Protocols 54–59
Emergency Department Protocol Commons
Consultation Edition, Version 0.9
Phase IX addresses six interdependent operational systems that enable an emergency department to continue providing safe care during infection threats, crowding, disasters, infrastructure failure, violence and organizational learning after harm.
The protocols provide structured pathways for infection prevention and outbreak response, crowding and capacity escalation, mass-casualty and disaster management, essential-service downtime, security and staff safety, and quality assurance—from early warning and incident activation through command, maintenance of life-critical services, coordinated escalation, recovery, reconciliation, debriefing and sustained improvement.
These protocols are intended for professional review and responsible local adaptation. They are not approved clinical policies, emergency plans or standing orders and must not be implemented without verification against current guidance, public-health and occupational-safety law, local emergency and disaster plans, infection-control requirements, approved staffing and licensed spaces, fire and evacuation rules, utilities and oxygen capacity, cybersecurity and data-protection requirements, diagnostic and equipment contingencies, security and police arrangements, staff-support systems and institutional governance requirements.
Download Phase IX
The complete phase may be downloaded in either of the following formats:
Download the complete Phase IX package — PDF and editable Word copies
Download the Phase IX editable Word package for local adaptation
Readers may also review the individual PDF consultation copies below.
How to Review This Phase
Reviewers are not expected to comment on all six protocols.
Please select the protocols most relevant to your experience and consider:
Clinical and operational safety and accuracy
Infection prevention, isolation, PPE, ventilation and outbreak readiness
Crowding measurement, boarding responsibility and whole-hospital escalation
Incident command, mass-casualty triage, patient tracking and CBRN safety
Backup power, oxygen, communications, information systems and manual workflows
Laboratory, imaging, equipment and biomedical-engineering contingencies
De-escalation, weapons, lockdown, missing-patient and staff-safety procedures
Quality measures, audit, simulation, incident review and action tracking
Equity, disability access, staff wellbeing and patient or family communication
Regional coordination, referral, evacuation and continuity arrangements
Resource-variable and small-island realities
Important omissions or unnecessary complexity
Please submit a separate feedback form for each protocol being reviewed.
Submit feedback on a Phase IX protocol
Protocol 54 — Infection Prevention, Isolation, and Outbreak Response
This protocol provides a practical framework for preventing transmission while preserving timely emergency assessment, resuscitation, diagnosis and compassionate care.
It covers standard and transmission-based precautions, syndromic screening, source control, patient placement, personal protective equipment, environmental safety, occupational exposure, surveillance, public-health notification, outbreak activation, continuity of care and quality governance.
Read or download the PDF consultation copy
Protocol 55 — Emergency Department Crowding, Boarding, Surge, and Capacity Escalation
This protocol addresses emergency-department crowding, access block, boarding and recurrent surge as whole-hospital and whole-system patient-safety risks.
It covers early warning, operational-status levels, protected resuscitation capacity, executive and whole-hospital escalation, safe care of boarded patients, surge areas, full-capacity actions, ambulance and regional coordination, recovery and governance review.
Read or download the PDF consultation copy
Protocol 56 — Mass-Casualty Incident and Disaster Response
This protocol provides an all-hazards framework for preparing for, activating, managing and recovering from a mass-casualty incident or disaster affecting the emergency department and hospital.
It covers hospital incident command, facility-based mass-casualty triage, clinical zones, one-way patient flow, patient tracking, surge, resource stewardship, CBRN safety, family reunification, fatality management, continuity of routine emergencies, recovery and after-action learning.
Read or download the PDF consultation copy
Protocol 57 — Power, Oxygen, Information-System, Laboratory, Imaging, and Equipment Downtime
This protocol addresses loss or degradation of the essential utilities, information systems, diagnostics and equipment on which safe emergency care depends.
It covers early incident recognition, clinical command, protection of life-support capacity, backup power and oxygen, manual identity and documentation workflows, laboratory and imaging degradation, equipment substitution, cybersecurity considerations, transfer thresholds, staged restoration and post-downtime reconciliation.
Read or download the PDF consultation copy
Protocol 58 — Security, Violence, Missing Patients, and Staff Safety
This protocol provides a clinically grounded and legally aware pathway for preventing and managing violence, aggression, threats, weapons, unauthorized access, missing patients and other security incidents.
It covers dynamic risk assessment, treatment of reversible clinical causes, trauma-informed de-escalation, security and police response, least-restrictive intervention safeguards, weapons and lockdown, missing or absconded patients, staff care, factual reporting and organizational learning.
Read or download the PDF consultation copy
Protocol 59 — Emergency Department Quality Assurance, Audit, Simulation, and Serious-Incident Learning
This protocol establishes a continuous emergency-department quality system that measures care, identifies risk, tests readiness and verifies that learning produces sustained improvement.
It covers quality governance, meaningful measurement, clinical audit, quality improvement, case and mortality review, proportionate incident response, open communication, simulation, staff and patient support, action tracking, re-audit and organizational learning.
Read or download the PDF consultation copy
Submit Feedback
Feedback from emergency clinicians, nurses, infection-prevention and public-health teams, hospital executives, bed managers, inpatient and critical-care services, ambulance and transfer services, disaster and incident-command personnel, facilities and engineering teams, laboratory, imaging, pharmacy, blood-bank and biomedical-engineering services, information-technology and cybersecurity personnel, security and police partners, occupational-health and staff-support teams, educators, simulation faculty, quality and patient-safety personnel, patient representatives and other relevant reviewers is welcomed.
Please identify:
The protocol number
The relevant section or page
The concern or recommendation
Suggested replacement wording where possible
Supporting evidence or local experience
Whether the issue may represent an urgent patient-safety or operational-safety concern
Submit feedback on the Emergency Department Protocol Commons
Complete Protocol Index
Browse all 59 protocols and download individual PDF or editable Word copies
Navigation
Return to Phase VIII — Complex Disposition and End-of-Life Care
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This completes the nine-phase Emergency Department Protocol Commons Version 0.9 consultation series.