The Alternate Care Site (ACS)/Expanded Treatment Area (ETA) Planning Template [Word 9M] was developed by the New Jersey Department of Health (NJDOH) to assist healthcare facilities and communities with their planning efforts for alternate care in response to medical surge.

This template is scalable in size for the number of beds, medical supplies, equipment and pharmaceuticals and can be adjusted based upon available resources or the medical surge emergency.  It should be noted that the establishment of an ACS/ETA is a step of last resort to be used only after all other healthcare system resources have been exhausted.

The official release of the ACS/ETA Planning Template took place on October 2, 2013 during the NJ Preparedness Initiatives Webinar [PDF 5.5M].  The webinar agenda included opening remarks by Mary O’Dowd MPH, Commissioner of Health; a presentation on Sheltering Guidelines for Children and Families [PDF 129K] by Dr. Allison Blake, Commissioner of the Department of Children and Families; and a presentation on the ACS/ETA Planning Template by Paula Van Clef MPH, Public Health Planner.

The New Jersey Department of Health has developed an Alternate Care Planning Webinar that may be viewed at https://share.dhs.gov/p6086jb5i28/ through the Homeland Security Information Network (HSIN) Connect website.  This 22-minute webinar has been recorded by the New Jersey Department of Health - Public Health Infrastructure, Laboratories and Emergency Preparedness (PHILEP).  The webinar will provide you with an overview of the ACS/ETA Planning Template which is a planning document that will ultimately help New Jersey respond to the next public health emergency, especially one that can stress the capacity of our healthcare facilities.  For the best sound, please adjust the volume of your speakers. 

These forms may be helpful for Alternate Care Site (ACS)/Expanded Treatment Area (ETA) planning.  Please feel free to customize these forms to meet your healthcare facility’s or community’s needs.  You may add your facility/community logos and names at the top of the forms and revise them as needed. 

ACS/ETA Forms Available in Microsoft Excel [Excel 1.6M]

• Alternate Care Site (ACS) Facility Assessment Checklist
• Expanded Treatment Area (ETA) Space Assessment Checklist
• ACS/ETA Contact List
• ACS/ETA Equipment List
• ACS/ETA Pharmaceutical List
• ACS/ETA Staff Assignments
• Nurse's Triage/Assessment/Notes – Page 1
• Nurse's Triage/Assessment/Notes – Page 2
• ACS/ETA Nurse's Disaster Notes
• Physician Orders & Treatment Record
• ACS/ETA Progress Notes
• ACS/ETA Progress Notes-Health Education
• ACS/ETA Progress Notes-Crisis Counseling/Debriefing Unit
  

ACS/ETA Forms

• ACS/ETA Sample Patient Flow Algorithm [Visio 55k] [pdf 20k]
• ACS/ETA Sample Floor Plan [Visio 551k] [pdf 104k]
• ACS/ETA Incident ICS Chart [Visio 281k] [pdf 26k]
• ACS/ETA Branch of Operations ICS Chart [Visio 3380k] [pdf 30k]
• ACS Master List Form [word 346k]
• ETA Properties Operated by Hospital Form [word 346k]
• Facility Transfer Short Form Medical Record [word 414k]
• Facility Transfer Summary Form [word 363k]
• HICS 252 Personnel Time Sheet [word 56k]
• HICS 253 Volunteer Staff Registration [word 60k]
• HICS 254 Disaster Victim-Patient Tracking Form [word 359k]
• HICS 259 Hospital Casualty-Fatality Report [word 371k]
• Medical Equipment Inventory Form [word 365k]
• Rapid Discharge Orders [word 345k]
• Rapid Disharge Prescription Order [word 349k]
• Resource Accounting Record-Supplies Donated Form [word 77k]
• Resource Accounting Record-Supplies Received Form [word 63k]
• Vendor Considerations Checklist [word 52k]