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Surge Tool Kit and Facility Checklist

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 It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work.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.

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Facilities

1. Preplanning

Description: Certain equipment, services, or staffing required for surge use of the shuttered hospital will necessitate advance arrangements, including identification of providers, contracts, specifications, and protocols.

Timeframe: As soon as a potential surge facility or facilities have been selected based on the inspection of shuttered hospitals, these preparedness arrangements should be initiated. Once finalized, these arrangements should be reviewed every 6 months to ensure that readiness is maintained.

Action Checklist

Advance Contracts or Formal Arrangements Needed

  • Bulk and portable medical gas supplier. Specify response time.
  • Fire safety equipment supplier.

Identification of Providers Needed:

Advance contracts are not required for these providers, but advance contact is recommended. Also, identification of more than one provider is recommended as a backup.

  • Commercial or disaster reparation cleaning services.
  • Moving companies.
  • Mechanical services temporary staffing agency (if major hospital cannot provide such staff).
  • Refrigerated truck rental or leasing companies.
  • Medical gas system verifier.
  • Medical gas system parts supplier.
  • Medical gas regulator and mask supplier.

Advance Notification/Communication Recommended:

  • Local fire department should be notified if target facility fire suppression system is not functional, and a fire watch will be needed. Local fire department should also be notified regarding emergency fire inspections prior to surge facility opening if needed.

2. Ramp-Up

Description: As necessitated by a catastrophic event, the surge facility must progress from the planning phase into an operating facility. The steps listed below must occur to complete this process.

Timeframe: As soon as the catastrophic event occurs, planned arrangements for the surge facility should be activated so that it can be opened as a functioning hospital within 7 days.

Action Checklist

  • Ask the facilities workers to report to the surge facility as soon as possible to conduct facility upgrade activities. These staff may be from the following sources:
    • Ask facilities staff from the major hospital to report to the surge facility; OR
    • Contact the identified mechanical services temporary agency, and request temporary employees.
  • Facilities workers must conduct the following activities:
    • Restore water and conduct fixture repair as needed so that toilets and sinks are functional in all areas of the facility that will be occupied.
    • Bring hot water system up to full capacity.
    • Check HVAC system for each area and modify as necessary.
    • Restore heat or air conditioning as needed to all areas of the facility that will be occupied.
    • Convert rooms or spaces to negative pressure as identified by medical staff for the isolation/quarantine scenario.
    • If it is feasible to use the centralized medical gas system, have medical gas system verifier test system and oversee needed repair activities.
    • As determined by security expert, partition off areas of the facility that will not be used.
    • Conduct other building access control modifications as determined by the security expert.
    • If possible, bring nurse call and code call systems up to functional status. If call systems cannot be made functional, install manual alternatives such as portable bells by beds for nurse call and bells above doors for code call.
    • If possible, bring telephone and other communications systems up to functional status.
    • Once repairs, upgrades, and ramp-up are completed, test all systems in all areas to be occupied.
  • Ensure that back-up power fuel supply is full, and order fuel if needed.
  • If elevator certificates are not current, contact the elevator company for an elevator inspection.
  • If public safety licensure is not current, contact the local fire department for an inspection.
  • Contact the identified moving company and have them report as soon as possible to conduct move-out of desks or other items in spaces to be used for patient care.
  • Contact the identified cleaning company and have them conduct facility cleaning as soon as the move-out is completed.
  • Activate the contract with the fire safety equipment company, and have them check automated fire suppression systems. If these systems are not functional, have them provide fire extinguishers. Ask them to conduct needed fire extinguisher training for employees.
  • Procure a refrigerated truck if supplemental morgue storage space is needed.

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3. Opening Day

Description: On the day the facility first accepts patients and begins operation, the security expert or designate(s) and key providers should be on-site to ensure that security equipment and staff are in place and functioning effectively for access control and other security functions.

Action Checklist

  • Inspect all occupied areas in the facility and all facility systems such as plumbing, hot water, HVAC, and electrical.
  • Retain facilities staff on-site to troubleshoot facilities issues and make any needed systems modifications.
  • Check with supervisory medical staff to see if there are any facilities issues relative to patient care.
  • Check with supervisory security staff to see if there are any facilities issues relative to security.

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4. Ongoing Operations

Description: Once needed staffing, equipment, and supplies are in place, and the facility has accepted patients, efforts will be needed to maintain fully operational status.

Timeframe: The operations activities listed below will begin on opening day and continue until the facility is closed.

Action Checklist

  • Retain at least one facilities staff person on-site to conduct any needed facility repairs or modifications.
  • Monitor levels of fuel, medical gasses, and other supplies, and reorder as needed.
  • Maintain communications with supervisory medical staff on facilities issues relative to patient care.
  • Maintain communications with supervisory security staff on facilities issues relative to security.

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5. Closure

Description: Shutdown of the surge facility will require removal of equipment and termination of on-going contracts or arrangements.

Timeframe: Once all patients can be discharged or transported back to the major hospital for continued care, and no on-going surge capacity is needed, the facility can be closed down. The shutdown should be expedited so that the facility can be returned to the control of the existing owners quickly and should be completed within days.

Action Checklist

Restore Facility to Non-Surge Use Condition

  • Ask cleaning services contractor to conduct a full cleaning of all areas used after surge operations cease and all equipment and supplies have been removed.
  • Ask moving company to return furniture or other items to original locations as needed for normal non-surge use of the facility. If the centralized medical gas system was used, have the medical gas system verifier conduct system close-down procedures to preserve system integrity for future use.
  • Shut off water to areas of the facility closed during normal use of the facility.
  • Shut off heat (or reduce temperature to minimum level to prevent freezing) or air conditioning to areas of the facility closed during normal use of the facility.
  • Ramp down hot water system to levels needed during normal use of the facility.
  • Restore mechanical ventilation system to operating conditions for normal use of the facility.

Termination of Agreements and Equipment Return

  • Decontaminate refrigerated truck used for morgue storage, return to provider, and terminate rental/lease agreement.
  • Terminate mechanical services temporary staffing agency agreement.
  • Terminate fire safety supplier agreement and have the supplier pick up fire extinguishers.
  • Terminate agreement with portable medical gas supplier, and have the supplier pick up all bottles.
  • Terminate agreement with medical gas accessories supplier, and return any returnable equipment.

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Staffing

1. Preplanning

Description: During this phase, the Planning and Management Team will identify expert(s) in the area of hospital staffing, who will in turn recruit and formalize a surge facility staffing team. The staffing team will, based on information and direction from the Planning and Management Team, define types and numbers of staff needed, identify sources for each type of staff, develop procedures for the verification of credentials, and prepare training and orientation materials.

Timeframe: As soon as a decision is made to pursue the use of area shuttered hospitals for surge capacity, and the Planning and Management Team is formed.

Action Checklist

Identifying Staff Types

  • Receive direction from the Planning and Management Team regarding potential patient types and staff skills needed.
  • Receive direction from the Planning and Management Team regarding hospital services to be provided (e.g., meal service, laboratory, X-ray, and pharmacy services).
    • Identify potential vendors needed.
    • Execute agreements for any contracted services.

Identifying Sources for Staffing

  • Review Federal Government resources (e.g., disaster medical assistance teams (DMATs), urban search and rescue teams, Public Health Service, VA).
  • Review State government resources (e.g., public health departments). Determine numbers of people, skills, and availability.
  • Identify non-government resources for staffing.
    • Review mutual aid agreements with surrounding area hospitals.
    • Identify temporary staffing agencies in the area with available local and non-local staff. Establish agreements for supplemental staffing.
    • Identify nursing, medical, dental, veterinarian, and allied health professions schools as potential sources for student and instructor volunteers. Meet with appropriate individuals and establish agreements and procedures to be followed in the event of a disaster. Identify volunteer programs as sources for potential clinical and non-clinical staff.
    • Check Web site listings for State agencies for community service and the Corporation for National Community Service.
    • Identify local programs (e.g., Community Emergency Response Teams, Medical Reserve Corps, SeniorCorps, AmeriCorps). Meet with leadership for information on group size, skills, availability, response time, and ongoing activities.
    • Research funding/grant opportunities to support local volunteer teams.

Licensing, Credentials, and Privileging Issues

  • Verify credentials.
    • Investigate the State's licensing/certification verification systems for all relevant staff types.
    • Determine if State is part of a mutual recognition system. If not, initiate discussion on advantages, disadvantages, and processes involved.
    • Investigate the existence of agreements between neighboring States for waiving license verification in a disaster situation.
  • Establish a Database of Potential Staff (if not already in place).
    • Create a database structure or obtain software to hold relevant information.
    • Identify or select desired fields (contact information, specialty area, schedule, employment, etc.).
    • Enter information into database, and establish a policy for updating database.
  • Review State and Federal Regulations.
    • Review existing regulations on hospital staffing requirements and identify regulations for which a waiver will be needed.
    • Identify waivers in place for declared disaster situations.
    • Work with legislators, boards of medicine, nursing societies, medical societies, and others to initiate changes to existing regulations.
  • Investigate and select a badge/ID system (if not already in place).

Orientation, Training, and Support

  • Provide training on Incident Command System (or another organization system) for key leadership staff.
  • Develop and present mock disaster training exercises for key leadership staff.
  • Develop orientation procedures for each staff type.
  • Identify resources for providing support to workers.

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2. Ramp-Up

Description: When the decision has been made that a surge facility will be required, final decisions on the types of patients to be cared for and services provided will need to be made. Notification to potential staff will go out, and staff will begin arriving. Clinicians will need credentials verified and all workers will be issued surge facility ID badges.

Timeframe: These activities will begin after the disaster has been declared and the decision made that a surge facility will be needed.

Action Checklist

Finalize Identification of Staff Types and Numbers

  • Finalize staff skills needed based on patient types to be cared for.
    • Determine if any additional specialty areas will be needed.
  • Finalize hospital services to be provided.
    • Finalize staff numbers needed.

Identify Sources for Staffing

  • Notify Incident Command (or Management Team Leader) of staffing needs potentially provided by Federal, State, and non-government sources.
    • Activate any mutual aide agreements with surrounding area hospitals.
    • Contact temporary staffing agencies under agreement with staffing needs.
    • Contact identified nursing, medical, dental, veterinarian, and allied health profession schools with staffing needs.
  • Contact identified volunteer programs with staffing needs.

Licensing, Credentials and Privileging Issues

  • Using the database contact all potential staff with information on where and when to report.
  • Verify current status of regulations waiving licensing requirements.
  • Verify credentials.
    • For in-State clinicians, check photo ID, record licensure information, and issue surge facility ID badge.
    • For out-of-State clinicians, determine legal status (i.e., Federalized, from a mutual recognition State, or waived State license requirement due to disaster declaration). Check photo ID, record licensure information, and issue surge facility ID badge.
    • Verify hospital privileges for physicians and nurse practitioners.
    • For all non-clinical workers and volunteers, verify and record identification and issue surge facility ID badge.

Orientation and Training

  • Provide tour of building as workers arrive.
  • Provide orientation to specific units as workers arrive.

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3. Opening Day

Description: Staffing-related activities on opening day will center on verifying staffing needs and the processing and orientation of workers.

Timeframe: Opening day.

Action Checklist

Licensing, Credentials and Privileging Issues

  • Using the database, continue contacting potential staff with information on where and when to report.
  • Continue verification of credentials process for newly arriving workers.
    • For in-State clinicians, check photo ID, record licensure information, and issue surge facility ID badge.
    • For out-of-State clinicians, determine legal status (i.e., Federalized, from a mutual recognition State, or waived State license requirement due to disaster declaration). Check photo ID, record licensure information, and issue surge facility ID badge.
    • For all non-clinical workers and volunteers, verify and record identification and issue surge facility ID badge.
    • Verify hospital privileges for physicians and nurse practitioners.

Orientation and Training

  • Provide tour of building as workers arrive.
  • Provide orientation to specific unit as workers arrive.

Updating Sources for Staffing (Based on Patient Population at the End of Opening Day)

  • Update Incident Command (or Management Team Leader) on any additional staffing needs potentially provided by Federal, State or non-government resources.
    • Update hospitals with mutual aid agreements regarding daily staffing needs.
    • Update temporary staffing agencies with daily staffing needs.
    • Update the identified nursing, medical, dental, veterinarian, and allied health professions schools with daily staffing needs.
  • Update identified volunteer programs with daily staffing needs.

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4. Ongoing Operations

Description: Staffing-related activities during days of operation will center on continuously updating and verifying staffing needs, processing and orienting of any newly arrived workers, assessing staff for stress, and providing support as needed.

Timeframe: Includes the days after opening until the facility shuts down.

Action Checklist

Daily Review of Staff Types and Numbers Needed

  • Verify that staff skills and numbers identified as needed remain appropriate.
    • Determine if any additional specialty areas are needed.
  • Update vendors providing hospital services.

Daily Update Sources for Staffing

  • Update Incident Command (or Management Team Leader) of any changes in staffing needs provided by Federal, State and non-government resources.
    • Update hospitals with mutual aid agreements regarding daily staffing needs.
    • Update temporary staffing agencies with daily staffing needs.
    • Update the identified nursing, medical, dental, veterinarian, and allied health profession schools with daily staffing needs.
  • Update identified volunteer programs with daily staffing needs.

Licensing, Credentials and Privileging Issues

  • Using the database, continue contacting potential staff with information on where and when to report.
  • Continue the verification of credentials process for newly arriving workers.
    • For in-State clinicians, check photo ID, record licensure information, issue surge facility ID badge.
    • For out-of-State clinicians, determine legal status (i.e., Federalized, from a mutual recognition State, or waived State license requirement due to disaster declaration). Check photo ID, record licensure information, issue surge facility ID badge.
    • For all non-clinical workers and volunteers, verify and record identification and issue surge facility ID badge.
    • Verify hospital privileges for physicians and nurse practitioners.
    • Collect surge facility ID badges from workers whose service is ending.

Orientation and Training

  • Provide tour of building as workers arrive.
  • Provide orientation to specific unit as workers arrive.

Staff Support

  • Identify individual(s) skilled in assessing and providing support to stressed workers.
  • Assess staff stress and fatigue levels.
  • Offer support/relief as needed.
  • Identify outside sources for staff support if needed post-event.
  • Debrief with individuals not returning.

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5. Closure

Description: Staffing-related activities at the point of facility closure center on notifying all staffing sources of closure, and preserving all staffing-related records.

Timeframe: When all patients have been discharged or transported back to the major hospital for continued care and staff is no longer needed.

Action Checklist

Informing All Staffing Sources and Vendors of Closure

  • Update Incident Command (or Management Team Leader) to communicate closure to Federal, State, and non-government resources.
  • Notify hospitals with mutual aide agreements.
  • Notify temporary staffing agencies.
  • Notify identified nursing, medical, dental, veterinarian, and allied health profession schools.
  • Notify the volunteer programs.
  • Notify the vendors providing hospital services.

Updating and Preserving Records

  • Update the database to include information on all those who worked at the surge facility.
  • Transfer the database to appropriate management team member or sponsoring hospital.
  • Organize and transfer all paper staffing records (e.g., copies of licenses and certificates, schedules, personnel records) to appropriate management team member or sponsoring hospitals.

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6. Review/Replanning

Description: In the event of a disaster requiring the use of a surge facility, it would be useful to review lessons learned during the operation after closure. Even if the surge facility is not used, decisions and agreements made will need to be revisited on a regular basis to determine continued appropriateness.

Timeframe: After surge facility closure and/or every 6 months.

Action Checklist

Review of Staff Types and Numbers

  • Review patient types treated at surge facility and/or identified as potential patients.
  • Review hospital services provided (or planned to be provided) by surge facility.
  • Review existing vendor agreements for contracted services.
  • Review staff skills used (or planned for use) at surge facility.
  • Review staff numbers used (or planned for use) at the surge facility. Establish a policy/procedure for review of staff types, numbers, and services to be provided.

Review of Sources for Staffing

  • Review the use of Federal, State and non-government resources at the surge facility.
  • Establish a policy on how frequently information on Federal, State, and non-government staffing resources should be updated.
  • Review any mutual aid agreements provided by surrounding hospitals during surge facility operation. Establish a policy for how frequently mutual aid agreements should be reviewed.
  • Review the use of temporary staffing agencies during surge facility operation. Establish a policy for how frequently agreements for supplemental staffing should be reviewed.
  • Review the use of nursing, medical, dental, veterinarian, and allied health profession school students and instructors as surge facility workers. Periodically meet with appropriate persons and establish or review agreements and procedures to be followed in the event of a disaster.
  • Review the use of local volunteers at the surge facility. Establish a policy for who or which agency will be responsible for reviewing local volunteer resources and at what frequency.

Licensing, Credentials and Privileging Issues

  • Review the worker database after surge facility use. Modify based on recommendations.
  • Review the process used (or planned for use) during surge facility operation for identifying workers, verifying credentials, and issuing ID badges.
  • Establish a policy for how frequently the database should be updated with new contact information, which agency will be responsible, and how often the database software should be reviewed for continued utility.
  • Establish a policy and procedure for obtaining and reviewing updated information on current State and Federal regulations on hospital staffing requirements, waivers in place for declared disaster situations, mutual recognition systems, and agreements between neighboring States on waiving license requirements in a disaster.

Review of Orientation, Training and Support Procedures

  • Obtain feedback from surge facility staff on orientation and training and modify procedures based on comments.
  • Develop new mock disaster training exercises for key staff.
  • Establish a policy for a periodic review of orientation, training, and support procedures.

Review of Surge Facility Operations

  • Review the process used (or planned) for opening and closing the surge facility. Modify as necessary.
  • Review the communication processes used for daily staffing updates with staffing sources, internal surge facility staff, and management team. Modify as necessary.

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Security

1. Preplanning

Description: Certain equipment, services, or staffing required for surge use of the shuttered hospital will necessitate the set-up of advance arrangements including identification of providers, contracts, specifications, and protocols.

Timeframe: As soon as a potential surge facility or facilities have been selected based on the inspection of shuttered hospitals, these preparedness arrangements should be initiated. Once finalized, these arrangements should be reviewed every six months to ensure that readiness is maintained.

Action Checklist

Advance Contracts or Formal Arrangements Needed

Equipment:

  • A portable radio communications advance contract is needed with a radio communications vendor. In advance of facility opening, this vendor must conduct radio penetration testing in the building, apply for a radio frequency, and program the repeater (if needed).
  • An advance contract is needed wit a security equipment vendor for monitoring and access control devices (remote door controls, door card readers, cameras). Ideally, the vendor will be able to tour the facility in advance and create an equipment plan.
  • An advance contract and physical procurement of satellite telephone equipment is needed. A fully satellite-based technology is recommended.

Staff:

  • Partner Organization Security Staff. Conduct a review of available security staff from partner organizations on the surge facility team, such as the major hospitals. Outline and formalize arrangements with the partner organizations relative to use of their security staff.
  • Temporary Security Staff. An advance contract will be needed with a security firm if partner organizations cannot provide all needed security staff. This contract must specify: response time, staffing level, uniforms, weapons, training, and security protocols (as developed by the security expert). Ideally, supervisors from this firm will be able to conduct an advance walkthrough of the site and facility.

Identification of Providers Needed

  • Fencing. Area contractor(s) who can install temporary chain-link site fencing must be identified. An advance contract is not required, but an advance communication is recommended. The selected contractor should conduct both installation and removal of this fencing. Site fencing may not be required under all scenarios, the security expert must make this determination.
  • Traffic Control Devices (jersey barriers). Check with local and state highway authorities for availability of this equipment. Identify commercial vendors. Advance contract not required, but advance communication might be useful. Jersey barriers may not be required under all scenarios; the security expert must make this determination.

Advance Notification/Communications Recommended

  • Police and Military Personnel. These staff cannot be arranged for in advance (with the exception of police details), but will simply respond to crisis situations. Ideally the security expert will notify local police and military with details on the planned surge facility, and will discuss possible scenarios and responses.

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2. Ramp-Up

Description: As necessitated by a catastrophic event, the surge facility must progress from the planning phase into an operating facility. The steps listed below must occur to ensure that process.

Timeframe: As soon as the catastrophic event occurs, planned arrangements for the surge facility should be activated so that it can be opened as a functioning hospital within 7 days.

Action Checklist

Equipment

  • Activate communications firm contract. Test radios on-site.
  • Activate security firm monitoring and access control devices contract.
  • Remote access controls, such as card readers, must be installed at all entranceways that will not be locked or manned with security staff.
  • Photo-identification badges must be prepared for all staff members, and programmed for compatibility with card readers.
  • Transport satellite phones to the surge facility, and test communications back to base.
  • Keys must be obtained from current facility owner/operator for use by security staff.

Staffing

  • Activate security staff loan arrangements with partner organizations.
  • Activate security firm staffing contract, including conducting security staff training.

Other Needed Actions

  • Post security procedures and emergency call information in key building locations.

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3. Opening Day

Description: On the day the facility first accepts patients and begins operation, the security expert or designate(s) and key providers should be on-site to ensure that security equipment and staff are in place and functioning effectively to achieve access control and other security functions.

Action Checklist

Providers Needed On-Site

  • Radio communications vendor.
  • Security equipment vendor.
  • Security staffing firm supervisor.

Needed Activities

  • Provide identification/access badges to new staff.
  • Apprise all non-security staff of building security procedures.
  • Review security at all site and building access points.
  • Provide supplemental security staff instructions/training as needed.
  • Identify any needed modifications to established security protocols.
  • Assess if security is needed for patient transport vehicles.

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4. Ongoing Operations

Description: Once needed staffing, equipment, and supplies are in place, and the facility has accepted patients, efforts will be needed to maintain fully operational status.

Timeframe: The operations activities listed below will occur between opening day and until the facility is closed.

Action Checklist

Provider Oversight

Equipment:

  • Have the communications vendor troubleshoot radio issues and supply additional hand-helds as needed.
  • Have security equipment vendor supply additional access control and monitoring equipment and maintain existing equipment as needed.
  • Security badges must be provided to new staff.

Staffing:

  • On-going oversight of security firm staffing contract to ensure appropriate staffing levels and observance of protocols.

Special Considerations for Extended Facility Duration:

  • Building access control achieved through staffing or temporary devices might be replaced with fixed technology such as permanent door card readers.
  • Site access control achieved through staffing might be replaced with installation of fixed technology such as fencing or security cameras.

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5. Closure

Description: Shutdown of the surge facility will require removal of equipment and termination of ongoing contracts or arrangements.

Timeframe: Once all patients can be discharged or transported back to the major hospital for continued care, and there is no ongoing surge capacity need, the facility can be closed. The shutdown should be expedited so that the facility can be returned to the control of the existing owners quickly, and should be possible within a matter of days.

Action Checklist

Equipment Removal

  • Have radio communications contractor remove repeater and take back hand-held radios.
  • Have fencing contractor remove site fencing.
  • Have local or state highway authority or vendor remove jersey barriers.
  • Have security equipment contractor remove portable/temporary access control and monitoring equipment.
  • Retrieve staff identification badges.

Termination of Contracts/Formal Agreements

  • Notify partner organizations that borrowed security staff is no longer necessary.
  • Terminate security firm staffing contract. This may require a step-down approach whereby limited security staff remains until the removal of assets from the facility has been completed.

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