Appendix Document 3 Incident Response Guidelines.pdf

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]

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

8

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

9

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.

11

  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

12

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

13

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

14

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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M08
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M07
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M17
√
M04
√
M02
√
M12
√
M06

√
M16
√
M05
√
CCU
√
√
√
M14
√
√
√
√

M03
√
A2
√
√
√
A3
√
d A4
√
ra AMU
√
√
√
W g 51
√
nita 52
√
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uca WAU D/S
√
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vE 53
√
E07
√
NBU
√
√
√
√
ORP2
√
OPR3
√
√
OPR4
√
√
OPR1
HDUSS
√
√
√
√
ICU
√
√
√
√
Theatre
√
√
√
√
PACU
√
√
√
√
MCC L1
√
√
MCCL2
√
√
Cath Lab
MediH
√
WOPD
√
√
Braemar
SX
Other
Transit

34