Skip Navigation U.S. Department of Health and Human Services www.hhs.gov
Agency for Healthcare Research Quality www.ahrq.gov
Archive print banner
Disaster Alternate Care Facility Selection Tool

Public Health Emergency Preparedness

This resource was part of AHRQ's Public Health Emergency Preparedness program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.

This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://info.ahrq.gov. Let us know the nature of the problem, the Web address of what you want, and your contact information.

Please go to www.ahrq.gov for current information.

Appendix C: Alternate Care Facility Questionnaire

As part of a previous task order for the Agency for Healthcare Research and Quality (AHRQ), we developed a site selection matrix for use in the selection of Alternative Care Sites (a.k.a. Alternate Care Facilities, ACF) for use in providing health care during mass casualty events and disasters.1 We have been asked to revise this tool based on the experience gained during Hurricanes Katrina and Rita and as the result of other planning. We have also been asked to develop protocols for staffing and supplying an ACF, again with input from those who have participated in their use or have done extensive planning for their use.

You have been identified as an individual who can make a significant contribution to this area of knowledge. Therefore, we kindly ask if you, with input from those you work with (or worked with at your ACF), would be willing to spend a few minutes to assist us with this task. We have developed a questionnaire to facilitate this process (attached). It has two parts; the first asks for information about your actual or planned ACF. The second component asks for your thoughts concerning the usefulness of the different categories of information used in the facility selection tool and for any suggested additions or deletions. Because of the sensitive nature of some of these data, information supplied will be treated confidentially and will not be identified as to any source.

Thank you in advance for your assistance with this project, which we feel has the potential to help all of us in providing the best possible care for patients during mass casualty events and disasters when we may need to use non-traditional sites of care. The summary results of this effort will be submitted to AHRQ and will subsequently be released to the medical community.

Please feel free to call or email me if I can be of any help with your participation in this project, or if you feel you are unable to assist us with this project.

Most sincerely,

Stephen V. Cantrill, MD
Denver Health & Hospital Authority
777 Bannock St.
Mail Code 8800
Denver, CO 80204-4507
Phone: 303-436-7174
Email: stephen.cantrill@dhha.org

For the Disaster Alternate Care Facility Task Order Group
Stephen V. Cantrill, MD
Peter T. Pons, MD
Carl J. Bonnett, MD
Sheri L. Eisert, PhD
Susan L. Moore, Project Manager

AHRQ Contract No. HHSA290200600020, Task Order No. 4
Title: Disaster Alternate Care Facilities


1 Rocky Mountain Regional Care Model for Bioterrorist Events: Locate Alternate Care Sites During an Emergency. December 2004. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/altsites.htm


Return to Contents

Part One. Information about your past or planned Alternate Care Facility

I. Initial Data.

Please check all that apply to your Alternate Care Facility (ACF), whether actually used or planned:

These responses are based upon:
___ A planned ACF (if so, please consider all questions to be in the future tense)
___ An actual ACF
        If an actual ACF, please supply:
        Location/Name: _______________________
        Dates of operation: _____________________
        Total number of patients cared for: _____________________
       Total number of staff utilized: ________________________
Structure utilized:
___  Structure of opportunity (a pre-existing building that is, in lieu of its primary purpose, used as a medical facility)
If so, please specify the structure used (e.g. hotel, retail store, etc):
_________________________________________________________
___  Portable (a structure, such as a tent, that can be transported to a location for use as a medical facility)
___  Mobile (a wheeled structure, such as a trailer, that can be moved or driven to a location for use as a medical facility)

Function:
   Inpatient Level Care:
      Health Care Augmentation (augmentation of existing in-patient health care delivery systems, either on site at the traditional health       care delivery location or at a more distant site)
       ___  Adult
      ___  Pediatric
       ___ Special Populations (e.g. prisoners)
       Please specify: ____________________________________________
       ____________________________________________________________
       ___  Special Medical Needs Populations (e.g. hemodialysis, chronic ventilator)
          Please specify:_______________________
        _________________________________________________

   Health Care Replacement (replacement of existing in-patient health care systems that have been directly affected by the incident)
        ___  Adult
        ___  Pediatric
        ___ Special Populations (e.g. prisoners)
        Please specify: _____________________________________________
        _____________________________________________________________
        ___  Special Medical Needs Populations (e.g. hemodialysis, chronic ventilator)
        Please specify:_____________________________________________
       _____________________________________________________________

Ambulatory/Primary Care:
      Health Care Augmentation (augmentation of existing out-patient health care delivery systems, either on site at the traditional health       care delivery location or at a more distant site)
      ___  Adult
      ___  Pediatric
      ___  Public Health Support (vaccinations, prophylaxis, triage)

     Health Care Replacement (replacement of existing in-patient health care systems that have been directly affected by the incident)
      ____  Adult
      ___  Pediatric
      ___ Special Populations (e.g. prisoners)
        Please specify: _____________________________________________
      _____________________________________________________________
      ___  Special Medical Needs Populations (e.g. hemodialysis, chronic ventilator)
          Please specify: _____________________________________________
_____________________________________________________________
___  Shelter Support (routine ambulatory medical support necessary for shelter operations for a displaced population)

Governance: (the organization responsible for the oversight, command, and operation of the ACF)
     ___  Institutional/Health care system (Hospital or hospital system based)
     ___  Nonprofit/Volunteer/Faith-Based (e.g. Red Cross, Salvation Army)
     ___  Local (Local government/Municipal/County)
          ___ Office of Emergency Management
          ___ Public Health
          ___ Other: Please specify: _________________________________________
     ___  State
     ___  Federal
          ___  DHHS
            ___  PHS (FMS)
            ___  NDMS (DMAT, NMRT)
            ___  Other: Please specify: _______________________
            ___  Department of Defense

II. ACF Command Structure

A. General

1. Did you set up an incident command system at your ACF?
   ___  Yes   ___  No
   1a.  If so, what was it modeled on (e.g. HICS)? ___________________________

2. Was an Incident Action Plan (IAP) prepared?
     ___  Yes   ___  No
    2a.  If yes, was it done:  
    ___  Once ___  Daily ___  Other frequency: _____________________________
    2b.  Was the IAP a:
     ___  Previously prepared form ___  A form we created

3. Were there any problems with the command structure?  
    ___  Yes   ___  No
    3a.  If yes, please elaborate: _________________________________________
   ________________________________________________________________

4. How was the transfer of command facilitated at change of shift:
     ___  Verbal report ___  Written report
     ___  Both               ___  Other (Please specify): ___________________________

5. How did you decide to open your ACF: _________________________________________
     _______________________________________________________________________
     _______________________________________________________________________

6. Who made the decision (by job title, not name): __________________________________
      _______________________________________________________________________

7. How did you decide to close it:_________________________________________________
      ________________________________________________________________________
      ________________________________________________________________________

8. What, if any, were the predetermined requirements to be met before closing it: ____________
      _________________________________________________________________________
      _________________________________________________________________________

9. Did you have a concept of operations (or operational plan) which you adhered to?
      ___  Yes   ___  No

10. Did your command staff have National Incident Management System and/or Hospital Incident Command System Training?
      ___  Yes   ___  No
     10a. If yes, what percentage of the staff were trained:____________%

11. Did you have any issues related to the Emergency Medical Treatment & Active Labor Act (EMTALA) during the operation of your       ACF?
      ___  Yes   ___  No
      11a. If so, what were the issues and how did you handle them: ________________________
      _________________________________________________________________________
      _________________________________________________________________________

12. Were there any issues related to public information management?
      ___  Yes   ___  No
      12a. If so, please specify: _____________________________________________________
       _________________________________________________________________________
       _________________________________________________________________________

13. How did you coordinate the dispatch of EMS resources to the ACF with the everyday dispatch operations of the local        community: ________________________________________________________________
        _________________________________________________________________________
        _________________________________________________________________________
        _________________________________________________________________________

14. Did you have rules of behavior for the patients (e.g. curfew, no weapons, lights out time)?
      __  Yes   ___  No
      14a. If yes, please list or include with the returned questionnaire: _______________________
      _________________________________________________________________________
      _________________________________________________________________________
      _________________________________________________________________________

15. Are there any other issues with regards to the command of an ACF which you would like to share?
        _________________________________________________________________________
        _________________________________________________________________________
        _________________________________________________________________________

B. Security

1. Did you have uniformed security personnel at your ACF?
     ___  Yes   ___  No

2. If so, were any of them armed?
___  Yes   ___  No

3. Did you have any issues with violence at your ACF?
     ___  Yes   ___  No

4. Are there any other issues related to the security of an ACF that you believe are important and wish to share?      ____________________________________________________________________________
      ___________________________________________________________________________
      ___________________________________________________________________________
      ___________________________________________________________________________
      ___________________________________________________________________________

III. ACF Planning Component

A. General

1. Did you have a plan for an ACF before you were called upon to stand one up?
      ___  Yes   ___  No

2. Did you select the site for your ACF after the need for it arose or had the site been determined in advance of the event?
      ___  When need arose  ___  Determined in advance

3. Were you familiar with the Rocky Mountain Regional Care Model for Bioterrorist Events Alternative Care Site Selection Tool prior  to     setting up your ACF (go to Appendix A)?
      ___  Yes   ___  No
      3a.  If yes, did you use this tool to help select the site of your ACF?
               ___  Yes   ___  No
      3b.  If not, do you think it would have been helpful?
              ___  Yes   ___  No

4. What consideration, if any, was given to locating the ACF in proximity to the transportation network and/or evacuation routes?
     ___________________________________________________________________________
     ___________________________________________________________________________
     ___________________________________________________________________________

5. Any other issues with regards to site selection which you would like to share: ______________
     ___________________________________________________________________________
    ___________________________________________________________________________
    ___________________________________________________________________________
    ___________________________________________________________________________

6. Did you have plans for the following services?
      ___  Social services
      ___  Cleaning services
      ___  Recreational services
      ___  Warehousing services
      ___  Contracting/purchasing services
      ___  Other services:
       Please specify: ____________________________________________________________

7. Are there any other issues with regards to additional services which you would like to share:
      __________________________________________________________________________
     __________________________________________________________________________
     __________________________________________________________________________

B. Bed/Case Mix

1. What percentage of each of the following did you expect/plan for at your ACF?
      ___  Acute care cases: _____%     Chronic care cases: _____%
      ___  Pediatric patients: _____%      Adult patients: _____ %
      ___  No specific expectations

2.    What percentage of each of the following did you actually receive at your ACF?
      ___  Acute care cases: _____%    Chronic care cases: _____%
      ___  Pediatric patients:_____ %     Adult patients: _____%
      ___  No specific expectations

3. Have you changed your bed/case mix plans for future ACFs as a result?
      ___  Yes   ___  No
      3a.  If so, please specify: _________________________________________

C. Pediatrics

1. Was the care of children an integral part of your initial plan?
      ___  Yes   ___  No

2. Was there a specific location within your ACF set aside for the care of children?
      ___  Yes   ___  No

3. Which of the following types of individuals were involved in the planning for the care of children (please check all that apply)?
      ___  Emergency nurses?
      ___  Emergency physicians?
      ___  Midlevel practitioners (e.g. nurse practitioners, physician assistants)?
      ___  Pediatric emergency physicians?
      ___  Pediatric nurses?
      ___  Other?
      Please specify: _________________________________________________________

4. Were any of the following consulted to help plan for pediatric patients (please check all that apply)?
      ___  Pediatric tertiary care center?
      ___  Pediatrics department at your local hospital?
      ___  Other?
      Please specify: _______________________________________________________

IV. ACF Logistics

A. General

1.Who provided the equipment to stand up your ACF? _________________________________
    _________________________________________________________________________
    _________________________________________________________________________

2. Who provided you with re-supply? ______________________________________________
    _________________________________________________________________________
    _________________________________________________________________________

3. Did you tap into any federally administered medical supply caches?
    ____ Yes   ____ No
    3a. If so, please specify which one(s): ___________________________________________
    _________________________________________________________________________
    _________________________________________________________________________

4. Did you have any partnerships with private industry to help provide service or supplies at your ACF (e.g. commercial  pharmacies)?
    ____ Yes   ____ No

5. How did you feed the health care workers and patients at your ACF? ____________________
    _________________________________________________________________________
    _________________________________________________________________________

6. Did you also provide food for the families of patients?
    ____ Yes   ____ No

7. Was the dining area separate from the treatment area?
     ____ Yes   ____ No

8. Did you have medications for children?
     ____ Yes   ____ No
    8a. If so, did you have appropriate type and quantity of medications for pediatric patients?
           ____ Yes   ____No
    8b. Who supplied them? _____________________________________________________
    _________________________________________________________________________
    _________________________________________________________________________

9. Did you have other medical supplies for children?
     ____ Yes   ____ No
    9a. If yes, did you have adequate quantity?
    ____ Yes   ____ No
    9b. Who supplied them? ______________________________________________________
    _________________________________________________________________________
    _________________________________________________________________________

10. What supplies, equipment, and drugs were most important to the operation of your ACF?
    _________________________________________________________________________
    _________________________________________________________________________
    _________________________________________________________________________
    _________________________________________________________________________

11. What supplies/equipment/drugs that you needed could not be obtained? _______________
    _________________________________________________________________________
    _________________________________________________________________________
    _________________________________________________________________________
    _________________________________________________________________________

12. Are there any other issues with regards to general logistics that you would like to share:
    _________________________________________________________________________
    _________________________________________________________________________
    _________________________________________________________________________
    _________________________________________________________________________

B. Staffing & Credentialing

1. Did you have set shifts which were worked by health care providers?
     ____ Yes   ____ No
    1a. If yes, were they:
    ____ 8 hour   ____ 12 hour   ____   Other: _____________________________

2. Did you have different staffing patterns for day vs. night?
    ____ Yes ____ No

3. How many physicians did you have working at one time? _____________________________
    _________________________________________________________________________

4. How many midlevel practitioners did you have working at one time?____________________
    _________________________________________________________________________

5. How many nurses did you have working at one time?________________________________
    _________________________________________________________________________

6. How many emergency medical technicians did you have working at one time?_____________
    __________________________________________________________________________

7. How many pharmacists did you have working at one time? ____________________________
    __________________________________________________________________________

8. Did you have dedicated clerks and/or administrative support?
    ____ Yes   ____ No
     8a. If so, how many did you utilize? ________________________________________________
    __________________________________________________________________________

9. Did you have health care providers from different health care facilities/systems working in your ACF?
     ____ Yes   ____ No
    9a. If so, were there any command and control issues and how did you resolve them? ________
    ___________________________________________________________________________
    ___________________________________________________________________________
    ___________________________________________________________________________

10. Were there any out-of-state licensing issues?
     ____ Yes   ____ No

11. Did you have a need for interpreter services?
     ____ Yes   ____ No
    11a. If so, how did you meet that need?
      ____Trained interpreters
      ____Bilingual/multilingual care providers
      ____Family members
      ____Other
      Please specify:________________________________________________________________

12. What types of volunteers were utilized?
      ____ None   ____ Medical ____ Non-medical
      12a. Did you have a volunteer coordinator?
               ____ Yes  ____ No

13. What lessons did you learn with regards to integrating non-health care provider volunteers into the operation of the ACF?     ________________________________________________________________________________
    ________________________________________________________________________________
    ________________________________________________________________________________

14. How did you verify the credentials of health care providers who worked in your ACF?____________
      ______________________________________________________________________________
      ______________________________________________________________________________

15. Did you create identification cards for the workers?
      ____ Yes   ____ No
     15a. If so, what did you use (e.g. commercially available product)?___________________________
     ______________________________________________________________________________

16. Is there anything you would do differently for worker identification in the future?________________
      ______________________________________________________________________________
      ______________________________________________________________________________
      ______________________________________________________________________________
     ______________________________________________________________________________

17. Did you have anyone impersonate a health care provider and try to gain access to your ACF?
       ____ Yes   ____No

18. What steps were taken at the State level to facilitate the use of out-of-state medical professionals?
      ______________________________________________________________________________
      ______________________________________________________________________________
     ______________________________________________________________________________
     ______________________________________________________________________________

19. Did your staff have any specialized pre-event training?
     ____Yes   ____No
     If yes, please specify: _____________________________________________________________
    ______________________________________________________________________________
    ______________________________________________________________________________

20. Are there any other issues with regards to staffing or credentialing which you would like to share (including what other staff you        found helpful to have)? ____________________________________________________________
       ______________________________________________________________________________
      ______________________________________________________________________________
      ______________________________________________________________________________
      ______________________________________________________________________________
      ______________________________________________________________________________
      ______________________________________________________________________________

Return to Contents
Proceed to Next Section

The information on this page is archived and provided for reference purposes only.

 

AHRQ Advancing Excellence in Health Care