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Terrorist Threat Response Plan

To establish the actions taken when Sandhills Regional Medical Center has received information regarding explosive, pyrotechnic, thermonuclear, biological, or chemical devices placed within this building.

This policy applies to all persons on the property of Sandhills Regional Medical Center.

1. To identify the hospital's response and outline an orderly reaction when a threat is received.
2. To protect life and property to the maximum extent possible.
3. To provide effective communication during an existing or anticipated terrorist threat or attack.

Terrorist Threat; any communication either verbal, visual or written that describes, implies or defines an action that has the potential to cause personal injury or property damage directed at the hospital, its staff, patients, visitors or guests.

Terrorist Attack; the introduction by any means, of any device, animal or person, capable of creating a risk, to the life or health of any person, or the integrity of property, to Sandhills Regional Medical Center buildings or property.

Responsible Authority; any person given jurisdiction for response by the governing bodies of the City of Hamlet and/or Richmond County for the particular threat involved.
Bomb; any device of a chemical, biological, radiological, or explosive nature designed to detonate or release it’s attacking agent automatically upon a predetermined triggering event. (i.e. timer, radio signal, trip wire, exposure, etc.) 

Chief Executive Officer will ensure that the Security Plan meets the needs of the facility.

Assistant Administrator will assist the Chief Executive Officer to ensure compliance with the Security Plan.

Safety Officer will advise the Chief Executive Officer to ensure the Security Plan meets the needs of the facility, and is implemented in an effective and efficient manner.

Human Resources Department shall provide appropriate identification badges for employees, vendors, and contractors.

Director of Marketing and Public Relations shall represent the hospital as Official Spokesperson when directed by, or in the absence of, the Chief Executive Officer.

All Employees will comply with the policy and procedures of the Security Plan.

1. A terrorist threat against the hospital may be received at any time by any means and must be reported to the “Administrator on Call” IMMEDIATELY.

2. The only persons to authorized to represent the hospital, as official spokesperson to the press is either the Chief Executive Officer or the Marketing Manager.

3. The Administrator on Call will call a “Director’s Meeting” announced for the Education Conference Room.

4. Once a threat is received by:

a. Contaminated Person:
1. Maximize the distance of separation between triage and admitting personnel and the potentially contaminated person.
2. Wear all appropriate personal protective equipment.
3. Notify the Administrator on Call.
4. Move the contaminated person only via designated decontamination routes. (See Radiation Protection Plan)
5. Ensure the contaminated person is quarantined.

b. Phone:

1. Access yellow phone card and complete while attempting to keep caller on line.
2. Keep line open after caller has hung up.
3. If possible, have someone else notify the Administrator on Call. 
4. Call a “Director’s Meeting.”

c. Written:

1. Do not handle material; every effort must be made to retain evidence.
2. Notify “Administrator on Call”.
3. Call a “Director’s Meeting”

d. Unknown material or suspicious parcel or package:

1. Do not handle material; every effort must be made to retain evidence.
2. If the package has already been opened, do not further disturb its contents. REMAIN WHERE YOU ARE!
3. Notify Administrator on Call and await trained response personnel.
1. In instances involving potential airborne pathogens: 
a. Announce a code yellow to the affected area.
b. Announce “Code Green” three (3) times via the overhead page system.


c. Shut down all air handling equipment by activating the fire alarm system, and notifying the PBX operator to silence alarm and notify Hamlet Fire Department that a potential “Hazardous Material Spill” has occurred.
d. PBX operator is to announce via overhead paging system to disregard the fire alarm.
e. Do not leave or disturb the material/package until told to do so by responsible authority.
f. The building will remain in Code Green until released by responsible authority.
g. If necessary, any or all of the elevators may need to be secured to prevent inadvertent contamination.
h. If required or desired, The Administrator on Call may call a “Director’s Meeting”, or activate the Command Center.
i. Once the release of the potential airborne pathogen has been isolated, the air handlers for the affected area can be manually secured and the fire alarm system reset to return the ventilation for unaffected areas to normal operation.
2. In cases not involving potential airborne pathogens, once department managers have assembled in the Education Conference Room, the Chief Executive Officer or designee will set Threat Condition Bravo.

3. The following personnel will be notified:
a. Richmond County Office of Emergency Management 997-8238.
b. Richmond County Sheriffs Department 997-8283.
c. Hamlet Police Department 582-2551.
d. Hamlet Fire Department 582-2441.

4. The decision will be made to either attempt to locate and neutralize the device or prepare to evacuate.
5. If the decision is to prepare to evacuate refer to the evacuation plan under Emergency Preparedness.
6. If the decision is to locate and neutralize then proceed to step 7.

7. The Chief Executive Officer or designee shall:
a. Activate the Command Center
b. Initiate “Phased Recall” if (and only if) additional staff is required.
c. Direct the initiation of area searches by department.

8. Department Managers shall return to their departments and;
a. Organize search teams.
b. Commence search of their designated area(s). See (Enclosure 17)
c. Report to the Command Center results of area searches.
d. Await instructions.

9. Personnel shall:
a. Search assigned areas utilizing the following procedure:
1. Move to various parts of the room and stand quietly with both eyes shut, and listen for a clockwork device.
2. Divide the room into equal parts or as near equal as possible.
3. The first searching sweep will cover all items resting on the floor up to hip height.
4. Both people go to one end of the room division line (step A.) and start from a back?to?back position.
5. Each person now starts searching his/her way around the room, working toward the other person.
6. When the two people meet, they will have completed a "wall sweep" and shall then work together and check all items in the middle of the room up to the selected hip height.
7. The two people return to the starting point and repeat the searching techniques from the hip to the chin or top of the head.
8. The third sweep is then made from the chin or top of the head to the ceiling.
9. The fourth sweep involves investigation of a false or suspended ceiling in this area.
10. If an object is discovered that is suspect or potentially an explosive device, DO NOT ATTEMPT TO TOUCH OR MOVE the object.
11. Call the Control Center and report the device immediately, and await further instructions.

b. Mark door or cabinets with paper tape as they are checked.
c. Inform the Command Center of results upon completion of search.

10. Do not use elevators until checked by Engineering and cleared for use.
11. Request visitors to remain calm and remain where they are until the “all clear” is announced.
12. Visitors who insist on leaving the hospital must be allowed to do so, however, close attention should be paid in order to provide an accurate description of the person(s) involved if necessary.
13. Never stand in front of a door when opening it and always open the door slowly.
14. Do not leave your department unless told to do so.

1. When bomb or suspected object is discovered, the following actions will be taken:

b. Clear immediate area.
c. Inform Command Center and await orders.

2. The Command Center will notify the appropriate agency for disposal.

Only qualified personnel from the appropriate agency will attempt device removal or disposal. 

Only the Administrator will release information concerning a terrorist threat to the public or news media.

1. At any time, all or portions of the Fire Plan, may be implemented by the Administrator.
2. At the discretion of the Chief Executive Officer, should detonation/activation occur or believed to be imminent, the hospital may be evacuated in accordance with the Evacuation Plan (Policy 1502).
3. Should a detonation occur, damage to the hospital would be contained/combated in accordance with the Fire/Internal Disaster Plan (Policy 1301) as long as there is no chemical, radiological or biological threat.

Terrorist threat response will be determined by the order of the Administrator or his alternate. The all clear will be given by the Command Center to the department managers via phone or messenger.