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Emergency Response Procedures Warren Health Service

Printed or saved electronic copies of this policy document are considered uncontrolled. Always source the current version from WACHS HealthPoint Policies.

Date of Last Review: May 2018 Page 1 of 154 Date Next Review: May 2023

Effective: 25 June 2018

WACHS SOUTH WEST Warren Health Service

Emergency Response Procedures

FOREWORD

Facilities require capabilities to cope with emergencies that can arise internally. For these reasons, the following Emergency Response Procedures provide guidance for planning and the actions required by staff for responding to internal emergencies at the Warren Health Service. In the event of an emergency that requires or triggers the intervention of a Hazard Management Authority (HMA) (i.e. the Department of Fire and Emergency Services), the facility is to transfer control of the response to the hazard to the relevant HMA whilst maintaining command and coordination of other elements of the facilities core business functions. The Warren Health Service is, at all times, to have positions nominated to fulfil the duties and responsibilities of the Emergency Controller, the position responsible for the emergency response at the Warren Health Service. Where appropriate, the Emergency Controller is to communicate the activation of an emergency code to the Warren District Manager as soon as reasonably practicable. Staff are to undertake essential training including regular practical training exercises to ensure a desired level of efficiency when responding to emergencies. These procedures are informed by Australian/New Zealand Standards AS/NZS 4083 and AS/NZS 3745 and links with state level Disaster response plans to form part of a coordinated emergency and disaster management response.

Jeremy Higgins

Inland Hospitals Operations Manager

https://healthpoint.hdwa.health.wa.gov.au/policies/Pages/WACHS-Policies-Landing.aspx

Emergency Response Procedures – Warren Health Service



TABLE OF CONTENTS

FOREWORD ....................................................................................................................... 1

1. EMERGENCY MANAGEMENT FRAMEWORK ........................................................... 7 1.1 Emergency Management Plan .............................................................................. 7 1.2 Emergency Management Manual .......................................................................... 7 1.3. Emergency Response Procedures ......................................................................... 7

1.3.1. Emergency Response Procedures ................................................................ 8 1.3.2. Business Continuity Plan............................................................................... 8

1.4. Documents ............................................................................................................. 8 1.4.1 Action Cards ................................................................................................... 8 1.4.2 Warren Hospital Code Communications Log ................................................. 9 1.4.3 New Action Cards .......................................................................................... 9

1.4.3.1. Action Cards ...................................................................................... 9 1.4.3.2. MER Form ......................................................................................... 9

1.5. Organisational Details ............................................................................................ 9 1.5.1. Description of Service ................................................................................... 9 1.5.2. Organisational Aim ........................................................................................ 9

2. DOCUMENT CONTROL ............................................................................................. 10 2.1 Amendment Control ............................................................................................... 10 2.2 Review ................................................................................................................... 10 2.3 Distribution and Availability .................................................................................... 10

3. ADMINISTRATION AND GOVERNANCE .................................................................. 12 3.1 Authority to Plan .................................................................................................... 12

4. CODE RED EMERGENCY RESPONSE PROCEDURES .......................................... 13 4.1 Purpose ................................................................................................................. 13 4.2 Fire Prevention and Protection .............................................................................. 13

4.2.1 Fire Initiation and Development and Control ................................................ 13 4.2.2 Smoke Development and Spread and Control ............................................. 13 4.2.3 Fire Spread and Impact Control ................................................................... 13 4.2.4 Fire Detection ............................................................................................... 13 4.2.5 Fire Alarm Systems ...................................................................................... 14 4.2.6 Fire Strategy ................................................................................................. 14 4.2.7 Fire Warning System .................................................................................... 14 4.2.8 Fire Suppression Systems ........................................................................... 14 4.2.9 Evacuation and Control ................................................................................ 14 4.2.10 Department of Fire and Emergency Service Intervention ........................... 15

4.3 Other Considerations ............................................................................................. 15 4.3.1 Hot Work ...................................................................................................... 15

4.4 Essential Steps ...................................................................................................... 15 4.4.1 Life Safety .................................................................................................... 15 4.4.2 Call the Department of Fire and Emergency Services ................................. 15 4.4.3 Evacuation ................................................................................................... 15 4.4.4 Fight the Fire ................................................................................................ 15 4.4.5 Communications .......................................................................................... 15





4.5 Code Red Response Procedures (Action Cards) .................................................. 16 4.5.1 First Responder – Code Red Immediate Actions ......................................... 16 4.5.2 Emergency Controller – Code Red Action Card ........................................... 17 4.5.3 Communications Officer – Code Red Action Card ....................................... 21 4.5.4 Area Warden/Warden – Code Red Action Card ........................................... 22 4.5.6 Emergency Response Team Member - Code Red Procedure ..................... 23

5. CODE PURPLE EMERGENCY RESPONSE PROCEDURES ................................... 24 5.1 Purpose ................................................................................................................. 24 5.2 General .................................................................................................................. 24 5.3 Identifying Bomb Threats ....................................................................................... 24 5.4 Assessing Bomb Threats ....................................................................................... 24

5.4.1 Specific and Non Specific Threats ............................................................... 25 5.4.2 Tools to Aid Assessment .............................................................................. 25 5.4.2.1 Telephone Bomb Threat Checklist ............................................................................... 25

5.4.2.2 HOT-UP ............................................................................................................................ 25

5.4.3 Risk Evaluation ............................................................................................ 26 5.4.4 Actions ......................................................................................................... 26 5.4.5 Searching ..................................................................................................... 26 5.4.6 Evacuating ................................................................................................... 27

5.5 Code Purple Action Cards ..................................................................................... 28 5.5.1 First Responder – Immediate Actions Telephone Threat ............................. 28 5.5.2 First Responder – Immediate Actions Letter Threat ..................................... 29 5.5.3 First Responder – Immediate Actions Suspect Item .................................... 30 5.5.4 Emergency Controller – Code Purple Action Card ....................................... 31 5.5.5 Emergency Controller - Search without Evacuation Procedure .................... 35 5.5.6 Communications Officer – Code Purple Action Card ................................... 36 5.5.7 Communications Officer – Search without Evacuation Procedure ............... 38 5.5.8 Area Warden/Warden – Code Purple Action Card ....................................... 39 5.5.9 Area Warden/Warden – Search Without Evacuation Procedure .................. 41 5.5.10 Emergency Response Team Member - Code Purple Action Card ............. 42 5.5.11 Emergency Response Team Member – Search without Evacuation

Procedure ................................................................................................... 43

6. CODE BLACK EMERGENCY RESPONSE PROCEDURES ..................................... 44 6.1 Purpose ................................................................................................................. 44 6.2 General .................................................................................................................. 44 6.3 Responding to the Aggressive Person .................................................................. 44

6.3.1 De-escalation ............................................................................................... 45 6.3.2 Withdrawal ................................................................................................... 46 6.3.3 Evasion ........................................................................................................ 46

6.4 Management Strategies for the Aggressive Patient ............................................... 46 6.4.1 Patient Care Plan ......................................................................................... 46 6.4.2 Environmental Management Plan ................................................................ 47 6.4.3 Discharge/Release ....................................................................................... 47 6.4.4 Seclusion ...................................................................................................... 47 6.4.5 Restraint ....................................................................................................... 47





6.5 Code Black Action Cards ....................................................................................... 49 6.5.1 First Responder – Unarmed Confrontation Immediate Actions .................... 49 6.5.2 Code Black Immediate Actions – Armed Confrontation ............................... 50 6.5.3 Emergency Controller – Code Black Action Card ......................................... 51 6.5.4 Communications Officer – Code Black Action Card ..................................... 53 6.5.5 Area Warden/Warden – Code Black Action Card ......................................... 55 6.5.6 Emergency Response Team Member - Code Black Procedure ................... 57

7. CODE BLACK ALPHA – SUB PLAN ......................................................................... 58 7.1 Purpose ................................................................................................................. 58 7.2 General .................................................................................................................. 58 7.3 Code Black Alpha Action Cards............................................................................. 59

7.3.1 First Responder – Infant/ Child Abduction Immediate Actions ..................... 59 7.3.2 Emergency Controller – Code Black Alpha Action Card .............................. 60 7.3.3 Communications Officer – Code Black Alpha Action Card ........................... 64 7.3.4 Area Warden/Warden – Code Black Alpha Action Card .............................. 66 7.3.5 Emergency Response Team Member - Code Black Alpha Action Card ...... 68

8. CODE BLACK JUMPER – SUB PLAN ...................................................................... 69 8.1 Purpose ................................................................................................................. 69 8.2 General .................................................................................................................. 69 8.3 Security Procedures .............................................................................................. 69 8.4 Code Black Response Procedures (Action Cards) ................................................ 70

8.4.1 First Responder – Jumper Immediate Actions ............................................. 70 8.4.3 Emergency Controller – Code Black Jumper Action Card ............................ 71 8.4.4 Communications Officer – Code Black Jumper Action Card ........................ 74 8.4.5 Area Warden/Warden – Code Black Jumper Action Card ............................ 75 8.4.7 Emergency Response Team Member - Code Black Jumper Procedure ...... 76

9. CODE YELLOW EMERGENCY RESPONSE ............................................................. 77 9.1 Purpose ................................................................................................................. 77 9.2 General .................................................................................................................. 77 9.3 Essential Service Disruptions ................................................................................ 77 9.4 Infrastructure Damage ........................................................................................... 78 9.5 Code Yellow Action Cards ..................................................................................... 79

9.5.1 First Responder – Code Yellow .................................................................... 79 9.5.2 Emergency Controller – Code Yellow Action Card ....................................... 80 9.5.3 Communications Officer – Code Yellow Action Card

(includes sub plans) .................................................................................... 84 9.5.4 Area Warden/Warden – Code Yellow Action Card ....................................... 85 9.5.5 Emergency Response Team Member - Code Yellow Action Card (includes

sub plans) ................................................................................................... 87 9.5.6 Code Yellow Workarounds ........................................................................... 88

10. CODE YELLOW BUSHFIRE – SUB PLAN ................................................................ 89 10.1 Purpose ............................................................................................................... 89 10.2 General ................................................................................................................ 89 10.3 Fire Prevention and Protection ............................................................................ 89





10.4 Preparation .......................................................................................................... 89 10.4.1 Fire Danger Ratings ................................................................................... 89 10.4.2 Bushfire Warnings ...................................................................................... 89

10.5 Code Yellow Bushfire Action Cards ..................................................................... 91 10.5.1 Emergency Controller – Code Yellow Bushfire Action Card ....................... 91 10.5.2 Communications Officer – Code Yellow Bushfire Action Card ................... 95 10.5.3 Area Warden/Warden – Code Yellow Bushfire Action Card ....................... 97 10.5.4 Emergency Response Team Member - Bushfire Action Card .................... 99

11. CODE YELLOW FLOOD SUB PLAN ....................................................................... 101 11.1 Purpose ............................................................................................................. 101 11.2 General .............................................................................................................. 101 11.3 Flood Prevention ............................................................................................... 101 11.4 Preparation ........................................................................................................ 101 11.5 Flood Warnings ................................................................................................. 101 11.6 Code Yellow Flood Action Cards ....................................................................... 103

11.6.1 Emergency Controller – Code Yellow Flood Action Card ......................... 103 11.6.2 Communications Officer – Code Yellow Flood Procedure........................ 107 11.6.3 Area Warden/Warden – Code Yellow Flood Action Card ......................... 109

12. CODE YELLOW STORM SURGE - SUB PLAN ....................................................... 113 12.1 Purpose ............................................................................................................. 113 12.2 General .............................................................................................................. 113 12.3 Preparation ........................................................................................................ 113

12.3.1 Weather Warnings ................................................................................... 113 12.3.2 Other Considerations ............................................................................... 113

12.4 Code Yellow Storm Surge Action Cards ............................................................ 114 12.4.1 Emergency Controller – Code Yellow Storm Surge Action Card .............. 114 12.4.2 Communications Officer – Code Yellow Storm Surge Action Card .......... 118 12.4.3 Area Warden/Warden – Code Yellow Storm Surge Action Card .............. 120 12.4.4 Emergency Response Team Member - Storm Surge Action Card ........... 122

13. CODE YELLOW HAZARDOUS MATERIAL INCIDENT SUB PLAN ....................... 124 13.1 Purpose ............................................................................................................. 124 13.2 General .............................................................................................................. 124 13.3 Material Safety Data Sheets .............................................................................. 124 13.4 Hazardous Chemical Register ........................................................................... 124 13.5 Prevention and Preparedness ........................................................................... 125

13.5.1 Storage ..................................................................................................... 125 13.5.2 Impact Protection ..................................................................................... 125 13.5.3 Mechanical Ventilation ............................................................................. 125 13.5.4 Labelling ................................................................................................... 125 13.5.5 Signage .................................................................................................... 125 13.5.6 Training .................................................................................................... 125 13.5.7 Personal Protective Equipment and Clothing (PPEC) .............................. 125 13.5.8 Spill Kits ................................................................................................... 125

13.6 Code Yellow Hazardous Material (Action Cards) .............................................. 126 13.6.1 Emergency Controller - Hazardous Material Incident Action Card ........... 126





13.6.2 Communications Officer – Code Yellow Hazardous Material Incident Action Card ................................................................................. 129

13.6.3 Area Warden/Warden – Code Yellow....................................................... 130 13.6.4 Emergency Response Team Member Hazardous Material Action Card .. 131

14. BUSINESS CONTINUITY PLAN ............................................................................... 132

15. CODE ORANGE EVACUATION PROCEDURES ..................................................... 133 15.1 Purpose ............................................................................................................. 133 15.2 General .............................................................................................................. 133 15.3 Assessing the Situation ..................................................................................... 133 15.4 Authority to Evacuate ........................................................................................ 133 15.5 Preferred Order of Evacuation ........................................................................... 133

15.5.1 Evacuation Stages ................................................................................... 134 15.5.2 Evacuation Routes ................................................................................... 134

15.6 Muster Points ..................................................................................................... 135 15.7 Assembly Areas ................................................................................................. 136 15.7 Evacuation Centres ........................................................................................... 136 15.8 Other Considerations ......................................................................................... 137

15.8.1 Mobility Impaired Staff .............................................................................. 137 15.8.2 Records Relevant to Immediate Patient Care .......................................... 137 15.8.3 Evacuation Equipment ............................................................................. 137 15.8.4 Head Counts ............................................................................................ 137 15.8.5 Communications ...................................................................................... 137 15.8.6 Logistical Support and Resupply .............................................................. 137 15.8.7 Pharmacy ................................................................................................. 137

15.9 Patient Care after an Evacuation ....................................................................... 138 15.9.1 Decanting Inpatients................................................................................. 138

15.10 Clearing an Emergency Code .......................................................................... 138 15.11 Code Orange Evacuation Procedures Action Cards ........................................ 139

15.11.1 First Responder – Immediate Actions .................................................... 139 15.11.2 Emergency Controller – Confirmed Emergency ..................................... 140 15.11.3 Communications Officer – Confirmed Emergency ................................. 141 15.11.4 Area Warden – Confirmed Emergency ................................................... 142 15.11.5 Emergency Response Team Member – Confirmed Emergency ............ 143

16. APPENDICES ........................................................................................................... 144 16.1 Patient Transfer/Discharge Record ................................................................... 144 16.2 Evacuation Checklist ......................................................................................... 145 16.3 Personal Emergency Evacuation Plan (Mobility Impaired Staff) ........................ 147 16.4 Bomb Threat Card ............................................................................................. 149 16.5 Offender Description Form ................................................................................ 151 16.6 Essential Services Contacts List ........................................................................ 152 16.7 Fire Danger Ratings .......................................................................................... 153

17. REFERENCES .......................................................................................................... 154

18. RELATED DOCUMENTS ......................................................................................... 154





1. EMERGENCY MANAGEMENT FRAMEWORK

Within the WA Country Health Service – South West (WACHS-SW), Emergency Management documentation outlines the region's strategies and systems for preventing, preparing for, responding to and recovering from emergencies. The Warren Health Service Emergency Response Procedures (these procedures) form part three of the WACHS-SW Emergency Management documentation and are designed to be read in conjunction with the WACHS-SW Emergency Management Plan and the WACHS-SW Emergency Management Manual.

Emergency Management Documentation

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Emergency Management

ManualEmergency

Management Plan

Emergency Response

Procedures

Business Continuity

Plan

1.1 Emergency Management Plan

The Emergency Management Plan (EMP) outlines the high level approach taken toward emergency management by the regions Emergency and Disaster Sub Committee (EDSC). The Emergency Management Plan outlines the systems to prevent, prepare for, respond to and recover from emergency situations.

1.2 Emergency Management Manual

The Emergency Management Manual forms part two of the region's Emergency Management Plan. The Emergency Management Manual provides facilities with information and instructions relevant to emergency operations which are appropriate to the size of the facility. 1.3. Emergency Response Procedures The WACHS-SW outlines its response to an incident in one of two main documents depending on the phase of the response to the incident. These are:

· the emergency response phase - executed through emergency response procedures

· the business continuity phase - executed through Business Continuity Plans and Business Continuity Team Action Plans.

Typically, phases occur in a sequential order but significant overlap in phases often occurs.


https://healthpoint.hdwa.health.wa.gov.au/policies/_layouts/DocIdRedir.aspx?ID=TS4KSNFPVEZQ-210-5545





1.3.1. Emergency Response Procedures Emergency Response Procedures are designed to be invoked immediately following an emergency at a facility to protect people and assets. Emergency Response Procedures are facility specific and cover:

· immediate actions to be taken by the first responder; and · follow-on actions (action cards) to be taken by staff that forms the facilities

Emergency Management Team (EMT).

Note: a) Emergency Controller – white vest b) Area Warden(s) – orange vest c) Emergency Team Member – no vest d) Communications Officer – no vest

Note: Code Yellow Emergency Response Procedures outline the immediate actions taken in response to an infrastructure and other internal emergency (including essential service disruptions, infrastructure damage, hazardous chemical and natural incidents) which may lead to the significant disruption of critical business activities and the activation of the Business Continuity Plan.

1.3.2. Business Continuity Plan The Business Continuity Plan (this plan) sets out the actions to be followed should any incident cause or threaten to cause disruption critical business functions of the Warren Health Service. The Business Continuity Plan operationalises the response options identified in step 3 of the Business Continuity Management process for the resumption and continuity of critical business Functions within the Maximum Tolerable Period of Disruption. The Business Continuity Plan is designed to be used by Warren Health Service Business Continuity Team.

1.4. Documents

1.4.1 Action Cards The Action cards for each Emergency Response Team member’s role are to be completed by the relevant team member and are sent to the Nurse Unit Manager for review and reporting at the following committees: · Code Red - SW Emergency and Disaster Management Committee · Code Purple - Warren OSH Committee · Code Black - Warren OSH Committee · Code Yellow - SW Emergency and Disaster Management Committee · Code Orange - SW Emergency and Disaster Management Committee · Code Blue - Inland Patient Safety and Quality Committee · Code Brown - SW Emergency and Disaster Management Committee





1.4.2 Warren Hospital Code Communications Log The Communications Officer is to commence a Communications Log for business continuity actions following a 9 call to switch. Where the business continuity response is stood down, the Administration Assistant is to review the Communications Log for accuracy before sending to the Nurse Unit Manager (NUM). Once reviewed, the NUM is to attach the log to action card documentation for that event.

1.4.3 New Action Cards The Emergency Controller is responsible for ensuring that the completed Action Cards and forms are sent to the NUM for review and that new Action Cards are printed and replaced in the Warden Kits and at the Muster Points.

1.4.3.1. Action Cards The Action Cards for each Emergency Response Team member’s role are to be completed by the relevant team member and are sent to the NUM for review and reporting to the relevant Committee. 1.4.3.2. MER Form On completion of a Medical Emergency Response, a copy of the MER form is sent to the NUM for review. Once reviewed, the event and its outcome is reported to the Inland Patient Safety and Quality Committee.

1.5. Organisational Details

1.5.1. Description of Service The Warren Health Service (WHS) is located in the South West town of Manjimup, 138km from the regional South West Health Campus in Bunbury. The WHS is classified as an Integrated District Health Service and in conjunction with the Pemberton/Northcliffe Multi-Purpose Service (MPS), the Northcliffe Nursing Post, the Warren Blackwood Population Health and the Lower South West Mental Health Team, forms part of the Warren Health District. The WHS provides the following services: · Inpatient services 18 acute inpatient beds, medical, surgical, obstetric,

rehabilitation, palliative, acute mental health, radiography/sonography, pathology.

· Nursing Home Type (NHT) awaiting placement (no ongoing NHT patient beds) · Emergency Department – ED staffed 24/7 by registered nurse supported by

VMPs, Emergency Telehealth Service. · Outpatient services – Primary Care, Community Health, Allied Health,

Screening and Health Promotion, Aboriginal Liaison, Radiography, Pathology, Palliative Care and Cancer Support, Mental Health Team.

· Continuing Care – Meals on Wheels, Aged Care Assessment Team, Community Aids and Equipment Program.

The WHS General Ward and Emergency Department operate 24 hours per day, 7 days per week. 1.5.2. Organisational Aim The aim of the Warren Health Service is to support WACHS-SW to provide quality and accessible health services.





2. DOCUMENT CONTROL

2.1 Amendment Control

The Warren Health Service Emergency Response Procedures are a controlled document which is not to be altered other than those amendments approved by the Regional Director. These procedures are intended to be a ‘live’ document and all suggested amendments or additions are to be forwarded to the Warren District Manager.

VERSION NO

DATE RECEIVED

DATE AMMENDED

DETAILS OF AMMENDMENT INITIALS

1 - Jul 2016 Review and full rewrite of Facility Emergency Procedures Manual.

ST

Table 1: Amendment History

2.2 Review

The Inland Patient Safety and Quality Committee meeting reviews the effectiveness of these procedures at least annually, and provide advice of any amendments to the Emergency and Disaster Sub Committee (EDSC). The EDSC may review, or renew the procedures when considered appropriate to do so.

2.3 Distribution and Availability

The current editable version of these procedures is held by the WACHS Policy unit. The procedures are available electronically to all staff via the WA Health intranet facility - HealthPoint.

Hard copies of the WHS Emergency Management folder are to be held in the following locations:

1. Main Reception 2. Emergency Department – staff station 3. Inpatient Unit – staff station 4. Learning and Development meeting room 5. Kitchen / Support Services - office 6. Engineering - office 7. PathWest 8. Ambulatory Care – work station area 9. Surgical Services – staff station

10. Medical Imaging – write up area

Action Cards for all Codes are to be available across the facility at Muster Points.


https://healthpoint.hdwa.health.wa.gov.au/policies/Pages/default.aspx




These Emergency Response Procedures have been distributed to the following:

NAME ORGANISATION POSITION Online Access via HealthPoint WACHS

WACHS SW Inland Hospitals Operations Manager

Department of Fire and Emergency Services (Manjimup) Manager

WA Police (Manjimup) Sergeant Andrew Campbell Manjimup Shire Council Chief Executive Officer

(CEO)


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3. ADMINISTRATION AND GOVERNANCE

3.1 Authority to Plan The Warren Health Service Emergency Response Procedures have been prepared and issued under the authority of the WACHS-SW Regional Director in accordance with applicable legal and other requirements.

These Emergency Response Procedures have been formally recommended by the Warren District Manager, endorsed by the Inland Operations Manager and approved by the WACHS-SW Regional Director as the Standard Operating Procedures to be followed in an emergency of any type at the Warren Health Service.

Recommended Sally Towie A/District Manager Warren WACHS-South West 21 May 2018 Approved Jeremy Higgins Inland Operations Manager WACHS-South West 21 May 2018 Endorsed Kerry Winsor

Regional Director WACHS-South West 22 May 2018





4. CODE RED EMERGENCY RESPONSE PROCEDURES

4.1 Purpose The purpose of this section is to outline:

· the fire safety measures in place to prevent and protect staff from fires · Emergency responses to a fire and/or smoke (Code Red).

4.2 Fire Prevention and Protection

4.2.1 Fire Initiation and Development and Control · Scheduled electrical equipment safety inspections. · Regular plant maintenance. · No smoking policy. · Regular building maintenance to ensure stairs corridors and exit paths are

free of combustibles and obstructions.

4.2.2 Smoke Development and Spread and Control · Automatic shutdown of the air handling units and extraction systems in fire

compartments that is in fire mode. Non affected compartments will remain operational.

· Fire and smoke dampers (smoke doors and walls) located throughout the facility, including ductwork that penetrates fire compartments.

Note: In the event that a non-affected compartment(s) have their air handling

units and extraction systems automatically shut down, the system can be manually overridden by the Maintenance Officer through the Building Management System (BMS) to reinstate air supply systems to the non-affected compartment(s).

4.2.3 Fire Spread and Impact Control · Fire compartments (size, fire doors and roof space fire rated barriers)

designed in accordance with the requirements of the Building Code of Australia.

· Fire Rating Limits (FRL) within compartments – 60 minutes · Fire Rating Limits between compartments – 120 minutes.

4.2.4 Fire Detection · Smoke detectors are located throughout the facility and are linked to the Fire

Indicator Panel (FIP). Smoke detectors will initiate an alarm in the Fire Indicator panel when particles which are the result of combustion are detected.

· Thermal Detectors are located throughout the facility and are linked to the Fire Indicator Panel. Thermal detectors will initiate an alarm in the Fire Indicator panel when heat consistent with a fire is detected.

· Manual Call Points (also known as break glass alarms) are located throughout the facility and initiate an alarm in the Fire Indicator Panel when broken.





4.2.5 Fire Alarm Systems The Fire Indicator Panel (FIP) is located in corridor of main entrance to the hospital. The Fire Indicator Panel displays the location of the alarm activation and also allows the isolation of zones.

4.2.6 Fire Strategy If a fire/smoke is detected in a fire compartment at the WHS the following is to occur. · the fire doors located in this specific compartment and the adjacent

compartment(s) will close · the access control doors located in this specific compartment and the

adjacent compartment(s) will unlock · an alert tone will start in the entire facility

4.2.7 Fire Warning System An Emergency Warning Intercommunication System (EWIS) is located in the corridor of the main entrance of the hospital. The EWIS comprises of two sub-systems:

· Emergency Warning System ( EWS ) - Transmits via speakers in evacuation zones, alert signals, evacuation signals and allows the Emergency Controller to publicly address the facility .The EWS can automatically initiate an evacuation or be manually operated; and

· Emergency Intercommunication System (EIS) - A totally independent intercommunication system provided to communicate on a one to one basis from the Master Emergency Control Panel to the individual Warden Intercommunication Points (WIPs) within the evacuation zones.

Note: The Emergency Warning System and Emergency Intercommunications

System are collectively referred to as the Emergency Warning and Intercommunication System (EWIS).

4.2.8 Fire Suppression Systems

· Fire ring main supplied by water authority. · The facility contains the following types of fire extinguishers:

- carbon dioxide 4.2.9 Evacuation and Control · Phased/zoned Code Orange evacuation procedures. · Evacuation diagrams. · Egress/exit signage and emergency lighting located throughout the facility. · Staff trained and exercised in evacuation. · There are two assembly areas located at:

- Front of the hospital adjacent to the doctor on-call car park near the ambulance entrance

- Rear of the hospital in the staff car park outside the gate





4.2.10 Department of Fire and Emergency Service Intervention · The Department of Fire and Emergency Services are automatically notified

when an alarm is initiated in the Fire Indicator Panel. · Fire hydrants are located around the facility. · The Department of Fire and Emergency Services have perimeter access to

the facility in the event of a fire. 4.3 Other Considerations

4.3.1 Hot Work Persons responsible for hot work being carried out at the WHS, are to ensure that a formal risk assessment of the work is carried out and a WACHS hot work permit is issued prior to the work commencing.

4.4 Essential Steps

Fire response embraces the following essential steps, which in most cases will need to be carried out concurrently.

4.4.1 Life Safety The primary duty of general site staff and Emergency Management Team personnel is not to combat fires but to ensure as far as reasonably practicable the safety of themselves and other sites occupants. In a fire, life takes precedence over operations and asset protection at all times.

4.4.2 Call the Department of Fire and Emergency Services The Code Red ‘immediate actions’ for first responders, prescribes alerting the Department of Fire and Emergency Services when there is a fire or a suspicion of one (e.g. the smell of smoke). Additionally, the Department of Fire and Emergency Services are also notified automatically when an alarm in the Fire Indicator Panel is initiated. Despite this, the Emergency Controller is to ensure that the fire alarm is followed up by a 000 call to confirm the receipt of the alarm.

4.4.3 Evacuation The Code Red ‘immediate actions’ for first responders, prescribes the removal of people from the immediate area (Stage 1 evacuation) when there is a fire or a suspicion of one (e.g. the smell of smoke). Additionally, the WHS Code Orange evacuation procedures outline the specific details of an evacuation in an emergency. Refer to the WHS for further details.

4.4.4 Fight the Fire The WHS has fire extinguishers installed to help control fires. Where firefighting becomes an unacceptable risk (that is greater than the size of a waste bin), responders are to withdraw from the situation.

4.4.5 Communications All communications during a Code Red are to be through the Audible Public Announcement (PA) system or Wi-Fi phones located throughout the facility. The Emergency Controller DECT Phone number will be announced on the Audible PA during the initial PA announcement.





4.5 Code Red Response Procedures (Action Cards)

4.5.1 First Responder – Code Red Immediate Actions

Position: First Responder Action Card 1

Reporting to: Area Warden

Responsibilities • Ensure the immediate safety of anyone within the vicinity of the

fire/smoke. • Take measures to ensure that the Department of Fire and Emergency

Services are notified. • Take measures to ensure that the Emergency Controller is notified.

A staff member who discovers a fire or smells smoke, or who is alerted to a fire and/or smoke, is to carry out

the following immediate actions

Time Sign

1.

Remove all people from the immediate danger.

2.

Alert the Department of Fire and Emergency Services by activating break glass alarms. Where this is not possible dial 000 directly.

3. Contain the fire by closing doors and windows.

4.

Extinguish the fire with the correct firefighting equipment if safe to do so (e.g. fires smaller than a waste basket) and if trained in the equipment use.

a) Fire extinguishers b) Fire hose c) Fire Blankets

5.

Establish contact with the Switchboard Operator by dialling 55 and give the first report. If this is not possible establish contact with the Emergency Controller by dialling EXT 5235 or 5236

First Report: a) caller's name b) exact location of the incident c) type of incident (fire/smoke)

6. Move to your safest muster point and wait for instructions from the Area Warden.





4.5.2 Emergency Controller – Code Red Action Card Emergency Controller : Clinical Nurse Manager Ext 5235 Deputy Controller : General Ward Shift Coordinator Ext 5236

Action Card 2

Reporting to : District Manager 0428 955 818

Responsibilities - Control the internal emergency response of an emergency within the

facility. - Ensure the health and safety of patients (including permanent care

residents), staff and visitors when faced with an emergency.

ON ALERT Time Sign

1. Proceed immediately to the Fire Panel located in the main entrance of the hospital.

2. Collect white vest and action card. a) Don vest. b) Keep action card on hand.

3. Ensure the Department of Fire And Emergency Services have been notified on 000.

4. Open the glass door with the key located in the fire extinguisher box opposite the Fire Indication Panel.

5. Press the Silence Buzzer button on the left hand side of the upper panel.

6. Ascertain the zone of alarm from the fire indicator panel and identify the location of the fire by referring to the zone map for fire alarm indicators.

7.

Change the Emergency Warning Intercommunications System panel from automatic to manual. Refer to the Original Equipment Manufacturers (OEM) manual for instructions on changing the EWIS panel from automatic to manual.

8.

Activate the PA system for the entire facility (press ALL PA) and make the fire alert announcement. “Attention all areas, attention all areas, this is the Emergency Controller. Possible Code Red – <say location>. Staff in <say location> are to carry out their code red immediate actions. All other staff are to remain calm, report to your Area Warden at your Muster Point and wait for further instructions” (Wait 10 seconds and then repeat announcement).





9.

Establish contact with the Area Warden at the point of alarm by whatever means available and request a verbal SITREP. Note:

· Where the Area Warden does not answer the phone, deploy staff to investigate.

· Where the area is out of hours, deploy an Emergency Response Team member/staff with a means of communication to investigate and to report back.

10.

Ensure the main entrance is clear and public access to the facility is restricted. Note: Where a fire alarm is activated, entry to the facility is

only permitted by Emergency Services.

11. Establish contact with the Area Wardens adjacent to the point of alarm by whatever means available and provide SITREP.

11. Brief Department of Fire and Emergency Services personnel upon arrival on the type, scope and location of the emergency.

12. Provide Department of Fire and Emergency Services personnel with an escort to the source.

13.

Complete an impact assessment and determine:

a) business functions disrupted b) maximum tolerable periods of disruption (refer to

Warren Hospital Business Continuity Plan)

14. Contact the Operations manager to activate Business Continuity Plans if the situation warrants this.

15. Where a fire is confirmed, carry out confirmed Code Red actions.

16. Where Department of Fire and Emergency Services or the Engineering Officer confirm that there is no fire/smoke, carry out the Code Red all clear actions.





CONFIRMED Time Sign

1.

Activate the P.A system for the entire facility and make the Code Red confirmed announcement. “Attention all areas, attention all areas, this is the Emergency Controller. Confirmed Code Red. Remain calm and wait for instructions to evacuate.” I repeat, this is the Emergency Controller. Confirmed Code Red. Remain calm and wait for instructions to evacuate.”

2.

Change the Emergency Warning Intercommunications System panel from manual to automatic. Refer to the Original Equipment Manufacturers (OEM) manual for instructions on changing the EWIS panel from automatic to manual.

3. Carry out Code Orange evacuation procedures.

4. Establish contact with District Manager and provide a verbal SITREP.

5. Respond to the directions of Department of Fire and Emergency Service Officer in Charge (OIC).

6. Maintain communications with all key stakeholders.

7. Where the Department of Fire and Emergency Services or the Engineering Officer render the area safe, carry out the Code Red all clear actions.





ALL CLEAR Time Sign

1.

Advise the Area Warden to wait for the arrival of Department of Fire and Emergency Services or the Engineering Officer.

2.

Where the area is rendered safe by the Department of Fire and Emergency Services or the Engineering Officer, activate the PA system and make the Code Red all clear announcement. "Attention all areas, attention all areas, this is the Emergency Controller. Code Red – All clear." "I repeat, this is the Emergency Controller. Code Red – All clear".

3.

Ensure fire prevention and protection measures are reinstated.

4.

Reset the Emergency Warning Intercommunications System panel.

5.

Refurbish vest and action card in the Fire Indicator Panel in the corridor of the main entrance to the hospital.

6.

Commence debriefing processes with all senior staff and key stakeholders. (Refer to the WACHS-SW incident debrief template.)

7.

Compile an emergency response report for the District Manager (Refer to the WACHS-SW Emergency Response Report Template.)





4.5.3 Communications Officer – Code Red Action Card

Communications Officer : Main receptionist (day shift) Ext 55 : Second Nurse in charge (afternoon & night shift)

Action Card 3

Reporting to : Emergency Controller - Clinical Nurse Manager Ext 5235 :Deputy Controller - General Ward Shift Coordinator Ext 5236 Responsibilities: To assist with clerical and record maintenance during and emergency response.

ON ALERT Time Sign

1. Activate a possible code red group page.

2. Proceed immediately to the Fire Panel located in the corridor of the main entrance of the hospital.

3.

Collect the Communications Officer action cards from the Front Reception. a) Keep action card on hand.

4.

Where received, provide the first report to the Emergency Controller. a) Caller's Name b) Exact location of the incident c) Type of incident (Fire/smoke).

5. Return to the switchboard and commence a running log of events and incoming calls.

6. Maintain Communications with the Emergency Controller.

7. Respond to the directions of the Emergency Controller.

CONFIRMED FIRE Time Sign

1. Notify the Emergency Management Team ‘confirmed Code Red’ group page.

2. Continue logging events and incoming calls.

3. Maintain communications with the Emergency Controller.


ALL CLEAR Time Sign

1. Notify the Emergency Management Team ‘Code Red – all clear’ group page.

2. Collate all action cards (complete and incomplete) and ensure records are saved electronically and in hard copy format.

3. Refurbish action cards in the Front Reception.

4. Participate in the debriefing process.





4.5.4 Area Warden/Warden – Code Red Action Card

Area Warden/Warden: Nominated role for each shift. Action Card 4

Reporting to : Emergency Controller - Clinical Nurse Manager Ext 5235 :Deputy Controller - General Ward Shift Coordinator Ext 5236

Responsibilities: Control the initial response to the emergency in the area.

ON ALERT Time Sign

1. Proceed to the local area warden point.

2. Collect orange vest and Area Warden action card. a) Don vest b) Keep action cards on hand.

3. Ensure the area is checked (where practicable in pairs) for signs of smoke or fire.

4. Ensure fire doors and smoke doors are properly closed.

5. Provide a verbal SITREP to the Emergency Controller. Advise if there is a need to evacuate.

6. Maintain communications with the Emergency Controller and take control of emergency response activities in the area.


CONFIRMED

1. Liaise with the Emergency Services, provide a verbal SITREP and advise of any particular hazards and special areas for consideration.

2. Respond to the directions of the Emergency Services.

3. Carry out Code Orange evacuation procedures were instructed to do so or when the situation warrants this.


5. Where the Code Red all clear message is heard, carry out the all clear actions.

ALL CLEAR

1. Where patients have been evacuated, coordinate their return to their wards or relocation as appropriate.

2. Coordinate the reinstatement of fire prevention/protection measures.

3. Refurbish vest and action cards and the Area Warden Kit at the local Area Warden.


5. Act as directed by the Emergency Controller to compile a report.





4.5.6 Emergency Response Team Member - Code Red Procedure

Emergency Response Team Member : Orderly (day shift) Ext 5232 : Third staff member on duty (i.e. Enrolled Nurse, assistant in nursing) (afternoon and night shift).

Action Card 6

Reporting to : Emergency Controller - Clinical Nurse Manager Ext 5235 Deputy Controller - General Ward Shift Coordinator Ext 5236

Responsibilities: Carry out emergency response activities.

ON ALERT Time Sign

1. Proceed immediately to the Fire Indicator Panel located in the corridor of main entrance of the hospital.

2. Collect action card a) Keep action card on hand.

3. Report to the Emergency Controller.

4. Where the Emergency Controller is absent, assume the responsibilities of the Emergency Controller until they arrive.


CONFIRMED Time Sign

1. Proceed to the affected area as a team.

2. Respond to the directions of the Area Warden.


4. Carry out Code Orange evacuation procedures were instructed to do so or when the situation warrants this.

5. Where the Code Red all clear message is heard, carry out all clear actions.

ALL CLEAR Time Sign

1. Clean and service used specialised equipment as necessary.

2. Replace specialised equipment as necessary.

3. Refurbish action cards






5. CODE PURPLE EMERGENCY RESPONSE PROCEDURES 5.1 Purpose

The purpose of this section is to provide information on, and outline emergency responses to, a bomb threat (Code Purple).

5.2 General

Bomb threats are usually made by individuals seeking to create a state of fear, confusion and anxiety amongst occupants as well as disrupting critical business functions of the service. Despite this, bomb threats may also warn of an impending attack and therefore should never be discredited. In other words, all bomb threats are to be treated as real until proven otherwise.

5.3 Identifying Bomb Threats

Bomb threats may be identified through one or more forms including: Verbal threats Threats made over the telephone or in person to a patient, staff member or visitor; or relayed verbal messages. The most popular medium for a verbal threat is over the telephone. Written threats Threats made by letters, emails or facsimiles; Suspect items Items found at the facility by patients, staff members or visitors and present as a possible threat by virtue of its characteristics, location or circumstances.

Identification of a bomb threat is critical, because it allows further analysis to be made by the facilities Emergency Management Team.

5.4 Assessing Bomb Threats

An analysis of a bomb threat involves developing an understanding of the threat to help managers decide on an appropriate course of action. Threat analysis involves considering on hand threat information to determine the level of risk that the facility faces.

This involves: · categorising the bomb threat as either a specific or a non-specific threat or a

suspect item. · analysing the adverse consequences should an unwanted event occur (a threat

may have multiple consequences); and · analysing the likelihood that those consequences can occur. The way in which

consequences and likelihood are combined will determine the risk level of the bomb threat.





Note: The confidence in the assigned level of risk should be communicated effectively to decision makers and, as appropriate, other stakeholders. Factors such as divergence of opinion among experts, uncertainty and the quality and quantity of information should be highlighted. For these reasons, people with appropriate knowledge should be involved in analysing threats.

5.4.1 Specific and Non Specific Threats Categorising the bomb threat as a specific or non-specific threat will assist the Emergency Management Team with the analysis of the threat. (Specific threats are more likely to be a real than non-specific threats). Despite this, all threats should be treated as possible until proven otherwise. Table 1 provides a description and an example of specific and non-specific threats.

Type of Threat

Description

Example

Non Specific

Simple statements with little additional information given.

“there’s a bomb in the hospital and its gunna explode at midday’”.

Specific

More detailed statements and may describe the type of device, its exact location and why the device has been placed.

“this is the last time my kids have to wait so long to see a Doctor. I have placed a barrel with fertilizer and diesel near the back loading dock. I am using a mobile phone to make sure that it will explode when I decide to call it. I suggest that you get out of the hospital now”.

Table 1: Threat Types

5.4.2 Tools to Aid Assessment 5.4.2.1 Telephone Bomb Threat Checklist The telephone bomb threat checklist is a tool that can assist in the assessment of a bomb threat made by the telephone. The person who receives the threat has a vital role to play in capturing all relevant information. 5.4.2.2 HOT-UP HOT-UP is a tool to be used by the Emergency Management Team to assess an unattended, doubtful or suspect item and determine a course of action. The HOT-UP principle relies on responses to the following questions:

Is the item Has there been

Hidden? Obviously a bomb? Typical of its environment?

Unauthorised access? Perimeter breach?





5.4.3 Risk Evaluation Risk evaluation involves comparing the level of risk found during the analysis process against acceptability criteria as outlined in the WA Health Integrated Corporate and Clinical Risk Analysis Tables and Evaluation Criteria. Risk evaluation will lead to an action.

5.4.4 Actions Based on the comparison of the risk level against acceptability criteria, the following actions can be considered:

· Search without an evacuation for low risk threats. · Evacuate without search for medium high risk or greater threats.

Decisions to act are to be in accordance with delegation schedules as outlined in the WA Health Integrated Corporate and Clinical Risk Analysis Tables and Evaluation Criteria.

5.4.5 Searching Searches of an area should be carried out by personnel who generally occupy the area. The purpose of the search is to identify items that do not belong in the area at any given time.

Where a search has been initiated by the Emergency Controller, the following search sequence should be followed:

· The location as described by the individual making the threat (specific threats only).

· Public areas outside the facility including the assembly areas. · The main entrance and exit points to the facility as well as those that lead

into and out of respective departments. · Public areas (waiting rooms, wards, cafes etc.) within the facility.

Staff selected for search duty are to follow the following:

1. Proceed with utmost caution. 2. Commence at the outside of the room and work towards the inside. 3. Start with the lowest level and work towards the top. Search from floor level

to waist level, starting and finishing at a fixed point then search from waist to ceiling.

4. Look for hidden items, items that obviously look like a bomb or items atypical to their environment.

Note: It should not be assumed that staff, when asked, will carry out a search.

For this reason, the Emergency Controller is to have a clear understanding of exactly what roles can provide a search when requested. Where staff are willing to search an area at the request of the Emergency Controller, staff should not expose themselves to excessive risk by spending unnecessary time near items identified as suspect or by touching or disturbing the item.


http://ww2.health.wa.gov.au/%7E/media/Files/Corporate/general%20documents/Quality/PDF/WA_risk_analysis_tables.ashx

http://ww2.health.wa.gov.au/%7E/media/Files/Corporate/general%20documents/Quality/PDF/WA_risk_analysis_tables.ashx




5.4.6 Evacuating Evacuating the facility because of a bomb threat is a big decision for the Emergency Management Team to make because of the variety of potential negative consequences associated with an evacuation. This includes but is not limited to:

· patient safety · staff safety · critical services interruptions · organisational objectives.

Although a stage three (entire facility) evacuation may seem the most appropriate response to a bomb threat, the negative consequences associated with the evacuation in response to a bomb threat may contribute to a higher risk than the bomb threat itself. Stage 1 or Stage 2 evacuations may be lower risk options to manage risk associated with both the bomb threat and the evacuation.





5.5 Code Purple Action Cards

5.5.1 First Responder – Immediate Actions Telephone Threat

Position : First Responder Action Card 1

Reporting to : Area Warden

Responsibilities : - Take measures to record relevant information. - Take measures to ensure that the person responsible for the emergency

response is notified.

A staff member who receives a bomb threat by telephone is to carry out the following immediate actions Time Sign

1.

Remain calm and if possible attract the attention of another staff member.

2.

Where you can attract the attention of another staff member, signal to them ‘bomb threat’ and instruct them to give the first report.

3.

Do not hang up the phone – keep the line open for possible tracing.

4.

If not already done, establish contact with the Switchboard Operator by dialling 55 and give the first report. If this is not possible, establish contact directly with the Emergency Controller by dialling Ext 5235 or 5236 First Report:

a) caller's name b) exact location of the incident c) type of incident (telephone bomb threat).

5. Complete the Telephone Bomb Checklist. Appendix 16.4

6.

Wait for instructions from the Area Warden.





5.5.2 First Responder – Immediate Actions Letter Threat



Responsibilities : - Take measures to retain evidence. - Take measures to ensure that the person responsible for the emergency

response is notified. A staff member who identifies a written bomb threat

is to carry out the following immediate actions Time Sign

1. Place the threat document in a paper envelope or folder.

2. Do not photocopy the threat document.

3.

Restrict access – the document is considered physical evidence and should be surrender to the Police.

4.

If received by electronic means, takes steps to secure the information such as saving and printing.

5.

Establish contact with the Switchboard Operator by dialling 55 and give the first report. If this is not possible, establish contact directly with the Emergency Controller by dialling Ext 5235 or 5236 First Report:

a) caller's name b) exact location of the incident c) type of incident (telephone bomb threat).

6. Wait for instructions from the Area Warden.





5.5.3 First Responder – Immediate Actions Suspect Item



Responsibilities - Take measures to ensure the Police are notified. - Take measures to ensure that the person responsible for the emergency

response is notified. - Ensure the immediate safety of anyone within the vicinity of the suspect

object. A staff member who receives or identifies a suspect item

is to carry out the following immediate actions. Time

Sign

1. Do not touch the item.

2.

Remove all non-essential persons and equipment from the immediate area. A distance of 25 metres is recommended.

3.

Establish contact with the Switchboard Operator by dialling Ext. 55 and give the first report. If this is not possible, establish contact with the Emergency Controller by dialling Ext 5235 or 5236. First Report:

a) caller's name b) exact location of the incident c) type of incident (suspect item).






5.5.4 Emergency Controller – Code Purple Action Card

Emergency Controller : Clinical Nurse Manager Ext 5235 Deputy Controller : General Ward Shift Coordinator Ext 5236

Action Card 4


Responsibilities - Control the internal emergency response of an emergency within the facility. - Ensure the health and safety of patients (including permanent care


ON ALERT Time Sign

1.

Proceed immediately to the Fire Indicator panel located in the corridor of the main entrance of the hospital.

2.

Collect white vest and action card

a) Don vest b) Keep action card on hand.

Note: Do not use radios or mobile phone to communicate

with the Emergency Response Team. Communications are to be made by other non-radio frequency means (e.g. landlines, WIP phones, PA system, runners).

3.

Receive the first report from the Communications Officer and determine the need to notify the Police. Where needed, instruct the Communications Officer to dial 000 and notify the police.

4.

Where possible, ascertain the nature and the location of the bomb threat.

5.

Establish contact with the Area Warden of the affected area by whatever means available and provide/receive a verbal SITREP. Note: Where the Area Warden does not answer the phone,

deploy two Emergency Response Team members to investigate.





Time Sign

6.

Establish contact with Area Wardens adjacent to the point of alarm and provide a verbal SITREP.

7.

Categorise the bomb threat as either specific (detailed information) or non-specific (a simple statement), or suspect item.

8.

Brief Emergency Services personnel upon arrival on the type, scope and location of the emergency and provide an escort to the affected area.

9.

Convene key stakeholders and carry out a quick risk assessment of the situation.

10.

Where the bomb threat is verbal or written and the risk level is assessed as medium or greater, carry out the Code Orange evacuation procedure.

11.

Where the threat is verbal or written and the risk level is assessed as low, carry out the search without evacuation procedure.

12.

Where a suspect item is confirmed carry out the confirmed suspect item actions.





CONFIRMED SUSPECT ITEM Time Sign

1. Convene all key stakeholders and re-analyse the risk.

2.

Activate the PA system for the entire facility and make the confirmed Code Purple announcement. “Attention all areas, attention all areas, this is the Emergency Controller. Confirmed Code Purple. Remain calm and wait for instructions to evacuate.” “I repeat, this is the Emergency Controller. Confirmed Code Purple. Remain calm and wait for instructions to evacuate.”

4.

Ensure the main entrance is clear and public access is restricted. Note: Where a suspect item is identified, entry to the facility is

only permitted by police.


6.

Provide a verbal SITREP to the District Manager and request any additional resources.

7. Respond to the directions of the Police.

8.


a) business functions disrupted b) maximum tolerable periods of disruption (refer to


9. Contact the Operations Manager to activate Business Continuity Plans if the situation warrants this.


11. Where the area is rendered safe by the police, carry out all clear actions.





ALL CLEAR Time Sign

1. Advise the Area Warden to wait for the arrival of the Police.

2.

Once the area is rendered safe by the Police or the Engineering Officer, activate the PA system and make the Code Purple all clear announcement. “Attention all areas, attention all areas, this is the Emergency Controller. Code Purple – All clear “I repeat, this is the Emergency Controller. Code Purple – all clear”.

3.

Refurbish vest and action cards in the Fire Indicator Panel in the corridor of the main entrance of the hospital.

4.

Commence debriefing processes with all senior staff and key stakeholders. (Refer to the WACHS-SW incident debrief template).

5.

Compile an emergency response report for the District Manager. (Refer to the WACHS-SW Emergency Response Report Template).





5.5.5 Emergency Controller - Search without Evacuation Procedure Emergency Controller : Clinical Nurse Manager Ext 5235 Deputy Controller : General Ward Shift Coordinator Ext 5236

Action Card 5



residents), staff and visitors when faced with an emergency. Where the bomb threat is verbal or written and the

risk level is assessed as low Time Sign

1.

Establish contact with the District Manager, provide a verbal SITREP and request approval to search without evacuation. Note: Approval to search an area after an evacuation should

be based on the assessed level of risk. Where risk levels are intolerable (i.e. assessed as high or greater), approval to search should not be given.

2.

Instruct the Area Warden of the affected area to initiate a search of the given area in the following order: a) The area/department in which the threat has been made. b) The departments muster point any routes that people may

use to evacuate. c) The department’s entrances and exits. d) Public areas within the department (waiting rooms, public

toilets). e) Other areas.

3. Maintain communications with all key stakeholders (i.e. police, Area Wardens, Emergency Response Team and Tier 4 Manager).

4.

Where an item is identified, categorise the item as either suspect or not suspect: a) Is the item unidentified/unaccounted for? b) Is the item unusual for the area? c) Is the item obviously a bomb? d) Is the item hidden or concealed in any way? e) Has there been unauthorised access to the area? f) Has there been a breach of the areas physical security?

Note: The above questions provide guidance of assessing

an item.

5. Where an item is confirmed as suspect, carry out the Code Purple confirmed suspect item actions.

6. Where a suspect item is not identified, carry out the Code Purple all clear actions.





5.5.6 Communications Officer – Code Purple Action Card

Communications Officer : Main receptionist (day shift) Ext 55

: Second Nurse in charge (afternoon & night shift). Action Card 6

Reporting to: Emergency Controller - Clinical Nurse Manager Ext 5235 Deputy Controller - General Ward Shift Coordinator Ext 5236 Responsibilities: To assist with clerical and record maintenance during and

emergency response.

ON ALERT Time Sign

1. Proceed immediately to the Fire Indicator Panel located in the corridor of the main entrance of the hospital.

2.

Ensure the Emergency Management Team have been notified possible Code Purple by whatever non radio frequency means available (I.e. Not pagers or mobile phones).

3.

Collect the Communications Officer action cards from the Front Reception office. a) Keep action card on hand.

4.

Provide the first report to the Emergency Controller. a) caller's name b) exact location of the incident c) type of threat:

i. specific or non-specific ii. written or verbal threat or suspect item.

5.

Return to the switchboard and commence a running log of events and incoming calls.

6.

Where directed by the Emergency Controller, establish contact with the Police by dialling 000 and give the first report.











ALL CLEAR Time Sign

1.

Collate all action cards (complete and incomplete) and ensure logs and records are saved electronically and in hard copy format.

2. Refurbish action cards in the Front Reception office.






5.5.7 Communications Officer – Search without Evacuation Procedure

Communications Officer : Main receptionist (day shift) Ext 55 : Second Nurse in charge (afternoon & night shift).

Action Card 7

Reporting to : Emergency Controller - Clinical Nurse Manager Ext 5235 Deputy Controller - General Ward Shift Coordinator Ext 5236 Responsibilities: - To assist with clerical and record maintenance during and emergency

response. Where the bomb threat is verbal or written and the

risk level is assessed as low Time Sign








5.5.8 Area Warden/Warden – Code Purple Action Card

Area Warden/Warden : Nominated role for each shift. Action Card 8

Reporting to : Emergency Controller - Clinical Nurse Manager Ext 5235 : Deputy Controller - General Ward Shift Coordinator Ext 5236


ON ALERT Time Sign


2.

Collect orange vest and Area Warden action card. a) Don vest b) Keep action cards on hand.

3.

Provide a verbal SITREP to the Emergency Controller using either: a) Bomb threat card (verbal and written threats); and/or b) HOTUP information (identified items).

i. Hidden items? ii. Obviously a bomb? iii. Typical of its environment?

Has there been: iv. Unauthorised access? v. Perimeter Breach?

4. Maintain communications with the Emergency Controller







1.

Ensure the evacuation point including the routes that people will use to evacuate is clear.

2.

Ensure doors and windows are opened and public access to the area/department is restricted.

3.

Ensure mobile phones and pagers are switched off. Where practicable shut down computers and switch off electrical equipment.

4.

Where evacuation announcement is made, carry out code orange evacuation procedures ensuring personal belongings are taken.



7. Co-opt Emergency Management Team to assist where necessary.

ALL CLEAR Time Sign

1.

Where patients have been evacuated, coordinate their return to their wards or relocation as appropriate.

2.

Instruct staff to reinstate the area to original operational status (i.e. close doors and windows etc.).

3. Refurbish vest and action cards.







5.5.9 Area Warden/Warden – Search Without Evacuation Procedure


Reporting to : Emergency Controller - Clinical Nurse Manager Ext 5235 Deputy Controller - General Ward Shift Coordinator Ext 5236 Responsibilities: Coordinate the initial response to the emergency in the

area.

Where the bomb threat is verbal or written and the risk has been assessed as low Time Sign

1. Establish contact with the Emergency Controller and request approval to search the area.

2.

Where a search has been approved, initiate a discrete search of the given area by local staff (in pairs) and in the preferred order: a) The area that is threatened. b) The department’s assembly area including any routes that

people may use to evacuate. c) The department’s entrances and exits. d) Public areas within the department (waiting rooms, public

toilets). e) Other areas. Note: Where an item is located, staff should not touch, cover

or move the item.



5. Co-opt Emergency Management Team to assist where necessary.





5.5.10 Emergency Response Team Member - Code Purple Action Card

Emergency Response Team Member : Orderly (day shift) Ext 5232 / 5233 : Third staff member on duty (I.e. Enrolled Nurse, assistant in nursing) (afternoon and night shift).

Action Card 10



ON ALERT Time Sign

1. Proceed to the local Area Warden point.

2.

Collect action card. a) Keep action card on hand.

3.

Report to the Emergency Controller. Where the Emergency Controller is absent, assume the responsibilities of the Emergency Controller until they arrive.


CONFIRMED SUSPECT ITEM



ALL CLEAR


2. Refurbish action cards.






5.5.11 Emergency Response Team Member – Search without Evacuation

Procedure Emergency Response Team Member :Orderly (day shift) Ext 5232 / 5233 : Third staff member on duty (i.e. Enrolled Nurse, assistant in nursing) (afternoon and night shift).

Action Card 11


Responsibilities : Carry out emergency response activities.

Where the bomb threat is verbal or written and the risk has been assessed as low Time Sign

1. Proceed to the affected area as a team.


3.

Maintain communications with the Area Warden and other key stakeholders, Emergency Response Team.





6. CODE BLACK EMERGENCY RESPONSE PROCEDURES

6.1 Purpose The purpose of this section is to outline the emergency responses to an armed or unarmed personal threat. Note: In addition to Code Black personal threat emergencies, the following codes

are used to facilitate the identification and communication of additional risks. For these emergencies sub plans have been established.

• Code Black Alpha – Infant or Child Abduction, and • Code Black Jumper – Suicide / self-harm through jumping. • Code Black Missing Person – Missing Person. (Refer to WACHS Missing Person

or Suspected Missing Inpatient Procedure or Missing Aged Care Resident Procedure.)

• Code Black Bravo – Active Shooter (Under development, 2016)

6.2 General A personal threat is an incident where staff, patients and/or visitors are verbally, physically abused, threatened or assaulted. Personal threats are categorised as unarmed or armed. Unarmed confrontations may occur when there is a threat to staff, patients and/or visitors by an unarmed person confronting them in a violent or threatening manner. This includes but is not limited to: • verbal aggression – threatening or abusive language involving excessive swearing

or offensive remarks • threatening behaviour • physical aggression • wilful damage to hospital property. Armed confrontations may occur when there is a threat to staff, patients and/or visitors by a person confronting them armed with a weapon. A weapon is defined as any article used to cause injury. Some personal threats may be de-escalated quickly and easily addressed at a local level (because the issue is medically related) however some may require a coordinated effort from the hospital’s Emergency Management Team to resolve. A Code Black refers to a personal threat, actual or perceived that requires a coordinated effort from the hospital’s Emergency Management Team to resolve. A Code Black call can be made by any staff member who feels the situation is an emergency and requires assistance.

6.3 Responding to the Aggressive Person If an incident occurs or escalates, staff are to respond to the situation in accordance with the immediate actions. The immediate actions prescribe the initial notification and response actions for first responders to a Code Black emergency.


https://healthpoint.hdwa.health.wa.gov.au/policies/Policies/WACHS/Missing%20or%20Suspected%20Missing%20Inpatient%20Procedure.pdf

https://healthpoint.hdwa.health.wa.gov.au/policies/Policies/WACHS/Missing%20or%20Suspected%20Missing%20Inpatient%20Procedure.pdf






6.3.1 De-escalation De-escalation is the process of recognising the early signs of distress, anger or frustration and intervening to reduce the level or the intensity of those feelings before the behaviour becomes aggressive and violent. Where confronted with an aggressive situation, staff should first attempt to de-escalate the situation by using the LASSIE technique. All de-escalation interventions are to be documented in the patient’s records with an evaluation of the effectiveness of the technique.

Acronym Intervention

Listen to what the person is saying.

· Use open ended questions · Ascertain the trigger (e.g. Fear, frustration,

manipulation, intimidation) · Paraphrase to reinforce you understand

Acknowledge the feelings.

· Reaffirm your understanding · Begin to set boundaries for inappropriate

behaviour

Separate the person form others

· Remove the person from distracting/hectic

environments. · Establish a communications plan with colleagues

and a means of communications (I.e. duress alarm)

· Sanitise the area of potential weapons where possible

· Dual access and egress – do not isolate yourself

Sit the person down

· Eye level · Expand on what you have heard

Indicate options

· Options should specific, achievable, realistic and

time bound

Encourage

· Encourage the person to choose an option · Commit yourself to the chosen option





6.3.2 Withdrawal Where a situation cannot be de-escalated, staff should withdraw to a safe area/room and call a Code Black. The decision to withdraw should be assessed with consideration to the following: · The consequences to staff safety should a withdrawal not be carried out; · The proximity of the aggressor to other patients and visitors; · The clinical risks associated with withdrawing staff from clinical areas.

A withdrawal is to be via a person’s most direct and safe route to their nearest safe area/room.

6.3.3 Evasion Evasion is a technique that helps staff safely remove themselves from a violent situation when a withdrawal route is blocked, when under the threat of attack or when being attacked. Where withdrawal to a safe area is not practicable, staff should: · call loudly for help · remain as calm and confident as possible · communicate with the aggressor by using their name · stay out of striking range – use barriers (staff stations, desks etc.) if you can · remain alert for cues (clenched fists, picking up a weapon etc.) · make an escape plan – where is the door, where is the safe room? · defend themselves where necessary – escape from holds, deflect punches

and kicks.

6.4 Management Strategies for the Aggressive Patient

If an incident occurs or escalates, the Emergency Controller in consultation with other Emergency Management Team members (I.e. Area Wardens) and key stakeholders should initiate a management strategy appropriate to the situation and the training of staff. After an initial evaluation of the situation, the following management strategies may be initiated to manage an aggressive person.

6.4.1 Patient Care Plan · Behavioural assessment: an assessment that aims define the

aggressive/violent behaviour. · Investigations; actions taken to investigate the physiological cause of the

aggressive/violent behaviour. · Interventions/Treatments; medical and or nursing actions taken to manage

aggressive/violent behaviour.





6.4.2 Environmental Management Plan · Reduce environment stimuli: actions taken to reduce the level of stimulation

in the physical environment. · Reduce patient confusion: actions taken to maintain clear and concise lines

of communication. · Protect the person from harming self or others: actions taken to utilise

engineered solutions to protect the patient, staff and others from harm. · Tolerate restlessness: defining actions that may be made by the person

which are tolerable for staff.

6.4.3 Discharge/Release · Discharge/release: the actions taken to discharge the patients or allow them

to be released.

6.4.4 Seclusion · Seclusion: The act of restricting voluntary movement by locking a person in a

room. See: WACHS Restraint and Seclusion Minimisation Clinical Practice Standard Considerations

- Authority to seclude. - Patient dignity. - The provision of basic needs. - The period of seclusion. - The availability of potential harmful objects while secluded. - Constant supervision/observation. - Distress to other patients. - The preparation of a contingency plan. - Discontinuing seclusion. - Post seclusion interviews. - Documentation.

Note: Seclusion is an endorsed management strategy for mentally ill patients

accessing care in an approved mental health facility.

6.4.5 Restraint · Chemical Restraint: An action that aims to influence aggressive/violent

behaviour through the use of medication (sedatives).

See: WACHS Restraint and Seclusion Minimisation Clinical Practice Standard







Considerations

- Discussing the option with the patients’ medical officer - Medical co morbidities. - Cardiovascular/pulmonary problems, including corrected QT interval. - Certain disorders affecting metabolism. - The presence of mental disorders with accompanying physiological

consequences. - The elderly and frail. - The use of alternate forms of medicines.

· Manual Restraint: An action that aims to restrict the voluntary movement of

the aggressor by physically holding them.

Important: Manual restraint is not an endorsed management strategy at the Warren Health Service and where required, is to be left to the police.





6.5 Code Black Action Cards

6.5.1 First Responder – Unarmed Confrontation Immediate Actions


Reporting to : Area Warden Responsibilities - Ensure the safety of yourself and anyone within the immediate vicinity of the

aggressor. - Take measures to ensure that the Emergency Controller is notified.

UNARMED CONFRONTATION Time Sign 1. Remain calm. Avoid showing signs of fear or panic.

2. Attempt to de-escalate the situation by using the LASSIE technique.

3. Where the situation can be deescalated, notify the Area Warden and if applicable commence risk reporting processes.

Where the situation cannot be de-escalated.

4.

Activate duress and withdraw to your nearest safe room/area. Note: Where a duress alarm cannot be activated, a call for assistance should be made by whatever means available (I.e. staff assist, attract the attention of other staff).

5.

Establish contact with the Switchboard operator by dialling 55 and give the first report. If this is not possible, contact the Emergency Controller by dialling Ext 5235 or 5236 First Report:

a) caller's name b) exact location of Incident c) type of incident (unarmed confrontation).

6. Record all information on the Offender Description Form, Appendix 16.5. Note: This should be carried out individually.

7. Wait for instructions from the Area Warden (includes directions on reporting risk).

Where you cannot withdraw to your nearest safe room/area. 8. Call loudly for assistance.

9. Remove possible weapons or at least be aware of these.

10 Stay out of striking range – use barriers.

11. Avoid acting aggressively except when needing to defend yourself - escape from holds, deflect punches and kicks.

12. Make you withdrawal plan, position yourself so you can withdraw – withdraw when you can.

13. When escaped, move to your nearest safe room/area and carry out steps 4 – 6.





6.5.2 Code Black Immediate Actions – Armed Confrontation



Responsibilities - Ensure the safety of yourself and anyone within the immediate vicinity of the

aggressor. - Take measures to ensure that the Emergency Controller is notified.

ARMED CONFRONTATION Under no circumstance should staff, patients or visitors place

themselves in further jeopardy. Time Sign

1. Remain calm and in control – avoid showing signs of fear and panic.

2. Obey the offender’s instructions (this includes surrendering property), but do only what you are told and nothing more. Do not volunteer any information.

3. Carefully observe any vehicle used by the offender, taking particular note of its registration number, type and colour and number of occupants and their description.

4. Carefully observe the offenders speech, mannerisms, clothing and distinguishable features such as tattoos.

5. If able to do so without danger, activate duress. Note: Where a duress cannot be activated, a discrete call for assistance should be made by whatever means available.

Where the danger has passed.

6.

Establish contact with the Switchboard operator by dialling 55. If this is not possible, contact the Emergency Controller directly by dialling Ext 5235 or 5236 and give the first report. First Report:

a) caller's name b) exact location of Incident c) type of incident (unarmed confrontation).

7. Record all information on the Offender Description Form. Appendix 16.5.

8. Wait for instructions from the Area Warden (includes directions on reporting risk).





6.5.3 Emergency Controller – Code Black Action Card


Action Card 3

Reporting to :: District Manager 0428 955 818



residents), staff and visitors when faced with an emergency. ON ALERT Time Sign


2. Collect white vest and action card.

a) Don vest. b) Keep action card on hand.

3. Ascertain the point of alarm and the nature of the incident. Ensure the police have been notified on 000.

4. After hours proceed with caution to the point of alarm.

5. Contact the Area Warden/First Responder at the point of alarm by whatever means possible and request a verbal SITREP.

6.

Ensure all areas are notified possible Code Black by whatever means possible. Note: Notification should be discrete and not via the PA system. Notification “This is the Emergency Controller, possible Code Black <say location>. Staff in <say location> are to carry out their code black immediate actions. All other staff are to remain calm and wait for further instructions” (Wait 10 seconds and then repeat announcement).

7. Establish contact with Area Wardens adjacent to the point of alarm and provide a verbal SITREP.

8. Evaluate the situation and determine the need for further assistance (e.g. clinical, police etc.). Ensure additional resources are sourced where required.

9. Where applicable, brief additional clinical staff and/or Police upon arrival on type, scope and location of the emergency.

10. Where an unarmed/armed confrontation is confirmed, carry out confirmed Code Black actions.

11. Where the police or the most senior person in the affected area confirm that there is no confrontation, carry out Code Black all clear actions.





CONFIRMED

1.

Ensure all areas are notified confirmed Code Black by whatever means available. Note: Notification should be discrete and not via the PA system

Notification “This is the Emergency Controller, confirmed Code Black < say location> remain calm and wait for instructions to move to a safe area” (Wait 10 seconds and say again).

2. Liaise with the Area Warden of the affected area an initiate appropriate management strategy.

3. Establish contact with the District Manager and provide a verbal SITREP.

4. Monitor the progress of management strategy.

5.

Complete an impact assessment and determine: a) business functions disrupted; b) maximum tolerable periods of disruption (refer to


Contact the Operations Manager to activate Business Continuity Plans if the situation warrants this.


7. Where the police or the Emergency Controller in the affected area, confirm that there is no confrontation and carry out all clear actions.

ALL CLEAR Time Sign

1.

Ensure all areas are notified Code Black all clear by whatever means available. Note: Notification should be discrete and not via the PA system.

Notification “This is the Emergency Controller, Code Black <say location> all clear”. (Say twice.)

2. Ensure physical protective measures are reinstated and third parties (i.e. monitoring company, police who are in bound etc.) are stood down.

3. Refurbish vest and action cards in the Fire Indicator Panel.

4. Commence debriefing processes with all senior staff and key stakeholders. (Refer to the WACHS-SW incident debrief template).

5. Compile an emergency response report for the District Manager. (Refer to the WACHS-SW Emergency Response Report Template).





6.5.4 Communications Officer – Code Black Action Card

Communications Officer : Main receptionist (day shift) Ext 55 Second Nurse in charge (afternoon and night shift).

Action Card 4

Reporting to :: : Emergency Controller - Clinical Nurse Manager Ext 5235 : Deputy Controller- General Ward Shift Coordinator Ext 5236 Responsibilities: To assist with clerical and record maintenance during

and emergency response.

ON ALERT Time Sign

1. Ascertain the nature and location of the emergency from the first responder.

2. Notify the site ‘possible Code Black’ group page.

3.

Establish contact with Police by dialling 000 and give the first report. a) Caller's Name b) Exact location of the incident c) Type of incident (unarmed / armed / self-harmer /

abduction).


5. Collect the Communications Officer action cards from the Front Reception office. a) Keep action card on hand.

6. Provide the first report to the Emergency Controller.




CONFIRMED Time Sign








ALL CLEAR


2.

Collate all action cards (complete and incomplete) and ensure records are saved electronically and in hard copy format.

3. Refurbish action cards in the Front Reception Office.






6.5.5 Area Warden/Warden – Code Black Action Card Area Warden/Warden : Nominated role for each shift.

Action Card 5

Reporting to : Emergency Controller - Clinical Nurse Manager Ext 5235 : Deputy Controller - General Ward Shift Coordinator Ext 5236 Responsibilities : Control the initial response to the emergency in the area.

ON ALERT Time Sign


2.


3. Direct Wardens/staff to check the area/floor for any abnormal situations.

4. Supervise the locking up of offices, securing records, files, cash and other valuable property if the situation in the area warrants this.

5. Withdraw staff to a safe area if the situation in the area warrants this.

6. Provide a verbal SITREP to the Emergency Controller and any actions taken.

7. Maintain communications with the Emergency Controller by whatever means available.

8. Liaise with and provide a verbal SITREP to the Emergency Response Team, additional clinical staff and/or Police upon arrival.

CONFIRMED Time Sign

1.

Convene all key stakeholders (i.e. clinical staff, Emergency Response Team, police), evaluate the situation and develop an appropriate management strategy.

2. Communicate management strategy with the Emergency Controller

3. Act on the directions of the Emergency Controller to initiate management strategy.






ALL CLEAR

1.

Coordinate the return of the area to operational state (I.e. unlocking offices, records, files, cash and other valuable property etc.).

2. Coordinate the reinstatement of physical protection.



5.

Respond as directed by the Emergency Controller to compile a report.





6.5.6 Emergency Response Team Member - Code Black Procedure

Emergency Response Team Member :Orderly (day shift) Ext 5232 / 5233 : Third staff member on duty (I.e. Enrolled Nurse, Assistant in Nursing) (afternoon and night shift).

Action Card 6


Responsibilities : Carry out emergency response activities.

ON ALERT Time Sign

1. Proceed immediately and with caution to the point of alarm and liaise with the Emergency Controller

2. Where the Area Warden is absent, identify the first responder. Withdraw the first responder to a safe area if the situation in the area warrants this.

3. Respond to the directions of the Area Warden. Where the Area Warden is absent, assume the duties of the Area Warden.

CONFIRMED

1. Liaise with the Area Warden and participate in the development of the management strategy.

2. Brief staff on the management strategy and thereafter respond to the directions of the Area Warden.

3. Maintain communications with the Area Warden.

ALL CLEAR

1. Respond as directed by the Area Warden.

2. Refurbish any specialised equipment as necessary.






7. CODE BLACK ALPHA – SUB PLAN

7.1 Purpose

The purpose of this sub plan is to outline the emergency responses to an infant or child abduction.

7.2 General

Although an unlikely event, the abduction of an infant or child patient from a health facility has significant impacts on families and staff. In the absence of a parent or guardian, the Warren Health Service has the responsibility for keeping all infants and child patients secure.

The two most likely abduction events are: · by a stranger interested in acquiring an infant/child. The most likely abduction

attempt is of a well neonate, less than seven (7) days and of the same racial type as the abductor. Infants up to six (6) months of age may also be targeted; or

· by a non-custodial parent or family member.

A Code Black Alpha is called by any staff member when an infant or child patient is abducted from the hospital.

Note: Code Black Alphas are extremely emotive and staff should remember to

remain calm and focused.





7.3 Code Black Alpha Action Cards

7.3.1 First Responder – Infant/ Child Abduction Immediate Actions


Reporting to: Area Warden.

Responsibilities: Take measures to ensure that the Emergency Controller is notified.

INFANT OR CHILD PATIENT MISSING Time Sign

1.

Establish contact with the Switchboard by dialling Ext 55 and give the first report. Where this is not possible, dial the Emergency Controller directly.

a) Caller's name. b) Exact location of emergency c) Type of incident (infant/child missing)

2.

Stay with parents (where applicable), provide reassurance and commence compiling the Offender Report Form. Appendix 16.5.

3. Wait for instructions from Area Warden.





7.3.2 Emergency Controller – Code Black Alpha Action Card


Action Card 2


Responsibilities ; - Control the internal emergency response of an emergency within the



ON ALERT Time Sign

1.

Proceed immediately to the Fire Indicator Panel located at the main entrance of the hospital.

2.

Collect white vest and action card.


Note: Ensure you have a means to communicate with the

Emergency Controller.

3.

Receive the first report from the Communications Officer and ascertain the nature and the location of the emergency. Confirm the police have been notified by 000.

4.

Ensure all areas are notified possible Code Black Alpha by whatever means available. Note: Notification should be discrete. Notification “This is the Emergency Controller, possible Code Black Alpha <say location>. Remain vigilant and wait for further instructions”. (Say twice.)





Time Sign

5.

Establish contact with the Area Warden at the point of alarm by whatever means available and request a verbal SITREP (Infant/child details and abductors details if known). Instruct Area Warden to: Secure the unit and have dedicated staff posted at exits; a) Initiate a search of the unit including a head count and

identity match of all parents/carers and infants/children. b) Direct all visitors to exit through one point and ensure

bags are checked if suspect. Note: · Where the Area Warden does not answer, call the

Emergency Response Team to investigate. · Where the area is out of hours, call Emergency Response

Team and request a verbal SITREP.


7. Access CCTV footage to gain information.

8. Evaluate the situation and determine the need for Police presence.

9. Where required, instruct Communications Officer to contact Police by dialling 000 and confirm that they are needed.

10. Where applicable, brief police upon arrival on type, scope and location of the emergency and provide an escort to the affected area.

11. Where abduction is confirmed, carry out the confirmed Code Black Alpha actions.

12. Where the infant/child is located, carry out the all clear actions.





CONFIRMED Time Sign

1.

Ensure all areas are notified confirmed Code Black Alpha by whatever means available. Note: Notification should be discrete. Attention all areas, attention all areas, this is the Emergency Controller. Confirmed Code Black Alpha <say location>. Remain vigilant and wait for further instructions. I repeat this is the Emergency Controller. Confirmed Code Black Alpha <say location>. Remain vigilant and wait for further instructions.

2. Ensure all information on the abductor and the infant/child is cleared for release by the District Manager to the Police and other key stakeholders. Release information as required.

3. Liaise with the Area Wardens and Emergency Response Team Members and initiate a comprehensive (internal and external) search of the facility.

4.

Instruct Area Wardens adjacent to the affected area and other key areas/departments to: a) secure units/departments and have dedicated staff posted

at exits b) initiate a search of the unit/department c) direct all visitors to exit through one point and ensure bags

are checked if suspect

5. Instruct Communications Officer to notify surrounding health care facilities about the incident and provide a full description of the infant/child and abductor.

6. Monitor the progress of the search(s).

7.

Complete an impact assessment and determine: a) business functions disrupted; b) maximum tolerable periods of disruption (refer to Warren

Hospital Business Continuity Plan)


9. Maintain communications with all key stakeholders, including surrounding health care providers.

10. Where police and/or the Area Warden confirm the infant/child location, carry out the Code Black Alpha all clear actions.





ALL CLEAR Time Sign

1.

Ensure the police have collected all required evidence and have finished with the scene.

2.

Ensure all areas are notified Code Black Alpha all clear by whatever means available. Note: Notification should be discrete. Attention all areas, attention all areas, this is the Emergency Controller. Code Black Alpha – All Clear. I repeat this is the Emergency Controller. Code Black Alpha – All Clear.

3.

Ensure security measures are reinstated and third parties are stood down.


5.

Commence debriefing processes with all senior staff and key stakeholders. (Refer to the WACHS-SW incident debrief template.) Note: Be sensitive to staff who may experience post incident

stress.

6.

Compile an emergency response report for the District Manager. (Refer to the WACHS-SW Emergency Response Report Template).





7.3.3 Communications Officer – Code Black Alpha Action Card

Communications Officer : Main Receptionist (day shift) Ext 55 Second Nurse in charge (afternoon & night shift).

Action Card 3

Reporting to : Emergency Controller Ext 5235 Deputy Controller : General Ward Shift Coordinator Ext 5236 Responsibilities: To assist with clerical and record maintenance during and emergency response.

ON ALERT Time Sign


2. Activate the Emergency Management Team ‘possible Code Black Alpha’ group page.

3.

Establish contact with Police by dialling 000 and give the first report. a) caller's name b) exact location of the incident c) type of incident (unarmed/armed/self-harmer/abduction).

4. Proceed immediately to the Fire Indicator Panel located at the main entrance of the hospital.

5. Collect the action card. a) Keep action card on hand.


7. Return to the switchboard, prepare for an influx of calls and commence a running log of events and incoming calls.

8. Prepare a sighting form to gather information quickly and uniformly.







CONFIRMED Time Sign

1.

Activate the Emergency Management Team ‘confirmed Code Black Alpha group page’.




ALL CLEAR

1.

Activate the Emergency Management Team ‘confirmed Code Black Alpha group page’ group page.

2.

Collate all action cards (complete and incomplete) and ensure records are saved electronically and in hard copy format.

3. Refurbish action card.






7.3.4 Area Warden/Warden – Code Black Alpha Action Card


Reporting to : Emergency Controller - Clinical Nurse Manager Ext 5235 Deputy Controller : General Ward Shift Coordinator Ext 5236

Responsibilities : Control the initial response to the emergency in the area.

ON ALERT Time Sign




4. Supervise the manning of egress points, the direction of all visitors through one access/egress point and the checking of bags (where suspect).

5. Lock down the area if the situation in the area warrants this.

6.

Ensure a staff member is with the parents (where applicable) and an Offender Description Form (Appendix 16.5) is being compiled. Hand this over to the Emergency Controller when complete.

7. Obtain a colour photograph and a full written description of the infant/child from the medical records. Hand this over to the Emergency Controller.




11. Liaise with and provide a verbal SITREP to the Emergency Response Team and/or police upon arrival.





CONFIRMED Time Sign

1.

Convene all key stakeholders (i.e. clinical staff who know the child/infant, Emergency Response Team, police), evaluate the situation and develop an appropriate search plan. Communicate search plan with the Emergency Controller. Note: Search the entire interior and exterior of the facility

starting with the unit. This should include a head count of all parents/carers and infants/children.

2. Act on the directions of the Emergency Controller to initiate search plan.

3. Move the parent(s) to a quite area and assign a staff member to be with them at all times to ensure their privacy and monitor their condition.

4. Ensure the scene is secured in order to preserve any evidence that may be collected or required by the Police.

5. Ensure staff remain on duty until excused by the police.

6. Maintain communications with the Emergency Controller and other key stakeholders (including unit staff).

7. Reassure anxious parents/carers.

ALL CLEAR

1. Coordinate the return of the area to operational state.

2. Coordinate the reinstatement of security measures.








7.3.5 Emergency Response Team Member - Code Black Alpha Action Card

Emergency Response Team Member : Orderly (day shift) Ext 5232/ 5233 : Third staff member on duty (I.e. Enrolled Nurse, assistant in nursing) (afternoon and night shift).

Action Card 5



ON ALERT Time Sign

1.

Proceed immediately to the point of alarm and liaise with the Area Warden. Where the Area Warden is absent identify the most senior person in the area.

2.

Where the Area Warden is not present, assume the responsibilities of the Area Warden until they arrive.

3. Respond to the directions of Area Warden.

CONFIRMED Time Sign

1. Liaise with the Area Warden and participate in the development of the search plan.

2. Brief the staff on the search plan and thereafter respond to the directions of the Area Warden.


ALL CLEAR








8. CODE BLACK JUMPER – SUB PLAN

8.1 Purpose

The purpose of this sub plan is to outline the emergency responses to a person threatening to jump from the building.

8.2 General

‘Jumper’ situations are categorised as an unarmed confrontation that arise when a person threatens to harm themselves by jumping from the building. The planning process for at risk patients should involve appropriate medical, nursing, administrative and security staff to minimise the risk of injury to the patient, staff and others.

A Code Black Jumper is called by any staff member who identifies a person threatening to harm themselves by jumping from the building.

8.3 Security Procedures

· High risk patients should be identified and the risk of jumping from the building

assessed.

· Risk assessments are to be documented, and included in the patients’ medical records and information provided on hand over.

· Risk treatment should include, close monitoring and restricted access to the first floor and the roof area.





8.4 Code Black Response Procedures (Action Cards)

8.4.1 First Responder – Jumper Immediate Actions

Position : First Responder Action Card 1 Reporting to : Area Warden Responsibilities : Take measures to ensure that the Emergency Controller is notified.

A Person Is Threatening To Jump From The Building Time Sign

1.

Establish contact with the Switchboard Operator by dialling 55 and give the first report. If this is not possible, establish contact with the Emergency Controller by dialling Ext 5235 or 5236

a) Caller's name. b) Exact location of emergency c) Type of incident (jumper)

2. Calmly clear the area of any unnecessary persons.

3.

In a professional, calming and non-confrontational manner and from a safe distance, identify yourself, state your role and state you are getting help.

4.

Observe and verbally assist the person from a safe distance. Ensure you have a safe withdrawal route.






8.4.3 Emergency Controller – Code Black Jumper Action Card Emergency Controller : Clinical Nurse Manager Ext 5235 Deputy Controller : General Ward Shift Coordinator Ext 5236

Action Card 2

Reporting to : District Manager 0428 955 818 Responsibilities - Control the internal emergency response of an emergency within the facility. - Ensure the health and safety of patients (including permanent care


ON ALERT Time Sign


2.



Note: Ensure you have a means to communicate with the Emergency Response Team.

3.

Receive the first report from the Communications Officer and ascertain the nature and the location of the emergency. Confirm the police and the Department of Fire and Emergency Services (DFES) have been notified by 000.

4.

Ensure all areas are notified possible Code Black Jumper by whatever means available. Note: Notification should be discrete. Notification “This is the Emergency Controller, possible Code Black Jumper <say location>. Remain calm and wait for instructions” (say twice).

5.

Establish contact with the Area Warden at the point of alarm by whatever means available and request a verbal SITREP (jumper’s details if known).

Note: · Where the Area Warden does not answer the WIP phone,

call the Emergency Response Team to investigate. · Where the area is out of hours, call Emergency Response

Team and request a SITREP.


7. Evaluate the situation and determine the need for emergency services, medical and/or mental health assistance.

8. Where required, instruct Communications Officer to contact emergency services and/or additional clinical staff and confirm that they are needed.





9. Where applicable, brief additional clinical staff and emergency services upon arrival on type, scope and location of the emergency and provide an escort to the affected area.

10. Where a jumper is confirmed, carry out the confirmed Code Black Jumper actions.

11. Where police and/or the most senior person in the affected area confirms the area is safe, carry out the Code Black Jumper all clear actions.

CONFIRMED

1.

Ensure all areas are notified ‘confirmed Code Black Jumper’ by whatever means available. Note: Notification should be discrete. Notification “This is the Emergency Controller, confirmed Code Black Jumper <say location>. Remain calm and wait for instructions”. (Say twice.)

2.

Liaise with the Area Warden of the affected area or the person in the area with the most expertise in the subject and initiate verbal negotiations with the person threatening to jump until police arrive.

3.

Ensure: a) clearing of the immediate area of unnecessary persons b) clearing the area beneath the jumper c) the control of vehicle movement (where necessary) d) discretely acquiring a cover sheet.

4. Respond to the directions of the police.

5. Monitor the progress of negotiations.

6.

Complete an impact assessment and determine: a) business functions disrupted b) maximum tolerable periods of disruption (refer to Warren




9. Where police and/ or the Area Warden in the affected area renders the area is safe, carry out the Code Black Jumper all clear actions.





ALL CLEAR Time Sign

1.

Ensure all areas are notified ‘Code Black Jumper all clear’ by whatever means available. Note: Notification should be discrete. Notification This is the Emergency Controller, Code Black Jumper <say location> all clear (Say twice.)


3. Commence debriefing processes with all senior staff and key stakeholders. (Refer to the WACHS-SW incident debrief template.)

4. Compile an emergency response report for the District Manager. (Refer to the WACHS-SW Emergency Response Report Template.)





8.4.4 Communications Officer – Code Black Jumper Action Card

Communications Officer : Main receptionist (day shift) Ext 55 : Second Nurse in charge (afternoon and night shift).

Action Card 3

Reporting to : Emergency Controller - Clinical Nurse Manager Ext 5235 : Deputy Controller - General Ward Shift Coordinator Ext 5236 Responsibilities : To assist with clerical and record maintenance during and

emergency response.

ON ALERT Time Sign


2. Notify the Emergency Management Team ‘possible Code Black Jumper’ group page.

3.

Establish contact with Police and the Department of Fire and Emergency Services by dialling 000 and give the first report.

a) caller's name b) exact location of the incident c) type of incident (jumper).


5. Collect the action card. a) Keep action card on hand.





CONFIRMED Time Sign




ALL CLEAR Time Sign


2. Collate all action cards (complete and incomplete) and ensure records are saved electronically and in hard copy format.







8.4.5 Area Warden/Warden – Code Black Jumper Action Card

Area Warden/Warden : Nominated role for each shift. Action Card 4



ON ALERT Time Sign


2. Collect orange vest and action card. a) Don vest b) Keep action cards on hand


4. Supervise the clearing of the area of all unnecessary persons.

6. Where a staff member is verbally assisting the person, ensure staff are at a safe distance. Withdraw staff to a safe area if the situation warrants this.



9. Liaise with and provide a verbal SITREP to the Emergency Services, specialist clinical staff and Emergency Response Team upon arrival.

CONFIRMED

1.

Convene all key stakeholders (i.e. clinical staff who know the person, Emergency Response Team, Police), evaluate the situation and develop an appropriate negotiation plan. Communicate negotiation plan with the Emergency Controller.

2. Act on the directions of the Emergency Controller to initiate negotiation plan.


ALL CLEAR

1. Coordinate the return of the area to an operational state.








8.4.7 Emergency Response Team Member - Code Black Jumper Procedure

Emergency Response Team Member : Orderly (day shift) Ext 5232/ 5233 Third staff member on duty (i.e. Enrolled Nurse, assistant in nursing) (afternoon and night shift).

Action Card 6

Reporting to : Emergency Controller - Clinical Nurse Manager Ext 5235 Deputy Controller : General Ward Shift Coordinator Ext 5236


ON ALERT Time Sign

1. Proceed immediately to the point of alarm and liaise with the Area Warden.

2. Where the Area Warden is absent identify the most senior person in the area.

2. Where the Area Warden is not present, assume the responsibilities of the Area Warden until they arrive.

3. Respond to the directions of Area Warden.

CONFIRMED

1. Liaise with the Area Warden and participate in the development of the negotiation plan.



ALL CLEAR








9. CODE YELLOW EMERGENCY RESPONSE

9.1 Purpose

The purpose of this section is to outline the emergency responses to an infrastructure and other internal emergency (includes essential service disruption). These Code Yellow emergency response procedures are to be read in conjunction with the Warren Hospital Business Continuity Plan (BCP).

Note: In addition to Code Yellow infrastructure and other internal emergency, the

following codes are used to facilitate the identification and communication of additional risks. For these emergencies sub plans have been established.

· Code Yellow Bushfire · Code Yellow Floods · Code Yellow Storm Surge · Code Yellow Hazardous Material (HAZMAT) incident.

9.2 General

A Code Yellow describes an event that may adversely affect the delivery of service and/or the safety of people and for these reasons requires a coordinated response. Events include but are not limited to the disruption of essential services such as power, medical gases and suction, water, natural gas and Information Communications and Technology (data network, telecommunications, paging and call bell systems) and damage to the physical surroundings of the facility. Additionally, Code Yellow describes hazardous material and nature related incidents.

9.3 Essential Service Disruptions

The Warren Health Service is dependent on the integrity of a number of essential services. Numerous planned and unplanned incidents can disrupt the critical business functions of the Warren Health Service which may have adverse impacts on the safety of patients, staff and visitors.

Although the Warren Health Service has a number of contingencies in place to minimise the risk of essential service loss, these contingencies may also fail at a critical stage. These Code Yellow emergency response procedures address contingency failure through the implementation of manual workarounds. Where contingencies have failed and manual workarounds have become unsustainable, causing disruption to critical business functions beyond tolerable periods, the Business Continuity Plan is to apply. Refer to the Warren Health Service Business Continuity Plan to determine essential service contingencies and unit/area dependency levels on essential services.





9.4 Infrastructure Damage

The Warren Health Service is made up of a number of structures where critical business functions are carried out. Damage to certain infrastructure may affect the effective functioning of units and may threaten the safety of patients, staff and visitors. These Code Yellow (infrastructure damage) emergency response procedures address infrastructure damage through the implementation of emergency actions. Where emergency actions have failed and infrastructure damage disrupts critical business functions for periods greater than the tolerable period or threatens the safety of people, the Business Continuity Plan and Code Orange emergency response procedures are to apply.





9.5 Code Yellow Action Cards

9.5.1 First Responder – Code Yellow



Responsibilities : - Ensure the immediate safety of anyone within the vicinity of the hazard. - Take measures to ensure that the person responsible for the emergency

response is notified.

A staff member who identifies a disruption to an essential service, significant infrastructure damage,

nature related or HAZMAT incidents, is to carry out the following immediate actions

Time Sign

1. Remove all people from immediate danger.

2.

Establish contact with the Switchboard by dialling 55 and give the first report. If this is not possible, establish contact with the Emergency Controller by dialling Ext 5235 or 5236 First Report:

a) caller's name b) exact location of the incident c) type of disruption (infrastructure / essential service)

3.

Wait for directions from the Area Warden.





9.5.2 Emergency Controller – Code Yellow Action Card


Action Card 2




ON ALERT Time Sign

1.

Proceed immediately to the Fire Indicator Panel located in the corridor of the main entrance of the hospital.

2.



3.

Receive the first report from the Communications Officer and ascertain the nature and the location of the emergency.

4.

Instruct the Communications Officer to notify:

a) Engineering Officer b) Emergency services (where applicable) c) Service provider (where applicable and following

discussion with the Engineering Officer). Establish estimated time of arrival/restoration time. Note: Refer to Appendix 16.6 Contact list.

5.

Activate the PA system for the entire facility and notify the site. “Attention all areas, attention all areas, this is the Emergency Controller. Possible Code Yellow <say incident category and location>. Remain calm and wait for further directions.” (Say twice.)





Time Sign

6.

Establish contact with the Area Warden of the affected area(s) by whatever means available and request a verbal SITREP. a) Critical business functions disrupted b) Manual workarounds in place. Note: Where the Area Warden does not answer the WIP

phone, use the PA system to ask the Area Warden/ Warden to attend to the WIP or deploy two Emergency Response Team members to investigate.

7.

Establish contact with Area Wardens adjacent to the affected area(s) and provide a verbal SITREP.

8.

Complete an impact assessment and determine: a) Critical business functions disrupted and for how long b) Maximum Tolerable Period of Disruption (refer to Warren

Business Continuity Plan).

9.

Brief the Engineering Officer, Emergency Response Team and emergency service personnel (where applicable) upon arrival on type of emergency, scope and location.





CONFIRMED Time Sign

1. Don Emergency Controller vest.

2.

Activate the PA system for the entire facility and notify the site. “Attention all areas, attention all areas, this is the Emergency Controller. Confirmed Code Yellow - <say category and say location>. Remain calm and wait for further directions. (Say twice.)

3.

Establish contact with Area Wardens of affected areas by whatever means available and initiate appropriate workarounds. Refer to manual workarounds.

4.

Ensure additional resources are sourced to support operations.

5.

Establish contact with the District Manager and provide a verbal SITREP: a) Disruption type b) Workarounds in place c) Critical business functions affected d) Restoration times e) Maximum Tolerable Periods of Disruptions for affected

activities. Determine the need to activate relevant Business Continuity Plans.

6.

Contact the Operations Manager to activate Business Continuity Plans if the situation warrants this.

7. Maintain communications with key stakeholders.





ALL CLEAR Time Sign

1.

Advise the Area Warden to wait for the arrival of Emergency Services or the Engineering Officer.

2.

Once the area is rendered safe and operational by Emergency Services Officer in Charge or the Engineering Officer, activate the PA system and notify the site. “Attention all areas, attention all areas, this is the Emergency Controller. Code Yellow <say category type> – All clear. (Say twice.)


4.

Commence debriefing processes with all senior staff and key stakeholders. (Refer to the WACHS-SW Emergency Response Report Template.)

5.

Compile an emergency response report for the District Manager. (Refer to the WACHS-SW Emergency Response Report Template.)





9.5.3 Communications Officer – Code Yellow Action Card (includes sub plans)


Action Card 3

Reporting to : Emergency Controller - Clinical Nurse Manager Ext 5235 Deputy Controller - General Ward Shift Coordinator Ext 5236 Responsibilities: To assist with clerical and record maintenance during and

emergency response.

ON ALERT Time Sign


2. Notify the Emergency Management Team ‘possible Code Yellow’.


4. Collect the action cards from the Front Reception Desk. a) Keep action card on hand.

5.

Provide the first report to the Emergency Controller. a) caller's name b) exact location of the incident c) type of disruption/incident (e.g. essential services, hazardous

substance incidents, natural events).


7. Respond to the directions of the Emergency Controller. 8. Maintain communications with the Emergency Controller.

CONFIRMED Time Sign

1. Notify the Emergency Management Team ‘confirmed Code Yellow’.


3. Maintain communications with the Emergency Controller and other key stakeholders.


ALL CLEAR Time Sign

1. Activate the Emergency Management Team ‘Code Yellow – all clear’ by whatever means available.

2. Collate all action cards (complete and incomplete) and ensure logs and records are saved electronically and in hard copy format.







9.5.4 Area Warden/Warden – Code Yellow Action Card

Area Warden/Warden: Nominated role for each shift Action Card 4



ON ALERT Time Sign


2.


3.

Direct Wardens to check the area/floor for any abnormal situations.

4.

Commence Code Orange evacuation procedures if the situation in the area warrants this.

5.

Provide a verbal SITREP to the Emergency Controller and any actions taken.






CONFIRMED Time Sign

1. Don orange Area Warden vest.

2.

Respond to the directions of the Emergency Controller to implement workarounds.

3.

Liaise with Engineering Officer/Emergency Response Team / Emergency Services and advise them of any particular hazards and areas for special consideration.

4.

Review resource requirements for business continuity. Report deficiencies to the Emergency Controller. a) ICT systems and applications b) Specialised equipment c) Office and Telecommunications Equipment d) Workforce e) Essential services (power, water etc.) f) Physical Premises g) Transport requirements.


ALL CLEAR Time Sign


2. Instruct staff to reinstate the area to original operational status.


4. Act as directed by the Emergency Controller to compile a report of the actions taken during the emergency for the debrief.






9.5.5 Emergency Response Team Member - Code Yellow Action Card

(includes sub plans)

Emergency Response Team Member : Orderly (day shift) Ext 5232/ 5233 : Third staff member on duty (i.e. Enrolled Nurse, assistant in nursing) (afternoon and night shift).

Action Card 5


Responsibilities: Carry out emergency response activities as directed.

ON ALERT Time Sign


2.

Collect action card.

a) Keep action card on hand.

3. Muster with the Emergency Controller.

4. Where the Emergency Controller is absent, assume the responsibilities of the Emergency Controller until they arrive.


CONFIRMED



ALL CLEAR

1. Respond to the directions of the Emergency Controller to clean, service and/or replace specialised equipment.







9.5.6 Code Yellow Workarounds

Disruption / Incident Type Workarounds

Medical Gas · Portable bottles at various locations

Suction · Venturi twin o vac units at point of use

Water · Bulk supply of bottled water located in the kitchen

Data Network (PC disruptions) · Department specific

Landline Communications

· Dedicated emergency mobile phones located in the general ward

· Runners · Satellite phones

Mobile Communications

· Satellite phones · Landlines · Runners · Last resort/disaster phones

- Emergency Department - General Ward

Paging system · SMS to mobile phones · Runners

Nurse call bells

· Wi-Fi phones · Mobile phones · Runners · Patient phones · Hand bells · Increased staff surveillance/rounding

Air Conditioning

· Blankets · Natural ventilation · Manual cool down methods (ice packs, moist towels,

showers etc.) · Portable fans

Ventilation · Natural Ventilation methods

Natural Gas · Liquid Petroleum Gas





10. CODE YELLOW BUSHFIRE – SUB PLAN

10.1 Purpose

The purpose of this sub plan is to outline the preventative and preparatory measures for and emergency responses to a bushfire. 10.2 General

Bushfires are a significant risk due to summer heat, the close proximity to trees, forests, scrub and grasslands and the catastrophic consequences that result from fires. A bushfire can start suddenly within the area and without time for the Department of Fire and Emergency Services (DFES) to issue a warning. The two most likely events associated with a bushfire are smoke enveloping part or the whole site and/or ignition of fires caused by embers. Where a fire ignites on site, a Code Red emergency response procedure is to apply. A Code Yellow bushfire call can be made by any staff member who feels the situation is an emergency. 10.3 Fire Prevention and Protection

There are a number of preventative and protective fire safety measures in place at Warren Health Service which increase the facilities survivability. Refer to the Warren Health Service Code Red Emergency Response Procedures. Additionally, every building and asset of critical infrastructure is surrounded by a Building Protection Zone (BPZ) that aims to reduce the flammable material in the immediate vicinity of structures and other assets.

10.4 Preparation

10.4.1 Fire Danger Ratings Fire danger ratings should be used as a guide to help decision makers evaluate the situation and initiate action before a fire even starts. Refer to Appendix 16.7 Fire Danger Ratings.

10.4.2 Bushfire Warnings

The Department of Fire and Emergency Services will provide information through a variety of means during a bushfire. Additionally, they will issue community alerts for bushfires that threaten lives and/or property. Alert levels escalate to reflect the increase in risk.





Advice

A fire has started but there is no immediate danger, this is general information to keep you informed and up to date with developments. Be alert and monitor the situation. Issued at 11am and 4pm daily. Watch and Act A fire is approaching and conditions are changing, you need to leave or prepare to actively defend and protect in place. Issued at least every two hours. Broadcast in full on ABC local radio and 6PR every half an hour on the quarter hour.

Emergency Warning Take immediate action to survive – you will be impacted by the fire. A siren sound called the Standard Emergency Warning Signal (SEWS) may be used to get your attention on radio and television. Issued at least every hour. Broadcast in full on ABC local radio and 6PR every 15 minutes. This message will start with the Standard Emergency Warning Signal.

All clear The danger has passed and the fire is under control, but you need to remain vigilant in case the situation changes. It may not be safe to return. Issued to close the incident.

A table detailing the bushfire warning system and detailed messaging is available via the Department of Fire and Emergency Services (DFES) web site.


http://www.dfes.wa.gov.au/safetyinformation/warningsystems/Pages/default.aspx




10.5 Code Yellow Bushfire Action Cards

10.5.1 Emergency Controller – Code Yellow Bushfire Action Card Emergency Controller : Clinical Nurse Manager Ext 5235 Deputy Controller : General Ward Shift Coordinator Ext 5236

Action Card 1




ON ADVICE Time Sign

1.




3. Receive the first report from the Communications Officer and ascertain the location of the bushfire.

4.

Establish information on the bush fire from the DFES website or by dialling 1300 657 209 or by listening to local media (ABC local radio or 6PR).

5.

Ensure all areas are notified of the situation by whatever means available. Notification “This is the Emergency Controller, A bushfire has started <say location> but there is no immediate danger Remain alert and monitor your areas” (Say Twice).

6.

Establish contact with the District Manager, Area Wardens and the Engineering Officer and evaluate the situation.

7. Review resource requirements (i.e. staff, transport etc.) for evacuation and ensure availability.





WATCH AND ACT Time Sign

1.

Establish information on the bushfire from the DFES website or by dialling 1300 657 209 or by listening to local media (ABC local radio or 6PR).

2.

Ensure all areas are notified of the situation by whatever means available. Notification “This is the Emergency Controller, a bushfire is approaching and conditions are changing. Remain calm and wait for further instructions”. (Say twice.)

3.

Contact Area Wardens and initiate the following actions:

a) contact mobile staff and advise them of the situation b) block cracks and gaps under all external doors c) prepare to relocate d) check on community patients (where applicable) and report

back patients needing assistance

4

Contact the District Manager and evaluate the situation. Consider:

a) discharging relevant patients into family care b) transferring acute patients c) cancelling elective surgical cases.

5.

Maintain communications with the District Manager and other key stakeholders (i.e. DFES).

a) Inform stakeholders of hospital lead time. b) Monitor the need to relocate.

Note: Lead time is the amount of time it would take to evacuate the health service to a place of safety.

6. Initiate Code Orange evacuation procedures if the situation warrants this.

7. Where a fire/smoke is confirmed in the facility, carry out Code Red procedures.





EMERGENCY WARNING Time Sign

1. Don white Emergency Controller vest.

2.

Ensure all areas are notified of the situation by whatever means available. Notification “This is the Emergency Controller; there is a confirmed bushfire in the area. Where a fire/smoke is identified carry out Code Red procedures. Remain calm and wait for further instructions”. (Say twice.)

3.

Establish information on the bushfire from the Department of Fire and Emergency Services by dialling 1300 657 209. Where emergency assistance is required dial 000.

4. Respond to the directions of DFES.

5.

Instruct Engineering Officer to facilitate the shutting down of evaporative air conditioning systems.

6.

Establish contact with the District Manager and provide a verbal SITREP. Determine the need to evacuate. Evacuate when deemed necessary.

7.


a) business functions disrupted; b) maximum tolerable periods of disruption (refer to



9.

Maintain communications with the District Manager and other key stakeholders. Monitor the need to evacuate.





10. Initiate relocation procedures if the situation warrants this.

11.

Where a fire/smoke is confirmed in the facility, carry out Code Red procedures.

12. Where DFES issue the all clear, carry out all clear actions.

ALL CLEAR Time Sign

1.

Ensure all areas are notified Code Yellow – Bushfire all clear by whatever means available. Notification “This is the Emergency Controller; Code Yellow Bushfire – all clear”. (Say twice.)

2. Carry out a post emergency assessment to determine impact and immediate operational needs.

3.

Ensure resources are available for: a) ICT systems and applications b) Specialised equipment c) Office and telecommunications equipment d) Workforce e) Essential services (power, water etc.) f) Physical Premises g) Transport requirements.

4. Activate Business Continuity Plans if the situation warrants this.


6. Commence debriefing processes with all senior staff and key stakeholders. (Refer to the WACHS-SW Emergency Response Report Template.)

7. Compile an emergency response report for the District Manager (Refer to the WACHS-SW Emergency Response Report Template.)





10.5.2 Communications Officer – Code Yellow Bushfire Action Card


Action Card 2

Reporting to : Emergency Controller - Clinical Nurse Manager Ext 5235 : Deputy Controller - General Ward Shift Coordinator Ext 5236 Responsibilities: To assist with clerical and record Engineering during and

emergency response.

ON ADVICE Time Sign

1.

Ascertain the nature and location of the emergency from the first responder.

2.

Notify the Emergency Management Team ‘possible Code Yellow Bushfire’ group page.

3.


4.

Collect the action cards. a) Keep action card on hand.

5.

Provide the first report to the Emergency Controller. a) caller's name b) exact location of the incident c) type of incident (e.g. bushfire).

6.

Return to the switchboard and commence a running log of events and incoming calls.







WATCH AND ACT Time Sign

1.

Notify the Emergency Management Team ‘confirmed Code Yellow Bush Fire’ group page.




EMERGENCY WARNING Time Sign

1.

Activate a ‘Code Yellow Bushfire – Emergency Warning’ group page.




ALL CLEAR. Time Sign

1. Activate a ‘Code Yellow Bushfire – all clear’ group page.

2.








10.5.3 Area Warden/Warden – Code Yellow Bushfire Action Card

Area Warden/Warden : Nominated role for each shift Action Card 3

Reporting to : Emergency Controller - Clinical Nurse Manager Ext 5235: Deputy Controller - General Ward Shift Coordinator Ext 5236


ON ADVICE Time Sign

1. Proceed to the local Area Warden point.

2.

Collect orange vest and action card a) Don vest b) Keep action cards on hand.



WATCH AND ACT

1.

Ensure: a) area/floor is checked for any abnormal situations b) mobile staff are contacted and advised of the situation c) cracks and gaps under all external doors are blocked d) the area is prepared to evacuate e) community patients (where applicable) are checked on

and reported back patients needing assistance.







EMERGENCY WARNING




4.

Where a fire/smoke is confirmed in the area, carry out Code Red procedures.

ALL CLEAR

1.










10.5.4 Emergency Response Team Member - Bushfire Action Card

Emergency Response Team Member : Orderly (day shift) Ext 5232/ 5233 : Third staff member on duty (I.e. Enrolled Nurse, assistant in nursing) (afternoon and night shift).

Action Card 4

Reporting to : Emergency Controller : Clinical Nurse Manager Ext 5235 Deputy Controller : General Ward Shift Coordinator Ext 5236


ON ADVICE Time Sign

1.


2. Collect action card


3.



WATCH AND ACT

1. Respond to the instructions of the Emergency Controller.






EMERGENCY WARNING



3. Where a fire/smoke is confirmed, carry out Code Red procedures.

ALL CLEAR









11. CODE YELLOW FLOOD SUB PLAN

11.1 Purpose

The purpose of this sub plan is to outline the preventative and preparatory measures for and the emergency responses to a flood caused by nature.

11.2 General

Where floods cause disruption to critical business functions beyond tolerable periods, or threaten the safety of patients, staff and visitors, the Warren Health Service Business Continuity Plans are to apply. A Code Yellow flood call can be made by any staff member who feels the situation is an emergency.

11.3 Flood Prevention

Where practicable, flood risk is mitigated through planning schemes implemented at a local government level. Here a series of overlays have been used to influence the design and construction of a facility to reduce the effects of a flood caused by nature.

11.4 Preparation

Where a flood is expected, departments/areas are to prepare accordingly. This may include but is not limited to:

· securing hazardous items (e.g. sharps containers and other clinical waste, portable oxygen cylinders etc.)

· moving specialist equipment to a higher level

· water proofing medical records and other important documents

· relocating patients if it is safe to do so

· preparing sand bags to place over back flowing drains

· preparing patient essentials (medications, clothing, valuables etc.).

11.5 Flood Warnings

The Department of Fire and Emergency Services will provide information through a variety of different means during a flood caused by nature. Additionally, they will issue community alerts for floods that threaten lives and/or property. Alert levels escalate to reflect the increase in risk.





These include:

Flood Watch Provides information to generate early awareness of developing hydro meteorological conditions, which may lead to possible or likely flooding in a particular district during the next 24 to 72 hours. Messages will make short generalised statements about the developing weather situation, including forecast rainfall totals, the current state of the catchments and the indication of the rivers at risk from flooding. Enable people and the community to take action to increase safety and reduce the cost associated with flooding. Flood Warning Provides information to enable timely appropriate action to be taken when flooding is anticipated or occurring. Messages are issued for specific river basins and, where possible, will provide sufficient information to explain what is happening, where it is happening, how it will affect the recipient of the message and what possible evasive actions could be deployed.





11.6 Code Yellow Flood Action Cards

11.6.1 Emergency Controller – Code Yellow Flood Action Card Emergency Controller : Clinical Nurse Manager Ext 5235 Deputy Controller : General Ward Shift Coordinator Ext 5236

Action Card 1




FLOOD WATCH Time Sign




3.

Receive the first report from the Communications Officer and ascertain the location of the flood.

4.

Ensure all areas are advised of the situation by whatever means available. Notification “This is the Emergency Controller, developing weather conditions may lead to possible or likely flooding in <say location> during the next 24 to 72 hours. Remain alert and monitor your areas”. (Say twice.)

5.

Establish information on the flood from the Department of Fire and Emergency Services by dialling 1300 657 209 or listening to local media (ABC local radio or 6PR).

6.

Establish contact with the District Manager and evaluate and monitor the situation.

7. Review resource requirements (i.e. staff, transport etc.) for relocation and ensure availability.





FLOOD WARNING Time Sign

1.

Ensure all areas are advised of the situation by whatever means available. Notification “Attention all areas, attention all areas, This is the Emergency Controller, a flood is happening <say location>, which may affect the site. Remain calm and wait for further instructions”.

2.

Establish information on the weather from the Department of Fire and Emergency Services Information line by dialling 1300 659 213 or by going to www.dfes.wa.gov.au Where emergency assistance is required, call 000 or the SES on 132 500.

3.

Establish contact with the Area Wardens, provide a verbal SITREP and instruct them to:

a) prepare to evacuate b) raise essential equipment not in use and onto tables c) Secure dangerous objects (e.g. sharps containers,

oxygen cylinders etc.) d) water proof medical records and other important

documents.

4.

Establish contact with the District Manager and provide a verbal SITREP.

a) Discharging relevant patients into family care b) Transferring acute patients c) Cancelling elective surgery cases d) Preparing and deploying sandbags.

5.

Maintain communications with the District Manager and other key stakeholders (I.e. DFES).


Note: Lead time is the amount of time it would take to

evacuate the health service to a place of safety.


7. Where a flood is confirmed in the facility, carry out the confirmed flood actions.

8. Where DFES issues the all clear, carry out all clear actions


http://www.dfes.wa.gov.au/




CONFIRMED Time Sign


2.

Ensure all areas are notified Code Yellow – Flood by whatever means available. Notification “This is the Emergency Controller, confirmed Code Yellow -Flood. Remain calm and wait for instructions to evacuate”. (Say twice.)


4. Contact the District Manager and provide verbal SITREP.

5. Respond to the Department of Fire and Emergency Services.

6.


a) business functions disrupted; b) maximum tolerable periods of disruption (refer to Warren




9.

Where the Department of Fire and Emergency Services issue the all clear, carry out all clear actions.






1.

Ensure all areas are notified Code Yellow – Flood all clear by whatever means available. Notification “This is the Emergency Controller, Code Yellow Flood – all clear”. (Say twice.)

3.

Carry out a post emergency assessment to determine impact and immediate operational needs.

4.

Ensure resources are available for Warren Hospital:

a) ICT systems and applications b) Specialised equipment c) Office and telecommunications equipment d) Workforce e) Essential services (power, water etc.) f) Physical Premises g) Transport requirements.



7.


8.

Compile an emergency response report for the District Manager. (Refer to the WACHS-SW Emergency Response Report Template.)





11.6.2 Communications Officer – Code Yellow Flood Procedure

Communications Officer : Main receptionist (day shift) Ext 55 : Second Nurse in charge (afternoon & night shift).

Action Card 2

Reporting to : Emergency Controller - Clinical Nurse Manager Ext 5235 : Deputy Controller - General Ward Shift Coordinator Ext 5236 Responsibilities: To assist with clerical and record Engineering during an

emergency response.



2. Activate a ‘Code Yellow - Flood Watch’ group page.


4. Collect the action cards.


5.

Provide the first report to the Emergency Controller. b) caller's name c) exact location of the incident d) type of incident (flood)




FLOOD WARNING Time Sign

1. Activate a ‘Code Yellow - Flood Warning’ group page.








CONFIRMED Time Sign

1. Activate a ‘confirmed code yellow flood’ group page.




ALL CLEAR Time Sign

1. Activate a ‘Code Yellow Flood – All Clear’ group page.

2.








11.6.3 Area Warden/Warden – Code Yellow Flood Action Card






2.




FLOOD WARNING

1.

Ensure: a) area/floor is checked for any abnormal situations b) mobile staff are contacted and advised of the situation c) the area is prepared to evacuate d) community patients (where applicable) are checked on and

reported back patients needing assistance e) essential equipment not in use is raised of the floor f) dangerous objects (i.e. sharps containers, oxygen cylinders

etc.) are secured g) medical records and other important documents are water

proofed.







CONFIRMED

1. Don Orange Area Warden vest.



ALL CLEAR

1.


2.

Instruct staff to reinstate the area to original operational status.



5.

Act as directed by the Emergency Controller to compile a report.





11.6.4 Emergency Response Team Member - Code Yellow Flood Action Card


Action

Card 4 Reporting to : Emergency Controller - Clinical Nurse Manager Ext 5235

Deputy Controller : General Ward Shift Coordinator Ext 5236




2. Collect action card from the front reception office.


3. Report to the Emergency Controller. Where the Emergency Controller is absent, assume the responsibilities of the Emergency Controller until they arrive.


FLOOD WARNING



3. Where a flood is confirmed on site, carry out confirmed flood procedures.





CONFIRMED Time Sign



ALL CLEAR Time Sign



3. Refurbish vest and action cards in the front reception office.






12. CODE YELLOW STORM SURGE - SUB PLAN

12.1 Purpose

The purpose of this sub plan is to outline the preparatory measures for and emergency responses to a storm surge.

12.2 General

Storms are a significant risk to South West due to the damaging impacts caused by heavy rain, winds, lightning, hail and tornados that hit the region. Although storms are most likely to occur between May and October, they may also occur in the summer months.

This Code Yellow Storm Surge sub plan address storm surges through the implementation of emergency actions. Where structural damage has occurred on site, causing disruption to critical business functions beyond tolerable periods or threatens the safety of patients, staff and visitors, Business Continuity Plans and code orange evacuation procedures are to apply.

A Code Yellow Storm Surge call can be made by any staff member who feels the situation is an emergency.

12.3 Preparation

12.3.1 Weather Warnings There are a variety of means to keep up to date with the latest storm warnings and advice. This includes:

News bulletins: Local radio, TV or online. The Department of Fire and Emergency Services: www.dfes.wa.gov.au Bureau of Meteorology (BOM): www.bom.gov.au or by calling their Land Weather Warnings and Flood Warnings Advice Line on 1300 659 213.

12.3.2 Other Considerations

· Identifying loose material from around the health campus that can turn into potentially deadly missiles and notifying the Engineering department.

· Where practicable, moving vehicles to cover.

· Contacting mobile/outdoor workers and advising them to seek adequate shelter.

· Checking on community patients to see if they need help.





12.4 Code Yellow Storm Surge Action Cards

12.4.1 Emergency Controller – Code Yellow Storm Surge Action Card


Action Card 1




STORM WATCH Time Sign


2.

Collect white vest and action card


3.

Receive the first report from the Communications Officer and ascertain the location of the storm/weather.

4. Establish information on the weather from the Bureau of Meteorology by dialling 1300 659 213 or by going to www.bom.gov.au

5.

Ensure all areas are notified of the situation by whatever means available. Notification “This is the Emergency Controller, a storm surge is expected to affect <say location> by <say date and time>. Remain calm and wait for further instructions”. (Say twice.)

6. Establish contact with the District Manager. Evaluate and monitor the situation.


http://www.bom.gov.au/




STORM WARNING Time Sign

1.

Establish information on the weather from the Bureau of Meteorology by dialling 1300 659 213 or by going to www.bom.gov.au. Where emergency assistance is required call the SES on 132 500.

2.

Ensure all areas are advised of the situation by whatever means available. Notification “This is the Emergency Controller, a storm surge is affecting/ is expected to affect <say location> by <say date and time>. Remain calm and wait for further instructions”. (Say twice.)

3.

Contact Area Wardens and initiate the following actions:

a) contact mobile staff, advise them of the situation and instruct them to seek safe shelter

b) minimise all non-essential driving c) check on community patients (where applicable) and report

back patients needing assistance.

4. Contact the District Manager and evaluate the situation.

5.

Maintain communications with the District Manager and other key stakeholders (I.e. DFES).


Note: Lead time is the amount of time it would take to evacuate the

health service to a place of safety.


7.

Where a storm is confirmed in the facility, carry out confirmed storm actions.





CONFIRMED Time Sign


2.

Ensure all areas are notified of the situation by whatever means available. Notification “This is the Emergency Controller; there is a confirmed storm surge in the area. Remain calm and wait for further instructions”. (Say twice.)

3.

Establish information on the weather from the Bureau of Meteorology by dialling 1300 659 213 or by going to www.bom.gov.au. Where emergency assistance is required call the SES on 132 500 or dial 000.

4.

Where emergency assistance is required call the SES on 132 500 or dial 000.

5. Establish contact with the District Manager and provide a verbal SITREP. Determine the need to evacuate. Initiate Code Orange evacuation procedures if the situation warrants this.

Complete an impact assessment and determine: a) business functions disrupted; b) maximum tolerable periods of disruption (refer to Warren



7.

Maintain communications with the Department of Fire and Emergency Services and other key stakeholders (Local Emergency Management Committee, Engineering Officer, Area Wardens, Emergency Response Team and Tier 4 Manager).

8. When the storm is declared as ended by the Department of Fire and Emergency Services, carry out all clear actions.


http://www.bom.gov.au/




ALL CLEAR Time Sign

1.

Ensure all areas are notified Code Yellow – storm surge all clear by whatever means available. Notification “This is the Emergency Controller, Code Yellow storm surge – all clear” (Say twice.)

2. Carry out a post emergency assessment to determine impact and immediate operational needs.

3.

Ensure resources are available for Warren Hospital: a) ICT systems and applications b) Specialised equipment c) Office and telecommunications equipment d) Workforce e) Essential services (power, water etc.) f) Physical Premises g) Transport requirements.



6. Commence debriefing processes with all senior staff and key stakeholders. (Refer to the WACHS – SW Emergency Response Report Template).

7. Compile an emergency response report for the District Manager (Refer to the WACHS – SW Emergency Response Report Template).

8. Where applicable, complete safety/clinical risk report processes.





12.4.2 Communications Officer – Code Yellow Storm Surge Action Card

Communications Officer : Main receptionist (day shift) Ext 55 : Second nurse in charge (afternoon and night shift).

Action Card 2


emergency response.


1.

Notify the Emergency Management Team ‘possible Code Yellow Storm Surge’ group page.


3. Collect the Communications Officer action cards. a) Keep action card on hand.

4.

Provide the first report to the Emergency Controller. a) caller's name b) exact location of the incident c) type of incident (i.e. storm surge).




STORM WARNING Time Sign

1. Activate a ‘Code Yellow – Storm Warning’ group page.








CONFIRMED Time Sign

1.

Notify the Emergency Management Team ‘Confirmed Code Yellow Storm Surge’ group page.





1.

Notify the Emergency Management Team ‘Code Yellow Storm Surge – All Clear’ group page.

2.


3. Refurbish action cards in the front reception office.






12.4.3 Area Warden/Warden – Code Yellow Storm Surge Action Card

Area Warden/Warden: Nominated role for each shift Action Card 3





2.

Collect orange vest and Area Warden action card.

a) Don vest. b) Keep action cards on hand.



STORM WARNING

1.

Ensure:

a) area/floor is checked for any abnormal situations b) mobile staff are contacted and advised of the situation c) the area is prepared to evacuate d) Community patients (where applicable) are checked on

and reported back patients needing assistance.







CONFIRMED




ALL CLEAR

1.










12.4.4 Emergency Response Team Member - Storm Surge Action Card


Action Card 4





2.

Collect action card from the front reception office. a) Keep action card on hand.

3.



STORM WARNING







CONFIRMED



ALL CLEAR









13. CODE YELLOW HAZARDOUS MATERIAL INCIDENT SUB PLAN

13.1 Purpose

The purpose of this sub plan is to outline the preparatory measures and emergency responses to a hazardous material (HAZMAT) incident.

13.2 General

Numerous hazardous materials such as gases (medical and non-medical), flammable liquids, poisons, corrosive substances, radioactive materials and infectious materials are handled and stored within health service facilities. Additionally, HAZMAT may be transported along the main arterials near the health facility. HAZMAT incidents are most likely to be accidental, however may also be caused deliberately. Although the Warren Health Service has a number of engineered control measures in place to minimise the risk of HAZMAT incidents, these control measures may also fail at a critical stage. These emergency response procedures address control measure failure through the implementation of emergency actions. Where emergency actions are ineffective and the incident causes disruption to critical business functions beyond tolerable periods or adverse safety impacts on patients, staff and visitors, Business Continuity Plans and Code Orange evacuation procedures apply.

13.3 Material Safety Data Sheets

All Dangerous Goods (DG) and hazardous chemicals handled and stored on site have a current Material Safety Data Sheet in place.

· A paper copy of the MSDS is kept in a clearly marked master dangerous goods and hazardous chemical folder in the facilities main administration office; and

· A paper copy of the MSDS is kept in a clearly marked dangerous goods and hazardous chemical folder in all work areas that the hazardous chemical or dangerous good is to be used; and

· An electronic copy of the MSDS is kept in a dangerous goods and hazardous chemical folder in the sites Occupational Safety and Health (OSH) folder.

13.4 Hazardous Chemical Register

All approved dangerous goods and hazardous chemicals are registered in the sites hazardous chemical register. The register includes the following information:

· The name of all hazardous substances used on site (in red). · The name of all dangerous goods used on site (in black) · The average level of stock kept on site.

A paper copy of the hazardous chemicals register is kept in a clearly marked master hazardous chemical folder in the facilities main administration office and an electronic copy kept in a dangerous goods and hazardous chemical folder in the sites Occupational Safety and Health (OSH) folder.





13.5 Prevention and Preparedness

There are a number of preventative and protective measures in place at the Warren Hospital to prevent and protect people from hazardous material incidents.

13.5.1 Storage Stored in accordance with the Australian Dangerous Goods Code and AS/NZS 3833:1998, and the WA Country Health Service Storage and Handling of Gases in Cylinders Procedure and Guideline.

13.5.2 Impact Protection Dangerous goods and any structure (i.e. shelving, racking) or plant associated with the storage and handling of the dangerous goods is, so far as is reasonably practicable are protected against damage from impact with vehicles and/or mobile plant.

13.5.3 Mechanical Ventilation Mechanical ventilations systems that comply (so far as reasonably practicable) with the requirements set out in Australian/New Zealand Standard 3833:2007 - The storage and handling of mixed classes of dangerous goods, in packages and intermediate bulk containers.

13.5.4 Labelling Containers are labelled in accordance with National Code of Practice for the labelling of workplace substances. Enclosed systems are labelled in accordance with AS 1345:1995 - Identification of the Contents of Pipes, Conduits and Ducts.

13.5.5 Signage Warning signage for Dangerous goods storage areas are displayed to prohibit smoking and exclude other ignition sources (e.g. DANGER: NO SMOKING, NO IGNITION SOURCES). Chemical Storage warning signage is displayed to warn people that a location is used to store potentially hazardous chemicals and that access is restricted.

13.5.6 Training Employees whose work potentially exposes them to hazardous chemicals are trained every three years in OHCHZ EL2 - Chemical Hazards. Line Managers who are supervising others using hazardous chemicals at work are trained every three years in OHCHM EL2 - Chemical Hazards for Managers.

13.5.7 Personal Protective Equipment and Clothing (PPEC) Personal Protective Equipment prescribed as per the manufacturers Material Safety Data Sheet is readily available for use. Refer to the WACHS Personal Protective Equipment Policy (under review) for more information.

13.5.8 Spill Kits Clean-up equipment, chemicals for neutralizing or decontaminating spills and absorbent materials are kept in areas where dangerous goods and hazardous chemicals are kept or handled.








13.6 Code Yellow Hazardous Material (Action Cards) 13.6.1 Emergency Controller - Hazardous Material Incident Action Card


Action Card 1





ON ALERT Time Sign




3. Receive the first report from the Communications Officer and ascertain the nature and location of the incident.

4.

Instruct the Communications Officer to give the first report to the Department of Fire and Emergency Services by dialling 000.

a) caller's name b) exact location of the incident c) type of material (chemical, biological radiological) d) volume spilt.

Note: For chemicals, provide the name of chemical, the UN number (refer to the MSDS) and the state of the chemical (e.g. gas, liquid, solid).

5.

Ensure all areas are notified possible code yellow – HAZMAT by whatever means available. Notification “This is the Emergency Controller, possible Code Yellow – HAZMAT <say location>. Remain calm keep away from the area and wait for further instructions. (Say twice.)

6. Establish contact with the District Manager, Area Wardens and the Engineering Officer. Evaluate the situation.

7. Initiate Code Orange Evacuation procedures if the situation warrants this.





CONFIRMED Time Sign

1.

Ensure all areas are notified Code Yellow confirmed HAZMAT by whatever means available. Notification “This is the Emergency Controller, confirmed Code Yellow - HAZMAT <say location>. Remain calm, keep away from the area and wait for further instructions. (Say twice.)

2. Establish estimated time of arrival of the emergency services.

3.

Establish contact with the Engineering Officer and implement appropriate actions. (I.e. turning off air conditioning systems, isolating sources of possible ignition etc.).

4.

Establish contact with the Area Wardens, provide a verbal SITREP and implement appropriate actions. Including but not limited to:

a) closing all doors and windows of the area/department b) isolating the area and restricting access c) diverting traffic d) preparing to evacuate.

5.

Establish contact with the District Manager and provide SITREP. Determine the need to evacuate. Initiate Code Orange Evacuation procedures if the situation warrants this.

6. Brief emergency services personnel upon arrival on the type, scope and location and provide an escort to the source.

7.

Complete an impact assessment and determine: a) business functions disrupted b) maximum tolerable periods of disruption (refer to







9.

Maintain communications with the Department of Fire and Emergency Services and other key stakeholders (Local Emergency Management Committee, Engineering Officer, Area Wardens, Emergency Response Team and Tier 4 Manager).

10. When the incident is declared as ended by the Department of Fire and Emergency Services, carry out all clear actions.

ALL CLEAR Time Sign

1.

Ensure all areas are notified Code Yellow – HAZMAT, all clear. Notification “This is the Emergency Controller, Code Yellow HAZMAT <say location> – All Clear”. (Say twice.)

2.

Carry out a post emergency assessment to determine impact and immediate operational needs.

3.

Ensure resources are available for Warren Hospital: a) ICT systems and applications b) Specialised equipment c) Office and telecommunications equipment d) Workforce e) Essential services (power, water etc.) f) Physical Premises g) Transport requirements.

4. Activate Business Continuity plans if the situation warrants this.


6.


7.

Compile an emergency response report for the District Manager (Refer to the WACHS-SW Emergency Response Report Template.)





13.6.2 Communications Officer – Code Yellow Hazardous Material Incident

Action Card

Communications Officer : Main receptionist (day shift ) Ext 55 : Second Nurse in charge (afternoon and night shift).

Action Card 2


emergency response. ON ALERT Time Sign

1. Activate a ‘Code Yellow Hazmat – On Alert’ group page.

2. Collect the Communications Officer action cards from the Front Reception Office.


3.

Provide the first report to the Emergency Controller. a) caller's name b) exact location of the incident c) type of incident (i.e. storm surge).

4. Commence a running log of events and incoming calls.



CONFIRMED Time Sign

1. Activate the Emergency Management Team ‘confirmed Code Yellow HAZMAT' group page.





1. Activate the Emergency Management Team ‘Code Yellow HAZMAT – All Clear’ group page.

2. Collate all action cards (complete and incomplete) and ensure logs and records are saved electronically and in hard copy format.







13.6.3 Area Warden/Warden – Code Yellow Hazardous Material Incident Action Card




ON ALERT Time Sign



3. Ensure the area/floor is checked for any abnormal situations.



CONFIRMED

1. Carry out Code Orange evacuation procedures if the situation on the floor warrants this.

2.

Ensure: a) The area is isolated and people are restricted from

entering the incident site. b) Details on the material are obtained and passed onto the

Emergency Controller. Note: Chemicals information is found on the MSDS.

3. Review resource requirements for business continuity.



ALL CLEAR










13.6.4 Emergency Response Team Member Hazardous Material Action Card


Action Card 4



ON ALERT Time Sign


2.

Collect action card from the Front Reception Office. a) Keep action card on hand.

3. Report to the Emergency Controller. Where the Emergency Controller is absent, assume the responsibilities of the Emergency Controller until they arrive.


CONFIRMED



ALL CLEAR




4. Respond as directed by the Emergency Controller to compile a report.





14. BUSINESS CONTINUITY PLAN

Refer to the Warren Hospital Business Continuity Plan.





15. CODE ORANGE EVACUATION PROCEDURES

15.1 Purpose

The purpose of this procedure is to:

· provide information relevant to an evacuation of an area within or from the Warren Health Service

· outline the actions for an evacuation of an area within or from the Warren Health Service

15.2 General

An evacuation involves the movement of patients, staff and visitors from within or from the Warren Health Service when lives are threatened. An evacuation is to be carried out in a manner that is prompt and as safe as possible.

15.3 Assessing the Situation

The decision to evacuate should be assessed with consideration to the following:

· The consequences to patient, staff and visitor safety, should an evacuation not be carried out

· The distance between the hazard and patients, staff and visitors · The clinical risks associated with an evacuation of patients in the involved area.

15.4 Authority to Evacuate

The authority to order the removal of people from the immediate area (Stage 1) rests with any staff member. The authority to order the removal of people to a safe area (Stage 2) rests with the Area Warden or the Emergency Controller. The authority to order the removal of all people from the facility (Stage 3) rests with the Emergency Controller.

15.5 Preferred Order of Evacuation

· Those in immediate danger. · Ambulant people. · Ambulant people requiring assistance. · Non – ambulant people.





15.5.1 Evacuation Stages

Evacuations should be conducted in three distinct stages.

15.5.1.1. Stage 1 Evacuation A Stage 1 evacuation is the removal of people from the immediate area. This may include but is not limited to the removal of people from a room that is on fire or has an aggressive person in it.

16.5.1.2. Stage 2 Evacuation A Stage 2 evacuation is the removal of people to a safer area. This may include but is not limited to the removal of people from their compartment/zone, through fire/smoke doors to an adjacent compartment/zone or lower level.

15.5.1.3 Stage 3 Evacuation A Stage 3 evacuation is the removal of all persons from inside the building and to an assembly point.

15.5.2 Evacuation Routes The presence of a hazard may determine the choice of an evacuation route. In any case, an evacuation is to be via a person’s most direct and safe route to either: · their nearest muster point for Stage 1 evacuations; · their nearest safe area for Stage 2 evacuations; or · Their nearest safe assembly area for Stage 3 evacuations.

Evacuation diagrams provide evacuation information such as evacuation routes in pictorial format of the floor. Evacuation diagrams are strategically located throughout the facility.

Note: Lifts are not to be used to evacuate in a Code Red unless authorised by

the Department of Fire and Emergency Services (DFES) Officer in Charge (OIC).





15.6 Muster Points

There are a number of internal designated points (muster points) where patients, visitors and staff may be taken/assemble in the event of an evacuation.

DEPARTMENT MUSTER POINT Ambulatory Care / PathWest Corridor near meeting room at fire exit

Administration / Medical Imaging Main waiting room

Emergency Department Emergency department Staff Station

Inpatient / Birthing Unit Staff Station

Offices Corridor outside District Manager Office

Kitchen Corridor outside District Manager Office

Engineering Corridor outside District Manager Office

Operating Theatre Surgical Services Staff Station

Support Services Staff dining room or nearest muster point when working on the floor





15.7 Assembly Areas External designated places (assembly areas) where patients, visitors and staff may

be taken/assemble in the event of a Stage 3 evacuation are:

1. Primary Evacuation point – adjacent to the doctor on-call car park outside the Emergency Department

2. Secondary Evacuation point - the external staff car park at the rear of the hospital.

15.7 Evacuation Centres

The evacuation centre for the Warren Health Service will be determined in accordance with the nature of the hazard. Where suitable, the Shire of Manjimup may be contacted for access as an evacuation centre on the following numbers: The Shire of Manjimup may be contacted for access as an evacuation centre on the following numbers:

· 9771 7777 (in hours) · 6454 4600 (after hours)

Important: In the event of a bushfire, the assembly area for all departments is the Primary Evacuation point adjacent to the doctor on-call parking outside the Emergency Department.





15.8 Other Considerations

15.8.1 Mobility Impaired Staff

Line Managers should establish appropriate Personal Emergency Evacuation Plans (PEEP) (Appendix 16.3) for mobility impaired staff members under their direct supervision. Plans should be established and maintained in consultation with the staff member to ensure the appropriateness of the plan and be readily available to the relevant Area Warden. Refer to Appendix 16.3 – Personal Emergency Evacuation Plan Template.

15.8.2 Records Relevant to Immediate Patient Care Saving patient care records that are relevant to the immediate care of a patient is important however this should not be done at the expense of evacuating people.

15.8.3 Evacuation Equipment There is generally limited equipment that can be used to evacuate people. In most cases, equipment such as wheelchairs, ski sheets, mats, sked type devices etc. may need to be turned around quickly to ensure evacuation of non-ambulant patients.

15.8.4 Head Counts At the completion of an evacuation, the Area Warden is to ensure a headcount of all patients, staff and visitors is conducted to ensure the evacuation is complete.

15.8.5 Communications Good communication is essential during the evacuation process with rapidly changing patient and staff locations.

15.8.6 Logistical Support and Resupply Logistical support and resupply will be as per the WACHS-SW Emergency Management Plan.

15.8.7 Pharmacy Pharmacists are to coordinate the review of and access to medications for patients in the event of an evacuation.





15.9 Patient Care after an Evacuation

Patients are likely to need extra care following an evacuation until such time as they can be returned to their ward, found alternative accommodation within the facility or transferred to another WACHS-SW site.

15.9.1 Decanting Inpatients Where patients are required to be transferred to another WACHS-SW site as a result of an emergency, the District Manager is to ensure the Regional Disaster Health Coordinator is notified of the need to transfer. The Emergency Controller should record the transfer of patients in a patient transfer log. Refer to Appendix 16.1 – Patient Transfer/Discharge Log.

15.10 Clearing an Emergency Code

Following consultation with the Officer in Command (OIC) of the applicable Emergency Service, the Emergency Controller will notify the staff ‘ALL CLEAR’ and to either assist in the recovery effort or return to normal duties.





15.11 Code Orange Evacuation Procedures Action Cards

15.11.1 First Responder – Immediate Actions

Position: First Responder Action Card 1

Reporting to: Area Warden

Responsibilities: Take measures to move patients, staff and visitors within or from within the facility.

Where the situation requires the removal of people from immediate danger or when ordered to evacuate Time Sign

1. Where practicable, identify a ‘buddy’ to work with.

2.

Move patients and visitors to the nearest safe area via the nearest safe exit in the preferred order.

3.

Where it is safe to do so for each room:

a) turn the gas valves off b) turn the lights on c) close the door (do not lock) d) mark the door with a tape in the form of an X to

indicate that it has been cleared.

4.

Move to the nearest safe area via the nearest safe exit when all occupants, patients and visitors are evacuated or when the area becomes unsafe.

5.

Check off your name with the Area Warden.






15.11.2 Emergency Controller – Confirmed Emergency


Action Card 2


Responsibilities: - Control the evacuation within and from the facility. - Ensure the health and safety of patients (including permanent care

residents), staff and visitors when evacuated within or from the facility.

Confirmed Emergency That Warrants An Evacuation Time Sign

1. Establish contact with the Area Warden of area affected by whatever means available. Instruct Area Warden to prepare for an evacuation.

2.

Activate the PA system for the entire facility and make the evacuation announcement. “Attention all areas, attention all areas, this is the Emergency Controller. An emergency has occurred within the building. <say area/department or all areas> evacuate now.” (Say twice.)

3. Establish contact with the Area Warden of area adjacent to the affected by whatever means available. Instruct Area Warden to prepare for an evacuation.

4. Repeat steps 2 - 3 until all areas have been cleared or the emergency has abated.

5. Wait for Area Wardens to report back; on the progress of the evacuation. Record evacuation information on an evacuation checklist. Appendix 16.2 Evacuation Checklist

7. Where patients are evacuated, ensure the Senior Medical Officer is contacted and provided with an escort to the designated assembly area(s).

8. Where the evacuation is complete provide the Responsible Person with the evacuation checklist.

9. Where the emergency has abated, carry out all clear actions for the applicable code.





15.11.3 Communications Officer – Confirmed Emergency


Action Card 3


Responsibilities: To assist with clerical, communication and record maintenance duties during an evacuation.

EVACUATION ORDERED Time Sign

1. Notify the applicable Emergency Services that an evacuation has been ordered.

2.

Receive and transmit instructions, information and enquiries as required.

3. Record a log of the events that occurred during the evacuation.







15.11.4 Area Warden – Confirmed Emergency

Position: Area Warden/Warden - Nominated role for each shift. Action Card 4


Responsibilities: Coordinate the initial response to the emergency in the area.


1. Identify the nearest safe area that will provide the greatest isolation time from the hazard for patients, staff and visitors.

2

Provide SITREP to the Emergency Controller.

a) Exact location of evacuation point. b) Number and type of evacuees.

3.

Ensure the following are carried out:

a) Patient lists and staff rosters are collated b) the route to the safe area is cleared c) the Area Warden of the adjacent area is liaised with d) Evacuees are checked off the applicable list as they arrive

in the safe area e) triage is performed when evacuees arrive.

4.

Establish the priority order for evacuation and brief the evacuation order to the Emergency Response Team and area staff. a) Those in immediate danger b) Ambulant people c) Ambulant people requiring assistance d) Non – ambulant people

5. Maintain communications with the Emergency Controller and other key stakeholders.

6. Control the evacuation of the area.

7. Consider the collation of specialist medical equipment and medical records.

8. Move to nearest safe area when instructed to do so by the Emergency Controller or the Emergency Services or when the area is cleared.

9. Where the emergency has abated carry all clear actions for the applicable code (i.e. Code Red All Clear procedure).





15.11.5 Emergency Response Team Member – Confirmed Emergency

Emergency Response Team Member : Orderly (day shift) Ext 5232/ 5233 Third staff member on duty (i.e. Enrolled Nurse, assistant in nursing) (afternoon and night shift).

Action Card 5

Reporting to : Emergency Controller - Clinical Nurse Manager Ext 5235 Deputy Controller : General Ward Shift Coordinator Ext 5236 Responsibilities: Carry out emergency response activities.


1.

Liaise directly with Area Warden of the affected area to determine: a) the nearest safe area b) priority areas to be searched and cleared. Muster immediately with the Emergency Response Team.

2. Instruct Emergency Response Team members to ‘buddy up’ and commence removing people to the nearest safe area.

3. Report to the Emergency Controller via whatever means available when the task is complete. Wait for further instructions.






16. APPENDICES

16.1 Patient Transfer / Discharge Record

PATIENT TRANSFER/DISCHARGE LOG

Name / DOB Patient /Staff /Visitor Vehicle Registration Destination Time of Departure Discharge/Transfer





16.2 Evacuation Checklist

1. Occupied (O) - check box and record time when area is operational and occupants have not been ordered to evacuate. 2. Evacuating (E) - check box and record time when area is in the process of evacuating. 3. Clear (C) - check box and record time when Area Warden deems the area clear.

Nature of the Emergency Location Of the Emergency

Area O E C Location of remaining occupants Areas not searched

Inpatient Unit

Time: Evacuating to:

Emergency Department


PathWest


Medical Imaging


Administration






4. Occupied (O) - check box and record time when area is operational and occupants have not been ordered to evacuate. 5. Evacuating (E) - check box and record time when area is in the process of evacuating. 6. Clear (C) - check box and record time when Area Warden deems the area clear.

Nature of the Emergency Location Of the Emergency

Area O E C Location of remaining occupants Areas not searched Kitchen/ Support Services


Surgical Services


Engineering


Ambulatory Care







16.3 Personal Emergency Evacuation Plan (Mobility Impaired Staff)

PERSONAL EMERGENCY EVACUATION PLAN

Name:

Location:

1. Department/Area 2. Floor

1.

2.

Is an assistance animal required?

Yes / No

Are you trained in the emergency response procedures?

Yes / No

Preferred method of receiving updates to the emergency response procedures?

Preferred method for Notification of Emergency? (e.g. visual alarm, SMS, etc.)

Type of assistance required: (Please list procedures necessary for assistance)

Equipment Required for Evacuation





Egress procedure: (Give step by step details. Add lines as necessary)

1. 2. 3. 4.

Designated assistants and contact details: (Please list name, phone, mobile, email).

Are your designated assistants trained in the emergency response procedures (including the evacuation procedures)?

Yes/ No

Are your designated assistants trained in the evacuation equipment? Yes/ No

Diagram of preferred route for assisted evacuation: (Please provide diagram)

Issued Date: Review Date:

Occupant Approved: (Signature) Date:

Area Warden Approved (Signature): Date:





16.4 Bomb Threat Card

Remember to keep calm Place this card under the phone TELEPHONE BOMB THREAT CHECKLIST

Important Questions to Ask

Where did you put it? Where is the bomb going to explode?

What does it look like?

Exact wording of threat

Threat:

General questions to ask

How will the bomb explode? or How will the substance be released? Did you put it there? Why did you put it there?

Bomb threat questions

What type of bomb is it? What is in the bomb? What will make the bomb explode?

Chemical/Biological threat questions?

What kind of substance is in it? How much of the substance is there? How will the substance be released? Is the substance a liquid, powder of gas?





Other questions to ask

What is your name? Where are you? What is your address? Notes for after the call Callers Voice Accent (specify): Any impediment (specify): Voice (load, soft etc.): Speech (fast, slow, etc.): Diction (clear, muffled): Manner (calm, emotional): Did you recognise the caller: If so, who do you think it was? Was the caller familiar with the area? Threat Language Well spoke: Incoherent: Irrational: Taped: Message read by caller: Abusive: Other: Background Noises Street noises: House noises: Aircraft: Voices: Music: Machinery: Local call noise: STD: Other Sex of Caller: Estimated age: Duration of call: Number called: Action taken:

Who received the call

Name: Telephone Number: Date call received: Time received: Signature:





16.5 Offender Description Form

OFFENDER DESCRIPTION FORM

A separate form is required for each person. To be compiled immediately after the incident by each staff member and also by bystanders if possible. Place tick as applicable. If answer is unknown write UK against heading. Do not consult with others during compilation. Emergency Controller to collect forms and hand to Police. Name used: Sex: Male Female Approximate Age: Ethic Origin: Height: Weight:

Complexion fair dark pale

Build: thin stout

fresh ruddy suntanned medium nuggetty pimply

Voice clear loud

Accent: thick slangy Posture erect stooped slouched

Spectacles colour

Walk quick springy slow shape limp pigeon - toed thick glass tinted

Hair

colour Moustache/beard: type straight wavy bald Disguise curly think long

Hands

S M L crew cut other Calloused Soft

Eyes Colour Hairy Size S M L Nails missing /deformed fingers Intense stare squint

Ears Size S M L

Gloves Type

Shape Colour

Nose Size S M L

Jewellery Describe

Shape

Lips Size S M L Scars, marks or tattoos: Shape

Teeth good bad spaced missing protruding uneven

Clothing

Including hat, tie, shirt, coat, trousers, dress, skirt, sweater and shoes

Weapon Type:

Method of Operation (what did the offender do, say, touch carry etc. Method and direction of escape:

Make of Car: Model of Car: Registration: Signature: Colour: Number of Vehicles Used: Address:





16.6 Essential Services Contacts List

Name Position Phone Mobile Email

Alinta Natural Gas 24 Hour Service 13 13 58 N/A N/A

Alinta Power 24 Hour Service 13 13 58 N/A N/A

BOC Medical Gases 24 Hour Service 13 24 27 N/A N/A

WA Water Corporation 24 Hour Service 13 13 75 N/A N/A

ICT WACHS SW ICT Help Desk 1800 794 748 N/A [email protected]

Kleenheat Gas 24 Hour Service 13 21 80 N/A N/A

Synergy 24 Hour Service 13 13 51 N/A N/A


mailto:[email protected]




16.7 Fire Danger Ratings Fire Danger

Rating What does it mean What should be done

Catastrophic

· These are the worst conditions for a bush or grass fire

· If a fire starts and takes hold, it will be extremely difficult to control and will take significant firefighting resources and cooler conditions to bring it under control

· Spot fires will start well ahead of the main fire and cause rapid spread of the fire

· Embers will come from many directions

· Homes are not designed or constructed to withstand fires in these conditions

· The only safe place to be is away from bushfire risk areas

PREPARE FOR BUSHFIRES · Establish contact with

Department of Fire and Emergency Services for reports, updates and information.

· Establish contact with Local Emergency Management Committee (LEMC) chair. Determine the need for emergency LEMC meetings.

· Establish contact with the Regional Health Disaster Coordinator and provide SITREP. Discuss evacuation logistics.

· Prepare Local Emergency Operations Centre (LEOC) and check communications equipment.

· Review resource requirements(I.e. staff, transport etc.) for evacuation and ensure availability

· Consider discharging relevant patients into family care.

· Consider vulnerable community patients.

· Consider cancelling elective surgical cases

Extreme

· These are very hot, dry and windy conditions for a bush or grass fire

· If a fire starts and takes hold, it will be unpredictable, move very fast and difficult for fire-fighters to bring under control

· Spot fires will start and move quickly · Embers may come from many directions · Homes that are prepared to the highest level, have

been constructed to bushfire protection levels and are actively defended may provide safety

· You must be physically and mentally prepared to defend in these conditions

· The only safe place to be is away from bushfire risk areas

BE AWARE · Fire prevention and protective

measures are in place and operational

· Code red and code orange Emergency Response Procedures awareness is raised for all staff

· Prepare Local Emergency Operations Centre (LEOC)

Severe

Very High

· These are hot, dry and possibly windy conditions for a bush or grass fire

· If a fire starts and takes hold, it may be hard for fire-fighters to control

· Well prepared homes that are actively defended can provide safety

· You must be physically and mentally prepared to defend in these conditions





17. RELATED WACHS POLICIES

WACHS Emergency (Disaster) Management Arrangements Policy WACHS Missing or Suspecting Missing Inpatient Procedure WACHS Missing Aged Care Resident Procedure WACHS Restraint and Seclusion Minimisation Clinical Practice Standard WACHS South West Emergency Management Plan WACHS South West Emergency Management Manual

WACHS South West Emergency Management – Emergency Management - Quick Reference - Immediate Actions Procedure (Hospitals) WACHS South West Emergency Management –Emergency Management - Quick Reference - Immediate Actions Procedure (Community Sites)

18. RELATED WA HEALTH SYSTEM POLICIES

MP 0083/17 Emergency Management Policy

IC 0065/12 ‘Parry Pack’ Retrieval Kit Policy and Contents Guideline

Contact: Transition Project Officer (J.Omodei) Directorate: Nursing and Midwifery Services TRIM Record # ED-CO-16-48098

Version: < Policy Unit Only > Date Published: < Policy Unit Only >












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