE FAX Switchboard/PBX 775-786-7200 Switchboard/PBX 775-982-7000 775-982-7072 After hrs: 328-1247 Nursing Administration 775-328-1497 775-334-4163 Nursing Administration 775-982-7020 775-982-7027 Security Department 775-328-1234 Security Department 775-982-7362 775-982-7079 Safety Department 775-328-1472 Safety Department 775-982-7362 775-982-7079 Admitting 775-328-1294 Admitting 775-982-7300 775-982-7340 Emergency Department 775-328-1297 775-328-1783 Emergency Department 775-982-7144 775-982-7146 Operations Center 775-328-1450 775-328-1447 Operations Center 775-982-7010 775-982-7072 Page 34 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 TAHOE PACIFIC WEST TAHOE PACIFIC SOUTH MEADOWS ACCESS: PHONE/FAX PHONE FAX ACCESS: PHONE/FAX PHONE FAX Switchboard/PBX 775-770-7988 775-770-7976 Switchboard/PBX 775-326-6148 775-326-6185 Nursing Administration Nursing Administration Security Department Security Department Safety Department Safety Department Admitting Admitting Operations Center N/A N/A Operations Center N/A N/A NORTHERN NEVADA MEDICAL CENTER ACCESS: PHONE/FAX PHONE FAX Switchboard/PBX 775-331-7000 Nursing Administration 775-356-4008 775-356-4932 Security Department 775-745-8891 775-356-4527 Safety Department 775-352-5383 775-356-4885 Admitting 775-356-4961 775-331-3399 Emergency Department 775-356-4040 775-356-4943 Operations Center 775-356-5322 775-356-4986 Page 35 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 Carson Valley Medical Center Carson Tahoe Regional Medical Center ACCESS: PHONE/FAX PHONE FAX ACCESS: PHONE/FAX PHONE FAX Switchboard/PBX 775-782-1500 Switchboard/PBX 775-445-8000 Nursing Administration 775-783-4817 775-782-1602 Nursing Administration 775-315-7125 Security/Safety Pagers 775-580-1785 or 775-782-1561 Security Department 775-291-1203 775-782-1829 Emergency Department 775-782-1600 775-782-1633 Safety Department 775-291-1201 Admitting 775-782-1880 775-782-1504 Admitting 775-445-8727 Operations Center 775-783-4853 Emergency Department 775-445-8733 Tahoe Forest Hospital System Barton Memorial Hospital ACCESS: PHONE/FAX PHONE FAX ACCESS: PHONE/FAX PHONE FAX Switchboard/PBX 530-587-6011 530-582-3271 Switchboard/PBX 530-541-3420 Nursing Administration 530-587-3541 530-582-6644 Nursing Administration 530-543-5829 530-543-5513 Security n/a n/a Security Department 530-543-5521 530-544-0651 Safety n/a n/a Safety Department 530-543-5707 530-541-8683 Admitting 530-587-6011 530-582-3271 Admitting 530-543-5127 530-541-0554 Emergency Department 530-582-3208 530-582-3201 Emergency Department 530-543-5890 530-541-6374 Operations Center 530-582-6213 Operations Center4 530-543-5244 530-543-5840 Page 36 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 APPENDIX G - Hospital Evacuation Mileage Chart Washoe County Hospitals St Mary's Renown So. Regional & Meadows & Incline No. NV Tahoe Pacific VA Medical Renown Renown Tahoe Carson Tahoe Barton Hospitals Village Hospital W. Ctr Med Main Rehab Pacific So. Tahoe Forest Memorial Incline Village 0 39.6 36.8 34.3 34 34.1 26.7 27.6 19.7 29.7 Other Regional Hospitals No. Nevada Med Center 39.6 0 7.1 7.1 7.4 6.7 13.2 33.2 38.9 66.3 Saint Mary's Regional & Tahoe Pacific W. 36.8 7.1 0 2 1.9 2.1 10.2 30.2 32.4 62.8 VA Medical Center 34.3 7.1 2 0 1.2 1 7.6 27.6 34.5 60.6 Renown Regional Med Main 34 7.4 1.9 1.2 0 0.5 7.8 27.8 34.3 60.6 Renown Rehab 34.1 6.7 2.1 1 0.5 0 7.3 27.4 34.4 60.2 Renown So. Meadows & Tahoe Pacific So. 26.7 13.2 10.2 7.6 7.8 7.3 0 20.2 42 52.9 Page 37 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 HOSPITAL EVACUATION PLANNING WORKSHEET Date:______ Time:______ Hospital Transportation Unit Leader:____________________ Category of Hospital Evacuation _____ Immediate _____ Urgent Patient Category Number of Estimated Estimate of Patients Caregiver/ Caregivers Patient Ratio Needed en Route* Needed En Route Type #1 Special Equipment/Staff Required (Ventilators, etc.) Type #2 Bed, Gurney (Non-ambulatory) Type #3 Wheelchair Type #4 Ambulatory Totals Prepared by: _______________________________________________ Instructions: after the Hospital ICS Transportation Unit Leader summarizes the data received from each hospital unit, he/she will complete this summary form and give it to the Planning Technical Specialist assigned by the hospital to work with the field ICS Patient Transportation Group Supervisor Page 38 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 FIELD EVACUATION TRANSPORTATION WORKSHEET Date: __________ Time: ___________ Patient Transportation Group Supervisor:_______________________________ Transport Requirements Patient Type Number Critical Care BUS/ of Ground/Air Patients ALS BLS OTHER (CC G/A) Type #1 Special Equipment/Staff Required (Ventilators, etc.) Type #2 Bed, Gurney (Non- ambulatory) Type #3 Wheelchair Type #4 Ambulatory Units by Type # of Pts # of Units Total CC G/A Units Needed Total ALS Units Needed (1-2 per unit) Total BLS Units Needed (2 per unit) Total Bus/Other Units Needed (# Varies; Avg. 25) This form is completed based on the information provided by the Hospital Planning Technical Specialist (see "Hospital Evacuation Planning Worksheet") who is assigned to work with the Field Patient Transportation Group Supervisor Page 39 Revisions Approved by DBOH 02/23/12, Effective 07/01/12 Page 40
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UJ hires coach with 244 wins, four conference titles to his credit
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Mongoct, others....will this plumbing work?
What I want: Tub, showerhead and handshower system , which allows showerhead and handshower to be used either separately or together.
I've read the primer posts by Mongoct and as much else as I can find and have, I think, come correctly to the conclusion that what I need is either a thermostatic valve and three separate volume controls for the three outlets OR a pressure-balance valve and separate diverter with the correct number of ports.
What I am specifically now wondering about (IF my understanding is correct) is this: Can I get what I need by combining a tub/shower system with an pressure balance valve with integrated diverter (since I don't like tub spout diverters) and a four-port ( 1 in, 3 out) diverter? I'm assuming that this would work by sending water from PB valve to either tub or showers. If to the showers, the flow would go through a separate diverter, allowing either overhead alone, hand shower alone or hand shower and overhead together.
Logically, this makes sense to me...but, of course, I have no idea how any plumbing REALLY works and whether in real life that's a practical solution.
On a separate note, I'm seriously looking at Symmons faucets/valves...they seem to be well-made, long-lasting, well priced and reasonably attractive, if not sexy. The lovely all-brass Rohl stuff I had in a previous home is too costy for this project, and as near as I can tell, the Symmons are at least as well made as Grohe, Kohler, etc. Anyone know differently?
I took a quick look at the Symmons catalog, there were two systems that I found right away within the Temptrol line.
The Water Dance system can do what you want. 1-7520-X for chrome. The literature states that the diverter can feed both shower heads at the same time.
Less expensive setup is S-96-600-B30-L-V, like the Water Dance system is has all of the components that you want, but I'm not sure if the diverter can supply both shower heads at the same time.
If you wanted to piece it all out there are ways to do that too; buying a supply valve, buying a diverter, and then sourcing your heads and tub spout separately.
You could also go with two separate Symmons Temptrol pressure-balance supply valves. One valve with an integral diverter for one of the shower heads and the tub. A second valve with no diverter for the second shower head. The advantage of that is with two valves you could have different water temps out of the two heads. Each valve is only about $100 with trim kit included.
So there are different ways to accomplish it.
A call to Symmons help line might offer other ideas.
Good luck!


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After a gunman killed three people in a Swiss village, experts are examining how and why it happened. Although guns are almost as widespread as in the United States, shooting sprees in Switzerland are rare.
Gun ownership and recreational shooting are widespread in Switzerland. According to estimates - there are no official figures - at least one in every three of its less than eight million inhabitants holds a gun. In fact, after the US and Yemen, Switzerland ranks third on the list of most guns per person.
Willy Pfund, president of the Swiss weapons lobby ProTell, defended the high proportion of weapons in the small, heavily armed nation. "One must be prepared," he said. If enemies were to invade Switzerland, he explained, people would have to own weapons and know how to use them in order to defend themselves.
Pfund also emphasized that armed Swiss citizens have the duty to use their weapons responsibly. And they do, Pfund told Deutsche Welle - gun attacks are few and far between.
"Over the past 30 years, there have been between 45 and 55 homicides per year involving firearms, the figures have not changed much," Pfund said. "An element of risk always remains, no law can eliminate that."
Easy access
A mass shooting in the regional parliament in the canton of Zug in 2001 triggered a debate over gun control in Switzerland. Voters 10 years later rejected a proposal to tighten the country's liberal firearm laws in a referendum.
The Alpine country does not have a standing army; rather, a people's militia that can be mobilized quickly to defend Swiss neutrality. Service weapons are traditionally stored at home.
US weapons laws are much more liberal, Pfund pointed out, saying that contrary to common practice in several US states, Swiss are not allowed to carry loaded weapons in public places.
"Americans own weapons - but it is not enough to own them," Pfund argued. "You have to store a weapon responsibly, use it responsibly, and if there is reason to believe you cannot do that, the weapon must be taken away," Pfund said - words to heed in light of the tragic Newtown shooting in Connecticut.
The root of the problem
Although weapons are widespread in both the US and Switzerland, crime rates in the two countries differ greatly - due, some experts say, not to differing weapons laws, but rather mentality and culture.
Christian Pfeiffer, head of the Hannover-based Criminological Research Institute of Lower Saxony, said that what matters more "is a person's upbringing, not whether weapons are available."
"A childhood in Switzerland is relatively free of violence; Swiss children grow up knowing tolerance and trust," he told Deutsche Welle. "Accepted practices of upbringing in the US are quite different."
Many point to the high level of violence in American television and film, not to mention violent video games played by children starting at a young age.
Affecting change
Pfeiffer cited the example of corporal punishment, quoting a Human Rights Watch study reporting that in 2009, more than 200,000 American school students, mostly in southern states, were paddled by their teachers. Pfeiffer says the root of the problem is that parents throughout the country have a right to practice corporal punishment.
Pfeiffer urged Americans to focus on "analyzing the underlying causes: why are such violent rampages so much more frequent there than in Europe, and why do they think that owning weapons and dealing out severe punishments are the only ways of combating evil?"
He even indicated capital punishment is an extreme example of the effects of violence against children.
The former state justice minister is convinced that a total ban on the rights of teachers and parents to beat their children would be a good solution.
Banning the possession of assault rifles by private individuals is necessary, Pfeiffer added. "But the greatest chances of success in the long run come from mental disarmament."
Following the Newtown massacre that left 27 dead, including 20 children, the NRA, the American gun lobby, has called for schools to be protected by armed security guards. Christina Bergmann comments. (22.12.2012)
How many weapons are in private possession in Germany? The question has emerged again after the shooting spree in Newtown, CT. A central registry aims to minimize the danger of similar incidents in the future in Germany. (18.12.2012)
In a desperate attempt to make sense of the Germanwings plane crash, many people are focusing on the co-pilot's mental health. But drawing conclusions between depression and violence is misleading and simply wrong.
Investigators have found drugs used in the treatment of psychological problems at the house of the Germanwings co-pilot. The findings were reported by German weekly Welt am Sonntag.
The former Romanian finance minister has been questioned over 101 paintings in his possession amid a corruption probe. They include three works signed by Spanish artist Pablo Picasso.
Italian investigators have found Pablo Picasso's missing 1912 "Violin and Bottle of Bass" oil painting. The authenticated work was given to a retired frame maker in Rome nearly 40 years ago and then forgotten about.


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Fusulinella, genus of extinct fusulinid foraminiferans (protozoans with a shell) found as fossils in Late Carboniferous marine rocks (those formed between 320 and 286 million years ago). Because of its narrow time range and wide geographic distribution, Fusulinella is an excellent guide fossil for Late Carboniferous rocks and time.
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Community Status Updates
Tom Foster
Finally weekend and the start of a week long break from school :)Mar 13 2015 11:18 PM
Ailime WrightSo jealous! :(
Mar 16 2015 10:55 PM
Tom FosterDon't feel too jealous lol, have had almost a whole week of blizzards, there probably wouldn't have been school anyway.
Mar 21 2015 02:31 AM
Prof. Hailey Potter
Like to color? Or maybe you want some easy beans? Go check out Spice's monthly contest in Spice Jar!Mar 05 2015 02:58 AM
Kim Alting
NEW NEW NEW monthly activity in Spice Jar! For beans ofcourse. Come and participate, it's fun!Mar 01 2015 02:21 PM
Prof. Jenny Lupin
Den Challenge update slightly delayed, waiting for one submission still. *pokes* I have time tomorrow so I will update ASAP! :)Feb 28 2015 03:44 AM
Prof. Jenny LupinTHANKS ZEE!!
Feb 28 2015 11:10 PM
Kim AltingSorry Jenny... Zenix and I are the only ones participating. :(
Mar 01 2015 02:21 PM
Prof. Jenny LupinI know, I'm sorry there aren't more people helping. :( But you two have done amazing! :)
Mar 03 2015 12:44 AM
Prof. Hailey Potter
So.... Hailey got her snow. I see now why y'all were complaining about it. LOL.Feb 20 2015 12:25 AM
Prof. Hailey PotterWellll.... you see, we got half ice and half snow so you couldn't really make a snowman. I pried two inches of ice off my car.
Feb 21 2015 07:26 PM
Kim AltingLol. That's the worst kind!
Feb 21 2015 08:43 PM
Tom Fosterlol, we got 85+ centimeters of snow last week and we're only just starting to get around.
Feb 24 2015 11:50 PM
Prof. Hailey Potter
Stop talking about snow, I want some but Tennessee lives under a dome and never gets any... :'(Feb 06 2015 12:32 AM
Natasha WynterborneSame with this area, Hailey. It's depressing. I mean, a person can only watch Frozen so many times.
Feb 07 2015 11:04 PM
Alessandra Gracesame here! It's too cold even for the snow, but when it snows we're trapped...
Feb 09 2015 08:46 PM
Prof. Zenix JamesI want snow, too. We're due for it sometime this month, hopefully
Feb 10 2015 01:22 AM
Tom Foster
snow, snow, and more snow. so far, we've had a storm last Saturday then on Tuesday they were calling for 30-35 cm and we got about 65. and another storm today. even though school was closed Tuesday and now today, bring on spring.Feb 05 2015 10:33 AM
Prof. Dario Šehović
Everyone, go check out February Den Challenge in the Den forum category! :DFeb 04 2015 01:33 AM
Ailime WrightBeans, beans, beans :D
Feb 04 2015 09:53 PM
Kim AltingYay, Yay, Yay :P
Feb 06 2015 10:56 AM
Prof. Jenny Lupin
Totally snowed in. :( I feel guilty not driving the mile and a half down to the gym tonight, but I've seen at least 2 cars get stuck in the snow on my street and the weather has only been getting worse today!! Crazy!Feb 02 2015 12:31 AM
Prof. Hailey PotterPlease send your snow to Tennessee. We will happily take it!! lol
Feb 02 2015 12:34 AM
Ailime Wright
and that's how amazing the weather in uk is: 5 mins ago it was pouring down with rain, it then started snowing, it stopped, it started snowing again, and now it's raining...#facepalmJan 29 2015 12:39 PM
Ailime WrightHaha that's a bit unusual lol I suppose I should get used to 2-3 seasons in the day
Jan 30 2015 05:21 AM
Tom FosterThat sounds about what it's going to be like here tomorrow. They're calling for a snow storm overnight into the morning, then into freezing rain and rain in the afternoon then back into snow in the evening.
Jan 30 2015 07:49 PM
Ailime WrightAnd I bet there.s gonna be a bit of tricky sunshine right. Either way I'm tired of this cold! :( I need the sun back in my life! ^_^
Jan 30 2015 09:57 PM
Ailime Wright
I seriously sound like a goose! I'm loosing my voice!! Thankfully here I only have to type!Jan 25 2015 11:04 PM
Ailime WrightCheers Pat!! Today is my 'no speaking' day so I can recover! Lol
Jan 27 2015 03:16 PM
Tom FosterHope you recover well, Ailime!
Jan 27 2015 11:19 PM
Ailime WrightThank you Tom! It's weird to go from talking non-stop to at all...haha but seems like my boss doesn't mind it haha
Jan 27 2015 11:37 PM
Tom Foster
Happy Birthday toooooo meeeeeeeeeeeeeeeeJan 17 2015 02:25 PM
Tom FosterThank you everyone, it was a very good day :)
Jan 17 2015 11:44 PM
Prof. Jenny LupinHAPPY BIRTHDAY!!!!!! :D
Jan 18 2015 02:47 AM
Tom FosterThank you :)
Jan 18 2015 10:22 PM
Ailime Wright
just ate a bogey flavoured bean (and I loved it!)Jan 15 2015 02:08 PM
Prof. Jenny LupinEww! I like the grass flavored ones. :)
Jan 16 2015 02:25 PM
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Marinfla March 2011--Spring Yard Update
My dogma ran over my Karma so I have been a bit out of the loop for a while and I have missed reading and keeping up with everyone's posts. But I am taking a deep breath and a step back to enjoy my tropical gardening and finally took some updated pictures. It was nice to see the difference from the last pics I took in 2010. I wish I could have made it to the PBRFC Sale this weekend.... but it may be just as well because I can't walk away from a good deal on a beautiful fruit tree and my husband may have killed me. I now have lychee on my mind and just started to germinate some pomegranate seeds. Happy Gardening :)
These are the Cherimoya seedlings I germinated in October 2010 are really doing well.
The Avocado seedling planted Nov 2005 grew at least 4 ft taller.... NO flowers so far this year :(
My potted Glenn mango in front of it.
Citrus Trees all fruiting:
Meyer Lemon
Var.Pink Lemonade with little fruits
Key Lime
Pink Grapefruit
The Navel Orange has little fruit but seems to be losing leaves and branches....this tree is not looking so good-?
THE MANGOES-- my favorite fruit!
Carrie, Pickering, Keitt
Glenn, Carrie, Pickering, Keitt
The Carrie (flowers all dried up and fell off- but it is started to send out more inflos again.
The Pickering is covered with fruit- not sure how many will make it but many are growing larger :)
The Lancetilla has lots of buds pushing-- not sure if it will grow foliage or flowers.
The Glenn and Cogshall did not hold their fruit but the Po Pyu Kalay has ONE, the Keitt did not flower (too young) and the seedlings are having nice growth flushes
The Fig trees are all growing new wood and foliage with a handful of briba figs and that big Oncidium in the left background is full of developing flower spikes-- it will turn into a big ball of yellow soon :)
In the dry season I water twice in a week....saturate them once and very lightly water the other time
- In the hot summer I water them usually 2-3 times a week depending on how much rain we get.... saturate them once or twice and if they need it in between I lightly water.
- I keep a bamboo stick close by and stick it into the soil all the way to the bottom of the pot first to see how dry they are beforehand to determine what it needs.
- Also every other week I mix half strength MG in gallon sized jugs and dump a gallon in each pot.
Seems to be working ok :)
Thank you Franktank232, I am grateful for this climate. Unfortunately I have a really small yard so I have to resort to container gardening. I probably have room for one more tree (or two if small) in the ground out in the front yard. I do have a good amount of balcony space on the second floor I haven't populated with planters yet...eventually :)
Marina - such nice staging you do for your pictures!
You must be some kind of creative person in your other life.....
Everything looks great - you do have a green thumb. Mangos are my favorites too....good luck with everything and thanks for the tour.........
Thanks guys LOL
jfernandez I actually am of the female variety :)
mangodog the only trees that concern me is the navel orange it has a bunch of baby fruits but it is dropping lots of leaves and a few branches have dried up and died. Not sure why so I am just leaving it alone to wait and see what happens. And I made the mistake of taking a fig tree that had rust on it. It spread to the ones I already had and copper spray hasn't kept it from going to the new growth :(
I was thinking maybe we should all post a picture of ourselves on a " meet the members" thread.... any votes??
Hi Marin! Wow...what a very nice yard and look at all those beautiful trees...Fantastic! They are all looking great and healthy and have grown...look at all the baby mangoes and citrus fruits you have...Congrats! Isn't it exciting!
Thanks for the update and the wonderful pictures...its nice to see you back!
Thanks all for the encouraging compliments. Until I took the time to do my pictures again I had forgotten just a bit just how much I love this stuff.... my life sometimes gets in the way of all this green thumb fun. It makes me optimistic that one day when I retire I will have plenty to keep me active because I just love the challenge of seeing what will grow. I think that is why I really enjoy growing the seedlings too because it is like rolling the dice on what you can get a tree germinated from seed to do and what will it give you in return...and will it be something notable :) It is good to be back to having time to keep in touch here. And Thanks to all of you for the warm welcome back :)
Tropicalgrower89 I contacted a guy that commercially grew avocados and he told me that he used a method to induce flowering, he would feed it with high phosphorus fertilizer and bang a few thick galvanized steel nails (20 pound ?)into the trunk about 3-4 feet above the ground and this was successful. I never followed up to find out what time of the year to do this so by the time I got my head out of the sand it was already February. That is when I did the nails and did the high P for the second time (1st time was in Nov/Dec.) The tree is pushing meg new growth but I don't see flowers :( Maybe next year...it is only 5 yrs/4 mo. in the ground so I guess I have to be more patient :)
I really wonder how long the cherimoyas will take to flower?? Anyone have an idea????????
I somehow overlooked these pics in the album:
Potted Bananas-a big one and many babies- I am not sure of the variety?
Flowering Po Pyu Kalay: one fruit growing large
Flowering Glenn: all the flowers dried up, no fruit :(
Flowering Cogshall: a few fruit developed, but all fell off
All my trees are loving spring fever!
Happy Growing


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All-American Men (Medley)
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All-American Men (Medley) arranged by Roger Emerson. For Choral (ShowTrax CD). Pop Choral Series. CD only. Published by Hal Leonard (HL.8201913).
This rousing medley of guy favorites is sure to bring down the house! Featuring easy to sing harmony, it includes: Sweet Home Alabama (Lynyrd Skynard), Ramblin' Man (The Allman Brothers Band) and All The Gold In California (The Gatlin Brothers).Available separately: TBB and ShowTrax CD. Performance Time: Approx. 6:00.
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All-American Men (Medley)
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All-American Men (Medley)
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See Similar Sheet Music
More by this Arranger: Roger Emerson Sheet Music Roger Emerson Choir Sheet Music Roger Emerson Choir Sheet Music
Instrument: Choir Sheet Music
Ensemble: Choir Music
Genre: Americana Sheet Music
Format: Accompaniment CD