ASTM E2413-04(2009)

This guide is intended to assist the leaders of hospitals in the design, planning, and response to be undertaken by hospitals and health care organizations to an event that necessitates the activation of an emergency operations plan.

This guide provides procedures to coordinate and provide a systematic and structured response to manage an incident.

This guide provides management tools that can assist in providing essential training objectives and decision-making models for hospital leadership and hospital regulatory agencies.

This guide will be as consistent as possible with the following existing industry standards: Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) Environment of Care (EC) standards, NFPA 1600, the National Incident Management System (NIMS), and the Health Resources and Services Administration (HRSA) Hospital Bioterrorism (BT) Preparedness Program.

Compliance with the JCAHO standards is of paramount concern to health care organizations. JCAHO’s EC standards include safety, security, hazardous materials and wastes, emergency management, fire safety, medical equipment, and utilities management. The EC chapter addresses planning and implementation and measuring and improving activities, with education and training activities addressed in standards relating to human resources.

NFPA 1600 is highly regarded as a national preparedness standard. NFPA 1600 serves as the basis for the standard used by the Emergency Management Accreditation Program (EMAP) for state, local, and tribal governments.

The National Incident Management System (NIMS) was required for all federal departments and agencies as a part of Homeland Security Presidential Directive #5. NIMS is also required for state and local government entities who receive federal grant funds. This impacts hospitals (public and private sector) through participation in the HRSA Hospital BT Program as well as the JCAHO Incident Command System/Incident Management System requirement.

The HRSA BT program is important because one of its objectives is to set national levels of readiness for hospitals. These minimum levels of readiness, articulated for each of the critical surge capacity benchmarks, are achieved through coalitions of individual hospitals (districts). The HRSA BT program is based on creating effective linkages between the levels and entities within the Medical and Health Incident Management System (MaHIMS) to include individual facilities, coalitions, jurisdictions, intrastate, interstate, and federal support.

1.1 This guide covers concepts, principles, and practices of an all-hazards comprehensive emergency management program for the planning, mitigation, response, recovery, and coordination of hospitals in response to a major incident.

1.2 This guide addresses the essential elements of the scope, planning, structure, application, and coordination of federal, state, local, voluntary, and nongovernmental resources necessary to the emergency operations plan for a hospital.

1.3 This guide establishes a common terminology for hospital emergency management and business continuity programs necessary to fulfill the basic service requirements of a hospital.

1.4 This guide provides hospital leaders with concepts of an emergency management plan, but an individual plan must be developed in synchrony with the community emergency operations plan and the National Incident Management System.

1.5 This guide does not address all of the necessary planning and response of hospitals to an incident that involves the near-total destruction of community services and systems.

1.6 For the purposes of this guide, the definition of hospital will be the current definition provided by the American Hospital Association for an acute care facility.

1.7 This standard does not purport to address all of the safety concerns, if any, associated with its use. It is the responsibility of the user of this standard to establish appropriate safety and health practices and determine the applicability of regulatory requirements prior to use.