School of Medicine Nephropathology Laboratory: Emergency Preparedness Plan

Title

School of Medicine Nephropathology Laboratory: Emergency Preparedness Plan

I. Principle

To ensure that UNC Nephropathology responds appropriately during emergencies, crises, disasters, or disaster drills, this policy has been developed to clarify disaster response and centralize reporting of available personnel.

II. UNC Health Care System Emergency Preparedness Procedures Manual

Specific policies for multiple types of disasters are outlined in the UNC Health Care System Emergency Preparedness Procedures Manual located in all UNC Health Care McLendon Lab sections. All lab departments have their Business Continuity of Plan specific for their lab sections. These documents are located in the specific departments. Additionally, the UNC Health Care Emergency Operations Plan can be found on the UNC Health Care Intranet.

III. Disaster Notification

In times of adverse weather or other times when the University is closed but Nephropathology may decide to open:

A. Communication Plan

  1. Audience: Employees of Nephropathology.
  2. Responsibility: The laboratory supervisor, Kimberly Burch, the Director, Volker Nickeleit, or the Associate Director, Sharan Singh, will contact the Essential Employees about whether or not the clinic will be open on a given day. If the employee does not receive notification, it is still the employee’s responsibility to contact one of the before mentioned persons to obtain the status of closure. The clinic may be open a partial day or have a delayed opening.
  3. Medium: Employees will be notified by email, phone call or text message.
  4. Content: Employees will be informed who will need to come into the clinic, at what time, for how long, and what they are to accomplish while at work. If the employee feels that they cannot make it to campus safely it is at this time that they must tell the supervisor of their concern so that another employee can be contacted or an alternate means of getting the employee to campus will be found.
  5. Timing/Frequency: This information will be presented each time the University is closed during normal business hours.

IV. Disaster Response

Different types of disasters require different responses. Below is a summary of disaster codes, descriptions, and general responses.

Disaster Codes, Descriptions, and General Reponses
Disaster Description Response
Fire Fire
  • Evacuate the building via the stairs, Nephro staff meet behind the Beach Cafe.
Loss of Staff Due to public health concerns, furloughs, adverse weather, etc.
  • For short period of time: Minimum # of technicians needed: 2, minimum # of pathologists needed: 1.
Loss of Utilities (i.e. water, electricity)
  • Multiple outlets in BBB are on emergency backup supply.
  • Electricity needed for all equipment, refrigerators, freezers, etc.
  • If a power outage occurs during business hours and the lights go out there are flashlights behind both doors in the lab.
  • Must have electricity for hoods and water for LM staining.
  • Would have to procure bottled water or alternate source of water.
(i.e. phones, computers, Internet access)
  • Loss of computers and Internet access: this would be no access to Pathagility (patient report worksheet for outside (non-UNC) kidneys), Epic (patient reports for UNC kidneys), or Beaker (Histology stains for UNC patients). Access is possible from “outside” computers with user name and password. Hard copies of all patient reports are still maintained on site. Patient reports (preliminary and final) would be handwritten and conveyed to Drs by phone, fax and/or mail. In-house (UNC) reports would be delivered via internal mail service. Stain requests through UNC Histology would be done in person.
  • Loss of phones: communications would be done by email.
  • Total loss of telecommunications: reports would have to be handwritten and mailed.
Entire Loss of Facility (due to fire, tornado, gas release, etc.)
  • Lab would have to be re-set up where there was a functional hood, electricity, lab equipment (see minimal equipment), sink, refrigerator, -80 freezer.
  • Equipment:
    • EM scope - Anatomical Pathology (UNC Hospital), Chapman Hall - Chapel Hill Analytical & Nanofabrication Laboratory;
    • Ultramicrotome - Chapman Hall - Chapel Hill Analytical & Nanofabrication Laboratory;
    • Fluorescent scope - Dermatological Pathology, School of Public Health;
    • Cryostat & Microtome - Histology Research Core Facility (GlaxoSmithKline Research Building).
Active Shooter Shots are being fired or a weapon is displayed by a non-law enforcement officer in or near UNC Hospitals.
  • All staff members should lock themselves in the nearest office, conference room, or other securable area, cover the windows, move patients, visitors and staff out of the waiting rooms or other open areas if possible; keep quiet and act as if no one is in the room; do not answer the door and call 911.
  • Then click on this specific code on the right hand side of the page on the screen.

V. Code Triage External and Code Triage Internal Disaster Response (Mclendon Labs)

A. Administrative Office (or Core Lab)

1. Responsibilities

i. Information

​​​​The Administrative Office (or Core Lab during weekdays 1700-0730, weekends, and holidays) may call the Disaster Command Center at 966-2393 to obtain as much information as possible, including nature of disaster and potential number of victims if this information has not already been communicated. Notification steps (below) should not be delayed if the Disaster Command Center is not manned yet or is unable to provide further information.

ii. Notification

Weekdays 0730-1700

The Administrative Office must notify the following people or laboratories (see appropriate Disaster Plan Checklist):

  • Medical Director and/or Director (Dr. Herb Whinna)
  • Laboratory Director (Dr. Volker Nickeleit)

Weekdays 1700-0730, Weekends, Holidays

The Core Lab must notify the following people or laboratories (see appropriate Disaster Plan Checklist):

  • Medical Director and/or Director
  • Laboratory Director
  • LIS (LIS on-call, if no staff on site), Microbiology, Phlebotomy, TMS
  • Lab Manager(s) of Anatomic Pathology

The Director may decide to notify Lab Manager(s) of Outreach, Cytogenetics and Family Practice if needed.

iii. Personnel Count

The Laboratory Supervisor (Kimberly Burch) or the Director (Volker Nickeleit) must tally the number of available laboratory personnel as each person calls in.

B. Director (or Designee)

1. Responsibilities

Disaster Plan Checklist

Monday-Friday 0730-1700

Please see the Laboratory Supervisor or Director for a list of employee's home and cell phone numbers.

Contact Information
Contact Person Office Phone # On-Site Available Personnel Off-Site/Off-Site Available Personnel
Charles Jennette      
Volker Nickeleit 2-2421    
Sharan Singh 2-2421    
Kimberly Burch 2-2421    
Branden Barrett 2-2421    
Sheila Deloney 4-9172 4-1476  
Computer Backup 919-962-HELP    
Emergencies
(police dispatch)
919-962-6565    
EH&S 919-962-5507    
Freezer Alarms 434-264-5340    
Freezer Failure 919-962-3456    
Generators 919-201-2782    
Heating/Cooling Problems 919-962-3456    
HVAC 919-962-3456    
Red Outlets 919-962-3456    
Sewer Backup 919-962-3456    
Utility Service Outage

- After Hrs emerg.
919-962-8394

919-962-1167
   
Water Outage 919-962-3456    
Command Center # 919-966-2393 Total # of Personnel:______________ Time Called:______________

Date: ____________________                      Signature: _________________________________________

The Utility and Systems Failures-Basic Staff Response information can be found in the UNC Health Care Emergency Operations Plan.

VI. History

Created: 10/2/15 LHR

Replaces: N/A

Revisions:

  • 6/17/20 KDB
  • 7/13/18 LHR
  • 6/22/16

Details

Article ID: 134339
Created
Sun 7/11/21 10:40 PM
Modified
Mon 3/6/23 12:51 PM
Effective Date
If the date on which this document became/becomes enforceable differs from the Origination or Last Revision, this attribute reflects the date on which it is/was enforcable.
06/17/2020 12:00 AM
Issuing Officer
Name of the document Issuing Officer. This is the individual whose organizational authority covers the policy scope and who is primarily responsible for the policy.
Issuing Officer Title
Title of the person who is primarily responsible for issuing this policy.
Medical Laboratory Supervisor
Last Review
Date on which the most recent document review was completed.
02/01/2023 12:00 AM
Last Revised
Date on which the most recent changes to this document were approved.
06/17/2020 12:00 AM
Next Review
Date on which the next document review is due.
02/01/2024 12:00 AM
Origination
Date on which the original version of this document was first made official.
10/02/2015 12:00 AM
Responsible Unit
School, Department, or other organizational unit issuing this document.
School of Medicine - Nephropathology Laboratory