1
Waiora Waikato Campus
Incident Response
Guidelines
For use in conjunction with 99777 Emergency Procedures
Flip Chart, First Response Team Guidelines, Department
Emergency Response Plans [DERPS], Site Health
Emergency Plan
Incident Response Guideline to be used with Waiora Waikato Health Emergency Response
Plan Final Document March 2016. Trevor Ecclestone/Delwyne Martin
[Type text]
link to page 10 link to page 12 link to page 13 link to page 14 link to page 15 link to page 16 link to page 18 link to page 20 link to page 21 link to page 22 link to page 23 link to page 23 link to page 28 link to page 28 link to page 28 link to page 28 link to page 28 link to page 29 link to page 30 link to page 31 link to page 32
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1.1 Establishing & Disestablishing the Emergency Operations Centre ......................... 10
1.2 Minor Security Incident ........................................................................................................ 12
1.3 Major Security Incident ........................................................................................................ 13
1.4 Information in a Hostage Situation ................................................................................... 14
1.5 Clinical Incident ...................................................................................................................... 15
1.6 Mass Casualty – Clinical Operations Response ............................................................ 16
1.7 Electricity Incident ................................................................................................................. 18
1.8 Sewage Incident ..................................................................................................................... 20
1.9 Water Incident ......................................................................................................................... 21
1.10 Steam Incident .................................................................................................................... 22
1.11 Reticulated Gas Incident ................................................................................................... 23
1.12 Hazardous Material, Chemical, Biological or Radiological Incident ...................... 24
1.13 Communications Incident ................................................................................................. 28
IS Network (computers etc) .................................................................................................. 28
Telephones (desk phone) ...................................................................................................... 28
Paging System ......................................................................................................................... 28
Mobile Network......................................................................................................................... 28
Fax failure .................................................................................................................................. 29
1.14 Fire Escalation ...................................................................................................................... 30
1.15 Earthquake/Building Damage ........................................................................................... 31
1.17 WH/HRBC Site Clinical Area Evacuation ....................................................................... 32
1.18 Waikato Hospital Ward/Unit Relocation Matrix………………………………………….104
Incident Response Guideline to be used with Waiora Waikato Health Emergency Response
Plan Final Document March 2016. Trevor Ecclestone/Delwyne Martin
[Type text]
3
ABBREVIATIONS USED IN THIS DOCUMENT
A&E
Accident & Emergency Centre
IAP
Incident Action Plan
AGM
Assistant Group Manager
IC
Incident Controller
Absent without Leave (Missing
AWOL
ICU
Intensive Care Unit
Patient)
Importance Level 4 (earthquake
BAU
Business as usual
IL4
protection)
BCP
Business Continuity Plan
IM
Incident Management
BEC
Bryant Education Centre
IMT
Incident Management Team
CA
Clinical Advisor
IOC
Integrated Operations Centre
Chemical Biological Radiological
Information Technology/Information
CBR
IT/IS
(Hazard)
Services
CD
Civil Defence
MOoH
Medical Officer of Health
Civil Defence Emergency
CDEM
MOH
Ministry of Health
Management
CEO
Chief Executive Officer
MH
Mental Health
Co-ordinated Incident Management
CIMS
MSDS
Material Safety Data Sheet
System
CISD
Critical Incident Stress Debriefing
Mtg
Meeting
CNM
Clinical Nurse Manager
MDCU
Medical Day Care Unit
COO
Chief Operating Officer
MCC
Meade Clincial Centre
Acronym used by St John to assess
COP
Clinical Operations Plan
METHANE
major incident response
CSU
Central Sterilising Unit
MIP
Major Incident Plan
CYFS
Child, Youth & Family Services
MCI's
Mass Casualty Incidents
Department Emergency Response
DERP
NGO’s
Non Government Organisations
Plan
DHB Svcs
District Health Board Services
NICU/NBU
Neonatal New Born Unit
DHB
District Health Board
NM
Nurse Manager
Duty Nurse Manager (Interchangeable
DNM
NZFS
New Zealand Fire Service
with FC)
DON
Director of Nursing
OPR
Older Persons & Rehabilitation
DOSA
Day of Surgery Admission Unit
OR/OT
Operating Theatre
EAP
Employee Assistance Program
PACU
Past Anaesthetic Recovery Unit
ED
Emergency Department
PHU
Public Health Unit
EM Manager Emergency Management Manager
P&I
Property and Infrastructure
EM Plan
Emergency Management Plan
P&I
Planning & Intelligence
EOC
Emergency Operations Centre
PPE
Personal Protective Equipment
Building Fire Control Monitoring &
EWIS
RACE
Remove,
Activate,
Contain,
Evacuate
Mgmt System
EWIS PA
Public announcement system
RC
Responsibility Centre
SYSTEM
attached to EWIS
Facilities Coordinator
FC
RRC
Regional Referral Centre
(interchangeable with DNM)
FRT
First Response Team
R/T’s
Radio - Telephones
Safety/Assess/Broadcast, Back up/
GM
Group Manager
SABC
Campaign plan
GP's
General Practitioners
SDAU
Same Day Admission Unit
HDU
High Dependancy Unit
SPOC
Single Point of Contact
HM
Hospital Manager
SR/Sit Rep
Situation Report
HPO
Health Protection Officer
TXT
Text message
HR
Human Resources
UPS
Uninterrupted Power System/Supply
HRBC
Henry Rongomau Bennett Centre
VC
Voice Communications (switchboard)
HRH
Hilda Ross House
WDHB
Waikato District Health Board
H&S
Health & Safety
WH
Waikato Hospital
Waikato Hospital/ Henry Rongomau
HW
Health Waikato
WH/HRBC
Bennett Centre
Incident Response Guideline to be used with Waiora Waikato Health Emergency Response
Plan Final Document March 2016. Trevor Ecclestone/Delwyne Martin
[Type text]
4
OVERVIEW
This document provides activity guidelines associated with specified events and links response
activity with the 99777 Emergency Flip Chart, Department Emergency Response Plans (DERPS)
and the Waiora Campus Health Emergency Plan.
In all responses to an emergency incident or major planned event a Coordinated Incident
Management System (CIMS) will be established based on the standard hospital management on
call structure. CIMS role work sheets are included in the Waiora Campus Health Emergency Plan.
This provides coordinated management activity supporting the many aspects of the response
through to the All Clear/Stand down including debrief event review and identified follow up
activities.
All departments on the Waiora Waikato Campus will have their own Department Emergency
Response Plan which defines those departments’ specific requirements in an emergency
response or planned major event and return to business as usual. The DERP also contains a
generic section providing response guidelines for reference in common events. It is the
responsibility of every staff member to be familiar with the Waiora Campus Emergency Flip Charts
and their department’s emergency response plan.
Every emergency incident and major planned event response undergoes a review process which
provides feedback opportunity for all staff. One of the outcomes of this process may be revision of
the content of the Waiora Waikato Campus Health Emergency Plan and/or the Incident Response
Guidelines’, therefore utilising the electronic version is recommended as printed versions may
become outdated without the readers knowledge. Version control is provided on the documents.
In the event the DERPS require updating outside of the predefined review date a communication
process will be initiated to ensure all staff are aware and have opportunity to participate in their
departments review and update.
Incident Response Guideline to be used with Waiora Waikato Health Emergency Response
Plan Final Document March 2016. Trevor Ecclestone/Delwyne Martin
[Type text]
5
MANAGING EMERGENCIES
Incident Response Guideline to be used with Waiora Waikato Health Emergency Response Plan Final Document March 2016. Trevor
Ecclestone/Delwyne Martin
[Type text]
6
Responding to an Emergency Incident
Internal
External
Mass Casualty notification
1
via ED & St John. St John
# n
Emergency Services
Public Health Incident
oi
Planned Event requiring
Regional or National event
t
99777 as per HW
Direct Observation or
Coordination Centre (ESCC) notified via Medical Officer
ac
Emergency Response
via SPOC to DNM
if
Emergency Flip Chart
reported
will issue a Txt message
of Health/Health
it
framework
(email/txt)
o
with contact details for the
Protection Officer
N
initial response
teleconference
2 # no
ED notifies DNM &
DNM initiates notification
it
DNM initiates Mass
ac
First Response Team notified
CIMS team established
appropriate call tree
of on call Asstistant Group
if
Casualty Call Tree
it
initiated
& Nurse Manager
o
N
Clinical Incident
Non Clinical Incident
n
CIMS & Clinical response
oit
First Response & affected
Planning and back out
Incident management (CIMS) Structure and clinical
teams established
avi
Clinical Response team
t
Infrastructural teams
processes established
response teams established
including regional &
c
A
attend
attend
national liaison teams
n
oi
Incident managed, SABC
Clinical & support response
ta
Clinical management &
Clinical and support response requirements assessed
r
applied & recovery plan
Planned event proceeds
requirements assessed &
e
p
SABC protocol applied
and initiated, SABC applied
O
established
initiated, SABC applied
Incident Controller in
Incident Controller
ra
Incident Controller
Incident Controller
conjunction with Medical announces stand down/all
el
Senior clinical responder
Planned event completed
C l
announces all clear and
announces all clear and
Officer of Health announce clear in conjunction with
l
terminates response
or back out declared
A
response closed down
response closed down
all clear & response closed
regional or national
down
Incident Control
Incident Response Guideline to be used with Waiora Waikato Health Emergency Response Plan Final Document March 2016. Trevor
Ecclestone/Delwyne Martin
[Type text]
ACTIVATION/ESCALATION OF EMERGENCY RESPONSE PLAN
Level
Who may be involved
Level 1
There is an internal or external incident or
24hrs:
Preparedn
anticipated conditions that may:
Duty Nurse Manager
ess
affect services and the public in or
Senior clinical staff
/Readiness
adjacent to the hospital or
Senior non-clinical support
Result in pressure on the hospital or health
staff
service.
Emergency Department
Require the participation of the hospital or
Public Health (HPO or
utilisation of resources and/or equipment in
MOoH)
the response to the alert.
Group Managers
Examples: Fire alarm, Airport alert, a number
of patients beginning to present with similar
Response: A Situation report
symptoms, threat of industrial action, etc.
and Action plan is developed to
ensure preparedness to meet
possible incoming demands.
Level 2
A major incident has been notified, occurred or
24hrs:
is imminent and co-ordination of the hospital or Duty Nurse Manager
health service emergency response is
Senior clinical staff
immediately required. Affected services
Senior non-clinical support
activate appropriate response plans.
staff
Group Managers
Examples: major transport crash, fire, public
Emergency Department
health emergency, industrial action, utility or
Public Health (HPO or
building failure, supply failure, etc.
MOOH)
WH on call team mobilised
Manager-Emergency
Management Planning
Media – Communications on
call
Fire
Police
Civil Defence
Response: An EOC is
established.
Coordinated
Incident Management System
(CIMS) structure established.
Initial situation report and
incident action plan drafted.
Level 3
The situation is escalating and the capability of
As above, plus:
the hospital or health service to cope is
Ministry of Health
Critical
becoming overwhelmed. More resources
Group Manager(s)
and/or equipment or support are required.
Fire, Police, St John
Hamilton City / Regional Civil
Examples: Civil Defence declaration, national
Defence / National Civil
pandemic/regional public health emergency,
Defence
major mass casualty incident, building failure,
Other agencies/utilities, e.g.
etc.
Telecom, Meridian Energy,
etc.
Neighbouring
Hospital/Health Services
(DHB and non-DHB)
7
Ministry of Health
Response:
The CIMS Incident
management Team identifies
resources and equipment
required
Defined assistance and
advice is requested from
other healthcare providers
Assistance and advice is
requested from external
agencies
The Ministry of Health is
updated
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WAIKATO HOSPITAL IOC EMERGENCY RESPONSE EQUIPMENT
Waikato Hospital IOC Emergency Response Equipment
Main Office
White Emergency Trol ey
Co-ordinated Incident Management Team packs
CIMS Templates
Clip boards
Stationery
Mobile Phones
Radio Telephones
Electronic Whiteboard
[2] Evacuation chairs
Hard hats
Protective high viz Jackets (First Response team)
Corridor Cupboards
Electrical extension cords
Light sticks
Torches
Batteries
Protective Gloves
Hazardous Drug Spil Kit
Parkas
Fluid shield masks
Evacuation sheets
Buckets (household)
Buckets (Cytotoxic waste)
Sign bases
Spil Kit Large
Spil Kit Small
Manual Call Bel s
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1.1 ESTABLISHING & DISESTABLISHING AN EMERGENCY OPERATIONS CENTRE
ESTABLISHING/DISESTABLISHING AN EMERGENCY OPERATIONS CENTRE
Notification may be via
Emergency Department
Switchboard
First Response Team escalation
Security team escalation
Other
Activation
Incident Activity Log commenced immediately by DNM/HRBC Shift Coordinator or
IC (available on DNM/HRBC Shift Coordinator desk folder)
Initiate/ensure appropriate Call Tree activation via Voice Communications
Incident Controller allocates CIMS roles as per on call roster
Incident Controller requests additional senior staff to fill CIMS roles
CIMS packs accessed (IOC emergency response trolley)
CIMS team contact details recorded on emergency trolley whiteboard
Signage put in place
Electronic Whiteboard prepared
Mobilise other equipment as required (stored in Integrated Operations Centre)
Radio telephones
Mobile Phones Torches
Light Sticks
Extension Cords
Evacuation Sheets
Evacuation Chair
Scene Protection Tape
Major incident response RC # is 1199
Operation
Incident Activity Log handed over to & maintained by Planning & Intelligence
Initial Situation Report drafted from Activity Log
Initial Incident Action Plan published
Initial CIMS meeting conducted and meeting schedule established
Duty Nurse Manager/Facilities Coordinator undertakes business as usual activity
unless instructed otherwise and reports to Operations
Bed Manager undertakes business as usual activity unless instructed otherwise
and reports to Operations
Inter-hospital Transfer Coordinator undertakes business as usual activity unless
instructed otherwise and reports to Operations
All Clear/Stand Down
Incident Controller or designate will issue the all clear/stand down instruction
based on assessment of all service/s capability to return to normal activity
All Clear/stand down message will be broadcast to all areas, services (internal and
external) via all available communication modalities
Incident management team repack CIMS packs & associated response equipment
returning EOC to IOC status.
All documentation related to the response to be kept and handed to Planning &
Intelligence or delegate
Recovery & Reconciliation
EOC or EOC activity may be required to remain in place for some time following
stand-down in order to provide ongoing support. This decision will be made by the
Recovery Manager or Incident Controller where a Recovery Manager is not
appointed
All incident response documentation to be collated and stored for use in event
documentation and review processes
10
Immediate (hot) debrief scheduled for involved staff
Event Review process initiated including initial draft report to COO within three
weeks
Staff monitoring & reminder of EAP self-referral if required
All equipment activated or utilised in the response will be checked in as per
instruction, recharged, replacements ordered, cleaned and stored.
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1.2 Minor Security Incident
Minor security incidents are routinely managed by the security team and do not require first
response team involvement, however at any time when a staff member is unsure of how to
proceed they should initiate a 99777 call stating the location and type of incident.
Minor Security Incident
Threat to personal safety
CYFS Pick up
Suspicious letter/package
Protest
Telephone threat
Missing/AWOL Patient (as per Missing Patient Policy)
Other
Notification
The Security team will be the primary responders to minor security incidents, however
they may take the decision to escalate to a Major Security Incident which will prompt a
First Response Team notification
Notify Security team via 0212220027 or 99777
WH/HRBC Security team respond
WH First Response Team on standby
AT ALL TIMES IF A PERSON IS IN DOUBT THEY SHOULD ESCALATE VIA
99777
Activation
Senior Security Officer takes lead
Request non security support (First Response Team) via further 99777 call
Request NZ Police via further 99777 call
Request clinical support via 99777 if required
Request St John attendance via 99777 if required
Operation
Immediate scene assessment
Establish perimeter, consider any evacuation requirements
Remove injured or disabled person/s from area
Initiate de-escalation processes
Request assistance/escalation to NZ Police response
Preserve scene for NZ Police investigation if required
Refer media enquiries to Media & Communications team via switchboard
Notify/update Duty Nurse Manager/Facility Coordinator of incident status
All Clear/Stand Down
All clear initiated by Security Officer in charge
All clear notified to all participant, media & communications, area staff, voice
communications
Recovery & Reconciliation
Documentation as per service requirement – Security Report/DNM Shift Report
Complete Incident Form
Complete Trespass documentation if process initiated
Review all participants
Offer EAP to all [staff] participants
Arrange debrief within 12 hrs. if relevant
Arrange Event Review if relevant
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1.3 Major Security Incident
Major Security Incident
Fall/threat to fall from Building
Hostage
Bomb/Arson Threat
Armed Hold Up
Infant Abduction
Abduction
Intruder
Other
AWOL/Missing Patient Escalation
Notification
99777 call to First Response Team initiated
First Response team activated
Major Security Incident team notification & activation
NZ Police notified
NZ Police requested to mobilise armed offenders squad
External Accident response activated if required
Hospital Manager on call notified
NZ Fire Service notified to stand by or attend
Parking notified to secure campus perimeter
Media & Communications notified
Activation
Senior Security Officer become Incident Controller until NZ Police on site when the
senior officer becomes the Incident Controller
Request clinical support via 99777 if required
Request St John attendance via 99777 if required
External Accident response activated if required
Operation
Immediate scene assessment
Establish perimeter, consider any evacuation requirements
Establish 50 metre cell phone, pager, radio telephone, electronic equipment
cordon until NZ Police Incident Controller advise stand down
Remove injured or disabled person/s from area
Initiate de-escalation processes
Respond to NZ Police requests
Preserve scene for NZ Police investigation if required
Refer media enquiries to Media & Communications team via switchboard
All Clear/Stand Down
All clear initiated by NZ Police Officer or Security Officer in charge of the incident
All clear notified to all participant, media & communications, area staff, voice
communications
Recovery & Reconciliation
Documentation as per service requirement – Security Report/DNM Shift Report
Complete Incident Form
Complete Trespass documentation if process initiated
Review all participants & initiate immediate (hot) debrief
Offer EAP to all [staff] participants
Arrange debrief within 12 hrs. if relevant
Arrange Event Review
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Major Security Incident
1.4 Information in a Hostage Situation
INFORMATION TO CONSIDER IN A HOSTAGE SITUATION
If possible advise hostage/s to consider/behave in line with the following points
Try to be patient, time is on your side
Attempt to establish rapport with Captor
Avoid drastic action, stay calm
The initial 40 minutes are the most critical
Always follow instructions – be alert – stay alive
Scan area for hazards that could endanger you, if possible move to a safe environment or safer
area within environment
Only speak when spoken to or when necessary
Always speak to the captor/s on the same level, adult to adult & do not physically stand higher
than them
If required negotiate calmly & quietly with captor/s. DO NOT argue with them
Endeavour to maintain eye contact with captor at all times, but DO NOT STARE
Always treat the captor with respect
Try to rest
Agree only to things you know can be delivered. Never make promises that cannot be filled
Comply with instructions as best you can & be honest
Expect the unexpected
Be observant & aware of the total environment, keep mental notes
You may be released or able to escape so consider safe routes
The personal safety of others may depend on your memory
Be prepared to talk to Police by phone if required
Be patient. WAIT. The more time that elapses the better the chance of a successful outcome
If medications/first aid or rest room privileges are required by anyone, say so
REMEMBER the captor will most likely not harm anyone if he/she feels in control
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1.5 Clinical Incident
Clinical Incident
Fall/threat to fall from Building (also refer
External Campus Accident
to Major Security Incident)
Cardiac Arrest
Other
Notification may be via
99777 notification
General public notification
Activation
Cardiac Arrest call tree activated
Clinical team attend location DO WE NEED A TRAUMA CALL TREE [D/W Kevin]
First Response Team attends location
FRT notifies Voice Communications to request St John attend if required
FRT notifies Voice Communications to request Police attend if required
FRT notifies Voice Communications to request NZ Fire Service to attend if
required
Operation
Clinical response initiated
Onlookers removed from area
Family/friends of affected person moved to another area and staff member
assigned to them
Perimeter/privacy established
FRT access additional medication, personnel and equipment as requested
FRT notify Emergency Department of incoming patient if required
Security (parking)ensure traffic (internal/external) flow is uninterrupted or
redirected
FRT arrange external site clean-up as required
All Clear/Stand Down
Senior clinician will determine outcome/stand down from clinical event
Duty Nurse Manager or Facilities coordinator issue stand-down in external
accident event
Hot debrief staff involved – record debrief follow up actions
Recovery & Reconciliation
Incident documentation in DNM Shift Report
Incident form completed for External Accident
FRT responsible to ensure external accident scene is clean & clear
15
1.6 Mass Casualty – Clinical Operations Response
Mass Admission Incident Clinical Operations Response
Mass Casualty
Mass Admissions for medical event
Other
Also refer to the WH Emergency Department Mass Casualty Plan
Notification
99777 notification
Population Health notification
MoH Notification
St John ESCC Notification txt
General public notification
Other
Activation
Mass Casualty Response Team Call tree initiated to stand by or full response
CIMS Team roles assigned
IM Team meetings scheduled
Staff call back assembly areas identified/commandeered (IC &/or Staff Coordinator)
St John ESCC & responder Teleconference – DNM / IC, ED / Trauma consultants
Operation
Clinical response initiated
Staff allocation to clinical roles
Hospital/ward/unit impact assessment completed
Staff call back initiated (all staff groups) & assembly point identified
Consider;
Bryant Auditorium
MCC Atrium [L1]
Hockin Café
Property & Infrastructure Tea Room
Human Resources
Distribution Centre (MCC Basement)
Scout Hall
Any of the buildings on the west side of Pembroke St
Reconciliation response area/process activated
Additional ward/bed capacity mobilised
Rapid decant/discharge activated
Media & Communications response initiated
Recovery options identified and process initiated
All Clear/Stand Down
Incident Controller will determine outcome/stand down from mass casualty clinical
operations response event in liaison with all clinical & CIMS team leaders
Incident Controller or designate will issue the all clear/stand down instruction based on
assessment of the whole hospitals ability to return to business as usual
All clear notified to all response participants, media & communications, hospital staff,
voice communications, internal and external agencies involved or previously notified of
incident
N.B.The reconciliation team/response may continue beyond the response stand down
16
Recovery & Reconciliation
Initial Incident documentation in DNM Shift Report
All IM team worksheets to be collated and stored for use in the event review process
Review all participants & initiate immediate (hot) debrief
Offer EAP to all [staff] participants
Arrange debrief within 12 hrs. if relevant
Arrange Event Review
Compile event report for CEO/COO/other
17
1.7 Electricity Incident
Electricity Incident
Notification
99777 or other notification to Voice Communications
Lack of utility noted & reported to P&I or IOC
Activation
First Response Team notification
On Call engineer notified
Facility Coordinator/Duty Nurse Manager assesses situation and request
escalation to Major Essential Utility Failure response via Voice Communications
Nurse Manager on call
Hospital Manager on call
Property & Infrastructure Manager on call
CIMS Incident Response structure established (refer Establish EOC Duty Card)
Utility provider notified by engineer
Media & communication on call notified
Parking notified by Security
Lift Service providers notified by engineer
Operation
Establish EOC and initiate CIMS response as per the EOC Duty Card
Facility Coordinator/DNM initiate department status calls & request urgent staff
deployment as required (refer critical area list below)
Distribute emergency mobile phones if required
Staff deployed to assess lifts & prioritise lift access and support trapped persons
Light sticks issued to be placed in stairwells
Extension cords issued if required
Assign senior staff to building liaison positions
Deploy staff to assist in critical areas as required
Assess patient relocation requirements
Number
Clinical requirements including consumables specific to patient groups
Impact on incoming numbers
Requirement to open closed areas
Staffing impact
Ongoing service impact/s
ELECTRICITY OUTAGE AREA REVIEW SEQUENCE
ICU
High Dependency Unit
NICU
Theatres & Interventional Suites
Emergency Department
Delivery Suite/WAU
Cardiac Care Unit 1/2/3
M14/ERU
Dialysis (ambulatory)
Dialysis (acute M03)
Lomas Oncology
Cardiac Catheterisation Unit
All Lifts
All inpatient & day case occupied areas
Pharmacy
Laboratory Radiology
Mortuary
Henry Bennett Rongomau Centre
18
Mothercraft
Nutrition & Food Services
Other as identified
Integrated Operations Centre (EOC)
Incident Controller will issue the all clear/stand down on the advice of the Manager
Property & Infrastructure
The All Clear may be issued prior to the Stand Down dependant on ward/unit
repatriation requirements/timing
Recovery & Reconciliation
All affected areas complete Incident Form/s
Ensure all affected staff have access to EAP
Arrange debrief within 12 hrs. if relevant
Arrange Event Review in collaboration with Estate & Property
Ensure Health & Safety follow up is in place where required
19
1.8 Sewage Incident
Sewage Incident
Notification
99777 or other notification to Voice Communications
Lack of utility noted & reported to P&I or IOC
Activation
First Response Team notification
On Call engineer notified
Facility Coordinator/Duty Nurse Manager assesses situation and requests
escalation to Major Essential Utility Failure response via Voice Communications
Nurse Manager on call
Hospital Manager on call
Property & Infrastructure Manager on call
CIMS Incident Response structure established (refer Establish EOC Duty Card)
Utility provider notified by engineer
Media & communication on call notified
Operation
Establish EOC and initiate CIMS response as per Establish the EOC Duty Card
Identify extent of the incident
Notify Cleaning Contract holder
Assess scope of clean up requirement
Assign cleaners as a priority
Access equipment to dry carpets etc.
Notify staff who have office ownership
Provide storage for confidential records etc. if rooms to be unlocked
Notify Infection Control service
Access Personal Protective Equipment (PPE)where required
Notify Laundry Contract holder
Increase in contaminated laundry
Increased Laundry bag requirements
Replacement of linen supplies
Rapid turnaround of curtains and screens required
Assess patient relocation requirements
Number
Clinical requirements including consumables specific to patient groups
Impact on incoming numbers
Requirement to open closed areas
Staffing impact
Ongoing service impact/s
Ensure any staff in direct contact with effluent are followed up by Health & Safety
All Clear/Stand Down
Incident Controller will issue the all clear/stand down on the advice of the Manager
Property & Infrastructure
The All Clear may be issued prior to the Stand Down dependant on ward/unit
repatriation requirements/timing
Recovery & Reconciliation
All affected areas complete Incident Form/s
Ensure all affected staff have access to EAP
Arrange debrief within 12 hrs. if relevant
Arrange Event Review in collaboration with Estate & Property
Ensure Health & Safety follow up is in place where required
20
1.9 Water Incident
Water Incident
no water, no hot water, contaminated water, flood
Notification
99777 or other notification to Voice Communications
Lack of utility noted & reported to P&I or IOC
Activation
First Response Team notification
On Call engineer notified
Facility Coordinator/Duty Nurse Manager assesses situation and requests
escalation to Major Essential Utility Failure response via Voice Communications
Nurse Manager on call
Hospital Manager on call
Property & Infrastructure Manager on call
CIMS Incident Response structure established (refer Establish EOC Duty Card)
Utility provider notified by engineer
Media & communication on call notified
Operation
Establish EOC and initiate CIMS response as per Establish the EOC Duty Card
Assess extent of the incident
Wards
ICU/HDU/NICU/ED
Theatres
Delivery Suite
Dialysis
Central Sterilising Unit
Laboratory
Nutrition & Food Services
Laundry
Heating
Other
Define management plan based on P&I advice
Advise staff of restriction management options/guidelines
Notify Infection Control service
Assess patient relocation requirements
Number
Clinical requirements including consumables specific to patient groups
Impact on incoming numbers
Requirement to open closed areas
Staffing impact
Ongoing service impact/s
All Clear/Stand Down
Incident Controller will issue the all clear/stand down on the advice of the Manager
Property & Infrastructure
The All Clear may be issued prior to the Stand Down dependant on ward/unit
repatriation requirements/timing
Recovery & Reconciliation
All affected areas complete Incident Form/s
Ensure all affected staff have access to EAP
Arrange debrief within 12 hrs. if relevant
Arrange Event Review in collaboration with Estate & Property
Ensure Health & Safety follow up is in place where required
21
1.10 Steam Incident
Steam Incident
may be associated with water supply or electrical incident
Notification
99777 or other notification to Voice Communications
Lack of utility noted & reported to P&I or IOC
Activation
First Response Team notification
On Call engineer notified
Facility Coordinator/Duty Nurse Manager assesses situation and requests
escalation to Major Essential Utility Failure response via Voice Communications
Nurse Manager on call
Hospital Manager on call
Property & Infrastructure Manager on call
CIMS Incident Response structure established (refer Establish EOC Duty Card)
Utility provider notified by engineer
Media & communication on call notified
Operation
Establish EOC and initiate CIMS response as per Establish the EOC Duty Card
Assess extent of the incident
Central Sterilising Unit
Nutrition & Food Services
Laundry
Heating
Other
Define management plan based on P&I advice
Advise staff of restriction management options/guidelines
Notify Infection Control service
Assess patient relocation requirements
Revised theatre schedule due to equipment constraint
Number
Clinical requirements including consumables specific to patient groups
Impact on incoming numbers
Requirement to open closed areas
Staffing impact
Ongoing service impact/s
All Clear/Stand Down
Incident Controller will issue the all clear/stand down on the advice of the Manager
Property & Infrastructure
The All Clear may be issued prior to the Stand Down dependant on ward/unit
repatriation requirements/timing
Recovery & Reconciliation
All affected areas complete Incident Form/s
Ensure all affected staff have access to EAP
Arrange debrief within 12 hrs. if relevant
Arrange Event Review in collaboration with Estate & Property
Ensure Health & Safety follow up is in place where required
22
1.11 Reticulated Gas Incident
Gas Incident
supply, interruption, leak
Notification
99777 or other notification to Voice Communications
Lack of utility noted & reported to P&I or IOC
Activation
First Response Team notification
On Call engineer notified
Facility Coordinator/Duty Nurse Manager assesses situation and requests
escalation to Major Essential Utility Failure response via Voice Communications
Nurse Manager on call
Hospital Manager on call
Property & Infrastructure Manager on call
CIMS Incident Response structure established (refer Establish EOC Duty Card)
Utility provider notified by engineer
Media & communication on call notified
Operation
Establish EOC and initiate CIMS response as per Establish the EOC Duty Card
Assess extent of the incident
Wards
ICU/HDU/NICU/ED
Theatres
Delivery Suite
Dialysis
Central Sterilising Unit
Laboratory
Nutrition & Food Services
Laundry
Heating
Other
Define management plan based on P&I advice
Advise staff of restriction management options/guidelines
Assess patient relocation requirements
Number
Clinical requirements including consumables specific to patient groups
Impact on incoming numbers
Requirement to open closed areas
Staffing impact
Ongoing service impact/s
All Clear/Stand Down
Incident Controller will issue the all clear/stand down on the advice of the Manager
Property & Infrastructure
The All Clear may be issued prior to the Stand Down dependant on ward/unit
repatriation requirements/timing
Recovery & Reconciliation
All affected areas complete Incident Form/s
Ensure all affected staff have access to EAP
Arrange debrief within 12 hrs. if relevant
Arrange Event Review in collaboration with Estate & Property
Ensure Health & Safety follow up is in place where required
23
1.12 Hazardous Material, Chemical, Biological or Radiological Incident
HAZARDOUS MATERIAL SPILL, CHEMICAL, RADIOLOGICAL INCIDENT
Hazardous Substance Spill
Unidentified Substance Spill
Radiation Incident
Notification
99777 notification to Voice Communications
First Response Team notification
Emergency services, Public Health Unit or Member of Public
VC will request the following information
Location
Substance
Spill size
Contact details of department and/or staff member inside contaminated
area
Material Safety Data Sheet
Other relevant information
Radiation Incident – Voice Communications notify Radiation Safety officer
VC Notify NZ Fire Service
VC notify Emergency Department of spill
ED establish standby response
Awareness of potential road closures around campus (ambulance)
VC notifies St John of incident location
VC notifies
Medical Officer of Health (MOoH)
Health Protection Officer (HPO)
Infection Control
Health and Safety
Activation
First Response Team speak to contact person
FRT WILL NOT ENTER AREA OF SPILL
Identify if any contact with spill N.B. It should be assumed the person who
has identified the spill is contaminated and should immediately be advised
to isolate and refrain from contact with other staff until HazMat unit
advises it is OK to
Any side effects requiring clinical intervention
Ability to contain / isolate
Advise self-isolation within agreed perimeter
request Material Safety Data Sheet (MSDS) or description from
Department Hazard Register
Identify Group/Building at risk. Liaise with ED, Medical Officer of Health,
NZ Fire
Radiation Incident – Provide resource as requested by the Radiation
Safety officer
Security establish perimeter
Cordon
Identify alternative route to maintain public and patient flow
Identify required road closure requirements
Evacuate/redirect uncontaminated people in adjacent areas to a safe
24
distance
Operation (Protect Yourself others and the environment)
FRT collect spill kit from IOC & proceed to their safe forward point
DO NOT PASS THROUGH CORDON
establish response location
Ensure area is cordoned off – restrict access / egress
Identify uncontaminated route to NZFS
Establish phone contact with area
Gain ongoing assessment of spill – Strength / Sensitivity
Ensure spill area is isolated within cordon
Review any contamination and clinical response requirements
Prioritise clinical intervention requirement with NZFS/ MOoH
Document names of those exposed
Length of exposure
Decontamination process
Assess if spill manageable
If yes appropriately protected staff to send in spill kit
Consider Air Circulation – Control Air Conditioner systems via Ops
Engineer
If unmanageable call 99777 for support from NZ Fire Service / MOoH / Infection
Control / H&S
Wait for further NZ Fire Hazmat team instruction
Notify building occupants (use EWIS if appropriate / available)
Develop appropriate Incident Management Plan
Develop appropriate Clinical Management Plan
Patient placements
Transport arrangements
Supplies
Staff deployments
Cleaning and area decontamination
All Clear/Stand Down
The Fire Service Senior will issue the all clear
Notify building / area (via EWIS if available)
Notify people outside building
Notify Voice communications 99777
Ensure documentation is completed by staff involved
Radiation Incident – All clear will be given by the Radiation safety officer
Recovery & Reconciliation
Reestablishment of affected areas
Establish staff / patient / family monitoring process
Arrange EAP
Establish recovery planning
Arrange hot debrief
Arrange event review meeting
Arrange staff communication
Complete Event Review report
25
1.13 Body Fluid/Specimen/Biological Waste/ Unidentified Biological Substance Spills
Body Fluid/Specimen/Biological Waste/ Unidentified Biological Substance Spills
N.B Day to day patient body fluid spills should be managed in the normal
manner using Infection Controls “Blood and Body Fluid” protocol.
This guideline should be implemented in the event of large infectious or
unknown biological substance spills.
Known Infectious Body Fluid Spill
Unidentified (at risk) Biological Substance Spill
Notification
99777 notification to Voice Communications
First Response Team notification
Emergency services, Public Health Unit or Member of Public
VC will request the following information
Location
Substance
Spill size
Contact details of department and/or staff member inside contaminated
area
Other relevant information
VC notifies
Medical Officer of Health (MOoH)
Health Protection Officer (HPO)
Infectious Diseases Clinician on call/Infection Control
Health and Safety
ED Coordinator
Activation
N.B A member of the FRT will collect spill kit from IOC & proceed to the safe forward point
First Response Team complete initial spill assessment
DNM/NM escalates to CIMS response if spill assessment indicates impact
on ability to provide business as usual.
Security arrange safe perimeter to be set up
o Identify alternative route to maintain public and patient flow
o Identify required road closure requirements
o Evacuate/redirect uncontaminated people in adjacent areas to a
safe distance
Engineers advised to terminate air conditioning/air flow in affected
area/building/pod & to cconsider/assess potential fluid run off to other
areas (floor/ducting etc.)
Operation (Protect Yourself others and the environment)
N.B No staff to pass through codon until all clear is given, or appropriate
PPE is utilised
Establish incident control point (consider using Fire Control Rooms where
that building is involved)
Security ensure area is cordoned off – restrict access / egress
Establish phone contact with area
26
o use WIP phones if Fire Control room being use
o use radio telephones (from IOC) if no other option
Gain ongoing assessment of spill – Strength / Sensitivity
Liaise with Medical Officer of Health re ongoing management options.
It should be assumed the person who has identified the spill is
contaminated and should immediately be advised to isolate and refrain
from contact with other staff
Standard Infection Control precaution implemented including use of PPE
Review any contamination and clinical response requirements
Prioritise clinical intervention requirement with MOoH & Infectious Disease
clinician
Document names of those exposed
Length of exposure
Decontamination process undertaken
Assess if spill manageable
If manageable appropriately protected staff to utilise spill kit
If unmanageable take advice from Medical Officer of Health
Notify building occupants (use EWIS if appropriate / available)
CIMS team to develop appropriate Incident Management Plan including
Clinical Management Plan
Patient placements
Transport arrangements
Supplies
Staff deployments
Cleaning and area decontamination
Personnel decontamination to be advised by Infection Control/Infections
Diseases Clinician or MOoH (Decontamination procedure to be developed by
IC team)
All Clear/Stand Down
The Medical Officer of Health or Incident Controller will issue the All Clear/Stand
Down
Notify building / area (via EWIS if available)
Notify people outside building
Notify Voice communications 99777
Notify Emergency Department Co-ordinator
Ensure documentation is completed by staff involved
Recovery & Reconciliation
Reestablishment of affected areas
Establish staff / patient / family monitoring process
Arrange EAP
Establish recovery planning
Arrange hot debrief
Arrange event review meeting
Arrange staff communication
Complete Event Review report
27
1.14 Communications Incident
COMMUNICATION OUTAGE
IS Network (computers etc)
Telephones (desk phone)
Paging System
Mobile Network
Fax failure
Patient Call Bell Failure
Notification
99777 call to Voice Communications or runner attends Voice Communications or
notifies Duty Nurse Manager
Notified planned outage
Identified lack of network or switchboard coverage
Activation
Facility Coordinator/Duty Nurse Manager notified
Facility Coordinator/Duty Nurse Manager assesses situation in conjunction with
service representative/s and requests escalation to Major Communications Failure
(identify type) response via Voice Communications
Nurse Manager on call
Hospital Manager on call
Manager Voice Communications (or delegate) notified
Information Services On Call notified
Manager Information Services notified
Chief Information Officer (or delegate) notified
Media & Communications’ on call notified
CIMS Incident Response structure established (refer Establish EOC Duty Card)
insert hyperlink
Operation
IS Network (computers etc.)
Assess extent and duration of outage
Advise all staff to initiated manual data tracking processes
DNM update latest Inpatient by Ward reports with ED admissions since time of
print
Distribute Inpatient lists as required (maintain a master copy)
Copy & distribute patient tracking templates as required
Initiate centralised data tracking process
Send patient updates to Enquiries
Initiate Dietary reporting/ordering process
Assess clerical support requirement for ED and redeploy clerical relievers as
required
Assess staffing impact of data back load requirement & plan rosters
Telephones (desk phone)
Assess extent and duration of outage
Advise staff to utilise mobile phones
Distribute emergency mobile phones
Paging System
Assess extent and duration of outage
Notify staff of outage
Voice Communications will distribute instructions
Distribute emergency mobile phones if required
Mobile Network
Assess extent and duration of outage
Media & Communications notify staff of outage via intranet, flyer, runner
28
Voice Communications will distribute instructions
Staff advised to utilise landlines
Pager staff notified via pager message
Radio telephones utilised for internal coordination communications
On call staff notifications where pagers are not utilised to be undertaken via
landline
Fax failure
Assess extent and duration of outage
Notify staff of outage
Voice Communications will distribute instructions on alternate fax numbers
Areas initiate business continuity strategies identified in DERP
All Clear/Stand Down
Incident Controller will issue the all clear in conjunction with the service
representative
In an event when data backload is required the stand down may be delayed
beyond the all clear to support the workload impact
Recovery & Reconciliation
All affected areas complete Incident Form/s
Ensure all affected staff have access to EAP
Arrange debrief within 12 hrs. if relevant
Arrange Event Review in collaboration with service provider
29
1.15 Fire Escalation
FIRE ESCALATION
For use where the First Response Team identify the need to escalate a routine fire
response to an evacuation or area shut down
Notification
First response team escalate evacuation requirement via 99777 to VC
VC notify Nurse & Hospital Manager on call
Media & Communications on call notified
Activation
CIMS structure established
Situation report gained and evacuation planning commenced
NZ Fire Service become the Incident Controller for the fire response with a
hospital Incident Controller assigned to manage the hospital response
Facilities Coordinator/Duty Nurse Manager remain at fire control panel
IC allocates FC/DNM support/liaison person at fire control panel
Security and/or Attendants directed to monitor all exits & entrances for
area/building
Operation
Identify relocation area for evacuees
Arrange patient decant, additional beds in evacuation area/s
Allocate clinical resource required to provide clinical safety in transport and end
point
Arrange transport staff and vehicles
Request assistance from St John if assessment shows a requirement
Arrange waiting areas for non-inpatient ambulatory persons
Distribute Evacuation sheets as required (require minimum 6 persons per sheet)
Distribute Evacuation Chair with certificated operator (1) and assistant
Establish liaison with Lift Service Contractor
All Clear/Stand Down
All clear issued by the NZ Fire Service Incident Controller via FC/DNM in charge
of fire control panel
FC/DNM broadcasts fire response all clear to areas
The fire response All Clear closes the fire response, however the CIMS response
will continue until the relocation and repatriation response continues therefore
Stand Down may occur sometime later
Recovery & Reconciliation
FC/DNM complete Fire Report
Incident Form/s completed
Debrief processes initiated
Ensure all staff are monitored post event and access EAP as required/directed
Event review process commenced
30
1.16 Earthquake/Building Damage
EARTHQUAKE/BUILDING DAMAGE
Notification
Voice Communications Notify First Response Team
Activation
Have the First Response Team assemble in a safe area.
Incident Management team established
Request clinical and non-clinical areas for a situation report re:
Injuries
Damage
Status of patients and staff
Ability to continue to provide all or part service
Request Operations Engineer situation report re:
Structural damage
Utility damage/availability.
Report to Emergency Operations Centre
NB: If damage is severe and shocks are ongoing, Engineers may / will turn off
main supplies of water, electricity, gas, steam and heating.
Liaise with and receive briefings from the most senior staff members available
Operation
Security to establish safe campus perimeter
Security secure unsafe areas & manage access as per instruction from IC or
Senior Security Officer
Organise a staff member to meet external responders and bring to a safe area
close to the incident.
If situation is not safe consider the need to evacuate nearby areas (refer
evacuation job card)
Initiate Mass Casualty response if necessary
Hospital Manager or designate to inform COO
Refer all media enquiries to Media Co-ordinator.
All Clear/Stand Down
All Clear decided by the Emergency Response team in liaison with external
responders
Incident Controller remains or delegates a recovery manager to remain in the
area until staff is able to resume functions and immediate support needs have
been met.
Inform All Clear to all staff:
Involved in the incident
Placed on stand-by
Recovery & Reconciliation
Arrange debrief for staff involved.
Arrange EAP/ counselling for people as necessary.
Ensure all staff involved is monitored for next six to eight weeks.
Document incident, including all actions and rationales for actions.
Arrange event review meeting with all key internal/external players.
Ensure someone is designated to provide COO with full report on incident within
three weeks.
31
1.17 Waiora Waikato Campus Clinical Area Evacuation
Waiora Waikato CLINICAL AREA EVACUATION
The campus buildings have 2 levels of evacuation
Stage 1 is undertaken in the event of a staged movement to the next safe fire cell.
This is most likely to occur as a result of a utility failure or fire.
Stage 2 involves total evacuation of part or a whole building. This is most likely to
occur as a result of building or infrastructural failure.
Each clinical ward/unit has a Department Emergency Response Plan (DERP) which
identifies optimal relocation preferences’ in the event of an evacuation.
Refer to Appendix 3.1
However the Incident Controller will have the final say of where services will relocate
Notification
The WH/HRBC first response team will identify the requirement for evacuation
and escalate this via Voice Communication 99777 call.
It is the role of the Waiora Waikato Campus Incident management Team to
direct and support the Services teams to effect safe and secure evacuation
Activation
Duty Nurse & Hospital Manager Building Evacuation Call Tree activated
Waiora Waikato Campus Incident Management team activate to standby or full
response
Designated Incident Controller identifies level of evacuation and the approach to
be taken. This may include:
Rapid Discharge
Respite Care
Relocation within the campus
Relocation external to the campus
Internal & external liaison roles assigned
Identify & facilitate transport requirements for safe patient & associated
equipment movement
Liaise with relevant personnel
Senior staff members
Engineering and Property
External support services e.g. Fire Service
Utilise the relevant ‘Relocation’ guidelines as a reference to decide the level of
evacuation decided and the approach to be taken.
Utilise Evacuation/relocation calculator to assess receiving areas capacity
Operation
Assist staff to,
Identify resource requirements
Clarify the plan
Designate responsibilities
If on-site relocation sites are required,
Identify key requirements of area/s being relocated
Calculate capacity needed and movements required to achieve this
(Relocation Matrix/Calculator)
Liaise with managers/senior staff in alternative locations
Keep staff informed at all times using IS solutions and the EWIS PA
system to communicate where available. process (Central EWIS PA
System in Duty Managers Office)
Once resource requirements are clarified, work with the Incident management
Team CIMS position managers to activate any on-site responses, or arrange
the support required taking people off-site.
This may include:
32
Security
Food & Nutrition
Laundry & Linen supplies
Operators & Enquiries
Attendants
Fleet and driver requirements
Pharmacy
Medical Gas
Clerical staff to manage patient tracking
IS staff re Information Services issues
Agency Administration
Clinical staff/transport nurse requirements
St John Ambulance Service
other
The Incident Management Team and relevant staff and managers shall develop
a management plan for next 24/48 hours.
This may include:
Repatriation of patients, staff and equipment back into usual accommodation or
into permanent short-term or long-term accommodation. Plan to include:
Prioritisation, timing and order of movement of clients
Identification of staff requirements
Identification of resource requirements (see 3 above)
Liaison with clean-up or engineering teams to ensure timing agreed
Assessment of ability to continue to provide a full service and appropriate
notifications if services are to be curtailed or cease (in the short or long term)
All Clear/Stand Down
Once the initial incident is over and all clients and staff are safe, the All Clear is
decided by the Incident Controller/s
Ensure that all staff who have been,
Involved in the incident, or
Placed on stand-by are informed
Ensure that a ‘hot debrief’ is held ideal y prior to shifts going home or within 12
hours of the event. Record issues / learning’s that are discussed.
Assist with the documentation of the incident.
Ensure that the Media Communications team have informed the media
Ensure Insurers informed.
Recovery & Reconciliation
Ensure that an event review meeting with all key internal/external players is
organised within two weeks of the incident stand down.
Ensure someone designated to provide COO with full report on incident within
three weeks.
33
1.18 WAIKATO HOSPITAL WARD/UNIT RELOCATION MATRIX
Destination Ward
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7
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6
6
5
4
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R3
R4
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52
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53
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M08
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M07
√
M17
√
M04
√
M02
√
M12
√
M06
√
M16
√
M05
√
CCU
√
√
√
M14
√
√
√
√
M03
√
A2
√
√
√
A3
√
d A4
√
ra AMU
√
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√
W g 51
√
nita 52
√
√
uca WAU D/S
√
√
√
vE 53
√
E07
√
NBU
√
√
√
√
ORP2
√
OPR3
√
√
OPR4
√
√
OPR1
HDUSS
√
√
√
√
ICU
√
√
√
√
Theatre
√
√
√
√
PACU
√
√
√
√
MCC L1
√
√
MCCL2
√
√
Cath Lab
MediH
√
WOPD
√
√
Braemar
SX
Other
Transit
34
35