|Timestamp||Email Address||1. Hospital Name|
2. Location of Facility (County)
3. 24/7 Primary Hospital Contact: Name
4. 24/7 Primary Hospital Contact: E-mail
5. 24/7 Primary Hospital Contact: Phone
6. 24/7 Alternate Hospital Contact: Name
7. 24/7 Alternate Hospital Contact: E-mail
8. 24/7 Alternate Hospital Contact: Phone
9. Total number of beds in your facility
10. Total number of ED beds (usual spaces used for patient care for hospital-based ED)
11. Total number of ED isolation (AIIR) rooms
12. Total number of portable isolation assets
13. Total number of ED surge beds (used for surge only- these are beds in addition to usual ED beds)
14. Total number of operating rooms
15. Total number of pre/post anesthesia care unit beds (PACU)
16. Total number of intensive care beds - adult
17. Total number of intensive care beds - pediatric
18. Total number of NICU beds
19. Total number of intensive care surge beds
20. Total number of bariatric beds
21. Total number of stepdown (intermediate care) beds (including cardiovascular drip medications, BiPAP. NOT mechanical ventilation or pressor support)
22. Total number of stepdown surge beds (must include cardiorespiratory monitoring, including remote telemetry)
23. Total number of medical/surgical beds (including operating (not licensed) adult and pediatric)
24. Total number of medical/surgical surge beds (may include activating closed areas or doubling patients in private rooms)
25. Total number of inpatient isolation (AIIR) rooms
26. Total number of inpatient psychiatry beds
27. Total number of burn center beds
28. Total number of hospital-owned cots that could be used to create alternate care areas
29. In the space below, provide any additional beds at your facility not included in the previous questions
30. Please upload your medical related cache inventory list(s), and locations, to the following Google folder: https://drive.google.com/drive/folders/1K9sTF5QDhNq5zGnG4xtyUpgCO6GKflrj?usp=sharing. Rename your document with your organization name in the title. If you are unable to access the Google Drive, please e-mail your inventory list to SWCHCC@gmail.com.
31. Please describe your medical related cache mobilization processes, including: activation process, chain of custody, restocking requirements, etc. If already documented, please upload to the following Google folder: https://drive.google.com/drive/folders/1ea7LwwvAvz3ex1BryjSkRBOo_9zVrKTo?usp=sharing. Rename your document with your organization name in the title. If you are unable to access the Google Drive, please e-mail your medical cache mobilization process to SWCHCC@gmail.com.
32. Which communication modalities currently exist within your agency (select all that apply)?
33. Please select all radio capabilities currently available within your facility
34. Number of portable or mobile radios programmed to be interoperable within the region:
35. Trauma designation:
36. Is the facility a critical access hospital?
37. Does your facility have a morgue?
38. If your facility has a morgue, are the coolers on emergency power?
39. If you facility has a morgue, what is its capacity?
40. What patient tracking system does your facility use on a day to day basis?
41. What patient tracking system does your facility use during an event/disaster?
42. Is the facility a specialty hospital? (if so, please list the specialties)?
43. What is your hospital's decontamination capacity: ambulatory (please use patients/hour as a measurement)?
44. What is your hospital's decontamination capacity: non-ambulatory (please use patients/hour as a measurement)?
45. Approximate number of patient redress/dry decon kits:
46. Total number of CHEMPACKs on-site:
47. Total number of Duodotes on-site:
48. Total number of Cyanokits on-site:
49. Total number of blood products on-site:
50. Please upload a spread sheet of your hospital's evacuation resources (sleds, stair chairs, pediatric equipment, evac buses) to the Google folder: https://drive.google.com/drive/folders/1q3BYj4lZe9sBWbhXUVQz9Y22k_sosQ6M?usp=sharing. Rename your document with your organization name in the title. If you are unable to access the Google Drive, please e-mail your spread sheet to SWCHCC@gmail.com.
51. Please list your hospital's personal protective equipment (PPE)/PAPRs for infectious disease/biological events (please list brand, model and quantity of PAPRs supplied):
52. Please list your hospital's personal protective equipment (PAPRs) for chemical events (please list brand, model, and quantity of PAPRs supplied):
53. Please list your hospital's supplied chemical protection suits (please list brand, model, and quantity of suits supplied):
54. Please list the brand/type of N-95 masks supplied within your hospital:
55. Please provide the total number of portable radiation detectors available within your hospital:
56. Please provide the total number of chemical detection devices available within your facility. Include the brand of device and type of chemicals detected, if applicable:
57. Please provide the total number of hospital-owned ventilators (do not include anesthesia machines in OR). Include transport ventilators with high/low pressure and other alarms suitable for longer-duration simple ventilation situations:
58. Please indicate which ventilators your hospital has on-site (select all that apply):
59. Please select which generator capabilities your facility currently supports (select all that apply)
60. Is your hospital signed on as a current member of the Colorado Department of Public Health and Environment's State Hospital MOU? (*please note that the most recent MOU has a signature due date of 9.18.18. Contact Greg Jones with any qustions: firstname.lastname@example.org)
61. Please list any disaster/emergency related MOUs that your hospital currently has in place:
62. In the space below, provide any additional assets or services of your facility not included in the previous questions:
Mercy regional Medical Center
|La Plata County||Ronald Trucott|
|9707642169||82||20||1||2||10||5||6||6||0||7||0||2||11||0||48||0||8||0||0||0||12 Labor and Delivery|
Only operational stock - No cache
Only operational stock - No cache
Voice Over Internet Protocol (VOIP), Internet-based (e.g., e-mail, web-based systems, etc), Cell phones, Mass Notification, Fax
800MHz radio(s), VHF/ UHF radio(s) radios, Internal Radios (no external communication capability)
|8||Level 3||No||No||No morgue||0||EPIC|
Self-designed through SharePoint
Cancer Care, Breast Care, Family Birthing Center, Heart and Vascular, Spine Center, Orthopedics, Sports Medicine
Med Sleds (Bariatric - 1, Adult - 16, Youth - 6, Infant/Toddler - 1)
Max Air 700 (18 ea), 3M N95 respirators (2000 ea)
Breathe Easy PAPRs (19) w/ 3M FR-57 CBRN Filters 3/PAPR (120 ea)
Tychem 4000 (XL - 18, L - 24, M - 21, S - 12)
|3M||2||0||11||None of the Above|
For water, food, alternate care sites at the college and fair grounds, transportation from 9R School District and Omnibus, DaVita Dialysis, several hotels/churches for staff
1 CT Scanner, 1 MRI scanner, 1 PET scanner, radiology, ultrasound, Cardiac Cath Lab, 4 bed outpatient surgery center, urology services
Southwest Memorial Hospital
|Montezuma County||Karen Labonteemail@example.com||970-565-6666||Scott Anderson|
Internet-based (e.g., e-mail, web-based systems, etc), Cell phones, Mass Notification, Fax
800MHz radio(s), VHF/ UHF radio(s) radios
|20||Level 4||Yes||Yes||No||8||cerner||emresource||no||20||10||40||1||0||0||58||n/a||n/a||n/a||n/a||n/a||2||0||5||None of the Above|
will need to check on this with admin